Permit Electrical Permit Application FOR OFFICE USE ONLY
Received Electrical
! C E Date/By: Permit No in 57 ov 3 -DO U /1
Cit of Ti and '•1 Planning Approval
y g Date/By: Permit No
13125 SW Hall Blvd. Review Other
Tigard, Oregon 97223 JUL Date/By• PermitNo.•
Phone: 503- 639 -4171 Fax: 503 -59 c' (OF TA E i l� Post-Review Land Use Date/By. Case No.:
Internet: www.ci.tigard.or.us �y LOIN . ,, . II Contact Juris.: See Page 2 for
24 -hour Inspection Request: 503 -63 X41 / Name/Method Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
❑ Addition/alteration/replacement ❑ Other: ❑ Service over 320 amps- rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
N 1 & 2- Family dwelling ❑ Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stones ❑ Feeders, 400 amps or more
Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: 1 222 o 5 (.() kill, ,S7Ltes LA), FEE* SCHEDULE
Suite #: Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: p 6 /if /4 p/Z/ 55 7 Description Qty Fee (ea.) Total
S New residential-single ginc ud or multi-family per
Cross street/Directions to job site: /2 1
T dwelling unit. Includes attached garage.
Service included:
1000 sq ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
5 T l-L�'5 L'J L 7 Limited energy, i 75.00 2
� )1/
Subdivision: / Lot #: —I non Limited energy, non residential ntial 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
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
❑ PROPERTY OWNER 1 ❑ TENANT 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
❑ APPLICANT ❑ CONTACT PERSON Branch n h circuits amps 133.75 2
Branch circuits -new, alteration, or
Name: p OA) /4 on 53-& e extension per panel:
A. Fee for branch circuits with purchase of
Address: 11236 &i iris Ova 5) ,, � 0 J' E' /06 service or feeder fee, each branch circuit 6.65 2
City /State /Zip: Lk/Cr 05/0-0 B. Fee for branch circuits without purchase of
service or feeder fee, first branch circuit 46.85 2
Phone: 563 -3r-7- 75'3ej1 Fax: 515 ' 3 — 2(..,/ Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: 2 31 /I /� Signal circuit(s) or a limited energy panel,
Business Name: j , ��J u alteration, or extension Page 2 2
Description •
Address: / D e G , , ' - SI t o
• City /State /Zip: A l„ virq O F • cf7 od 7 Each additional inspection over the allowable in any of the above:
Per inspection per hour (min. 1 hour) 62.50
Phone:573- 351,— k6,2 $" Fax: 5 —2s-q-233/ Investigation fee:
CCB Lic. #: 13 Lic. #: 3 y . Oth
2222- i # y ' 3 Electrical Permit Fees*
Supervising electrician Subtotal $
signature required: Plan Review (25% of Permit Fee) $
Print Name: L4•�, Youl Lic. if G (,75 State Surcharge (8% of Permit Fee) $
/ / TOTAL PERMIT FEE $
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: te: 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms \ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
iL .
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: • -
Fee for all systems $75.00
Check Type of Work Involved:
Audio and Stereo Systems
n Burglar Alarm
Garage Door Opener
I I Heating, Ventilation and Air Conditioning System
El Vacuum Systems
n 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
LI Boiler Controls
F Clock Systems
Data Telecommunication Installation
❑ Fire Alarm Installation
n HVAC
n Instrumentation
n Intercom and Paging Systems •
F7 Landscape Irrigation Control , `
Medical
❑ Nurse Calls
Outdoor Landscape Lighting •
!
Protective Signaling •
n
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
i \Dsts\Permit Forms\ElcPermitAppPg2.doc 01/03