Permit Electrical Permit Application FOR OFFICE USE ONLY
`J g Date /B rJ � o A E 9 000 - ,5
City of Ti and Permit No e
Ill 13125 SW Hall Blvd , Tigard, OR 97223 Plan Review
C Phone* 503 639 4171 Fax. 503 598 1960 Date/By Other Permit
T I G A It D Inspection Line 503 639 4175 Date Ready /By J RI See Page 2 for
Internet' www tigard - gov Notified/Method /(A Supplemental Information
TYPE OF WORK PLAN REVIEW
Please check all that apply (submit 2 sets of plans w /items checked below)
❑ New construction ❑ Addition /alteration/replacement
❑ 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
❑ 1 - 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 A
❑ Addition of new motor load of ❑ "A ", "E ", "I- 2 ", "I -3 ",
Job no.: Job site address: /57610 .c 5.6 & ) 0OPf2 ,_.) S 100HP or more occupancy
❑
❑ Six or more residential units Recreational vehicle parks
City/State/ZIP: -- r c,h2> U_ ❑ Health -care facilities ❑ Supply voltage for more than
❑ Hazardous locations 600 volts nominal
Suite/bldg. /apt. no.: Project name: /eU ,7 ,,) d E-4 ;5 ❑ 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 145 15 4
Ea. add'I 500 sq ft. or portion 33 40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
/4/gk- DESCRIPTION OF WORK (with above sq. ft )
(L \ J � 0 (I)G-tlT3 jH p 61/ reesidential (with above s sq Limited energy, 75 00 2
p 7l '� X r boq ft )
ft
� Q /d 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
Name:
� /4 n (0 /9- /./- 401 amps to 600 amps 160 60 2
601 amps to 1,000 amps 240 60 2
Address: Over 1,000 amps or volts 454 65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) Fax: ( ) 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 599 amps 133.75 2
Branch circuits - new, alteration, or extension, per panel '•
Owner signature: Date:
A Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 6 65 2
each branch circuit
Business name: B Fee for branch circuits
Contact name: without service or feeder fee, / 46 85 , � JS � 2
first branch circuit /
Address: Each add'l branch circuit 7 6 65 416c-5" 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( ) Reconnect only 66 85 2
E -mail: Pump or irrigation circle 53 40 2
CONTRACTOR Sign or outline lighting 53 40 2
Signal circuit(s) or limited -
Business name: /G / T17 gL6 t e /j - ( _ e_04)577 energy panel, alteration, or
Address: a 33x.2 N k. P.,p ,J_--, - extension Describe. Page 2 2
City/State /ZIP: `-j 5 ft P2 t _ i 2 / E w /+ 9. 8cie10 Each additional inspection over allowable in any of the above
0 ) Per inspection 62 50
// Phone: 6,3) - 0533 Fax: (303 ) ai g5-4 Investigation per hour (I hr min) 62 50
CCB Lic.: / 53 7L/ Electrical Lic.: 57^ � Suprv. Lic.: 2 (7 5 Industnal plant per hour 73 75
( ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: k ; ,...- Subtotal 9,3 , sf
Print name: k 1----,„cr..... L1----,„cr..... 3 /S / � ,„ /1 „� Date: g Plan review (25% permit fee) / .
( State surcharge (12% of permit fee) ii a
Authorized signature: TOTAL PERMIT FEE* /O i f, � Q/
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit
I \Bwldmg\Permus\ELC- PermiApp doc 05/23/06 440- 4615T(11 /05 /COM/WEB
1,
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Community Development � '- �uu�
tY p
TIGARD A SV 2
Request for Permit Action �� - -i r 109
G� o`WI
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor CX Staff
(check one)
REFUND OR Name: /// INVOICE TO: (Business or Individual) N -
VOID Mailing Address:
3 o�.S�� City/State /Zip:
/ Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: Eke ADO? — oo /69
Site Address or Parcel #: /5700 6.i.v PPm. /AJs red,.(/ AD.
Project Name: J r
Subdivision Name: J/f9- Lot #:
EXPLANATION: j f t /to itm-T /. i NS. t oo2lJ 61-,t) 6
N2 M fries /o ei Ak) /
Signature: E K Date: 0 / s'Z. ee /eP 8�
Print Name: h/ f}t�r41� - I5�� tt
Refund Policy
1. The Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fec for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended
e) not more than 80% of the building permit fee for issued permits pnor to any inspection requests
2. Refunds will be returned to the original Payer in the same method in which payment was received Please allow 1 -2 weeks for processing refunds
FOR OFFICE USE ONLY
Rte to Sys Admin: Date g pe or B, ' W Rte to Bldg Admin: Date / p ' By4 -- r
Refund Processed: Date /if By Invoice Processed: Date By
Permit Canceled: Date 3,Zs/Q,9 By .2566 Parcel Tag Added: Date By
Receipt # Date Method Amount $
I \Building \ Forms \RegPemutAcuon doc Rev 07/26/07
•
3/25/2008 .
Case Activity Listing 2:00:07PM
CCEIL Case #: ELC2008 -00169
Assigned Done Updated
Activity Description Date 1 • Date 2' Date 3 Hold Disp " ` To By By " Notes
ELCI510 Void permit 3/25/2008 None DONE DEB 3/25/2008 Void permit per Hap Watkins. Work
DEB can be done and inspected under
ELC2007 -00430 as originally
permitted.
Page I of l CaseActrvity rpt
•
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
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 $75.00
system V .
(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
❑ 1.,
Instrumentation
❑ -Intercom and Paging Systems
❑' Landscape Irrigation Control *' . - .
▪ Medical
❑: Nurse Calls - -
❑ Outdoor Landscape Lighting* •
❑ Protective Signaling V '
- ❑ Other
Total number of commercial systems:
*No.licenses.are required. Licenses are required V
for all other installations - -
I \Building\ertnits\ELC•PennitApp doc 03/23/06 - ' -