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Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 Permit # PLC' 7 0 ( ' 3
Date Issued I L) -q7
V iglirl'' Phone (503) 639 -4171
FAX (503) 684 -7297
CITY OF TIGARD TDD No. (503) 684 -2772
Inspection (503) 639 -4175
1. Job Address: / 4. Complete Fee Schedule Below:
Name of Development A, iesLe-vvy WeA j L s 143 � Number of Inspections per permit allowed
Address 1 3 00 3 S (..J Pock t �,4.i Dv Service included: Items Cost(ea) Sum
City /State /Zip r c.orri 4a. Residential - per unit
1000 sq. ft. or less $110.00 4
Name (or name of business) Each additional 500 sq. ft. or
portion thereof $25.00
Commercial El Residential El Limited Energy $25.00 1
Each Manuf'd Home or Modular
Dwelling Service or Feeder $68.00 2
2a. Contractor installation only:
� goo/ _ 4b. Services or Feeders
Electrical Contractor /',/ 1 ' J • �[ 00/ �+ c. Installation, alteration, or relocatio 8 60.00 2
c 200 amps or less
Address OO S l..) Q�yt c b.... 201 amps to 400 amps $80.00 2
f p �
City 1 qt _ State Zip Cf 7 223 401 amps to 600 amps $120.00 2
p 601 amps to 1000 amps
2
Phone N. 6, 39 - 5833 Over 1000 amps or volts $340.00 2
Job NO. Reconnect only $50.00 2
contractor's license NO. l4 - £f25 C 4c. Temporary Services or Feeders
Contractor's Board Reg. No. 1 3G q/ Installation, alteration, or relocation e o
Signature of Supr. Elec'n 200 amps or less cc - 2
License No. 3 ;cot S one No. (,,, ?- Sg33 201 amps to 400 amps $50.00 2
401 amps to 600 amps $75.00
Over 600 amps to 1000 volts $100.00
2b. For owner installations: see "b" above.
4d. Branch Circuits
Print Owner's Name New, alteration or extension per pane
Address a) The fee for branch circuits with
purchase of service or feeder fee. 2
City State Zip Each branch circuit $5.00
Phone No. b) The fee for branch circuits without
The installation is being made on property I own which is purchase of service or feeder fee. 2
not intended for sale, lease or rent. Eat ddch b $$5.00
Ea
a additional branch circuit $5.00
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or irrigation circle $40.00 2
Each sign or outline lighting $40.00
Signal circuit(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 $35.00
Per hour $55.00
-
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: 50.°
5a. Enter total of above fees $
NOTICE 5% Surcharge (.05 X total fees) $ 2. Sh
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $
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. wordkomdmAeieo ❑ Trust Account #
$
prm.wp
=
Balance Due $ -52--2=