12600 SW 128TH AVENUE 40
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Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd x,1
'Tigard, OP, 97223 Plan�. `1ec;. #
Permit # -�
Phone (503) 639-4171 Date Issued l
FAX (503) 684-7297 Issued by
CITY OF TIGARD TDD No. (503) 684-2772
Inspection (503) 639-4175
1. Job Address: 4. Corrp:-1e Fee Schedule Below:
Number of Ince:-:':=ns per permit allowed —
Name of Development Items cost(ea) Burn
,. l( l Q ...> \--1 k�, Senrice included
Add,ess_ �l • 4
4u. Residential-PW unit $11000
City/State/Zip_ c - woo eq n or leas
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C I Each addAtot al 500 eq It or _ t$2500
Name (or name of business
portion thereof E;5 no
�.i Limited Energy 2
rlesident'al Each Manurd Home or Modular $68 00
Commernial 11
0\.
Dwelling Service or"seder
2a. Contractor installation only: 4b.services Feouers 2
Installation,aherr bon,or re ovation Vic 00 2
200 amps or 1666 $80 00 2
Electrical Contractor 201 amp@ 400 amps __— $120 0o 2
Address `ls �~ 401 amps 10 800 auras $t o0 oo 2
.� -, 2
Stat@,�� L� ��.'`"'�_ � 801 amps to 1000 empe $340 00
Clty� C C..1 - over 1000 amps or volts $',000
Phone N Reconnect only ---
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Contractor's License No. —
_ 4c.Temporary Services or Feeders 2 Contractor's Board Reg No.. Installation,afternoon,or relocate 2
$5000 ?
200 amp@ or less $7500
Signature of Supr. EIeC'n hon .{� 201 amps to 400 aml $100 no
e NC '�b�r1-- 401 amps 1oeo0am a
License No. x>7 over 800 amps to 1( x)vollr•
see"b•nhove
2b. For owr►er installations: 4d. Branch circuits
New.alteration or extension pe,Penal
Print Owners Name___ a)The fee for branch circuda with 2
Address purchase of service or feeder Ne. $r,00
State Zip________ Each brarch circuit
City__- b)The lee for branch circuds without 2
Phone No. purchase of aervka or Nader Ne. , 2
First branch circuit 1—. X05 00
The installation i., being made r property I own which is Each additional branch arrxtd $5 00
not intended for salc, lease or rent.
4e. Miscellaneous 2
Owner's Sinnature —" (Service or feeder not included) 2
F ach pumo or irrigation circle $40 00
SAO 00
3. Plan iteview section (if required): Ep;,h sign or outfit*lighting 2
Signal circuit(s)ora limited energy
nal,aMsrelwn or extension $40 00
pl>sae check appropriate item end enter toe in section 58. Minor Lahe16 fig) $toO o0
4 or mnre reswential units in one structure
Service one feeder 225 amps or more 4f. Each additional inspection cove:
CL System over 600 volts nominal the allowable of the above
ble in any
Per i wpM mv, $5500
55 00
� Classified area or structure containing special occupancy _— 655 00 _
vt as described in WE C Chapter 5 I ''ef t1O1f $5500 _
Submit 2 sets of plans with application where or of the above
-i I Not required for temporary construction services. 5. Fees:
sPp Y P Y $ 3�J
� 5a. Enter total of above fees ] l�
NOTICE 5%Surcharge(.05 X tote!fees) $
w
Subtotal
J PERMITS BECOME VOID IF WORK OR CONSTRUCTION 5b.Enter 25%of line A for
AUTHORI2l=D IS NOT COMMENCED WITHIN 1Plan Review if required(Sec.3) $9U DAYS,OR IF Subtotal $
CONS'rRUCTION OR A PERIOD OF 180 DAYVS AT ANYTIMEADABANDONED AFTER WORK FOR
IS
❑ Trust Account! $
COMMENCED.
Balance Due
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CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspection:_
Footing Susp, Ceiling Sprink. Rough-in APP
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Foundation
Plb Underslab Mech. Rough-in Fireplace
Rough-in FINAL:
Post/Beam Struct. Plbg. Top Out Elec.
Post/Beam Mech. San. Sewer
Gas Line -Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm
Water Line Insulation -Mech.
Underflt Insul. Shear Wall G, Gyp. Bd.
- lect.
cl l —Time: AM PM
Data Requested:
Address: c�-� �� /
Builder:
Permit p: Ez—05,s - r 43
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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" ' I � � Date• ^�__�
Inspectors
APPROVED SUBJECT TO ABOVE
PPROVED —DISAPPR'JVED _
- Call For Reinsp.
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CITY OF T I GARD - RECEIPT OF P'AYME'NT RECE=IPT NO. :95-268022
CHECK AMOUNT n :36. '75
NAME'j e PHO17N I X ELECTRIC CASH AMOUNT 0. 00
A1)DRS : P O BOX 14:;i=' PAYMENT DATE=' 07/13/95
TUALATIN, OR WE)IVISIOh;
PURPO E ''AY'MEN'T AMOUNT PAID PURPOSE OF PAYMENT AMOUNT PAID
5. 00 ST. BUILD .PER 1. 7 5.
i
12600 ,W 128TH
T(:)'PAE. AMOUNT PAID — - } 36. 75 I
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