Permit EXPIRED i� 0 .-0..
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard Received `D a2/ee PernitNo.:7�8_Q Z
I3125 SW Hall Blvd.,Tigard,OR 97223 Plan Rev W
Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Other Permit/30226# , A
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Inspection Line: 503.639.4175 ;AV.-,�iI Date Ready/By:Date Ready/By: 1°ri+ H See Page 2for
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t b Internet: www.ci.tigard.or.us Notified/Method:fie ethod le menhlGfor �oo , G
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❑New construction 12 •ddition/alteration/replacement Please check all that apply:
❑Demolition Other: ['Service over 225 amps,comm'l ['Hazardous location
f ❑Service over 320 amps—rating ['Bulldog over 10,000 sq.ft.,
Y `:13'ize `45^ '0^;zF ti°s`a�qi(� _ 0,K. i of 1-and 2-family dwellings �4 or more new residential
'v.�.._ _ .., • •.
❑ 1-and 2-family dwelling 4 Commercial/industrial ❑Accessory building ['System over 600 volts nominal units in one structure
❑Multi-family ❑Master builder ❑Other:
['Building over three storks ❑Feeders,400amps or more
{ `A aft3 +r �a r y ❑Occupant load over 99 persons Manufactured structures or
- , - r:� 1 < ^,] a urri',) t ao, ta) 1.O.1,, ._)' ., E r ❑Egress/lightingplan RV park
Job no.: Job site address: ate$5 S-( J • - ❑Healthcare facility ['Other:
r a GL "' S Submit 2 sets of plans with any of the above.
City/State/ZIP: _ U' r k L� The above are not applicable to temporary construction service.•suite/bldg./apt.no.: V MC J r'.. 't ��t1..:x�?4 �� {j1.. ,4- •D�f Sj"'1 �'r i i; xa `
Project name: ow, i tj
Description Qty. Fee. Total
Cross street/directions to job site: New residential single-or multi-family dwelling unit.
Includes attached garage.
1,000 sq.ft.or less 145.15 _ 4
Subdivision: Lot no.: Ea.add'I 500 sq.ft.or portion 33.40_ 1
Limited energy,residential 75.00 2
Tax map/parcel no.: Limited energy,non-residential 75.00 2
`, �j s. ✓r manufactured modular feeder Each ufactured or
n� dwelling,service and/or f er 90.90 2
• � i _ r f Services or feeders installation,alteration,and/or relocation
200 amps or less 80.30 2
'.ii-, vua?.i ; : ,,a, ^ ,il ,:,w,,,- 201 amps to 400 amps 106.85 . 2
. 401 amps to 600 amps 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2—
Reconnect only _ 66,85 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
Phone:( ) Fax:( ) relocation
200 amps or less 66.85 l
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 1 100.30 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 600 amps 133.75 2
Owner signature: Date: Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with•ri,t��t � -;, � : fl.1/t7`.p[ �tl 1i'.,)X�t��b ^`
service or feeder fee,each
6.65 2
r,' branch circuit _
t• 11 «1.. B.Fee for branch circuits
Contact name: j i
{ without service or feeder fee,
Address: ■ each branch circuit 46.85 2
39 t Il_!—••1 Each add'l branch circuit 6.65 2
City/State/ZIP: t U V'4-t an d 0 12_ C ) a G a Miscellaneous(service or feeder not included)
Pump or irrigation circle 53.40 2 Phone: • ) a3 _ ( C Fax: :(u))D.- 01,...-1 o--as,
Sign or outline lighting 53.40 2
E-mail:
Signal circuit(s)or limited-
,4ti1�' { \lI±[�Y t energy panel,alteration,or
Business name: extension.Describe: I Page 2 2•
Address: 1 .3- c, 5e • # t Q 1 Each additional inspection over allowable in any of the above
3T Per inspection 62.50
City/State/ZIP: '---Pery..t 0 E S--)�j Investigation per hour(I hr min) 62.50 _
Phone:(5Z) r (D 0 Fax:(G7p�) ,—lD�Q Industrial plant per hour 73.75
rr�v�J U t¢ys ):,rF' Ii ..)ttff, lvar •t1sa ;i
EMERIENII
Electrical Lie.:G.6q�3(fit Sup. .Lic.:cloy 0 �' Subtotal `? , .�•,,)
Suprv. Electrician signature,required: ' 1'"- / Plan review(25%of permit fee)•
Print name: ti Y, A 0 _ 11 Date: /0—I— State surcharge(8%of permit fee)
Sn / Ii i TOTAL PERMIT FEE F 6j
Authorized signature: &A IM
, ` ' ` a Tbia permit application expiry if a permit is not obtained within 180
days after It has been accepted as complete
IMMEMBEIPMIORIMMIN Date: OH _0 1 • Fee methodology set by Tri-County Building Industry Service Board
••Number of inspections per permit allowed.
is\Building\Perrnita\ELC-PennitApp.doc 12/03 440-46151I0/02ICOM/WEB •