Permit CITY OF TIGARD ELECTRICAL PERMIT
NI COMMUNITY DEVELOPMENT Permit#: ELC2019-00806
Date Issued: 11/20/2019
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 2S101AD02700
Jurisdiction: Tigard
Site address: 12625 SW 69TH AVE
Project: Dr. Hayden Subdivision: WEST PORTLAND HEIGHTS Lot: 1-8, PLL
Project Description: (1)branch circuit to reconnect split system.
Contractor: WILLAMETTE HVAC LLC Owner: MCCROSKEY, JOHN B
3075 SW 234TH AVE.#206 1380 MORNING SKY CT
HILLSBORO, OR 97123 LAKE OSWEGO, OR 97034
PHONE: 503-259-3200 PHONE:
FAX: 503-848-2597
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 11/13/2019 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 11/13/2019 $6.74
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 OAR 952-001-0090. You may obtaiio_a.copy of the rules or direct questions to OUNC by calling 503.232.1987 0 1.800.332.2344. .
Issued By: __ Permittee Signature: /1
E
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:
LICENSE NO.
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 1 , FOR OFFICE USE ONLY
City of Tigard 97223 OR, Received
Ill 13125 SW Hall Blvd.,Tigard, N o v 9 e'l 9 Date/B : ` Srt �:.. �i�� /7
g Plan Review Other Permit:
III " Phone: 503.718.2439 Fax: 503.598.1960 Date/B
T I G A R O Inspection Line: 503.639.4175 Date Ready/By: Juris: WISee Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
Please check all that apply(submit 2 sets of plans w/items checked below):
El New construction E Addition/alteration/replacement
❑Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
less to ground,or exceeds 14,000 ❑Commercial-use agricultural
0 1-and 2-family dwelling ®Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system.
❑Addition of new motor load of ❑"A","E","1-2","1-3",
Job no.: Job site address: 12625 SW 69th Ave 100HP or more. occupancy.
❑Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIP:Tigard OR 97223 ❑Health-care facilities. 0 Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name:Dr.Hayden ❑Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I *
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
Tax map/parcel no.: Limited energy,residential
DESCRIPTION OF WORK (with above sq.ft.) 75.00 2
Limited energy,multi-family 75.00 2
reconnect split system residential(with above sq.ft.)
Services or feeders installation,alteration,and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER 0 TENANT 201 amps to 400 amps 133.56 _ 2
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
relocation
Phone:( ) Fax:( ) 200 amps or less 59.36 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168.54 2
Branch circuits—new,alteration,or extension,per panel
Owner signature: Date: A.Fee for branch circuits with
El APPLICANT ❑ CONTACT PERSON above service or feeder fee, 7.42 2
each branch circuit
Business name:same as below B.Fee for branch circuits without
service or feeder fee,first 1 56.18 2
Contact name: branch circuit _
Each add'I branch circuit 7.42 2
Address: Miscellaneous(service or feeder not included)
Each manufactured or modular
City/State/ZIP: dwelling,service and/or feeder 67.84 2
Phone:( ) Fax: :( ) Reconnect only 67.84 _ 2
Pump or irrigation circle 67.84 2
E-mail:
, Sign or outline lighting 67.84 2
`t �--. . 4�, ; IV . ...y.W ... �' i=s..,w, u.._, Signal circuit(s)or limited-energy
Business name:Willamette HVAC LLC panel,alteration,or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address:3075 SE Century Blvd Suite 206 Additional inspection(1 hr min) 66.25/hr
Investigation(1 hr min) 66.25/hr
City/State/ZIP:Hillsboro,OR 97123 Industrial plant(1 hr min) 78.18/hr
Phone:(503)259.3200 Fax:(503)848.2597 Inspections for which no fee is 90.00/hr
specifically listed('A hr min)
CCB Lic.: 56951 Electrical Lic.: 34346CRE Suprv.Lic.: 4025LEB ELECTRICAL PERMIT FEES
/� ./ Subtotal:
Suprv.Electrician signature,required: Plan review(25%of permit fee):
Print name: mike sicard Date: /V/ io/y State surcharge(12%of permit fee):
/ TOTAL PERMIT FEE:
Authorized Signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Michael Malstrom Date 1I l J�
Y Number of inspections allowed per permit.
I:\Building\Permits\ELC-PermitApp.doc 07/01/10 440-4615T(11/05/COM/WEB
Electrical Permit Application - City of Tigard n Other
Page 2 - Supplemental Information Total number of commercial systems:
LIMITED ENERGY PERMIT FEES• '`No licenses are required. Licenses are require
for all other installations
RESIDENTIAL WORK ONLY:
Fee for all residential systems $75.00
combined
Check Type of Work Involved:
Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
n Heating,Ventilation and Air Conditioning
System•'
n Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918-309-0000)
Check Type of Work Involved:
n Audio and Stereo Systems
❑ Boiler Controls
n Clock Systems
n Data Telecommunication Installation
❑ Fire Alarm Installation
n HVAC
❑ Instrumentation
Intercom and Paging Systems
n Landscape Irrigation Control*
Medical
n Nurse Calls
n Outdoor Landscape Lighting*
n Protective Signaling
I:\Building\Permits\ELC-PermitApp.doc 07/01/10