Permit
Electrical Permit Application ECEIN/
City of Tigard Rece,rd
MT Pem;4 1GLd~-
13121 $W Hall Blvd.. Tigard. OR 97223 Plan Rewew
tl Phone: 503.639.4171 Fax: 503.598.1960 Dale/ By. Other Permit:
Inspection Line: 503.639417,5 CITY OFTIGA2,(,)tifie0d',1M,4ethod. Date Rdy/By 7uris g See Page 2 for
Internet: www.tigard-or.gov ; .tl suppleroeotal Informetio~
f'tr
on/replacement N 1R
W~ Please check all that appIy (submit; sots of
New construction Add plans w/items checked below:
Qlonalte~
❑ Demolition ❑ Other: ❑ Service or feeder 400 amps or more ❑ Building over three stories.
where the availnble fault current ❑ Marinas and boatyards.
A')EGOIt l} 'ta(9iWS 1'tYt~~rtt?1\r „ exceeds 20,000 amps at ISO volts or ❑ Floating buildings.
El 1 -and 2-farm)y dwelling Cortttrter taI/industrial b Accessory building less to ground, or exceeds 14,000 ❑ Commervl-use agricultural
amps for all other installations. buildings.
❑ Multi-family ❑ Master builder 0 (hher. Ij Fire pump. D installation 0f75 1CVA or
` t~'i ` d ,4ir ! ~,~Yi2b i ° u F~~ ❑ Emergency system. larger scPsratclY derived
.nv n » li ^V h l,dl~ C i i P+ SYStem.
❑ Addition of new
motor load of ❑ "A" "E" "1-2" "I-3"
Job no.:2 2. 4490 Job site address 1 5 8 9 5 SW 7 2 n d Ave Ste 200 1 OOHP or more, occupancy,
❑ Six or 'no-v residential units ❑ Recreational vehicle parks.
City/State/ZIP: Tigard, OR 9 7 2 2 4 ❑ Health-care facilities. ❑ supply voltage for more than
0 Hazardous locations. 600 volts nominal.
Suitc/bldg./apt. no,; 'Rot project name: C I DA ❑ Service or feeder 600 amps or more.
Cross street/directions to job site; Aaerr lion Fm Tord
New residential single- or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no,; 11050 sq. ft or tcss 145.15 4
Ea, add'1 500 sq. ft. or portion 33.40
Tax I
map/parcel no,; Limited cncr
gy, residential
i WIN, M , .11 1 d { i{4;j, with above s q. ft. 75.00 2
installing voice/data cable Limited energy, multi-family
w residential with above . ft. 75.00 2
Services or feeders installation alteration and/or relocation
200 amps or less 80.30
2
i1,h» R Mr°edd
20) tarps to 400 amps 106.85 2
Name: CIDA (contact Judy Bandrp) 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 2g0.g0 2
Address' 1 5 8 9 5 SW 72nd Avenue Suite 200 over l >ooo amps or volts 254.65 2
City/State/ZIP' Tigard, OR 9 7 2 2 4 Temporary services or feeders Installation, alteration, and/or
rclOCgt(on
Phone: (5 0 3) 226-1285 Fax: ( ) 200 snips or less 66.85 I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sa1c, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Owner signature: Date' Branch circuits - nary alteration, OF extension er aoel
A. Fee for branch circuits with
° tt rot. o
. , above service or feeder fee,
each branch circuit 6.65 2
Fee for Business Warne B
branch circuits
Contact name: wil l service or feeder fee,
first branch circuit 46.85 2
Address: Each add'I branch circuit 6.65 2
Mlserllaneous service or feeder not Included
City/State/ZIP: Each manufactured or modular
Phone: - dwellin service and/or feeder 90,90 2
Reconnect only 66.85 2
E-mail . L Pump or irrigation circle 53.40 2
F r1 ,ld 9 `i luu G,1nI.1X,i~aiiia i 6 ? e:5,!rY rF i Sign Or Outline lighting 53.40
2
Busincssname: Tice Electric Company energy panel, anel, alt altererliatioon,, or
or n
energy 1 75.0
extension. Describe psi 2 2
Address: 5405 N Z,aoon Avenue
City/State/ZIP: Portland, Oregon 9721 7 Each additional inspection over allowable in an of the above
Phone: (5 0 3) 233-8801 Fax-1(503) 872-8290 Per inspection 62.50
Investigation per hour (i hr min) 62.50
CCB Lic.: 1 6 6 ✓ Electrical 1; ie.: 26-1 26C Suprv. Lic.: 2 5 8 6 S industrial plant per hour 73.75
Suprv. Electrician signature, required: 7 Z' 'i
Subtotal:
S 00
Print name: Date: 1 0 / 21 /09 Plan review (25% of permit fee):
John J . Maloney w State Surcharge (12% of permit fee);
Authorized sign atur 0 r
TOTAL PERMIT FEE: 8 4 , 0 0
Print name: ll'
Date: This permit application expires iEe permit is not obeeined within 160
X days after It has been accepted as complete,
NUMber of inspections allowed per pemnft
P`9uildingl}krtndta\FLC-Permitgpp doe OS/^.3/n6 Ca0-sC1ST(I I/OS/CO'~lME$
CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
ia COMMUNITY DEVELOPMENT Permit ELR2009-00333
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/22/2009
Parcel: 2S1 12D000500
Jurisdiction: TIGARD
Site address: 15895 SW 72ND AVE 200
Subdivision: OREGON BUSINESS PARK III Lot: 40
Project: CIDA
Project Description: Intallation of voice/data cable.
FEES
Owner:
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 Restricted Energy Permit 10/22/2009 $67.84
PORTLAND, OR 97224 12% State Surcharge - Electrical 10/22/2009 $8.14
PHONE: 503-624-6300
Contractor:
TICE ELECTRIC
5405 N. LAGOON AVE.
PORTLAND, OR 97217
PHONE: 503-233-8801
FAX: 503-872-8290
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 Total $75.98
Intercom/Paging: N Landscape/Irrigation: N
Required Items and Reports (Conditions)
Landscape Lighting: N Medical: N
Nurse Calls: N Protective Signal: N
Security Alarm: N Other: N
Other Desc:
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 952-001-0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
f
Issued By:~-Y Permittee Signature:' / C,• •y- i
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 an inspection that business day.
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.