Permit CITY OF TIGARD ELECTRICAL PERMIT
11111 s COMMUNITY DEVELOPMENT ELECTRICAL
ELC2014-00162
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/10/2014
T t G A ft f) 9 Parcel: 2S103AC05800
Jurisdiction: Tigard
Site address: 12621 SW 113TH PL
Project: LIDAY Subdivision: HUMBOLDT CREEK ESTATES Lot: 9
Project Description: (1)branch circuit for A/C unit.
Contractor: SIMPLY SHOCKING LLC Owner: LIDAY, GARRY F& LOUISE A REV LI
15118 S WOODGLEN WAY BY LIDAY, GARRY& LOUISE TRS
OREGON CITY, OR 97045 12621 SW 113TH PL
TIGARD,OR 97223
PHONE: 503-880-8649 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 04/10/2014 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 04/10/2014 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const: IB
Occupancy Grp:
Total $62.92
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 OAR 952-001-0090. You may obtain-. •• - •- • --or direct questions to OUNC by calling 503.232.1987 or 1.80 44
! __
Issued B Permittee Signature:
G 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.
Electrical Permit Application
. ..C.'49 I I lk ()I I It I I `NI (1\I.1
City of Tigard Cr.) vv Received
III g DateB el aye Permit No.:
• 13125 SW Hall Blvd.,Tigard,OR 97�M �� Plan Review
Phone: 503.718.2439 Fax: 503.59: ' Date/By: Other Permit:
i<I Inspection Line: 503.639.4175 'N.,, 1 ∎r. Ready/By: tuns: RI See Page 2 for
Internet: www.tigard-or.gov Q' `0. . ;y1 ed/Method: 6 Supplemental Information
Of WORK P � �. PLAN,
❑New construction OAddition/alteration/reArc, Please check all that apply(submit sets of plans w/items checked below):
❑Service or feeder 400 amps or more ❑Building over three stories.
Demolition ❑Other: �� where the available fault current
. ❑Marines and boatyards.
CA �r exceeds 10,000 amps at 150 volts or ❑Floating buildings.
•� and 2-family dwelling less to ground,or exceeds 14,000 ❑Commercial-use agricultural
- y g ❑Commercial/industrial ❑Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or
JOB SITE IIORMATI0IN AND LOCA LOCATION ❑Emergency system. larger separately derived system.
❑Addition of new motor load of ❑"A","E "1-2" "1-3",
Job no.: Job site address: �2 t;2� 5 41 //3" P/ 100HP or more. occupancy.
❑
❑Six or more residential units. Recreational vehicle parks.
City/State/ZIP:
• ❑Health-care cation. ❑Supply voltage for more than
J��.r' / Q� Q 2z3
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name: L/t�a ❑Service or feeder 600 amps or more.
`' FEE SCHEDULE
Cross street/directions to job site: oaerlptior I Qty. I Fee. I Tend I •
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
Tax map/parcel no.: Limited energy,residential
75.00 2
DESCRIPTION OF WORK (with above sq.(1.)
' Limited energy,multi-family 7500 2
Ac C.k - residential(with above sq.ft.)
Renewable Energy Cl See Page 2
Services or feeders installation,alteration,and/or relocation
0 PROPERTY OWNER 1 0 TENANT 200 amps or less 100.70 2
201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
Address: 601 amps to 1,000 amps 301.04 2
Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
Phone:( ) Fax:( ) relocation
200 amps or less 59.36 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168.54 2
Owner signature: Date: Branch circuits—new,alteration,or extension,per panel
0 APPLICANT I ❑ CONTACT PERSON A.Fee for branch circuits with
above service or feeder fee, 7 42 2
Business name: each branch circuit
B.Fee for branch circuits without
Contact name: service or feeder fee,first i 56.18 5-4-( 2
branch circuit
Address: Each add'l branch circuit f 7.42 2
City/State/ZIP: Miscellaneous(service or feeder not included)
Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Phone:( ) Fax: :( ) Reconnect only 67.84 2
E-mail: Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
Business name: ._ ' _54:1e /e71- // Signal circuit(s)or limited-energy See
U panel,alteration,or extension. Page 2 2
Address: /5`/,B W0Q/4 n G�/ Each additional inspection over allowable in any of the above
City/State/ZIP: �� t7 u _ Additional inspection(1 hr min) 66.25/hr
4r, G/ , Q r7 7 ) _ Investigation(1 hr min) 66.25/hr
Phone:(SBj) 6.-0 y -3o Fax:( ) Industrial plant(1 hr min) 78.18/hr
S Inspections for which no fee is 90,001 hr
CCB Lic.: /j yf Electrical Lie.: C 5°'7` Suprv.Lic.: J S specifically listed(%hr min) _
Suprv.Electrician] ure,required 7/ I I 1� ELECTRICAL i'F,Rliubt Subtotal: 54 1y
Print name: 57)L yI• 4 ,A4 oxit/ f Date: "XIV/�!/ Plan review(25%of permit fee):
9041,7 State surcharge(12%of permit fee): 6,-7 y Authorized signature: TOTAL PERMIT FEE: l ,9�
This permit application expires if a permit is not obtained within 180
Print name: on Date: it., S _. 9y days after it has been accepted as complete.
• Number of inspections allowed per permit.
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