Permit CITY OF TIGARD ELECTRICAL PERMIT
11 11 • COMMUNITY DEVELOPMENT
Permit #: ELC2012 -00720
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T t G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/18/2012
Parcel: 26 103BB09800
Jurisdiction: Tigard
Site address: 12020 SW 122ND CT
Project: Wells Subdivision: YE -OLDE WINDMILL Lot: 19
Project Description: (1) 200 amps or less
•
Contractor: PACIFIC NORTHWEST ELECTRIC INC Owner: WELLS, JONATHON A
PO BOX 310 12020 SW 122ND CT
OREGON CITY, OR 97045 TIGARD, OR 97223
PHONE: 503 - 657 -1188 PHONE:
FAX: 503 - 722 -9058
FEES
Quantity Description Date Amount
1 ea 12% State Surcharge - 12/18/2012 $12.08
Specifics: Electrical
1 ea Services or Feeders - 200 12/18/2012 $100.70
Type of Use: SF amps or less
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OAF 52 -001- 090. You Ji? may obtain
n a c of the rules or direct questions to OUNC by calling 503.2332..1 or 1.80003
.
Issued By: _ .3
Permittee Signature: l /A1 Al I tl e r ' T712ki
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
____. _ __ . ...... .... . . ...... __.__ . .._,_ „.. .,
al Permit. icati IVE
Electrical > FOR OFFICE: USE ONLY
City of Tigard DEC 1 7 Z012 ne�eeh3 r 8 // �,�
Permit No.. cif o a L,90 J
13125 SW Ha1lBlvd., Ti OR 97223 plan Review
' U
0. Phone: 503.718.2439 Fax: 503 4$ Date/BV: outer Permit.
Inspection Line. 503.639.41 ‘" � ' Date Ready03y: knit , a Sec Page 2 for
TiGARD B }t � G DIVISION Internet pp ��jj►l�i,„, l� t1 1x7 fv Notified/Me tvW� Supplemental information
— - ICE OF WORK �_ PLAN REVIEW
El New construction — Addition /alteration /replacement
Please check all that apply (submit 2 sets of plans wlitems checked below)
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the ailable Faultcuirent ❑ Marinas and boatyards
__ "- CATEGORY OE CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings
.
'~' less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
Ell and 2- family dwelling ❑ Commercial /industrial 0 Accessory building tnp foe all other installations. buildings.
0 Multi- family ❑ Master builder ❑ Other: ❑ Fire ❑ Installation of 75 KVA or
.IOII SITE INFORMATION AND LOCATION O Mdiu o n o system. "A", , Et'1 - 2" derived system.
_ ❑ Addieitm of new motor load of ❑ "A ° , E" `1 -2, " ' 13"
,lob no.: lob site address: 12.02 � ) 1001 IP or more occupancy:
l G` i1 G 0 Six or mare resideotfal units. ❑ Recreational vehicle parks.
City /State /ZIP: T j c ayy or,- '-) 2 2 . 3 ❑ Noalth -care facilities. El Supply voltage for more than
ti, - 014am-dous locations- 600 yolks nominal.
Suite/bldg. /apt. no.: Project name: ___(� S ❑ Service or feeder 600 amps or more.
- - -_ 111 FEE SCHEDULE
Cross strect/directions to job site: Dacriptlna t . Foe. _ Total
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lol no.:
L000 sq ft or l ess - 168.54 4
F.a. add'l 500 sq. tt. or portion 33.92 1
Tax map /parcel no.: Limited energy, 7500 2
gy, residcntiul
DESCRIr ION OF WORK _ � (with above sq. ft.)
Limited energy, multi - family 75.00 2
2 ,01) 04, k,�� ,(1 , jl (- u ;c.c.. residential (with above sq. ft.)
I Services or feeders installation, alteration, and /or relocation
200 amps or less i 100.70 On 0 2
0 PROPERTY OWNER ❑ 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
_- —
Phone: ( ) Fax: ( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that 1 own which is not - -- —
intended for sale, lease, rent, or exchange, according to ORS 447, 449. 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: ,,.� Date: . __ A. Fee for branch circuits with
—
C] APPLICANT Lj (:ONTAC:T PERSON above service or feeder tee, 7.42 2
each Nandi circuit
Business name: - B Fee foi<bitinch circuits without
service atfeedcr fee, first
Contact name: C .(Q branch circuit 56.18 2
I -- Each add'l branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included) _
Ci late /ZIP: Each manufactured or modular 67.84 2
dwelling, service and /or feeder
-
Ce Y
Reconnect only 67.84 2
Phone: ()) f O191 Fax: : ( ) _
` _ Pump or Irrigation circle 67.84 2
E mail: ' 0 0 f a C ' al ' .O fl _ _ Sign of outline lighting - 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
panel, alteration, or extension. Page 2 2
Business name: PC,ii(Gi c Ai 0l love S'1`° tie (7( c Each additional inspection over allowable in any of the above
Address: . J ,,), :3, Additional inspection (1 hr min) 66.25/ hr
Invesfrgatha (1 hr min) 66.25/ hr
City/State/ZIP: rp��s v, ti - C 04S
Industrial plant (1 hr min) 78.18/ hr
Phone r i ) (PS '} ,- / l l Fax 3) 1 2,-L-- c n5 inspections for which no fee is 90.00 / hr T ` -
r) specifically listed ('/ hr min) J
CCD Lie..) C1,245 3 I` Electrical Lie.: e (p Su Lie.: " bC 9 C _ ELECTRICAL PERMIT FEES
te '� 11 I d 1r t 3 Subtotal: (3, C}
Suprv. B a dt required: ( 7 ' Plan review (25 %ofpermit fee):
Print name:�..J3 l i A.N\ (Z(A, y\,k,( ,/,-2_ te: /�-' /'7' i 2 State surcharge(12 %of permit fee): /2-.C
} "'[/ /�
TOTAL PERMIT FEE: / 1 2- , `7 V'
Authorized signature: (• l _ C , o/ j�7 This permit application expires if a permit is not obtained within 18
J r \ J days after it has been accepted as complete.
Print name: � (Ai +� l � Date: Z - ' I • Number of Inspections allowed per pennit.
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