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--''� Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 PlanckMec. #
Permit #
A`�" Phone (503) 639-4171 Date Issued
CITY OF TIGARD 11 FAX (503) 684-7297 Issued by
TDD No (503) 684-2772
Inspection (503) 639-4175
1. Job Address: 4. Complete Fee Schedule Below:
Name of Development ,4 4 _ Number of inspections per permit allowed
Address�� LL;,_ �t/�)��� �„.I Serviro included Iterns Cost(oa) Sum
City/State)Zip % /4!!�:�3!, K r� cl 4a• Residential-per unit 4
71'D //j�,�, loon 644 11 OF lana
Name (or name of business)2 i- / !`�'/1,f(L`_� f ach addrbonal 500 arf It or
portion thereof _ S25 00
COmtrefClal❑ Residential Limited Energy 52500
Each Manurd Home or Modular
Dwelling Service or Feeder _r She 00
2a. Contractor installation only:
4b.Services or Feeders
Installation,alteration,or relocation
Flectrical Contractor y i- A ` l l ! C zoo amps or lees $60 00 2
Address cY(let) ✓. Sf Rn/�rArt 4r r, _ 201amps;o400amps S8000 _ — 2
�� ,n -T� 401 amps to 6.00 amps $12000 2
City 7/6 L/.' r'� / State C✓/ �� 801 amps to 1000 amps $18000 _ 2
Phone No. L , i'i 4e 1,L, IOver 1000 amps or volts $34000
Contractor's Cicense N0. r-S' ��' _ Reconnect only 55000
Contractors Board Reg. No. 'i C 4c. Temporary Services or Feeders
Irslallahon alln,pron.or relocation `
Signature of Supr. Eisen --tt' 200 amps o:'we $5000
Phone No.j��- (�% 201 amps to 400 amps �� $7500 —
License No. , 401 amNa to 600 amps $100 00
(Iver WO romps to 1000 volts
2b. For owner installations: sea•b•above
4d. Branch Circuits
Print Owner's Name �`- Now alteration or extension per panni
Address s)The fee for branch cocuds wt4h
City Y_ State_ Zip_ purchase of service or tlreder Mw 2
Earn branch rucud S5 00 I
Phone No. b)The lea for branch circuits without--- I
The inslallL';on is being made on property I own which Is purchase of service or feeder lire, �L)
First branch rucurt 535 00
riot intended for sale, lease Or rent. 5 v 2
Each addAwrti�l branch arcu�t - 55 00
Owner's Signature 49. Miscellaneous
(Service or feeder not included) 2
.3. Plan Review section (if required): Each pump or irrigation circle $4000 2
[w:h sign or outline lighting $4000
Signal orrud(s)or a limited energy 1
Please check appropriate item and enter tee in section 5B. panel alteration or extension $4000
4 or more residential units In one structure Mmor 1 atwls(10) $10000
Service and feeder 225 amps or more
4}. Each additional inspection over
System civet 600 volts nominal
_ Classified area or structure cnntalning special occupancy the allowable in any of the above
as described in N E C Chapter 5 Per usfx fin,
Per hour
In Plant -"-' Sr,_,,art
Submit 2 sets of plane with application where any of the above
apply. Not required for temporary construction services. S. Fees: {'
5e. Enter total of above fees
NOTICE 5%Surcharge(05 X total fees) $
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal5b. Enter 25%of line A far
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF plan Review if required(ciPC 3) $
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Subtotal $
A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS ---- —
COMMENCED. ❑ lrust Account R $
_ Balance Due $
X �