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Permit • City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN\/ 0 1 D 11 2r Request for Permit Action 9/4/u a TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www ti .gov TO: CITY OF TIGARD ?ek.)-° �p11 Building Division {+ 13125 SW Hall Blvd.,Tigard,OR 97223 eki 0 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildci rri3.gard-or.gov FROM: ❑ Owner E Applicant ❑ Contractor ity Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ANGEL/VOID PERMIT APPLICATION. n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). n INVOICE FOR FEES DUE (attach caset fee schedule and provide explanation below). Permit #: �t� GW, COfA fL Site Address or Parcel#: S Aei 51L._ bW/` Project Name: ,}� ©fif�Q`/•� ("ON'1srGtlij/74 dktclni- iffrl/UGj Subdivision Name: Lot#: EXPLANATION: Apofv8-r.2-G. ce*cf 11-7 flh'/!t-i6 Jc GC irk oli'd not-t-- r /,L� �G,uf � � 1 - g.s_ . he_ first-1!r'w} / ]'7ie f" i✓�cS 'Vra-lyd / S 1� 2O 2-# - L2D,.9© .4049 Signature: �/� Date: 4///oZ/ Print Name: ITC Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONLY Route to Sys Admin: Date ze// ,j By " Route to Records: Date / 0,ie By ./ 7 Refund Processed: Date 4//41 By WY Invoice Processed: Date By Permit Canceled: Date 7/ /#'/ By t/ Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_1 051 .doc pp Electrical Permit ApplicatioIRECEIVE D FOR OFFICE USE ONLY City of Tigard MAY 2 4 2021 Date/By:Received �/,,Z .i!j' 00;3I 7 V 11111 • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan R vie �r _ C Phone: 503.718.2439 Fax: 503.598.196Date/B l , J Inspection Line: 503.639.4175 "' OF TIGARD ReadyB ' Cmr ,r /'or TIGARI� p Y� ® SeePage2for Internet: www.tigard-or.gov BUILDING DIVtStOr, Notifie ethol (2 �/) of' Supplemental Information TYPE OF WORK /� PLAN REVIEW ❑New construction Di Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked): 0 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. El1-and 2-family dwelling ElCommercial/industrial ❑ Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural amps for all other installations. buildings. ❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived AddJob#: 30221 Job site address: 11565 SW Pacific Hwy ❑100H ion of new motor load of system. 00HP or more. ❑"A" "E" "l-2" "1-3" City/State/ZIP: Tigard,OR 97223 0 Six or more residential units. occupancy. ❑Health-care facilities. 0 Recreational vehicle parks. Suite/bldg./apt.#: Project name: On Point Credit Union Tigard ❑Hazardous locations. 0 Supply voltage for more than ❑Service or feeder 600 amps or more. 600 volts nominal. Cross street/directions to job site: Pacific Hwy W&SW Spruce St FEE SCHEDULIE Description I Qo. I Each I Total I " New residential single-or multi-family dwelling unit. Subdivision: CPO 4M METZGER Lot#: Includes attached garage. Tax map'parcel#: R284944 1 S 136DB00201 1,000 sq.ft.or less 168.54 4 Ea.add'1500 sq.ft.or portion 33.92 1 DESCRIPTION OF WORK Limited energy,residential (with above s ft. 75.00 2 Install(1)Sign Circuit for(1)illuminated wall sign q • Limited energy,multi-family 75.00 2 residential(with above sq.ft.) Renewable Energy 0 See Page 2 0 PROPERTY OWNER 0 TENANT Services or feeders installation,alteration,and/or relocation Name: *Please see attached Land Lord Approval Letter 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 ® CONTACT PERSON Branch circuits—new,alteration,or extension,per panel A.Fee for branch circuits with Business name: Ramsay Signs above service or feeder fee, 7.42 2 each branch circuit Contact name: Chris Slovick B.Fee for branch circuits without • Address: 9160 SE 74th Ave brasernchce it feederitfee,first 56 18 2 branch circuit City/State/ZIP: Portland,OR 97206 Each add'l branch circuit 7.42 2 Miscellaneous(service or feeder not included) Phone:( ) 503-777-4555 Fax: :( ) 503-961-7784 Each manufactured or modular Email: permits@ramsaysigns.com dwelling,service and/or feeder 67.84 2 Reconnect only 67.84 2 CONTRACTOR Pump or irrigation circle 67.84 2 Business name: Ramsay Signs Sign or outline lighting 1 67.84 1 2 Address: 9160 SE 74th Ave Signal circuit(s)or limited-energy 0 See Page 2 2 panel,alteration,or extension. City/State/ZIP: Portland,OR 97206 Each additional inspection over allowable in any of the above Additional inspection(I hr min) 66.25/hr Phone:( ) 503-777-4555 Fax:( ) 503-961-7784 Investigation(1 hr min) 90.00/hr Email: permits@ramsaysigns.com Industrial plant(1 hr min) 78.18/hr _. _ _,,, , Inspections for which no fee is 90 00/hr CCB Lic.: 63422 Electrical Lic.: 26-106CLS Suprv.Lic.: 493SIG specifically listed(%hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: Phd c to Subtotal: Print name: Phill Steiger Date: 5.18.21 0 Plan Review Required(25%of permit fee): �� /nJ� ,� // State surcharge(12%of permit fee): ��� Authorized signature:C... ;t ��OGALt 2# TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 Print name: Chris Slovick Date: 5.18.21 days after it has been accepted as complete. * Number of inspections allowed per permit. I:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(11/05/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Description * Fee for all residential systems combined: $75.00even I Total I y RenewableI QrS.electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 5.01 to 15 kva 133.56 2 2 ❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2 Wind generation systems in excess of 25 kva: n B• urglar Alarm 25.01 to 50 kva 301.04 2 50.01 to 100 kva 552.26 2 Garage Door Opener* g p >100 kva(fee in accordance 552.26 2 with OAR 918-309-0040) ❑ Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva: System* Each additional kva over 25 7.42 3 n V• acuum Systems* >100 kva-no additional charge 0.0 3 Each additional inspection over allowable in any of the above: n Other: Each additional inspection is 66.25/hr 1 charged at an hourly(1 hr min) Inspections for which no fee is 90.00/hr specifically listed(/hr min) COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES Fee for each commercial system: S75.00 Subtotal(Enter on Page 1): y * Number of inspections allowed per permit. (SEE OAR 918-309-0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls n Clock Systems ❑ Data Telecommunication Installation n F• ire Alarm Installation n HVAC ❑ Instrumentation ❑ Intercom and Paging Systems n Landscape Irrigation Control* n M• edical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* ❑ Protective Signaling Lf Other: (1) Sign Circuit Total number of commercial systems: 1 *No licenses are required. Licenses are required for all other installations \Building\Retinas\ELC_PermitApp_E'LR_ERE.doc Rev 06/17/2015 ?I,