Permit Electrical Permit • e m cation ,.,. FOR.OFFICE
Received , / Electrical n
N Date /By / / Permit No : e 46,00 -• t 2
City of Ti gar ��v D � Planning Approval Sign
y g O y Date/By Permit No
13125 SW Hall Blv ip Plan Review I Other
� 1
Tigard, Oregon 97223 p e Date/By Permit No..
Phone: 503- 639 -4171 Fax: Post-Review ' Land Use
u i i I i `� Date/By: Case No.:
Internet. wvvw.ci.tigard.or�� �� ell • Contact J Z See Page 2 for
24 -hour Inspection Reque stu 9 -4175 �'" "'' / (p' pp
ll�� Nam e/Method / Supplemental
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� I-1 New construction n Demolition ❑ Service over 225 amps- Health -care facility
commercial IC Hazardous location
® Addition/alteration/replacement I I Other: ❑ Service over 320 amps- rating of ❑ Building over 10,000 square feet,
,:;;::u' c = ; .s,#xFa,rz;'d:» = .Jr, "..,, '- aEGO " za.F Gb S P.O W. „ �?' 1 & 2 famil dwellm s four or more residential units in
1 & 2- Family dwelling I E] Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stones ❑ Feeders, 400 amps or more
n Accessory Building I Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
n Master Builder I i Other: ❑ Egress/lighting plan ❑ Other:
4 :f rd^ § F ;° x iiiV Submit sets of plans with any of the above.
`-= '''rJO,B'SIaT;E'INO TI'0;= a "nd`IOC'T -IONS.
' ` °T ' ` "''° "'' ` "'" '° The above are not applicable to temporary construction service.
Job site address: 9 0 51.4- c oi a) S-)- . .::5. 4 f m:. { . � r7 � max - a . r ? , y F.:...,, „i. ,.
* ilf, K=V,42``.;,:4':r�'.: *.'rts+".'z-'t§ LZ:$ "'#+'_"U .t E` rtdi z�t hsx:AiWWz, . ,':
Suite #: 2 00 Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: Dle . C-/c3,—/c Description Qty Fee (ea.) Total
New residential- single or multi - family per i
Cross street/Directions to job site: dwelling unit. Includes attached garage.
Service included:
1000 sq. ft. or less 145.15 4
• ` C �,2 J (,1/ I Z ^ J 7i),,/"' Each additional 500 sq. ft. or pomon thereof 33.40 I
Subdivision: Lot #: Limited energy residential 75.00 2
Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
: e`> p: ;: :� r ,r , .
%' W' Fr > -. "..:,: ,: D'FSCRI € N.O1 W0_.2TCt... . ,... ,3 service and/or feeder 90.90 2
D e n t a) F�. L e Services or feeders - installation,
T alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
_. .PROP TYOV NE � 3f.i, d1i ENeeT�„;.r :' i ti° F ' 601 amps to 1000 amps 240.60 2
L L A p Q - HO j Over
eco n nett amps or volts 466.85 2
ame: i Reconnect aril 66.85 2
Address: Sap 4. 40 (per -.i it goo Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: P TLb 6 2 4 7 AO V 200 amps or less 66.85 l
Phone: Fax: 201 amps to 400 amps 100.30 2
401 to 600 amps 133.75 2
1/ „EA "pP 7e:- u � l �`:;�, if Mr4. 4--'' 'I In WO 1 Tt,PER Q1 ,,.: tl Branch circuits - new alteration, or
Name: extension per panel:
A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 6.65 2
City /State /Zip: B. Fee for branch circuits without purchase of /J j
service or feeder fee, first branch circuit / 46.85 7 6 2
Phone: Fax: Each additional branch circuit 2.Z 6.65 / t /6' 2
E -mail: Misc.(Service or feeder not included):
W:Cifer:AtEDMAKOMMOVOIr=lgiMaSOW1 Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: 5 y Signal circuit(s) or a limited energy panel,
Business Name: (l) ; a ? 11-c 1` /i' 4' i i alteration, or extension / Page 2 7-5 l 2
Description:
Address: r ' 0 . ;3_), 230 Sy7 i .t 41-4-
City /State /Zip: T; S a� 1 0 /.2_ / 72e/ Each additional inspection over the allowable in any of the above:
Per inspection per hour (min. 1 hour) 62.50
Phone: 50 3 - 6 1 'r - ' 6 3 , Fax: S ' 3 - C i ,, - 2 7' 3 :?? Investigation fee:
CCB Lic. #: 07 5 J 5 i Lic. #: 3 `./ - 2 )"> C Other:
Supervising electrician Subtotal $ 26 a' , / c
Signature required: I. . 7 Plan Review (25% of Permit Fee) $ 6 7. d`/
Print Name: O a , F: F ( ic. #: / y 6) . 5 State Surcharge (8% of Permit Fee) $ Z / . ys
TOTAL PERMIT FEE $ 356 • 6y
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set.by Tri- County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms \ElcPermitApp.doc 01/03