Permit i 5 - - . 2 o.242fr -
,:! it' Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 Planck/Rec. #
�Gar ,l j .a Permit # LC c -0
� I Phone (503) 639 -4171 Date Issued I o - l0 _'f S
� . FAX (503) 684 -7297
CITY OF TIGARD TDD No. (503) 684 -2772 Issued by ��1
Inspection (503) 639 -4175
! 1. Job Address: 4. Complete Fee Schedule Below:
Name of Development D R X. 'I~ilIP®RI O h4, Number of Inspections per permit allowed
Address 1014 4 / Sw 4)AS0 SQ Ro Service included: Items Cost(ea) Sum
City/State/Zip 7 /G7,f3.2O oOLE-• 4a. Residential - per unit 4
DRUG 1000 sq ft or less $11000
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Name (or name of business) DRUG E kP RwA"l Each additional 500 sq ft or 1
portion thereof $25.00
Commercial Residential ❑ Limited Energy $25.00
Each Manuf'd Home or Modular 2
Dwelling Service or Feeder $68 00
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2a. Contractor installation only: 4b. Services or Feeders
Cep, 2 Installation, alteration, or relocation 2
Electrical Contractor t ,1` zoo 0 amps or less $so 00 2
Address Yd G 3 tr per ' . 124c.`,Fee__ 201 amps to 400 amps $80 00 2
City pc State ZI 9 72t 3 401 amps to 600 amps $120 00 2
`7 p 601 amps to 1000 amps $180 00 2
Phone No. ans..- 41$S$' ' Over 1000 amps or volts $340 00 2
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Contractor's License No. at, I M.C. L'S 1 o I Reconned only $50.00
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Contractor's Board Reg. No. (,Q 3 '1 LL . 4c. Temporary Services or Feeders
A
I nstallation, alteration, or relocation 2 Signature of Sr. Elec'nitj. 200 amps or less $50 00 2
License No. 5 O / SIG Phone .. 2,. t4,STS- 201 amps to 400 amps $75 00 2
401 amps to 600 amps $100 00
Over 600 amps to 1000 volts
2b. For owner installations: see 'b' above
Print 4d. Branch Circuits
rint Owner's Name
New, alteration or extension per panel
Address a) The lee for branch circuits with
City State Zip purchase of service or feeder lee. 2
Each branch circuit $5 00 I I
Phone No. b) The lee for branch circuits without `.
The installation is being made on property I own which is purchase of service or feeder fee. 2
First branch circuit $35 00 2
not intended for sale, lease or rent. Each additional branch circuit $500
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or imgation arde $40.00 2
Each sign or outline lighting / $40 00
Signal arcud(s) or a limited energy 2
Please check appropriate item and enter fee in section 5B. panel, alteration or extension $40.00
4 or more residential units in one structure Minor Labels (10) $100 00
Service and feeder 225 amps or more
System over 600 volts nominal 4f. Each additional inspection over
Classified area or structure containing special occupancy the allowable in any of the above
as described in N.E.C. Chapter 5 Per inspection $3500 - Per hour $55 00
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In Plant $55 00
Submit 2 sets of plans with application where any of the above
, apply. Not required for temporary construction services. 5. Fees:
NOTICE 5a. Enter total of above fees $ 4 140 °'
.
5% Surcharge (.05 X total fees) $ 7, a t9•
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $ s.
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5b. Enter 25% of line A for
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Review if required (Sec.3) $
A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal $
COMMENCED. 9 ❑ Trust Account # $
� / d % c; - Q S6 Balance Due $ '- , ��
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