Permit (4) p CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
'1 s COMMUNITY DEVELOPMENT Permittt: ELR2012 00232
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 10/03/2012
Parcel: 2S 110AA00900
Jurisdiction: Tigard
Site address: 14050 SW PACIFIC HWY 212
Project: NW Financial Subdivision: 2011 -041 PARTITION PLAT Lot: 1
Project Description: (1) low voltage for data /telecommunications
Contractor: BRIDGETOWN ELECTRIC Owner: ELLINGSON REVOCABLE INTERVIVOS T
5701 N LOMBARD ST BY ELLINGSON, JOSEPH M & JEAN E TRS
PORTLAND, OR 97203 -4113 420 W LASSEN AVE
CHICO, CA 95973
PHONE: 503 - 621 -7122 PHONE:
FAX: 503 - 621 -7123
FEES
Description Date Amount
Specifics: Restricted Energy Permit 10/03/2012 $75.00
12% State Surcharge - Electrical 10/03/2012 $9.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: N Boiler Controls: N
CCTV: N Clock Systems: N
Data & Telecommunications: Y Fire Alarm: N
HVAC: N Instrumentation: N
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N
Nurse Calls: N Protective Signal: N
Security Alarm: N Other: N 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 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 obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 11.800.332.2344.
or
Issued By: IJ��C.6�I Permittee Signature: ng ,1 LJcA 44 itTh S
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.
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Oct 03 2012 10: 40FIM Br idgetcutinz-,E.J.ectric.-- 503-621-7123 page 1
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Electrical Permit Application ' — •
City of Tigard OCT 0 S 2012 it...i,d .
Date/By: teVah,?, sr Poodtti.: 45Z-AA54,1.- 00
., is 13125 SW Hall Blvd., Tigard, OR 97223 Pl R ev i ew
I ll
_____ i Phone: 503.639.4171 Fax: 503,598.1960 (c--, ,,,c ,,,,.- ,.A.,.0.-17 ,, Datagy: Other Permit
Inspection Line: 503.639.4175 ,,, " . (,,:::c Pate Ready/Hy: Atria ,„ I RI Sea Page 2 for
Internet: www.figard-or.gov . ;J „ 4 , • , .' . NotiFtedMathod: ,_ 17 t I Supplemental Informtien
- • • ..: Torit......al,rrets,9:m ..a,pomi",9w.Frri.,, Fr: n:: g . 1i,. ,. ! , .•1 , ', i , ...4.;,-4 1 - -1,- tr
2SURrilliVira ,,I. „,- . ,„ .,.,,,, K , .■.. 1 , . E. ,
0 New construction Ps7 Addition/alteration/replacement Mae Cheek. that - . -1* Minnitleita 40 ,s,r4Patl, ' 17115%- ' ilebw):
0 Service or feedie4:10 lama Oriente Claradingevor three stories.
0 t • olition 0 Other: wham the available /holt current 0 Marinas and boatyards.
• 1 !:' r. .i' kt;triAlliM exceeds 10,000 aim. at 150 wits or 0 Floating buildings.
i A 104 4....1.0.14 :a.FrOVe;1,0 -"-ri'-w1.1?” WS to ground, or exceeds 14,000 In Commendai-use agricultural
D 1- mild 2-family dwelling i'l Commercial/industrial 0 Accessory building amps for all other Nmallations. Wangs.
0 Mul,ki-family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of75 KVA or
•;,, i. 1■:IP:"5 , - , ;. : , ,(1 , ! ,, ?;4"--MqViNeTrinziNkifWip Crifv414.wriltim . 1 1' Isitie,,zg,,, F 0 EtnergeneY system larger aeparsady derived system.
1 nrgliiistith4iii,,S j,..'01 ki, $7.. ,'I F..' id i',61.. Li Loi 6 ;166,.ti . 7 •: :.:; 0 Addition of new tr load of 0 "A", "E", '1-2", "1-3"..
Job no.: It Job site address: tI4br,O WA/ Ta, t,SrC c,„‘rkv,,N 100HP or more. ow:Taney.
0 six or more rook I units. 0 Seemational vehicle parts.
CittCRP: ... .-p-- OH. alth-eare faciii 0 Supply vohape for more than
y/Sa 1. t' —Oh ars.,. O ti "IAA
" ce. 0 Hazardous locatio - . 600 volts nominal.
Suite/b1cigJapt. no.: IA '1,.. 1 Project name: Nv V.,,,,,,,,,,,, ,j( 0 Service or
.:::' :Agit; A -:
Cross street/directions to job site: , L.! •
. ' New residential as _ e- or milti .'.. ", dwelling init.
Includes attached garage. ,
Subdivision: I Lot no.: , 1,000 sq. ft. or less 168.54 4
Ea. addl 500 sq. ft. , pottion 33.92 I
Tax ma I parcel no.: , } United energy. dee -.' dal
ttwok,IIRREW ViiMger21,7 . ., ,,U•ga•,';414 .1 4 , k,..1Q mg, a se - . ,•, 75530 2
it,4:0;,,dlnenao 4N naP n4 '.4,1;,, 412...;c.,■.io ■ ';.,1.2Alikiik ''' " ontid-'ZiDiktifaktP Attila '
Limited mangy, mu ....'-family 75.00 2
LOW VI/ U 9Vilvakittft. SvtivkA- elpi.majork"..- residential (with
Services or ked lostidlation, alteration, andfor rektestios
) A - 3' " 200 amps or less I 10670 2
,
Y;ki:Ws!,1:1:011: 5 11233:4 0 EFINIS . . i tiA07, Aytrf* 201 amps to400 ., . 133.56 2
401 amps to 600 • 1 200.34 2
Name: '
601 amps to 1,000 .- 301.04 2
,
Address: Over 1,000 amps.or I obit 552.26 2
Temporary sem . •' or feeders insfallatioi, site don, and/or
City/State/ZIP: reloeadon 1
Phone: ) 1 Fax: ( ) 200 anon Or 1eSS l 59.36 1
■ .t
Ownerlinstallndon: This installation is being made on property that I own which is not 201 amps to 400 125.08 2 ,
tunps . ...
interideii for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 to 599 . 168.34 2
Branch, circuits - ,w, alteration, or exteasion,Orpanel
Owner iiignatore: Date: A. Pee for branch '.- ' ,. with
9......,..p.i. ,.....1 . : j'AntitinSitINVW#91 ..e.,,F yil n-vittF,PROPIF:7212,11M above-service or . - , r fee. 742 . 2
Busineis name: B. Fee for branch ci , - .• , without
service or feeder •, fi
- rst
: 56.18 . 2
Contact name: . branch circuit
1 Each addi brine:be! -. 7.42 2
.._
Address: Miscellaneous (se ; . or feeder notincluded)
City/State/ZIP: Each manufactured : =lulu
(Melling, service . /or feeder 67.84 2
Phone: .( ) I Fax: : ( ) Reconnect only I 67.84 2
Pomp or irrigation -,' ., e 67.84 2
E-mail: i -
67.84 2
AVERRINtigiliVikligiWil st i ) ! -
. . , "
Busine8s n ame. , ... . ,. , :, -
' 13ttlii,Attit ELSCrP4c., Pand,altemtlon, or . ion. Page 2 1 2
Each additional' . iteedon over allowable in alive/ the above
Addres4: • S70/ b.) : 1-.0 rA-64+2 - i1eob - 7 - ,
Additional inspect ..'. (I hr tnin) 66.25Thr: 1
Cit PC)gtusa> ock 112. 03 - 1 3 on(1 iv .! )
Inchstrial plant() ..! , ).) 6615/ hr:
' 78.11/ hr.
Phone: ( )r T122. 1 F ( *00 ) �i 1113 . !
wipms fbr . .,, no forte . 90.001.br i
CCB pc.: 103 ez.4 El(xtrical Lie .: ' -SVC. Suprv. Lie.: 1 41771) 'Zki'faiii;C.:Itl.I.._.'.7.........( li&hiregliilifiWi
Sopry . ilectrician signatOre, requ . .4„e-x Zie .„
puliretal:' ri-. cro
P . I view (4.514 oyerin_itle0);,
Stara - , .!'cluage (12% 4041/Mit fee): ; 1 ;
Print rutme:" Sle ..W....5; /.40( Date:
,' TQTAL;e1AidiF FEZ..
Authmized signature: This Periods . . :; . . a alt4f-rOtlYtaccelitts" brwit**18°'
days •,., Itormitent -‘ . 'is emit
Print !lame: ate. • Number of inapt - , .agcnvedperinitnift-
.Emelidasprer reits\M-C-verodtApp.dix
07/01(10 440.46151
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Oct 03 2012 10:40RM Bridgetown Electric 503 - 621 -7123 page 2
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ s Audio and Stereo Systems*
❑ ; Burglar Alarm
❑ : Garage Door Opener* If'.
❑ Heating, Ventilation and Air Conditioning System* I.
❑ Vacuum Systems*
❑ Other. !
• COI1±> > ROWN. !O'RLO$L .,.:.
Fee for each commercial $75.00
system{ I'
(SEE., OAR 918
CheckType of Work Involved: I ,
❑ : Audio and Stereo Systems
❑ 'Boiler Controls
❑ !Clock Systems
Data Telecommunication Installation
❑ ;Fire Alarm Installation
❑ .FIVAC
• :Instrumentation
' I
❑ :Intercom and Paging Systems
❑ ; Landscape Irrigation Control*
❑ Medical
❑ .Nurse Calls
❑ 'Outdoor Landscape Lighting*
❑ :Protective Signaling
• ❑ : Other
Totall number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\BuildnOtermhs \\LC•PambAppdoe 02/01/10 5
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