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DEPARTMENT OF LAND USE 6 TRANSPORTATION
W'/�::,hII� � ! QN LAND DEVELOPMENT SERVICES DIVISION
155 NORTH FIRST,HILLSBORO,OR 97124
COUNTY) INSPECTION REQUESTS: 503/640-35611'693-4415
0R G111")N
NOTICE: This permit becomes null and void If the work or construction for which It Is Issued Is not commenced within 180 days. Once constructlon has started,
the permit becomes null and void if construction Is interrupted for a period of 180 days. I certify that the Information presented by the applicant and
his agent or agents In support of this permit is trite and correct to the best of our knowledge. I acknowledge that the Building Department's reliance
upon false and misleading Information may Invalidate this permit. All provisions of applicable laws and ordinances governing the construction and use
of this building or structure will be complied with whether or not specified on the plans or noted on the pians correction sheets. I acknowledge that
the granting of a permit does not grant outhorlti to occ,tss private property or to use easements. I further acknowledge that the use or occupancy of
the structure or building permitted depends upon my calling for Inspections at various limes during the process of construction and the building
Inspection staff verifying compliance with the variouu codes. Use or occupancy of the building or structure permitted prior to apps oval by the
Building Department Is solely at the risk of the applicant and such use or occupancy Is revocable until all Inspection requirements are satisfied and
approval Is given by the Building Off,,Ial. I further r.;knowledge that a lien may be placed on the title of the property upon which the permit is issued
specifying that the use or occupancy of the bulldlnp or structure Is provisional and revocable until the satisfaction of all Inspection requirements
AF�
WASHINGTON c:Qt1NTY ELECTRICAL PERMIT
Department of Land Use & Transportation
,4 Electrical Inspection Section p P�!CAT!C,)tV
155 North First avenue, #350-12
Hillsboro, Oregon 97124
Information: (503) 640-3470 Fax; (503) 693-4412 permit
PLEASE P)WAITNumber __-__�_ 'Z Date
P166"comple(e all sections, I through 5.. .4. Complete Fee Schedule below
1. Location of installation
Number of Inspections per permit allowed
—
Audress L%.) AM e S L-&t Service included: Items Cost(ea.) Sum
Buildingg A. Residential- per unit
City j q�. Suite No. 110. p°
1000 sq.n.or loss $110.00 4
Tenant NElme Each additional 500 sq.t, eC
(if commercial) _ or portion thereof —L $25.00 0�
tot at/ Limited Energy __ $25.00 1
Map No.___-� �_Tax Lot _ Each Manuf d Home or Modular
Dwelling Service or Feeder __ $68.00 2
Thomas Map Book: Page:.—_—._ Section:
Directions__—_ _ B. Services or Feeders
Installation,alterations or relocation
200 amps or less $60.00 2
Commercial ❑ Residontial L& 201 amps to 400 amps $80.00 _ 2
401 amps to 600 amps $120.00 — 2
2a. Contractor installation only: 601 amps to 1000 amps $140.00 -- 2
y' U��er 1000 amps or volts $340.00 2
Electrical Contractor
��IrtC Reconnect only $50.00 2
Address �
Date./ Job Number , _ C. Temporary Services or Feede►s
Property Owner m-J CA ft &Owej __ _ _ installation,alteration or relocation
Contractor's License No. a.y .;,YcL_ 1 200 amps or less $50.00 _ 2
Contra,tor's Board Re No. A)y 201 amps to 400 amps $75.00 2
Reg. "'L""�— 401 amps to 600 amps $100.00 2
Signature of Supr. Elec'n � _._��'t Over 600 amps to 1000 volts see'B'above
License No.-&2(o f Phone Wo. ` U C. Branch Circuits
New,alteration or extension per panel
2b. For owner installations: a) The fee for branch circuits with
purchase of service or feeder fee.
Print Owner's eme phone v Each branch circuit _� $5.00 Y _ _ 2
b) The fee for branch circuits without
A-dFre—ss — _ purchase of service or feeder fee.
First branch circuit $35.00
City _ tate Zip '— Each add'nl branch circuit $5.00 —__ 2
E. Miscellaneous (Service or Feeder not incloded)
The installation is being made on property I own Each pump or irrigation circle $40.00 2
which is not intended for sale, lease or rent. Each sign or outline lighting $40.00 2
Signal circuit(s)or a limited
Owner's Signature — ____ energy panel,alteration
or extension $40.00 2
F. Each additional inspection over the allowable
in any of the above
3. Plan Review section if required) Per inspection —_ $3500
Please check appropriate hem and enter fee in section 5B. Per hour _ $55.00
In Pian1 $55.00 .�
4 or more residential units in one structure I-- -
--Service and feeder, 800 amps or more 5. Fees
__-System over 600 volts nominal
A. Enter total of above fees $ ;�
_,Classified area or structure containing special 5 A', Surcharge (.05 X total fees) $ L
occupancy as described in N.E.C. Chapter 5 Subtotal $
B.Submit 2 sets of plans with appllcatlon where any of tht Enter 25% line A for
above apply. Not required for temporary construction Plan Re,riew if required (Section 3) $
services. Subtotal $
Less Bulk Lahel Fee $
Balance Due $ ._._,
For inspections call
This permit becomes null and vdd R the worts aulfrorlteJ by the permit is not canmerrced
640-3561 or 693-4415 within 1!o day-from data of Issuance of such permit or R the work aulhorits.l Is
suspended a abandoned al any time abler work Is commenced for a period d M days.
24-hour recorder, one working day in advance of need Eleelrlcal Permits are non-refundable and non-transferable.
4194