Permit (187) CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2016-00065
R, 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/28/2016
Parcel: 2S104AA90051
Jurisdiction: Tigard
Site address: 12666 SW KAREN ST 5
Project: BELLWOOD TERRACE LLC Subdivision: BELLWOOD TERRACE CONDO Lot: 5
Project Description: (2)branch circuits for washer&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 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 001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: ('\ Permittee Signature: L
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: . -IoA
LICENSE NO. -7 C) 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
Received
I:... City of Tigard Dated : 1 , Permit
1... 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
b . Phone: 503.718.2439 Fax: 503 598 1960 q Date/By: Related Permit1upplemental
Inspection Line: 503.639.4175 Ready DatelBy: Jug: See Page 2 for
,Internet: www.tigard or.gov `" NotiSed/MetLod: Information
TYPE OF WORK i± PLAN REVIEW
❑New construction ®Addition/alteration/replaeement ,a `,M'' Please check all that apply(submit 2 sets of plans w/items checked):
❑Service or feeder 400 amps or more ❑Building over three stories.
ElDemolitioII ❑Other: where the available fault current ElMarinas and boatyards.
CATEGORY OF CONSTRUCT exceeds 10,000 amps at 150 volts or ❑Floating buildings.
❑ 1-and 2-family dwelling ❑Commercial/industrial ccessory building tens to ground, 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
❑Addition of new motor load of system.
Job#: Job site address:12666 SW Karen St
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.#:5 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
Dmri ptioa Eacn
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
Washer and dryer circuit with above .ft.) 75.00 2
Limited energy,multi-family 75.00 2
residential with above sq.ft.
❑ PROPERTY"OWNER ❑ TENANT Renewable Energy ❑ See Page 2
Services or feeders installation, ration,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 1 552.26 1 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,alteratio or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee, 7.42 2
each branch circuit
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 1 7.42 7.42 2
Miscellaneous service or feeder not included
Phone:(503)481-0240 Fax: :( ) Each manufactured or modular
dwelling,service and/or feeder b7.84 2
Email: 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 j Fax:( ) Investigation(1 hr min) 90.00/hr
Email:Omiti—electric@hotmaH.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.: 42705 specificallylisted '/I hr min
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: 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 N a permit is not obtained within 180
Print name: John M.K Date: 1/28/18 days after it has been accepted as complete.
* Number of inspections allowed per permit
I:\13W&*PmakaU,C_PemM"_EI.R_ERE.doc Rev 06117/2015 440.4615T(I1/05/COM/WEB