Permit Building Permit Application FOR ULLICL l ()NI.)
City of Tigard 5/ al p?d Permit No.: 1-17 - DD/fpp
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review i r , -
Phone: 503.639.4171 Fax: 503.598.1960 t,. I I ' Date/B . Other Permit:
._
Inspe tion Line: 503.639.4175 ' _I _ 1 � Date Ready/By. t !� ® See Atta ched Ch
Int t: Ci.ti d.or �� �,Q Notifed/Method / ra. Supplemental Information ecklist for Lilo Pei2 TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
❑ Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ I- and 2- family dwelling ❑ Commercial /industrial Valuation: $ r / .3/q
❑ Accessory building ❑ Multi -family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 7554 5 dLAD O A.h.t t -F Cr _ New dwelling area: 57 3 square feet
City / State/ZIP: Garage /carport area: square feet
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Suite/bldg. /apt. no.: I Project name: 6 CQ fx 'moo - 444.) eiff Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: I Lot no.: Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
/►✓/
it $7 3 gi et,JF r.lr ,s1toD yr f /--/p,J t-7- Valuation: $
Existing building area: square feet
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New building area: square feet
ip PROPERTY OWNER ❑ TENANT Number of stories:
Name: 7) r NI 044. (x /) r 4 / x.) 62oUP !itie Type of construction:
Address: $ (1 )j LC) .1i 1_ t_ (1 QE 9r- Occupancy groups:
City /State/ZIP: ir'L1T OF2 9 2 x 9 Existing:
Phone: 5 ) 2_9'a,- 39. s 9 Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name: under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed. If the '
applicant is exempt from licensing, the following reasons
City / State/ZIP:
apply:
Phone: ( ) I Fax:: ( )
E -mail:
CONTRACTOR
Business name: t•-1q— Pi`a- 0 W 13 t /2— BUILDING PERMIT FEES'
Address:
Please refer to fee schedule.
City / State/ZIP: Fees due upon application
Phone: ( ) I Fax: ( ) Amount received
CCB lic.: I ' D
Date received:
Authorized signature: This permit application expires it'll permit is not obtained
within 180 days after it has been accepted as complete.
I Print name: I Date: I • Fee methodology set by Tri -County Building Industry
Service Board.
is\ Building \Permits \BUP- PmmitApp.doc 12/03 440- 46I3T(I1 /02/COM/WEB)
y
One- and Two - Family Dwelling
Building Permit Application Checklist IOR (.1FFICI List. ONI.l
City of Tigard
Received
�' DateBy. Permit No.:
13125 SW Hall Blvd., Tigard, OR 97223 Assoaated permits:
Phone: 503.639.4171 Fax: 503.598.1960 Ier,�
24- Hour Inspection Line: 503.639.4175 ? I I la Electrical ❑ Plumbing , ❑ Mechanical
Internet: www.ci.tigard.or.us "" ❑ Other.
THE FOLLO\VIN(; ITEMS ARE IZE()UIRED FOR I'LAN REVIEW W l us No N/A
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. • ■ ❑
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑
3 Verification of approved plat/lot. ❑ ❑ ❑
4 Fire district approval required. Name of district: . ❑ ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity ❑ ❑ ❑
6 Sewer permit. ❑ ❑ ❑
7 Water district approval. ❑ ❑ 0
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ 0 ❑
9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state 0 ❑ ❑
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.
11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ ❑
there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements
and driveway, footprint of structure (including decks); location of wells/septic systems; utility locations; direction
indicator; lot area; building coverage area; percentage of coverage; impervious area; existing structures on site; and
surface drainage.
12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑
and location.
13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑
furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc.
14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub- ❑ 0 ❑
floor, wall construction, roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings
and foundation, stairs, fireplace construction, thermal insulation, etc.
15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. ❑ ❑ ❑
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full -size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing (prescriptive path) and/or lateral analysis plans. Must indicate details and locations; for non- ❑ ❑ ❑
prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor /roof framing. Provide plans for all floors/roof assemblies, indicating member sizing, spacing, and bearing 0 ❑ 0
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ 0 ❑
systems, see item 22, "Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑
over 10 feet long and/or any beam/joist carrying a non - uniform load.
20 Manufactured floor /roof truss design details. ❑ ❑ ❑
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑
for four or more appliances.
22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or ❑ ❑ ❑
architect licensed in Ore on and shall be shown to be licable to the ro'ect under review.
23 Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17".
24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. ❑ ❑ ❑
26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document. ❑ ❑ ❑
27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑
28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard 0 ❑ ❑
Street Tree List.
29 Site plan to include tree protection measures as required by conditions of approval. ❑ ❑ ❑
30 A Clean Water Services' Sensitive Area Pre- Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
I:\ Building \Permits\BUP- RES- PermitApp.doc 2
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M chanical Permit Application roll 01:1 iCFF. USE ONLY
City of Tigard
Plan Review Permit No.:
13125 SW Hall Blvd., Tigard, OR , 97223 1-/.9 3 'a) / (o0
I ns o ection Line: 5031639.417503.598.1960 . , t * i .; l + , D�B Other Permit:
p _ l.1. ^I Date Ready/By. 3 El See Page 2 for
Internet: www.ci.tigard.or.us - -" J Notified/Method . 7 I G, Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
Mechanical permit fees* are based on the value of the work
❑ New construction ❑ Addition/alteration/replacement
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit
CATEGORY OF CONSTRUCTION Value: $
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ I- and 2 family dwelling ❑ Commercial/industrial ❑ Accessory building
For special information use checklist.
❑ Multi - family 0 Master builder
❑ Other:
'Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Job site address: 1 695 e,k) . ,0dh -; -7 Air conditioning or heat pump
(requires site plan showing placement) 14.00
City /State/ZIP: Furnace 100,000 BTU ( ducts/vents) 14.00
Furnace 100,000+ BTU (ducts/vents) 17.90
Suite/bldg. /apt..no.: Project name: Gas heat pump 14.00
Cross street/directions to job site: Duct work 14.00
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 10.00
Subdivision: Lot no.:
Flue /vent for any of above 10.00
Other: 10.00
Tax map/parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
Gas fireplace 10.00
Flue vent for water heater or gas
fireplace 10.00
Log lighter (gas) 10.00
Wood/pellet stove 10.00
Wood fireplace/insert 10.00
Chimney/liner/flue/vent 10.00
❑ PROPERTY OWNER I ❑TENANT Other: 10.00
Name: �,40C /ID,� / A "sf.4 -? g,)7$ Environmental exhaust and ventilation
Address: Range hood/other kitchen
equipment 10.00
City /State/ZIP: Clothes dryer exhaust 10.00
Fax: Single -duct exhaust (bathrooms, /
Phone:
( ) ' ( ) toilet compartments, utility rooms) ` 6.80
❑ APPLICANT ❑ CONTACT PERSON Attic/crawlspace fans 10.00
Business name: Other: 10.00
Fuel piping
Contact name: $5.40 for first four; $1.00 for each additional
Address:
Furnace, etc.
Gas heat pump
City / State/ZIP: Wall/suspended/unit heater
Phone: ( ) Fax:: ( ) Water heater
Fireplace
E-mail: .
. Range
CONTRACTOR Barbecue
/ �))
Business name: A - ../"--
J'9r Pa>r /1✓ Gt a 6QiQ�,//tJ(o Clothes dryer (gas)
Other:
Address: /6,0c C t. OE L V A) 5-r . MECHANICAL PERMIT FEES*
City /State/ZIP: �i Lif-c. A M f!-5 D2 9 74/ C Subtotal
Minimum permit fee ($72.50)
Phone: (603) (p — 46,6 9 - I Fax: ( ) Plan review (25% of permit fee)
CCB lic.: .7/ /7 l State surcharge (8% of permit fee)
TOTAL PERMIT FEE
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: I Date: • Fee methodology set by Tri - Cowry Building Industry Service Board
i:\ Building \Permits\MEC- PermitApp.doc 12103 440.461Tr(I1 /02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
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Commercial Fee Schedule:
Total Valuation: Permit Fee:
$1.00 to $2,000.00 Minimum fee $72.50
$2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30
for each additional $100.00 or fraction
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thereof, to and including $5,000.00.
$5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and
$1.80 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and
$1.35 for each $100.00 or • •
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fraction thereof, to and including •
$50,000.00.
$50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and
$1.25 for each additional $100.00 or
fraction thereof, to'and including
$100,000.00.
$100,000.01 and up $1,396.50 for the first $100,000.00 and
$1.10 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
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i:\ Building \Permits\MEC- PermitApp.doc 12/03 2
Building Fixtures
Plumbing Permit Application l(l( ()rrlcl IISE Owl.V
City of Tigard Received Permit No.: r 3 - a0/e4
13125 SW Hall Blvd., Tigard, OR 97223 plan R
Plan Review Other Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 G,�,�� i : �e/
24- Hour Inspection Line: 503.639.4175 . L j. - 'I I Date Ready/By: ti El See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method /t� Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition /alteration/replacement 0 Other: New 1- 2- family dwellings (includes 100 ft for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities _
Job site address: '759 S' w OA/1 - e--7 Catch basin or area drain 16.60
City /State/ZIP: Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Tax map /parcel no.: Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK
Back flow preventer Page 2
Backwater valve 16.60 .
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I i ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: % I/7, A P AJ E c r i J �i r-3 Expansion tank 16.60
Address: Fixture/sewer cap 16.60
City /State/ZIP: Floor drain/floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: • Primer 16.60
City / State/ZIP: Roof drain (comm.. ial) 16.60
Phone: ( ) I Fax: : ( ) Sink/basi / avatory / 16.60
Tub /showers ower pan / 16.60
E-mail: Urinal 16.60
CONTRACTOR Water closet
/ 16.60
Business name: i-e,c, Q/a1 ./ s P ,...0 t�ht Aid • Water heater 16.60
Address: -p a V 41 Other:
Subtotal
City / State/ZIP: (,f A Lprr - i>J 62 9 70to Minimum permit fee: $72.50
Phone: (RS ) (OA, a - II/ 3e' Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: $7 L Plumbing Lic. no.: V -Mr 6 Pb Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: I Date: This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
is\ Building \PenninWLMF - PennitApp.doc 05/0S 440.4616T(10/112/COM/WEB)
Plumbing Permit Application - City of Tigard 4 ' . .�4) .
Page 2. - Supplemental Information .
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1 e 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 •
Medical Gas Systems:
Water Service - each additional 100' 46.40 Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50 •
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each '
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections -per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof
Fixture Work: Plan Review for Complex Structures
Are you capping, adding or replacing fixtures? 'If "yes", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria
accurately report fixtures could result in increased sewer fees *. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new Commercial buildin .
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous Capped Added Fsisting ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool providing services to human beings.
Car Wash • - Each Stall ❑ Plumbing installations, alterations or additions to food service
- Drive Thru facilities where new plumbing fixtures, including interceptors, •
Cuspidor/Water Aspirator are being installed for the food service area.
Dishwasher - Commercial ❑ Any new residential building containing three (3) or more •
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- Domestic dwelling units.
Drinking Fountain
Eye Wash ❑ Any NFPA 13 -D multipurpose fire sprinkler system.
Floor Drain sink - 2" Submit 2 sets of plans with any of the above.
.
-4"
Car Wash Drain Isometric or Riser Diagram
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal -Commercial three (3) or more stories in height.
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work: .
Rec. Vehicle Dump Station
S hower -Gang
-Stall .
Sink - Bar/Lavatory •
- Bradley ,
- Commercial •
- Service . , ' •
Swimming Pool Filter -
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: _ plumbing permit can be issued.
is\Building\Per nia\PLM -Pe mitApp.doc 07 /06/05
Electrical Permit Application FOR OFFICE list: ONLY
City of Tigard A/ p ' ') x(
Plan Review
13125 SW Hall Blvd., Tigard, OR 97223 .. ���
Phone: 503.639.4171 Fax: 503.598.1960 '' .a'!.,. I ` Date/B . Other Permit:
Inspection Line: 503.639.4175 . ,_ ' I 1 ' Date Ready/By. El See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information •
TYPE OF WORK PLAN REVIEW
❑ New construction ❑ Addition/alteration/replacement Please check all that apply:
❑ Demolition ❑Other: ❑Service over 225 amps, comm'I ❑Hazardous location
❑Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
CATEGORY OF CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential
❑ 1 - and 2 family dwelling ❑ Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure .
❑ Multi - family ❑ Master builder ❑ Other; ❑Building over three stories ['Feeders, 400 amps or more
❑Occupant load over 99 persons ❑Manufactured structures or
JOB SITE INFORMATION AND LOCATION 0 Egress/lighting plan RV park
Job no.: Job site address: ?595 r5a) O NN�c Cr- ❑Health - care facility ❑other:
Submit • 2 sets of plans with any of the above.
City/ State/ZIP: The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name: FEE* SCHEDULE
Description I Qty. I Fee. I Total I ••
Cross street/directions to job site: New residential single- or multi - family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 4
Subdivision: I Lot no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Limited energy, residential 75.00 2
Tax map /parcel no.: Limited energy, non - residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
dwelling, service and/or feeder - 90.90 2
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
.PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2
) � 401 amps to 600 amps 160.60 2
Name: ----- 4 / l.-!" / / i 5 rrV /r j 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
Phone: ( ) I Fax: ( ) relocation
200 amps or less 66.85 1 •
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps . 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT I ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee, / 46.85 2
Address: first branch circuit
Each add'I branch circuit - / 6.65 2
City/State/ZIP: Miscellaneous (service or feeder not included)
Phone: ( ) Fax: : ( ) Pump or irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E - mail: Signal circuit(s) or limited- .
CONTRACTOR energy panel, alteration, or
extension. Describe: Page 2 2
Business name: 3ecig\012QE / 3 £L e % g q . (Jp
Address: x38 ( y.., g49, 01 Each additional inspection over allowable in any of the above
Per inspection 62.50
City/ State/ZIP: � p O & 4 70 55 Investigation per hour (1 hr min) 62.50
Phone: (5 ) g % -- t tipO'j Fax: ( ) Industrial plant per hour - 73.75 -
ELECTRICAL PERMIT FEES*
CCB Lic.: 13/0 3 1 1 Electrical Lic.: Qj-q *.(..I Suprv. Lic.: Oct / S Subtotal
Suprv. Electrician signature, required: Plan review (25% of permit fee)
Print name: Date: State surcharge (8% of permit fee)
TOTAL PERMIT FEE
Authorized signature: This permit application expires if a permit is not obtained within Igo
days after it has been accepted as complete
Print name: Date: • Fee methodology set by Tri- County Building Industry Service Board
•• Number of inspections per permit allowed.
i:\ Bwlding \Pennitn\ELC- PamitApp.doc 12/03 4104615T(10/02/COM/WEB
Electrical Permit Application - City of Tigard t
Page 2 - Supplemental Information
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LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined $75.00 •
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial system. $75.00
(SEE OAR 918 260 - 260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation •
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting* •
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
is\ Building \Pormits\ELC- Pam itApp.doc 04/03
•
Fees Associated With 1 12 12/ /2005
16/16 •
C ase #: MST2003 -00160
City of Tigard
Fee Start End Revenue Created
Type Date Date Dept Description Account Number By Date Amount Due
MPRT 1/1/1990 12/31/2005 [MECH] MEC Permit 245-0000-431010 HAP 4/21/2003 50.00 50.00
M5PC 1/1/1990 12/31/2005 [TAX] MEC 8% St Tax 100 - 0000 - 207020 HAP 4/21/2003 4.00 4.00
PPRT 1/1/1990 12/31/2005 [PLUMB] PLM Permit 245- 0000 - 431000 HAP 4/21/2003 50.00 50.00
P5PC 1/1/1990 12/31/2005 [TAX] PLM 8% St Tax 100- 0000 - 207020 HAP 4/21/2003 4.00 4.00
ELCF 1/1/1990 12/31/2005 [ELPRMT] ELC Permit 220 - 0000 - 431510 HAP 4/21/2003 42.85 42.85
ELC5 - 1/1/1990 12/31/2005 [TAX] ELC 8% St Tax 100- 0000 - 207020 HAP 4/21/2003 3.43 3.43
BPRT 1/1/1990 12/31/2005 [BUILD] Bldg Permit 245- 0000 - 432000 DEB 4/23/2003 250.00 250.00
B5PC 1/1/1990 12/31/2005 [TAX] Build 8% St Tax • 100- 0000 - 207020 DEB 4/23/2003 20.00 • 20.00
Total: $424.28
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