Permit CITY OF TIGARD ELECTRICAL PERMIT
I COMMUNITY DEVELOPMENT II
Permit#: ELC2021 00320
Date Issued: 6/16/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 2S112DC00500
Jurisdiction: Tigard
Site address: 15875 SW 72ND AVE
Project: Northwest Integrative Medicine Subdivision: FANNO CREEK ACRE TRACTS Lot: 40
Project Description: (19)branch circuits for TI.
Contractor: JOHANSEN ELECTRIC INC Owner: PACIFIC REALTY ASSOCIATES LP
16869 SW 65TH AVE, SUITE 311 ATTN: N PIVEN
LAKE OSWEGO, OR 97035 15350 SW SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE:
PHONE: 503-747-2503
FAX: 503-972-1861
FEES
Quantity Description Date Amount
19 crt Branch Circuits wo/Purchase 06/16/2021 $189.74
Specifics: Service or Feeder
1 ea Plan Review Electricial 06/16/2021 $47.44
Type of Use: COM 1 ea 12%State Surcharge- 06/16/2021 $22.77
Class of Work: ALT Electrical
5 Misc Administration Fee 06/16/2021 $5.00
Type of Const:
Occupancy Grp:
Total $264.95
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtai co y of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
.---- ;5„._____} .
Issued By: L/ Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale,lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
33- , 3 21
Electrical Permit Application r(lli OrF R I. t si.Oy►.v
City of Tigard eceived Aril, Permit#: _ —
a to/B : , i Arai ..�10
II 4 13125 SW Hall Blvd.,Tigard,OR 97223Fit E C E iV E Review
Phone: 503.718.2439 Fax: 503.598.196 Date B : A'� A �' Related Permit#:
Inspection Line: 503.639.4175 q Ready Dat 17: 0 See Page 2 for
l'I G:\R D Internet: www.tigard-or.gov JUN 3Go�� Notified/Method: ia rill Supplemental Information
TYPE OF WORK �, I,�,w,w$LAN REVIEW
❑New construction Addition/alteration/re91e
�`taps-TIGARD t Please check all th({�i.ppiy_(submit 2 sets of plans w/items checked):
❑Demolition El Other:
BUILDING DIVISION ❑Service or feeder 400 amps or more 0 Building over three stones.
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
O 1-and 2-family dwelling gr Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
O Multi-family 0 Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
15% 1 S '2 ,0 ` ❑100 Addition of new motor load of system.
Job#: Job site address: looHP or more. ❑"A","E","1-z","1-3",
Ci /State/ZIP: Six or more residential units. occupancy.
-T, may( ;Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: (//J _I Project name:1A0(.1-hxt lAktythfQ.lAtigeiflil- ❑Hazardous locations. 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total I *
New residential single-or multi-family dwelling unit.
Subdivision: I Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
T /n��, jj.., (with above sq.ft.) 75.00 2
hl.�Iv1� 1C1���J1► Spate.. Limited energy,multi-family
� j�� 11 1� residential(with above sq.ft.) 75.00 2
C(/L r .co ( ��!� � I� S I '"]��`�tl ���' Renewable Energy 0 See Page 2
0 PROPERTY OWNER ❑ ENANT Services or feeders installation,alteration,and/or relocation
Name: 200 amps or less 100.70 2
Address: 201 amps to 400 amps 133.56 - 2
401 amps to 600 amps 200.34 2
City/State/ZIP: 601 amps to 1,000 amps 301.04 2
Phone:( ) 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 0 CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: L -6 hax,se r\ ElG.C c I r c. above service or feeder fee, 7.42 2
t each branch circuit
Contact name: ClutAvItt _Q.€�n J�' B.Fee for branch circuits without
�Q r Q �J.h1 �✓Q -t[3(I service or feeder fee,first ' 56.18 S6.ig 2
Address: D b_1 yr branch circuit
City/State/ZIP: l.Q ()sweet.,, 6 R coo3�" Each add'l branch circuit I S 7.42 (35.r,,�2
Miscellaneous(service or feeder not included)
Phone:(r7, ) 1/47-2,D 3 Fax: :( ) 91 Z-/ ' o i Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Email: CA'c-:CA- a {D 1�n Q--I e.G-�'c- , COM Reconnect only 67.84 2
.....11 CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy 0 See Page 2 2
Address: panel,alteration,or extension.
City/State/ZIP: Each additional inspection over allowable in any of the above
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.: 5639 Electrical Lic.:3.21.6C, Suprv.Lic.:531 g S specifically listed('/hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: /$9.7e-/
Print name:ioN� YYY'��� ���✓✓���""`J"\b cn Date: 0 Plan Review Required(25%of permit fee): ill'.tit/
State surcharge(12%of permit fee): ZZ,71
Authorized signature: 0 TOTAL PERMIT FEE: * 9,9s"
This permit application expires if a permit is not obtained within 180
Print name h �^ OJEsQ� Date: i IN days after it has been accepted as complete.
111 * Number of inspections allowed per permit.
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Branden Taggart
From: Branden Taggart
Sent: Tuesday,June 15, 2021 5:50 PM
To: Charlynn
Subject: Northwest Integrative Medicine Permit: ELC2021-00320 - 15875 SW 72nd Ave.
Attachments: Invoice.pdf
Hi Charlynn,
The Electrical permit for Northwest Integrative Medicine is ready to issue now. The balance due is$259.95, and I have
attached an invoice above for you to reference. These fees can be paid online now at https://aca-
prod.accela.com/TIGARD/Welcome.aspx by searching for the permit record number ELC2021-00320 under the Building
tab. There is a 3%service fee for credit cards, but e-checks do not have a service fee.
Once paid, please email the Permit Technicians at TigardBuildingPermits@tigard-or.gov so that we may issue this
permit and make it available for pick up.
Thank you,
Branden Taggart
City of Tigard
Ear
_t% Senior Permit Technician
Community Development
tikaM
13125 SW Hall Blvd
Tigard, OR 97223
(503)718-2449
brandentctigard-or.gov
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