Permit A l`
CITY T I D ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT PERMIT #: ELR2008 - 00325
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 11/24/2008
PARCEL: 1 S136DC -04500
SITE ADDRESS: 07501 SW DARTMOUTH ST 100 WINCO ZONING: C - G
SUBDIVISION: PP1995 - 013 LOT: JURISDICTION: TIG
PROJECT: WINCO
Project Description: Low voltage for CCTV system.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: : HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER: CCTV X
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
WINCO FOODS LLC WILLAMETTE VALLEY SECURITY
650 N ARMSTRONG PL 28101 SW LADD HILL RD
BOISE, ID 83704 SHERWOOD, OR 97140
Phone: 208-377-0110 Contact #: PRI 503- 244 -5273
FAX 503- 625 -6144
Reg #: ELE 3- 370CLE
FEES LIC 96932
Description Date Amount
[ELPRMT] ELR Permit 111241200E $75.00
[TAX] 12% State Surch 111241200E $9.00 REQUIRED ITEMS AND REPORTS
Total $84.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow 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 copies of these
rules or direct questions to OUNC at 503.246.6699 or 1.800.332.2344.
Issued By: • 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'N: 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.
1
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JEll�c>t�ical Permit ApUlacatioaa .. �,- O ' . b '4'frr l { .. • rY: 61 `a City of Tigard ll ., 1' ■ / a 'J�� Perm No.: _ L _. i -ex S
13125 SW Hall Blvd., Tigard d t:• 3
+.. Dol f te viewr Other Permit /e. ( . 0W
Fil
4 1 Phone: 503.639.3171 Fax 503. 9 . '.k "- • Detdbt: �`
'a;e + lntpe Lion UK: 503.639.4175 Due Ready/By. Jura: II S
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t - �. ��' t' 4 , Wo ifi d0 cthvd: / rn) _ S.groketensal larormotien
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ww.tigard- or.gov \1
Ti(L f I _ t -' � PLAN REVIEW
❑ Additionlalr Please check ell That apply (submit b acts d plena Wilms checked below
❑ New rAt15bt/etioD IV I SIGN ❑ Servux dr tceder 400 4010, ar meta CI Banding overtime 'dories,
❑ Demolition ❑ Other- Q11111ING 0 f , 7 where ttce available fmrlt current 0 Marinas aidl?oetyards
CATEGORY OP CONSTRUCTION camoda 10.000 moos at 150 volts or 0 Fasting buildings.
:pasta gonad_ of mood' 11,000 0 1 u e zgneultural
Cl 1 - aid 2-familydwelling 0Commercial /industrial ❑ Accessory building amw foe an other installations. buld11Lp.
0 Multifamily ❑ Master buildm ❑ other: 0 Fire man. 0 Ms1allation of 75 1r VA or
❑ Emergency 'yam. larger sepia taly derived system,
108 SITE I NFOaMAITON AND LOCATION 0 Addition of new motor fwd of D "A ".'T:. "i-2 ". I - "
Job no.: j Job site address:iV 1 50 S c) aa.Y`t'r�0u-th Six or we res' Recreation
Q Six a more nsideatiai terrier_ ❑ Recreational 'Aids piles.
CI City/State/ZIP: Ct 0.r C�i 0 1 � ° 1 I a � o3 0 Hcaatk-aue oc facilities. ❑ 605 salts wings for taore than
pHr>�dwstoeacmta. b�n.oteanemieal.
Suite:/bldg./apt no.. E ,, 1 l pro name. L 1 r�4.0 FMS Os feeder IEEE mmgie I.E
Cross street/directions to job Ss,- " otaaym.e 1 Qt,. 1 Yee. J rte. f •
New roaidenlied single- or multi- family dwelling snit. I
Includes attacked garage
Subdivision; �Lo t ro,;v 1,000 sq. R or less j 145.15 4 1
Ea. Mtn six sq. R or portion 33. 1
Taos crap /place: 00.: United energy, residential ,
DESCRIPTION OF WORK (with above so. A.) 15.00 2
-/
Limited anew, multi-family rcvidential (with abase sq. 9.) 15.00 l 2
C G
Services or feeders installation, alteration, and/or relocation
200 amps or fast 80.30 i 2
❑ PRoPlc,R'LY OWN /It I ❑ TENANT 20t amps to 400 amps 106.85 , 2
Name: amps to 600 amps 160,60 2
601 amps to 1,000 amps 240.60 2
Address: Ova 1.000 arnps of volts 454.6.5 j 1
City/State/ZIP: Tetnporarysarvieaorfeeders instaWtion, alteration, and /or
relocation _
Phone:( ) Fax :( ) 200 =pa or less 66.85 1
Owner installation: This installation is being made On property
that I own which is not 201 amps to 400 amps 100.30 2
inicodcd for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
' Branch circuits - sew, alteration, or exrensist panel
Owner signature: Dale: A. Fee for branch circuits wish -
❑ APPLICANT 1 ❑ coNTACr PERSON above service or £seder fee.. 6.65 2
each branch circuit
Basin= Havre: B. Fee Six brunch circuits
Contact name,
widow service nr feeder Be. 46. BS 2
fist branch circuit
Address; k Each add' l branch circuit 6.65 2
Miscellaneous (service or feeder not included,
City1State/7_IP: Each manufactured or modular -
dwelling, service and/or feeder 90.90 '' 3
Phone: ( ) - Fax:: ( ) Rewriters only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
• CONTRACTOR Sign or attune lighting 53.40 3
+ } Val / + 1 t Signal circuit(s) or limitcd-
Business natDe:
crt.) 1 l 0.,, e, a i U e 5 `e C u r" rl energy panel, alteration or
Address: �2 8 i o 1 Sc .-J 1--ad d\1 1 t1 P_ O I =tendon. Desenbe: Page 2 2
City /Statc/ZI P: G er Woo d_ 0 q `1 1 y Each additional inspection aver allowable in auto( tbeabove
Pes inepeaion 62.50
Phone: ( 5 0 3 .2 Li 4 3 21 3 I Pax: (.Z13) G 2.5_ ( 14y Investigation pet hour (t hr min) 62.50
CCB Lic.: Electrical Lic.: 1 Suprv. Lic.: Industrial plant per hour 7375
ELECL7tUCAL PERMQT FEES
Sttprv_ Electrician signature, required: Subtotal: `1 ,5.cri .
Print name Date: Plan =view (25%ofpcnnit lee):
Seas surcharge (12%ofpermit fee): ' c A--1
Atthari cd signature: d TOTAL PERN•(FT FEL•: (- •
vo.A. � This penult �- application rapers if a permit is ova ooraiste within IN
Print name y weer dos. ^ fate: l _a \k- da niter it he beta accepted as mm pieta
• Number of inspections attowed pct pcmit
ttBuitd'epeermi ppdoc 054!106 ' 4104411TOI I. l.tr, AI/VB
24 08 03:14p p.3
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LTED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined .. S75.00
•
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial system ....................... 575.00
_ (SEE OAR 918 -260 -260)
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
O Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
O Other CC-
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
is\BuildirrVcrmiti ELGPemiulpp.doc 04103
WOMACK WATER WORKS, INC
CCB LICENSE #125943 08
BACKFLOW ASSEMBLY TEST REPORT NEW
PROPERTY OWNER: 'Pomp P/ ,1J�%„7 Y � '" ,�,L" � cl 4k� PHONE / .11 .11 ef2�8
MAILING ADDRESS: -7'�OD SGJ . '�" ' 01);ne.6)
CITY %9 e.fiC( ST G ZIP
ASSEMBLY ADDRESS: 5640'e. 0a)
3/4 RAM rye cv RS- Or 804,
WATER PURVEYOR: 7/
ASSEMBLY LOCATION: /'J ._ / ?o ^'m
INITIAL TEST RESULTS
REDUCED PRESSURE ASSEMBLY PVBA/SVBA INITIAL TEST
#1 CHECK -- DOUBLE CHECK AIR CHECK PASSED)<
7
PRESS DROP .0 (A) CHECK #1 INLET FAILED
RELIEF VALVE TIGHT X OPENED AT: PRESS DROP
OPENED AT 3'D (B) LEAKED PSID DATE /0/g
MIN 2 PSID PSID PSID
BUFFER / , CHECK #2
A -B= " I 'D TIGHT DID NOT FAILED SYSTEM
MIN 3 PSID LEAKED PSID OPEN PSID
RELIEF VALVE
PASS x FAIL
COMMENTS
REPAIRS
AND /OR
PARTS
TEST AFTER REPAIRS
REDUCED PRESSURE ASSEMBLY PVBA/SVBA AFTER REPAIRS
#1 CHECK DOUBLE CHECK DATE:
PRESS DROP (A) CHECK #1 OPENED AT: PRESS DROP
RELIEF TIGHT PSID
OPENED (B) CHECK #2 PASSED
BUFFER MIN 2 PSID TIGHT PSID PSID PSID
A-B=
MIN 3 PSID
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALABRATION DATE 01/27/2008 DETECTOR METER READING
TEST SIGNATURE CERT4096
TESTERS NAME JEREMY TOWER GAUGE W2095
TESTERS ADDRESS PO BOX 307, UTDALE, OR 97060 503 669 -2722
COMPANY NAME WOMACK WATE C PHONE
REPORT RECEIVED BY: X SERVICE RESTORED
(REPRESENTATIVE OR OWNER)
WOMACK WATE = '" ' RKS INC
CCB LICENSE #125943 08
BACKFLOW ASSEMBLY TEST REPORT NEW
PROPERTY OWNER: f / a M 4 , 1 4 7 /ry , ,L (a),>feo)
PHONE / 9 / s�'Z7V8
MAILING ADDRESS: 75 $ i 1)4 /4 ,.
CITY 746.0 ST '1.' LIP
AsSEMBLY ADDRESS: SClk4€ c2Q
_ 3 /y MiI en9 /'I3 -QT /977W
WATER PURVEYOR: I,avil T'
ASSEMBLY LOCATION: Uld SaY 41 AV ' G S.0 4;1 0Ai9
INITIAL TEST RESULTS
REDUCED PRESSURE ASSEMBLY PVBA/SVBA INITIAL TEST
#1 CHECK DOUBLE CHECK AIR CHECK PASSED 4Y
PRESS DROP / ' (A) CHECK #1 INLET FAILED
RELIEF VALVE TIGHT ,• OPENED AT: PRESS DROP
OPENED AT 3•Z (B) LEAKED PSID DATE /We
MIN 2 PSID PSID PSID
BUFFER /) CHECK #2
A -B= `1'Z TIGHTX DID NOT FAILED SYSTEM
MIN 3 PSID LEAKED_ PSID OPEN PSID
RELIEF VALVE
PASS /c FAIL
COMMENTS
REPAIRS
AND /OR
PARTS
TEST AFTER REPAIRS
REDUCED PRESSURE ASSEMBLY PVBA/SVBA AFTER REPAIRS
#1 CHECK DOUBLE CHECK DATE:
PRESS DROP (A) CHECK #1 OPENED AT: PRESS DROP
RELIEF TIGHT PSID
OPENED (B) CHECK #2 PASSED
BUFFER MIN 2 PSID TIGHT PSID PSID PSID
A -B=
MIN 3 PSID
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALABRATION DATE 01/27/2008 DETECTOR METER READING
TEST SIGNATURE CERT4096
TESTERS NAME JEREMY TOWER GAUGE W2095
TESTERS ADDRESS PO BOX 307, TROUTDALE, OR 97060 503 669 -2722
COMPANY NAMEWOMAC. AT a PHONE
REPORT RECEIVED BY: w X SERVICE RESTORED
(REPRESENTATIVE OR OW
• CITY OF TIGARD T
BUILDING DIVISION PERMIT #: FLR3000,003 25
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 11/24/2008
Phone: (503) 639- 41714�gIC
Inspection Requests (24 Hrs.): (503) 639-4175
"''' L.
INSPECTION WORKSHEET FOR DATE: 11/26/:7008 TIME: 7:O AM PAGE:
("--•
SITE ADDRESS: 07501 SW DARTMOUTH ST WI CLASS OF WORK: ,.i i�
SUBDIVISION: pp - 19g5r,013 LOT #: TYPE OF USE:
PROJECT NAME: wilco
DESCRIPTION: Low voltage for CCTV sy; tE m.
OWNER: WNCO FOODS LI -C, PHONE #: '2011 377-0110
CONTRACTOR: WILLAMETTE VALLEY SECURITY PHONE #: 503
Inspection Request Scheduled For: Date: •11/7€/2t)00 Pour Time:
Code # Inspection Description Confirm # Contact # Message
135 Low voltage 07E1570 503.312 - 080'l N
Corrections /Comments/ Instructions:
/. 09 ( Q.avUrt ;- • fa 6 e/ o- E ,'
►ice ASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
1 CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: /f- 26 _ Phone #: (503) 718 -