Permit Support Document 0 1 fl723
Electrical Permit Applicati r()K Olf1( I. I .l_0.1.1
Cityof TigardDate,/13y: -/,,i,..5 / iez /,--l1CT 9t�/
A c Received
Cl v, i " y. Permit
111 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
ft Phone: 503.718.2439 Fax: 503.598.19601 U L 2 3 2018 Date/By: Related Permit#:
Inspection Line: 503.639.4175Ready Date/13y: Juris: ® See Page 2 for
T I l \is D
Internet: www.ti gand-or. ov /'�g C I`1 - : ( Supplemental Su lemental Information
t+7.` 1 2.TYPE O# 'NG DIVIS.,I Ni PLAN REVIEW
❑New construction 0 Addition/alteration/replacement Please check all that apply(submit a sets of plans w/items checked):
Demolition Other•
0 Service or feeder 400 amps or more 0 Building over three stories.
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
1•v1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less to ground or exceeds 14,000 ❑commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family 0 Master builder 0 Other: ❑Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION
[AND LOCATION
, ❑Emergency system. larger separately derived
/'T�5 /�Y%d/Cz1i i „, . ❑Add00HP o of�w motor load of system.
Job#: Job site address: ) ' loolaP or more. ❑"A">"E^,"1-2","I-3", I
City/State/ZIP: --75 �f+ R 4 ❑Six or more residential units. uancy.
�""y' j `� 0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name: 0 Hazardous locations. 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: '-Di FEE SCHEDULE
Description I Qty. I Each 1 Total I "
New residential single-or multi-family dwelling unit.
Subdivision: /�'r1 e e r�/l�d �� f g-S Lot#: f a Includes attached garage.
Tax map/parcel#: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential 75.00 2
(with above sq.ft.)
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Renewable Energy ❑ See Page 2
PROPERTY OWNER 0 TENANT
// ��, Services or feeders installation,alteration,and/or relocation
Name: n,q/ ) - L u .I1/e / t1 MilF_ 200 amps or less 100.70 2
Address: C) l 1.� c5/4) fr 74R.�,AA 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP: `7 67ARcd , e R 9 / 601 amps to 1,000 amps 301.04 2
Phone:(693) - j.6-_6 z3,„ 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 742 2
Contact name: B.Fee for branch circuits without
Address: service or feeder fee,fust
branch circuit 56.18 2
City/State/ZIP: Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax::( ) Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Email: Reconnect only / 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Bunisicsn 1iffi 18'
Signal circuits)or limited-energy ❑ Page 2 2
Address: panel,alteration,or extension. aS
Each additional inspection over allowable in any of the above
City/State/ZIP: Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: Electrical Lie.: Suprv.Lie.: specifically listed(%2 hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required:
Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
///� C��,�� State surcharge(12%of permit fee):
Authorized signature ; ,4„.
TOTAL PERMIT FEE:
f r�/ This permit application expires if a permit is not obtained within 180
Print name: iesi`.4 _`�/�` •Date: 7/j 4'/,/K •
days atter it has been accepted as complete.
��9' Number of inspections allowed per permit.
I:\Building\Perrnits\ELC_PermitApp ELR ERE.doc Rev 06/17/2015 440-4615T(11/05/COM/WEB