Permit C ITY OF TI GAR® ELECTRICAL PERMIT
PERMIT #: ELC2005 - 00065
e��� DEVELOPMENT 5 SW Hall BId..iga Tigard. SERVICES
(503) 639 -4171 DATE ISSUED: 2/8/2005
PARCEL: 2 S 103AC -09300
SITE ADDRESS: 11486 SW FONNER ST
SUBDIVISION: GERTZ PARTITION ZONING: R
BLOCK: LOT : 002 JURISDICTION: TIG
Project Description: Temp service.
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: 1 PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL /PANEL:
MANF HM/ SVC/ FDR: 601 +amps - 1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
GERTZ CONSTRUCTION DEXHEIMER ELECTRIC INC
19200 SW46TH 10639 SE PRIDE FULLER ROAD
TUALATIN, OR 97062 PORTLAND, OR 97222
Phone: 503 - 638 -3390 Phone: 786 -0886
Reg #: SUP 2514 -S
LIC 43935
FEES ELF 26 -321C
Description Date Amount
Required Inspections
[ELPRMT] ELC Permit 2/8/2005 $66.85
[TAX] 8% State Surcharge 2/8/2005 $5.33
Total $72.18
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Speaalty Codes and all other applicable laws
All work will be done in accordance with approved plans This permit will expire if work is not started within 180 days of issuance, or if work is
suspended for more than 180 days ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those
rules are set forth in OAR 952 -001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC at (503)
246 -6699 or 1.800- 332 -2344
Issued By: ,G Permit Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease, or rent.
OWNER'S SIGNATURE: DATE:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N: \J _ DATE:6 'QS
LICENSE NO: ( - 9 / 4 s
Call 639 -4175 by 7:00pm for an inspection the next business day
EIe &ixical Permit Application . " FOR OFFICE USE ONLY "
Received
i ve d Electrical
Date /By: Permit No 6U-.20.)
-.G-0. K
City of 'Tigard Planning Approval Sign
Date /By. Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By Permit No..
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post-Review Land Use
�but��4I Date/By: Case No.•
�;1:�.' I
Internet: www.ci.tigard.or.us 1, Contact Juris • ® See Page 2 for
. 24 -hour Inspection Request: 503 -639 -4175 Name /Method Supplemental Information.
:'tea:.. KA „ce. i -'ii - ,a °. ,� y,.� ; fE° �; :.= n;;_= ,. :;-;° 4,: ARE IEW leaseheck atlih is p _ :
��. '�i'G °�� -„ ,. ti�=z n.; ��. ..- ��'Y�PE :QE;'WORIC���:..�.., _rx.,.,��..:,;. .�s��.� >waPLAN �' `e _ .._ at, 1 `_'� <'�z:'y -� •
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
❑ Addition/alteration/replacement ❑ Other: ❑ Service over 320 amps- rating of El Building over 10,000 square feet,
'„ 4,: t'r : tits- 4TEGQRI' -®F CONSTRU,CTION'M 'WC 1 & 2 family dwellings four or more residential units in
❑ 1 & 2- Family dwelling ❑ Commercial/Industrial El System over 600 volts nominal one structure
El
over three stones ❑Feeders, 400 amps or more
❑ Accessory Building ❑Multi-Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
..-77
❑ Master Builder ❑ Other: ❑ Egress/lighting plan 1=I Other:
s< " „Ar A2 JOB STTE4INF 1iiM- TIO tid` t CATION' r` ' .fi ' I :. Submit sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: / % - : ;: 'z : ; 's = : ,, . ° ,:' ;: ;,; t k.as .
G � (,(` � Ud 'r/1?/ e r^ ,��,. •�• '.FaEE SCHEDUIE�����; .,�.'�� �.�':��'. "�F_� <,N -'�3
Suite #: Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: Description Qty Fee (ea.) Total i
Cross street/Directions to job site: New residential - single or multi - family per
dwelling unit. Includes attached garage.
Service included:
I
1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Limited energy, residential 75.00 2
Subdivision: Lot #: Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
. w ;� ,, �:- a .,, `., t '� _ m r '' :: c ,; 4 - ,1�, service and/or feeder 90.90 2
ia;; :, _.'.. , :DESGRIP,TEIOiV' OF WORK : =, t =, _
Services or feeders - installation,
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
'' Ei 1?ROPETY OWNER'.;; ~ `r _ 1 ❑ TE NANT Ii , :14,1z , , , ,:.- - 601 amps to 1000 amps 240.60 2
Over 1000 amps or volts 454.65 2
Name: Reconnect only 66.85 2
Address: Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: 200 amps or less / 66.85 1
Phone: Fax: 201 amps to 400 amps 100.30 2
401 to 600 amps 133.75 2
':AP 1400. T z ',Illy s' "a� `' CONTACT,:'PERS,ON ;` , ,,k:
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
service or feeder fee, first branch circuit 46.85 2
Phone: Fax: Each additional branch circuit 6 65 2
E -mail:
Misc.(Service or feeder not included):
Each pu mp or irrigation circle 53.40 2
'' all :'' °' ` 0 :. , °! ;11 e,ONT i'l . , A � � i T4:y '; 53 40 2
Each sign or outline lighting
Job No: Signal circuit(s) or a limited energy panel,
t -{ . f n4 5 V El G Description
or extension Page 2 2
Business Name
• �� 7Cl � Description•
Address: /()G 31 c ),&_ rc-lL r,t—
Cit /State /Zi p .(/f 'f • ( �j 2-2 Z Each additional inspection over the allowable in any of the above:
Per inspection per hour (min 1 hour) 62.50
Phone: � X/ Fax: 7, 20 4/0 Investigation fee:
O
CCB Lic. #: 4 9',3 5 Lic. #: , 5 /4'.S Other:
:.' �,�. ,,; s. *� :.:
i 'M, vex w s ,T4ttlectrieal'Permitftees • -. : ' .I::. ;9$1.Z5
Supervising electrician X24,3z/c_ Subtotal $
signature required: ,Z)-- ,.Jj h� Plan Review (25% of Permit Fee) $
Print Name:yi4kit 2 6 • 0 £ X•1+ t-I`,* t..ic. #: (L /174___S State Surcharge (8% of Permit Fee) S
TOTAL PERMIT FEE $
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 pnnt name)
is \Dsts\Permit Forms \ElcPermitApp.doc 01/03 •
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
I I Audio and Stereo Systems
n Burglar Alarm
Garage Door Opener
Heating, Ventilation and Air Conditioning System
Vacuum Systems
FI Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
F Clock Systems
n Data Telecommunication Installation
I - 7 Fire Alarm Installation
n HVAC
n Instrumentation
n Intercom and Paging Systems
Landscape Irrigation Control
n Medical
n Nurse Calls
I Outdoor Landscape Lighting
n Protective Signaling
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations -
i:\Dsts\Permit Forms \ElcPermitAppPg2 doc 01/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (5 b3a-4175 , 7-005---6O6( 2_
INSPECTION DIVISION Business Line: ' . (53) 639 -4171
BUP
Received Date Requested o� — / M PM BUP
Location l / 4° Suite ✓ MEC
Contact Person _D Q.c J €_ Ph ( )7__e/ /3 PLM
Contractor Ph ( ) ,
BUILDING enant/Owner Uc_C= (
Footing
EL
Foundation
Acces
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing - am ` aC- -� f
Fi rewal I
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In � r
Water Service ` V
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL ",
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
� ce
e ti i In
UG /Slab
Low Voltage
F ?) rrri
Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
1 PART FAIL
Please call for reinspection RE: El Unable to inspect - no access
Fire Supply Line
ADA
Approach/Sidewalk Date Inspecto Ext
Other:
Final DO NOT REMOVE this inspection record from e job site.
PASS PART FAIL