Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
i II �. COMMUNITY DEVELOPMENT Permit#: ELR2020-00071
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/23/2020
Parcel: 2S101AB03100
Jurisdiction: Tigard
Site address: 12115 SW 70TH AVE 202
Project: Med RX Subdivision: 2012-009 PARTITION PLAT Lot: 3
Project Description: Limited energy for HVAC.
Contractor: WILLAMETTE HVAC LLC Owner: TIGARD TRIANGLE PARTNERS LLC
3075 SW 234TH AVE.#206 BY DEERING MANAGEMENT GROUP
HILLSBORO, OR 97123 4800 SW MACADAM AVE STE 120
PORTLAND, OR 97239
PHONE: 503-259-3200 PHONE:
FAX: 503-848-2597
FEES
Description Date Amount
Specifics: Restricted Energy Permit 05/29/2020 $75.00
12%State Surcharge-Electrical 05/29/2020 $9.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 0
Audio&Stereo: 0 Boiler Controls: 0
CCTV: 0 Clock Systems: 0
Data&Telecommunications: 0 Fire Alarm: 0
HVAC: 1 Instrumentation: 0
Intercom/Paging: 0 Landscape/Irrigation: 0
Landscape Lighting: 0 Medical: 0
Nurse Calls: 0 Protective Signal: 0
Security Alarm: 0 Other: 0 Total $84.00
Other Desc: 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 i follow the rules dopted by the Oregon Utility Notification 'Center. Those rules are set forth in OAR
952-001-0010 through OAR 01-00 . You may btain a co oft ules or direct questions to OUNC by calling 503.232.1 87 or 1.800.332.2344.
•
Issued By: Permittee Signature:
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 503.539A175 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 12 20Z� FOR OFFII E I. SE ONLI'
City of Tigard MAY Received 4I,1ffj'�
a I3125 SW Hall Blvd.,Tigard,OR 47�?�3 r1{�7 { �n `� ��� �� `�
i i �- ;1ry"s� Plan Review Z�
Ph ne; 503.718.2439 Fax: 5�3'A .T9)ifB!ro,k� iiCJkn 1, Datr/B : .LJ /_✓•, N.
T I G A I:I) Inspection Line: 503.639.41741 t' 4 ^ t 1 1 Date Ready/By: Jude. il See Page 2 or
Internet: www.tigardor.gov }lJ I Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
construction Please check all that apply(submit 2 sets of plans wtitems checked below):
❑New ®Addition/alteration/replacement
❑Service or feeder 400 amps or more 0 Building over three stories
❑Demolition 0 Other:
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
less to ground,or exceeds 14,000 0 Commercial-use agricultural
❑ I-and 2-family dwelling ®Commercial/industrial ❑Accessory building
amps for all other installations. buildings.
❑Multi-family 0 Master builder ❑Other: El Fire pump. 0 Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system.
0 Addition of new motor load of ❑"A","E","I-2","l-3",
Job no.: Job site address: 12115 SW 70'h Ave IOOHP or more. occupancy.
['Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIP:Tigard OR 0 Health-care facilities. 0 Supply voltage for mere than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apL no.:202 Project name:Med FIX ❑Service or feeder 600amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I nee. 1 Total 1
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq.ft.or less 168.54 4
Tax map/parcel no.: Fa.add'I 500 sq.ft.or portion 33.92 I
Limited energy,residential 75.00 2
DESCRIPTION OF WORK (with above sq.It)
Thermostat Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Services or feeders installation,alteration,and/or relocation
200 amps or less 100.70 2
0 PROPERTY OWNER ❑ 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
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that 1 own which is not
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 166.54 2
Branch circuits-pew,alteration,or extension,per panel
Owner signature: Date: A.Fee for branch circuits with
El APPLICANT ❑ CONTACT PERSON above service or feeder fee, 742 2
each branch circuit
Business name:same as below B.Fee for branch circuits wiihoar
service or feeder fee,first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous(service or feeder not included)
City/Stale/ZIP: Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Phone:( ) Fax::( ) Reconnect only 67.84 2 •
Pump or irrigation circle 67.84 2
E-mail: Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s)or limited-energy 1
Business name:Willamette H V AC 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(I hr min) 66.25/hr
' Investigation(1 hr min) 66.25i hr_
City/State/ZfP: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('4 hr min)
CCB Lie.: 56951 Electrical Lie.: 34346C E Suprv.Lie.: 4025LEB ELECTRICAL PERMIT FEES
t/ � . Subtotal:
,(si Suprv.Electrician signature,required: / C ��
Plan review(25%of permit fee):
Print name: mike sicard Date: 5/6/20 State surcharge(12%of permit fee):
-yam', q ') TOTAL PERMIT FEE:
Authorized signature: ( j fYl 1YYt1 This permit application expires If a permit is not obtained within 180
Printdays after it has been accepted as complete.
name: Michael Malstrom Date: 5/6/20
• Number of inspections allowed per permit.
1:`audding`Pennits‘ELC-PemitApp.dos 07/01/10 4404615T(11/05/COACH'®