Permit (221) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED
AUG 2020
Request for Permit Action
T I G A R 11 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigand-or CITY QF2 TIGARD
l�hJXLING DIVISION�
TO: CITY OF TIGARD V !
Building Division /
13125 SW Hall Blvd.,Tigard,OR 97223 �/ �C)
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ® Applicant ❑ Contractor ❑ City Staff
Check(/)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Point Monitor Corp.
Mailing Address: 5863 Lakeview Blvd#100
City/State/Zip: Lake Oswego, OR 97035
Phone No.: 503-627-0100
PLEAS ACTION FOR THE ITEM(S) CHECKED (1):
(� CANC~ /VOID PERMIT APPLICATION.
LX REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ELR2020-00102
Site Address or Parcel #: //9 S'p f 2 6,972_�- -is./ AL.-- . -/?-6
Project Name: SrT dl= D/�€�/� �j`/PGdyf;cii-- 17
Subdivision Name: Lot #:
EXPLANATION: _S'€? EC-A ZO Zp — DQ/per .4-e% £-9-7
Signature: Date: eF/ ��
Print Name: �/'�Y /�t7✓ 7 97t 7
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date By"0:7(
Refund Processed: Date /t//1A" By'SO 7 Invoice Processed: Date By
Permit Canceled: Date eP pl/yc,) By d Parcel Tag Added: Date By
1\Building\Forms\RegPermitAction_1 518.doc
Electrical Permit Application {¢ FOR OFFICE USE ONLY
City of Tigard I zReceived
l - 11 t5ate/By: 1 A() ,Q_ Perm"'• 13125 SW Hall Blvd.,Tigard,OR 97223 Plan eview o,� _�'�!r
Phone: 503.718.2439 Fax: 503.598.1960 2 Date
Related Permit#: //JJJ�?yip
Inspection Line: 503.639.4175 JUL 7OZO •S Z
TIGARD Read fe/By: I ® See Page 2for
Internet: www.tigard-or.gov 'fi e tat k Supplemental Information
E`OF W .: `0 REVIEW
❑ New construction n Addition/alteration/replacement ,y 1.7/✓ Please check all that apply(submit 2 sets of plans w/items checked):
UDemolition ,f v• ry ❑Service or feeder 400 amps or more 0 Building over three stories.
. ❑Other: CU.-,t' t.. `Li7f01 where the available •fault current ❑Marinas and boatyards.
*44
, GORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ I-and 2-family dwelling ®Commercial/industrial III Accessory building less to ground or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑ Multi-family ❑ Master builder ❑Other: ID Fire pum
p.p. ID Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
0 Addition of new motor load of system.
Job#: Job site address: 11950 SW Garden Place 100HP or more. ❑"A","E","i-2","l-3",
City/State/ZIP:Tigard,OR 97223 0 Six or more residential units. occupancy.
❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: 100 I Project name:BKM OED Bldg.7 ❑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
New residential single-or multi-family dwelling unit.
Subdivision: I Lot#: Includes attached garage.
1,000 sq.B.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 75.00 2
Fire Alarm Devices-Floor is (with above sq.ft.)
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Renewable Energy 0 See Page 2
❑ PROPERTY OWNER i TENANT Services or feeders installation,alteration,and/or relocation
Name:BKM OED-Bldg.7 200 amps or less 100.70 2
Address: 11950 SW Garden Place Suite 100 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Tigard,OR 97223 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 I ❑ CONTACT PERSON Branch circuits-new,alteration,or extension, •er panel
A.Fee for branch circuits with
Business name:Point Monitor Corp. above service or feeder fee, 7.42 2
each branch circuit
Contact name:Brooke Williams B.Fee for branch circuits without
Address:5863 Lakeview Blvd.Suite 100 service or feeder fee,first branch 2
branch circuit
City/State/ZIP:Lake Oswego,OR 97035 Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:(503)627-0100 Fax: :( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email:bwilliams a)pointmonitor.com Reconnect only 67.84 2
G",°'� iuesar ; ', CONTRACTOR 411.I. Pump or irrigation circle 67.84 2
Business name:Point Monitor Corp. Sign or outline lighting 67.84 2
Address:5863 Lakeview Blvd.Suite 100 Signal circuit(s)or limited-energy panel,
See Page 2 I 2
panel,alteration,or extension.
City/State/ZIP:Lake Oswego,OR 97035 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:(503)627-0100 Fax:( ) Investigation(I hr min) 90.00/hr
Email:bwilliams®pointmonitor.com Industrial plant(1 hr min) 78.18!hr
Inspections for which no fee is 90.00/hr
CCB Lie.: 135901 Electrical Lic.: 34508CLE Suprv.Lic.: 4460LEA specifically listed(/hr min)
Suprv.Electrician signature,required: ELECTRICAL PERMIT FEES
Subtotal: ] ,-'1'
Print name: Ben Breit Date: 7/28/2020 ❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee): 4-
Authorized signature 4e� _ TOTAL PERMIT FEE: ��t.
ak
This permit application expires if a permit is not obtained_`within 180
Print name: Ben Breit Date: 7/28/2020 days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:1au❑ding'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
Fee for all residential systems combined: $75.00 nesc RenewablIe electrical energy systems:
Check Type of Work Involved: 5 kva or less 100.70 2
5.01 to 15 kva 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301.04 2
❑ Garage Door Opener* 50.01 to 100 kva 552.26 2
>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
❑ Vacuum Systems* >100 kva-no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
❑ Other: Each additional inspection is 66.25/hr 1
charged at an hourly(I hr min)
Inspections for which no fee is 90.00/hr
s.-cificall listed %hr min
COMMERCIAL WORK ! f
Fee for each commercial system: $75.00 subtotal(Enter on Page I):
` Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
® Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems: 1
*No licenses are required. Licenses are required for all
other installations
IiBuildingPeimitsTLC_PermitApp_ELR_ERE.doc Rev 06/17/2015