Permit (118) a CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2016-00017
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/12/2016
Pal 2S103BB08400
Jurisdiction: Tigard
Site address: 12415 SW 122ND AVE
Project: Smith Subdivision: LAKE TERRACE Lot: 11
Project Description: Alter existing circuit for switch for new gas fireplace.
Contractor: OWNER Owner: SMITH,TIMOTHY&MOLLY
TIM &MOLLY SMITH 12415 SW 122ND AVE
1215 SW 122ND AVE TIGARD, OR 97223
TIGARD, OR 97223
PHONE: 503-521-1428 PHONE:
FAX
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 01/12/2016 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 01/12/2016 $674
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
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 actor 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
tlays.f
ON: Orego law uires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-0rough OAR 952- -00 0. ''ou may obtain//a copy of the rules or direct questions to CUING by calling 503 232.1987 or 1.,800.332.2344
Is L Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is�not
tiintended for sale,lease or rent.
OWNER'S SIGNATURE X t/l�/ �l�I"""�I �--� 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 ApplicationBe`�
City of Tigard LEI V ET DatrBea if;L
Permit u:6(Cao/(P-Gi�OI7
• 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 D'ete/B : Related Peoria H:
Inspection Line: 503.639.4175 I h" Ready Date By, loris ® See Page 2 for
Internet: www.tigard-or.gov Notified Method: Supplemental Information
TYPE��;Ulk PLAN REVIEW
❑New construction ❑Additi pp/�gp� i Please check all that apply(submit 2 sets of plans writems checked)
{f�tuJ jl l,�Ij ij l rJ� ❑Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10.000 amps at 150 volts or ❑Floating buildings.
❑ I-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14.000 ❑commercial-use agricultuml
amps for all other Installations. buildings.
❑ Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑mstallauon of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system, larger separately derived
-" - ❑Add it ion of new motor load o f system.
Job#: Job site address: 12 AkC 100 11 P or more, ❑-A "G`.'1-Z'."13',
❑Si x or more rcsidenl is l units_ occupancy.
City/State/ZIP: 'rl � ./J ef-I.2--13 ❑Health-care facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#: Project name: ❑Haiardous locations. ❑Supply vohage for more than
❑Service or Decrier 600 amps or Dore. 600 votes nominal.
Cross street/directions tojob site: FEE SCHEDULE
Degan tion I oil. I Each I Toul
New residential single-or multi-famih dwelling unit
Subdivision: Lot#: Includes attached garage.
1,000 sq,N.or less 168.54 4
Tax map/parcel#: Ea.add d1 500 sq.Ilor portion 3192 1
DE$4m"lON:OF W RK Limited energy,residential
(with above sq.Il.) 75 00 2
l•-ce ' Limited enema,multi-family 75,00
residential withabove. .Il.) -
Renewable Ener v ❑ See Pa e 2
PROPERTY OWNER ❑ TENANT Services or feeders installation,alteration,and/or relocation
Name: t yL sl"17-Y amps or less 100.70
Address: 1-2Y 15— n 201 amps to 400 amps 133.56 -
�W Z 401 amps to 600 amps 200,34
City/State/ZIP: -r/ j-WA 601 amps to 1,000 amps 30104
Phone:(-D3) Fax: ( ) Over 1,000 amps or volts 55226 2
Temporno services or feeders installation,alteration,and/or
Email: I t s / t a relocation
Owner instal tion:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale, lease,rent,or exch ge, ording to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 -
❑ APPLICANT ❑.CONTACT PERS N Branch circuits—new alteration or extension per panel
A.Fee I'or branch circuits with
Business name: eabove achsecc or feeder fee,
A^
branch circuit -
Contact name: B.Fee for branch circuits,olmot
service or feeder fee,firs) 56.18 6G'l4
Address:
branch circuit
City/State/ZIP: Each add-I branch circuit 7A2 -
Miscellaneous service or feeder not included
Phone:( ) Fax: :( ) Each manufactured or modular 67.84
doellin service and/or feeler
Email: Reconnect only 67.81
CONTRACTOR Pump or irrigation circle 67,84
Business name: Sign or outline lighting 67,84
Signal circuigs)or hmiucEcncrgy See Page 2 ^
Address: anel,alteration,or extension. -
Each additional inspection over allowable in any of the above
City/State/ZIP: Additional inspection(I hr mint 66-25/hr
Phone:( ) Fax:( ) Investigation(I hr min) 90.00/hr
Email: Industrial plant(I hr min) 78.18/hr
Inspections for which no fee is Who/hr
CCB Lic.: Electrical Lic.: Suprv.Lic.: s clficall listed s:hr min
ELECTRICAL PERMIT FEES
Suprv. Electrician signature,required: Subtotal: 3z.112
Prim[name: Dale: ❑Plan Review Required(25%of pconiI fee):
State surcharge(12%of permit fee):
Authorized signature:
TOTAL PERMIT FEE: ,9A
This permit application expires if a permit is not obtained within 180
Print name: D•a[e: days after it has been accepted as complete.
Number of inspections allowed per penult.
I:Build'mg 1'orII IS PermitAp, II RERE dnc Ree 061-'_a15 440.4615711105 COV w'EB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
h f Fxn
75k,a
tion n'. Face T iol
Fee for all residential systems combined: $75.00 wable electrical energy systems:
Check Type of Work Involved: or less lW70 2
15 kra 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301,04 ^_
50.01 to 100 kva 552.26 2
❑ Garage Door Opener* >I00 kva(fee in accordance
52.26
with OAR 918-309-0040)
❑ Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System*
Each additional kva over 25 7,;'+ ;
❑ Vacuum Systems* 1100 kca—no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
F-1 Other: Each additional inspection is
charged at an hour) (I hr min) 66_^5/hr I
Inspections for which no tee is 90.00,hr
scilically lisled('A hr min)
COMMERCIAL WORK ONLY: cAt eFnttur t EEs
Subtotal(Enter on Page I):
Fee for each commercial system: $75.00
(SEE OAR 918-309-0000) slumber of inspections allowed per permit.
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I Oulldnte Permlu PIAPennitA, FIR 1 RI Joc Rev 061-2_(115
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
12415 SW 122ND AVE, TIGARD, OR, 97223
Residential - Electrical
199 Electrical final
PASS - No C of O
ELC2016-00017
Jeff Grove
Violation Summary:
Inspector Contractor