Permit CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2016-00063
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/28/2016
Parcel: 2S104AA90042
Jurisdiction: Tigard
Site address: 12666 SW KAREN ST 4
Project: BELLWOOD TERRACE LLC Subdivision: BELLWOOD TERRACE CONDO Lot: 4
Project Description: (2)branch circuits for washer and dryer.
Contractor: OMNI ELECTRIC INC Owner: BELLWOOD TERRACE LLC
16670 SW WRIGHT ST PO BOX 189
BEAVERTON,OR 97007 YAMHILL,OR 97148
PHONE: 503-747-0805 PHONE:
FAX: 503-649-2709
FEES
Quantity Description Date Amount
2 crt Branch Circuits wo/Purchase 01/28/2016 $63.60
Specifics: Service or Feeder
1 ea 12%State Surcharge- 01/28/2016 $7.63
Type of Use: MF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $71.23
Required Items and Reports(Conditions)
This permit is i bject to the regulations contained In the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done i accordance w 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. TENTION: Oregon w r uires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-0 -0010 thr ugh OAR 9 -001 00 . You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Iss ed By: Permittee Signature:
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. Tri S
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
I-XII:... City of Tigard A
R
eceived
1.,. 13125 SW Hall Blvd.,Tigard,OR PlanR ( Q—b(o Permit#:
Plan Review
b... Phone: 503.718.2439 Fax: 503.5 �\ - Da Related Permit#:
Inspection Line: 503.639.4175Ready DateBy: rruis: H See Page 2 for
Internet: www.tigardor.gov " ,t otiBedlMethod: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑New construction ®Addition/alteratlo v'`- Please check all that apply(submit 2 sets of plans w/items checked):
❑Demolition ❑Other: ❑Service or feeder 400 amps or more ElBuilding over three stories.
where the available fault current
❑Mannas and boatyards.
CATEGORY OF CONS ION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
❑ 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
®Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived
Job#: Job site address:12666 SW Karen St ❑Addition of new motor load of system.
100HP or more. ❑"A","E","1-2","1-3",
City/State/ZIP:Tigard,OR 97223 ❑Six or more residential units. occupancy.
❑Health-care facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#:4 Project name:Bellwood Terrace ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total I ":..
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'1500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
with above .ft.) 75.00 2
Washer and dryer circuit Limited energy,multi-family
residential with above .ft.) 75.00 2
El PROPERTY OWNER ❑ TENANT Renewable EnergyEl See e 2
Services or feeders installation,alteration,,and/or relocation
Name: 200 amps or less 100.70 2
Address: 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP: 601 amps to 1,000 amps 301.04 2
Phone:( ) Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation: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 exchange,according 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 2
❑ APPLICANT ®CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
each branch circuit 7.42 2
Contact name:Grant Yozamp B.Fee for branch circuits without
Address: service or feeder fee,first 1 56.18 56.18 2
branch circuit
City/State/ZIP: Each add'1 branch circuit 1 7.42 7.42 2
Miscellaneous service or feeder not included
Phone:(503)481-0240 Fax: :( ) Each manufactured or modular 67.84 2
Email:
dwelling,service and/or feeder
Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name:Omni Electric Inc Sign or outline lighting 67.84 2
Address:16670 SW Wright St Signal circuit(s)or limited-energy ❑ See page 2 2
g el,alteration or extension.
City/State/ZIP:Beaverton,OR Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:(503)747-0805 Fax:( ) Investigation(1 hr min) 90.001 hr
Email:Omni_electric@hotmail.com Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: 176615 Electrical Lic.: C297 Suprv.Lic.: 4270S specifically listedYz hr min
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: z14Subtotal: 63.60
Print name: John M.Kelso Date: 1/28/18 ❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee): 7.63
Authorized signature: TOTAL PERMIT FEE: 71.23
This permit application expires if a permit is not obtained within 180
Print name: John M.Kelso Date: 1/28/18 days after it has been accepted as complete.
Number of inspections allowed per permit.
I:\BwMnig\Penmts\ELC_Pem iLkM ELR_ERE.doc Rev 06/17/2015 440-4615T(11/05/COM/wEB