Permit I`' q CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT ELECTRICAL
ELC2012 -00232
T f G A.RJJ 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/24/2012
Parcel: 2S110DD11900
Jurisdiction: Tigard
Site address: 10725 SW HIGHLAND DR
Project: Miller Subdivision: SUMMERFIELD NO.13 Lot: 689
Project Description: Replace panel.
Contractor: FUZION ELECTRIC LLC Owner: MILLER, VICKI
21782 SW KRISTIN CT 10725 SW HIGHLAND DR
ALOHA, OR 97006 TIGARD, OR 97223
PHONE: 503 - 528 -6033 PHONE:
FAX: 866 - 284 -0482
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 04/24/2012 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 04/24/2012 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
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 accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work i rspended for more the 180
days. ATTENT • . • • - eon la • requires you to follow the rules adopted by the Oregon Utility Notification Center. Th•- - as are set forth in OAR
952 -001 -01 • through OAR . —001 •0991 You may obtain a copy of the rules or direct questions to OUNC by calling 5' . 32.1 or 1.:0' i 44.
Issue. By: � .. / ' Permittee Signature: `i��
J/
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:
(34 • • NTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' # / G Date:
LICENSE NO. /
Ca ' 3.639.4175 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.
tsue
Electrical Permit Applicat`' B ' ? `' FOR OFFICE USE ONLY
City of Tigard APR 2 2012 Received N 2� '8 - (Z) Permit No.: p,Qw. -ppA3y
13125 SW Hall Blvd., Tigard,OR 972 Plan Review
' C Phone: 503.718.2439 Fax: 503.59 1l960 DateB Other Permit:
71 G n It u Inspection Line: 503.639.4175 I I Y OF :G. i a® Date Ready/By: kris: BI See Page 2 for
Internet: www.tigard BUILDII1C n Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction ddition/alteration/replacement Please check all that apply (submit a sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: 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
and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: j Job site address: /Q 7/23 5 (,) A � � / V ❑ 100HP or more. oaupa or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: f t om+, aL 1/ i r ❑ Health -care facilities. ❑ Supply voltage for more than
• - ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: V (! L k I � r /( ✓ ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I •
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 I
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
p _ (// a n , ^ n ( Limited energy, multi-family
LO P 10t el Y � residential (with above e sq. q. ft.) 75.00 2
Services or feeders installation, alteration, and/or relocation
200 amps or less i 100.70 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
•
Address: Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
h relocation
Phone: ( ) Fax: ( ) • 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, er panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑ 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 2
Contact name: branch circuit
Each add'I branch circuit 7.42 _ 2
Address: Miscellaneous (service or feeder not included)
Ci /State /ZIP: Each manufactured or modular 67.84 2
h dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name ay 1 G L � panel, alteration, or extension. Page 2 2
7A U� Each additional inspection over allowable in any of the above
Address: 2 i -7r._ 7 G ] ( ,,) < y i ' J k 7 Additional inspection (1 hr min) 66.25/ hr
Ci /State /ZIP: '7 a - 6j Investigation (I hr min) 66.25/ hr
ty 1q l p Ito, / ` v Industrial plant (1 hr min) 78.18/ hr
Phone: ( e ' 9„_F- coo 33 Fax: ( ) Inspections for which no fee is
specifically listed (Vs hr min) 90.00 / hr
CCB Lic.: / yq„. Electrical Lic.: C-$ ( . 4 , Su.rv. Lic.: 55'9_$ - S ELECTRICAL PERMIT FEES
d Subtotal
it. / - _ _ Plan review (25 % of
Suprv. Electrician signature, require permit fee): : /e0. 70
Print name: 3r `J - ` ) I Date: t( /2 2______ 2______ [� ( State surcharge (12% of permit fee): 4Z -Og
/ TOTAL PERMIT FEE: // a .7g
Authorized signature. �, Al 0
��— This permit application expires if a permit is not obtained within 180
yi Print name : - -- j UY� Date: • dope Lion it has pe accepted as complete Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 07/01/10 440-4615T(11 /05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
r 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:
rCOMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000)
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
p 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 •
I:\ Building \Permits\ELC- PermitApp.doc 07/01/10