Permit " -c 02-e /o -- 000 o 7
111 a ° Community Development
T l c n ii Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor g City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.: /p 1
6
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED ( ✓): JO 1 n
JD rl
E CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available). 0 t
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below 0 L n
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). IQ � � �` •` Q
0 Perm #: E LC 2 c /C - DODO -7
'1
Site Address or Parcel #: /c)/ A y az.0 WR' //i ti/d re.A.) Kef
Project Name: FE3> i 3> Zx
Subdivision Name: /07- Lot #: � 4-
EXPLANATION: L DDIei PEgle,/ #6 ' / F�pe it T C ,9,
2 EQ !ICS o A z_z___ A-4 w Pe d-ti ■ , g >< & - co /CDC,
Signature: 0 / Date: JA
Print Name: / Ait5/C gi
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date. Emu Rte to Bld Admin: Date /Q d B .1 f1
Refund Processed: Date ii/ By .- " Invoice Processed: Date By
Permit Canceled: Date 4 /41 By d%' r Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPemmitAction.doc Rev 07/26/07
I -;;. CITY OF TIG ELECTRICAL PERMIT
'' I11 COMMUNITY DEVELOPMENT Permit #: ELC2010 -00007
, Date Issued: 01/07/2010
.til Gf1RD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 1S 135BA00102
Jurisdiction: Tigard
Site address: 10124 SW Washington Square RD
Subdivision: Lot: 0
Project: FedEx Office
Project Description: Replace (1) sign /outline lighting.
Owner: FEES
PPR SQUARE TOO LLC Quantity Description Date Amount
BY THOMSON PROPERTY TAX SERVICES,
2235 FARADAY AVE STE #0 1 ea Sign or Outline Lighting 01/07/2010 $67.84
PHONE: 1 ea 12% State Surcharge - 01/07/2010 $8.14
Electrical
Contractor:
IMAGE NATIONAL INC
16265 STAR RD
NAMPA, ID 83687
PHONE: 208- 345 -4020
FAX: 208- 336 -9886
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $75.98
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 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
r 1
Issued By: a_ 0j • 1 � _ . �. ' Perm ittee Signature:
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' �Q 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.
' 01 - 06 -'10 10 :22 FROM -Image National 2083369886
(v 'COW( T -719 P002/005 F -056
Electrical Permit Application
City of Tigard R ECEIVED R Permit No.: Fu 't �7
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
' a Phone: 503.639,4171 Fax: 503,598 D ateBy: Other Permit 231Q•
1 . c , `1 , t � Inspection Line: 503.639.4175 JAN 0 6 2010 Date Ready/By: lu^r. See. Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TY OF TIGARD • . TYPE OF: WO ', • • • • • 0. ` ,.!.:.H::.. '3 , pLAN iiEY Et, W •
❑ New construction ® Addition/alter a 'v - 'acement Please check all that apply (submit? 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 O Marinas and boatyards.
' - CATEGORY OF CONSTRDCTTON exceeds 10,000 amps at 150 volts o r ❑ Floating buildings. • less to ground. or exceeds 14,000 El Commercial -use agricultural
❑ I- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings,
❑ Multi- family ❑ Master builder ® Other: Signs O Fire pump. ❑ Installation of 75 KVA or
, ❑ Emergency system. larger separately derived system.
_JOB SITE INFORMATION AND LOCATION ' ` ❑ Addition of new motor load of ❑ "A" "E" "1 - "i 3"
19011P or more, occupancy.
Job no.: Job site address: 10124 SW Washington Square
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: 97223 CI Health-care facilities. 0 Supply voltage for more than
L Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: FedEx Office DServicc or feeder�O0 amps or more.
.... , , - ,FEE ;'SC1DDULk ,,
Cross street/directions to job site: SW Greenburg Rd Dnertpeon 1 Qry, 1 Fre. 1 Total 1 •
New residential single or multi - family dwelling unit.
includes attached garage.
Subdivision: Lot no.: 1.000 sq. ft. or less 168,54 4
Tax map/parcel no.: Ea. add'I 500 sq. R. or portion 33.92 1
rc _ Limited energy. residential
67.84 2
. DESCRIPTION OF WORK ' ° (with above so. tt.)
Limited energy, multi- family 67.84 2
Remove existing illuminated channel letters and replace with New illuminated cite residential (with above sq. 11.)
Services or feeders installation, alteration, and/or relocatio
200 amps or less 100.70 2
, ® ,.PROPERTY OWNEa ,j,. • ❑ ,TENANT:' : 201 amps to 400 amps 133.56 2
Name: Macerich 401 amps to 600 amps 200 2
601 amps to 1,000 amps 301.04 2
Address: 700 Fifth Ave Over 1.000 amps or volts 552.26 2
City/State/ZIP: Seattle WA Temporary services or feeders installation, alteration, and/or
relocation
Phone: (503)639 -8860 Fax: ( ) 200 amps or less 59.36 1
Owner installation: This installation is being made on property that 1 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:' L rk.-1 -1 a .l� • A. Fee for branch circuits with
®: APPLICAN , ., , f ` CONTACT;PERSON %'.` above service or feeder fee, 7.42 2
' � each branch circuit
Business name: Image National Inc B. FCC for branch circuits
Contact name: Michele Phelps without service or feeder fee, 56.18 2
p first branch circuit
Address: 16265 Star Rd Each add °I branch circuit 7.42 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Nampa ID 83687 Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: (209) 345 -4020 Fax: : (208) 336 -9886 Reconnect only 67.84 2
E -mail: michele.phelps @imagenational.com Pump or irrigation circle 67.84 2
. .. . CONTRACTOR, . • .• , ' • Sign or outline lighting 1 67.84 2
Business name: Image National , tin t i Signal p al r limited-
energy p alteration, or
Address:46,156Star RD 1 1-00 IPS extension. Describe: Page 2 2
City /State /Z1P: Nampa. ID 83687 Each additional inspection over allowable in any of the above
- Per inspection 66.25
Phone: (208) 345 -4020 Fax: (208) 336 -9886 Investigation per hour (1 hr min) 66.25
CCB Lic,: 66465 Electrical Lic.: 37 -24CLS Suprv, Lic. :L Industrial plant per hour 78,1
I t ( I • — ELECTRICAL PERMIT FEES
Suprv. Ele signature, required: / I Subtotal: ( • 84„
Print name: / _ Date: Plan review (25% of permit fee):
�1 ,_ ` f , t .- `e State surcharge (12% of permit fcc): . 1
Authorized signature /Tc C.-3W4,4- ,. TOTAL PERMIT FEE: 1
J
This permit application expires if a permit is not obtained within i>fU
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
1. E Idatg \Permit, \5LC- PermitApp.doc 10/01/09 440- 4615T(I )/05 /C0.M..
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