Permit i
` CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
Ill
`.. COMMUNITY DEVELOPMENT Permit #: ELR2009 00363
:,TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 12/18/2009
Parcel: 2S101 DA00102
Jurisdiction: Tigard
Site address: 13221 SW 68TH PKWY 300
Subdivision: TRIANGLE CORPORATE PARK Lot: 2
Project: Health Net
Project Description: Install restricted energy systems for CCTV and access control.
FEES
Owner:
GK TRIANGLE CORPORATE PARK III L Description Date Amount
BB# 73- 1771- GK1130, CBRE, PO BOX 2096 Restricted Energy Permit 12/18/2009 $67.84
WARREN, MI 48090 12% State Surcharge - Electrical 12/18/2009 $8.14
PHONE: Restricted Energy Permit 12/18/2009 $67.84
12% State Surcharge - Electrical 12/18/2009 $8.14
Contractor:
HUSER INTEGRATED TECHNOLOGIES
1313 NW 17TH AVE
PORTLAND, OR 97209
PHONE: 503 - 227 -6688
FAX: 503- 227 -5941
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 2
Audio & Stereo: N Boiler Controls: N
CCTV: Y Clock Systems: N
Data 8, Telecommunications: N Fire Alarm: N
HVAC: N Instrumentation: N Total $151.96
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N Required Items and Reports (Conditions)
Nurse Calls: N Protective Signal: N
Security Alarm: N Other: Y
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 set forth in OAR
952 - 001 -0010 through DAR 952-001-0100. You may obtain a copy of the rules or direct questions to OUNC C by calling 503.246.6699 or 1.80 .332.23
Issued By: � V � /v1' \/� tIIAA Permittee Signatr7
Ai
V
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.
Electrical Permit Applica pi . ECFtV r � 0 ' •!,- "
ipli
City of Tigard Date/B : �"1 /��ty Permit No.: ? Q2Q0 oa3
q 13125 SW Hall Blvd., Tigard, OR 97r v 200 Plan Re
Date/By: Phone: 503.639.4171 Fax: 503.598 9. Other Permit �?
1:1 (-;•A K I) Inspection Line: 503.639.4175 Date Ready /By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov CITY OF TIGARD Notified/Method: 11 S Supplemental Information
' TYPE 0 thilialit1G DIVISION PLAN REVIEW
❑ New construction Addition/alteration /replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ 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 ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ I- and 2- family dwelling 71 Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "I -3 ",
Job no.: Job site address: < IOOHP or more. occupancy.
1 sw ��� Y ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: / 6 D O 97 ? 3 - V3,143 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. 1 Fee. 1 Total J •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 I
Tax map /parcel no.: Limited energy, residential 67.84 2
DESCRIPTION OF WORK (with above sq. ft.)
. 6PV4N r / � % - Rg � T C residential (with above sq. Limited energy, multi- family 67.84 2
¢j Cif•/ / 9C$ R.)
CO trine C d-- CGTV C f9 tez4 5 M Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
Name: 11 4c.T: N 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: / Z '/ 8 (9 P4,,)lc 3 L ✓D Over 1,000 amps or volts 552.26 2
City /State /ZIP: 000f)4.,4 ;) 11 / 7 /S C4. 9 376 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (q /6 ) ,A06 3,e0 Fax: ( ) 200 amps or less 59.36 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 _ 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT . 1 ❑ CONTACT PERSON above service or feeder fee,
7.42 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 56.18 2
first branch circuit
Address: Each add'I branch circuit 7.42 2
Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 67.84 2
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
E -mail: Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
�/ '^ AA Signal circuit(s) or limited-
Business name:
/? �, g. _4.-7;0 6i Tei% energy panel, alteration, or
Address: /3 /3 /') / 7 R ve__. extension. Describe: Page 2 2
City /State /ZIP: Pog_7 (�44441n OR 77 ' o ? Each additional inspection over allowable in any of the above
GG �/ Per inspection 66.25
Phone: 1503 ) 2 Z7 _ G 6 O 0 Fax: (�p3) 2d 7 .. s f (// . Investigation per hour (I hr min) 66.25
CCB Lic.: / 77? .7 Electrical Lic.: 01.& 13 Suprv. Lic.:3 /` 46,1 Industrial plant per hour 78.18
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required:,Se Subtotal:
S e Or 1/4) Tu 0 42 Date: / Q G Plan review (25% of permit fee):
Print name:
,5 B J / f State surcharge (12% of permit fee):
Authorized signature: TOTAL PERMIT FEE: l 1 , ct(
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\ Building \Permits\ELC - PermitApp.doc 10/01/09 440-46t5T(1I /05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
.RESIDENTIAL WORK ONLY:
Fee for all residential systems combined $67.84
Check Type of Work Involved:
n Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $67.84
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
n A • udio and Stereo Systems
•
n B • oiler Controls
❑ Clock Systems
n Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
n Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
F. Protective Signaling CC J 0- dCW.A.S Co" ..7 - .. • '
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1:\Building\Permits\ELC- PermitApp.doc 10/01/09