Permit -r , CITY OF TIGARD ELECTRICAL PERMIT
1111 COMMUNITY DEVELOPMENT Permit #: ELC2011 -00699
Date Issued: 12/13/2011
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Parcel: 2S103DD01100
Jurisdiction: Tigard
Site address: 13939 SW PACIFIC HWY
Project: Walgreens Subdivision: MELROSE Lot: 7 -8
Project Description: (1) branch circuit for EV charging station.
Contractor: A & A ELECTRICAL CONTRACTORS INC Owner: WALGREEN CO #5780
1588 SKY TERRACE PO BOX 901
SALEM, OR 97306 DEERFIELD, IL 60015
PHONE: 503 - 949 -3193 PHONE:
FAX: 503 - 378 -9085
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 12/13/2011 $56.18
Specifics: Service or Feeder
1 ea 12% State Surcharge - 12/13/2011 $6.74
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in = cordanc- 'th approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. AT ENTION: Oregon aw re. • as you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0110 thro _. h OAR 952-611-!19*. Y-.0 ay obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
' �.�i�4"
Issued B� • • /� !� � Permittee 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' • tee -0,.1 ✓A„' _ Date: �-
LICENSE NO. ' 5761
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Application _ FOR OFFICE. USE ONLY
City of Tigard RECEIVED Received ���_ al E'��/ f.ene
UPI Date/13 �� / Permit No.:
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
' C • tit: `�
Phone: 503.718.2439 Fax: 503.598.1960 2011 D : Other Permit.
Inspection 503.639.4175
T I G A R D p� Date Ready/By: hail: See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
CITY OFTIGARI
, • TYPE OF OF
" I41i 11�[� �d[�IO�I :. , PLA R EVIEW
New construction ❑ Addition/alteration/replacement P check all that apply (submit 2 sets of plans w /items checked below):
❑ Demolition Other:
El Service or feeder 400 amps or more ❑ Building over three stories.
where the available fault current ❑ Marinas and boatyards.
• CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling JE Commercial/industrial El Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
.., . ❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LO , ° x.
ID Addition of new motor load of ❑ "A" "E" °1 -2 "] -3"
10OHP or more. occupancy.
Job no.: Job site address: ( 3 5.k) pqc }c■ C HG ❑ /l Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: f J OR 72.-D a ❑ Health -care facilities. ❑ Supply voltage for more than
L ` _ ❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: Project name:
it:, Service or feeder 600 amps or more.
Project ( A /. g, 5 P
Cross street/directions to job site: " , °FEE "SCI DU LE -
J Description I Qty. I Fee. I Twat •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.:
Limited energy, i
L residential 2
' DESCRIPTION OF •WORK . +. (with above sq. ft.)
/ `I Limited energy, multi- family 75.00 2
/ C If C. E �1 C h Ci f y 1 n j S IO r residential (with above sq. fl)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
'PROPERTY OWNER' ,..• ❑ .TENANT 201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
601 amps to 1,000 asups 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State/ZIP: relocation
Phone: ( ) F ax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT , • . . ❑ 'CONTACT PERSON above service or feeder fee, 7.42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 I 2
Contact name: branch circuit
Each add'] branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
Each manufactured or modular
City/ State /ZIP: dwelling, service and/or feeder 67.84 2
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail:
CONTRACTOR Sign or outline lighting 67.84 2
Signal circuit(s) or limited- energy
Business name: A +A e (ec r j ca I coo, ' , panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: / l ` S fs Y le,{-.r,{ t e SE. Additional inspection (1 hr min) 66.25/ hr
(} �+ Investigation (1 hr min) 66.25/ hr
City / State/ZIP:
5,11 M (:)1
1 \ ' 1 7 ;o 'C Industrial plant (1 hr min) 78.18/ hr
Phone: (5o) 11-1 - 3 ( q 3 I Fa4: :o3) 3 75_ 10 g 5' 0 1,6 1 Inspections for which no fee is 90.00 / hr
(t t specifically listed CA hr min)
CCB Lie.: /S3 ) 1 Electrical Lie.: 36 `6 C Suprv. Lie.: 3 �61 5 ' • ELECTRICAL- PERMIT FEES • -
,
Suprv. Elect required: Subtotal: S� , / �
Plan review (25% of permit fee):
' tint name: Date: State surcharge (12% of permit fee): 6 , 7S
TOTAL PERMIT FEE: 62, , r 3
Authorized sign e: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: • Number of inspections allowed per permit
I:\ Building \Permils\ELC- PemiitApp.doc 07/01/10 440-46t5T(11/05 /COM/WEB