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Permit
I I Community Development TIGARD 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 tXCity Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) V ® i r) Mailing Address: City /State /Zip: 0/0 /C4 Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 5 CANCEL PERMIT APPLICATION. REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ . REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: E G..L° p`ZDD 7- aQ q 1 Site Address or Parcel #: 944 LA D (2)6 9-/ . SQ Project Name: .D I CA 5 4 m /"d 1T N �0OQ' S Subdivision Name: Lot #: EXPLANATION: -1 1,0912 ` (.l lD f:2 Eke 7 - -00 7/4/ ` I Fe f. Q E. 1..Y1 e.o t..)17 - e- - r v2 . Oki anJ 1.) Al,? S • )LJO7 QQu(f - l f7 1)0p SC EEC ,20 7 -0'7 7/Y Signature: AV 'i A /I J/ � Date: / 0 Print Name: a - v I 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 b) not more than 80 of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 Sys Admin: Date By Rte to Bldg Admin: Date w 2 (v /C f' By WI'' - Refund Processed: Date rt/ /il By Invoice Processed: Date By Permit Canceled: Date ,1f4 /Q By Parcel Tag Added: Date By Receipt # Date - Method Amount $ I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07 CITY OF TIGARD ELECTRICAL PERMIT N T; ' PERMIT #: ELC2007 -00441 • COMMUNITY DEVELOPMENT DATE ISSUED: 6/29/2007 TIGAR . D> 1 3125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 T - PARCEL: 1S12600-00300 SITE ADDRESS: 09402 SW WASHINGTON SQUARE RD ZONING: C -G SUBDIVISION: WASHINGTON SQUARE LOT : JURISDICTION: TIG PROJECT: DICK'S SPORTING GOODS Project Description: (3) sign lighting. See attached location. RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS 1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION: EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG: 3 LIMITED ENERGY: 401 - 600 amp: SIGNAL /PANEL: MANF HM/ SVC/ FDR: 601 +amps - 1000 volts: MINOR LABEL (10): SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS 0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION: 201 - 400 amp: 1st W/O SRVC OR FDR: PER HOUR: 401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT: 601 - 1000 amp: PLAN REVIEW SECTION 1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL: Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC: Owner: Contractor: WASHINGTON SQUARE LLC ES & A SIGN & AWNING BY THE MACERICH COMPANY 1210 OAK PATCH RD TIGARD, OR 97223 EUGENE, OR 97402 Phone: Contact #: PRI 541 - 485 -5546 FAX 541- 485 -5813 FEES Description Date Amount Reg #: ELE 20- 243CLS [ELPRMT] ELC Permit 6/29/2007 $160.20 LIC 163470 [TAX] 8% State Surcharge 6/29/2007 $12.82 SUP 305SIG Total $173.02 REQUIRED ITEMS AND REPORTS 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: ( . e,y 4. j t j t.A..) Permittee Signature: n (14) 1114"""___ (Lw r j yam, 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. - -- G4-4907-- e, /3 . rical Permit Application FOR OFFICE USE ONLY City of Tigard R Date/S : / ' a� O .25 / Permit N. ,... G j f po 1 / 1 -8 - 13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie • Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit: Inspection Line: 503.639.4175 1 ' Date Ready/13y: Juris: ® See Page 2 for T I GA R D p Internet: www.tigard- or.gov Notified/Method: Supplemental Information TYPE OF WORK PLAN REVIEW Please check all that apply (submit 2 sets of plans w /items checked below): ❑ New construction ik Addition/alteration/replacement ❑ 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 ❑ 1- and 2- family dwelling ® Commercial /industrial ❑ Accessory building amps for all other installations. buildings ❑ Multi- family ❑ Master builder ❑ Other: ❑ 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 ", "I -2 ", "1 -3 ", 100HP or more. occupancy. Job no.: Job site address:gq'0 ,j /, ��C1 J I1 , S9 j ❑ Six or more residential units. ❑ Recreational vehicle parks. ��}} G�/� (�/7J ❑ Health -care facilities. ❑ Supply voltage for more than Clty /State /ZIP: �/�� © IL r ( <3 ❑ Hazardous locations. 600 volts nominal. Suite /bldg. /apt. no.: I' Project name:Dr /, j ,4 ( 5 6 c� ❑ Service or feeder 600 amps or more. �t ' 1 �j FEE SCHEDULE Cross street/directions to job site: Adrpv f1 Description 1 Qty. 1 Fee. 1 Total New New residential single - or multi - family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4 Ea. add'I 500 sq. ft. or portion 33.40 1 Tax map /parcel no.: Limited energy, residential DESCRIPTION OF WORK ( with above sq. ft.) 75.00 2 • Limited energy, multi - family 75.00 2 474 /6e e ,-AL 14 i,. te L c Pro 1,' j p Q residential (with above sq. ft.) `/ Services or feeders installation, alteration, and /or relocation 6 T 6 1 , e: (e -t L /t L 200 amps or less 80.30 2 0 PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2 401 amps to 600 amps 160.60 2 Name: �J�, A /�/�A e �, `/� � � • 601 amps to 1,000 amps 240.60 2 Address: / 4.9 5' N ` /'!T I Over 1,000 amps or volts 454.65 2 Temporary City/State /ZIP: E 4 D�� /Jig V05-2 relocation services or feeders installation, alteration, and /or Phone: (4,S) R Fax: ( 4 /0 1 5 7 Y4)1 - /5-77 200 amps 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 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 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, 6.65 2 each branch circuit Business name: Q�,p 0�E T D , B. Fee for branch circuits � ^f without service or feeder fee, 46.85 2 Contact name: first branch circuit i/ CII ?J ✓SSJ Address: / p .s od / >e Each add'1 branch circuit 6.65 2 v Miscellaneous (service or feeder not included) City/State /ZIP: Cigok/ r l I P / 944/ Each manufactured or modular 90.90 2 / dwelling, service and/or feeder Phone: + xi Fax: : 2 /3") Reconnect only 66.85 2 E -mail: "usS J 0 .7 - 44 ¢4 &--"DA j ie / A3Q , e_ ill Pump or irrigation circle 53.40 2 CONTRACTOR Sign or outline lighting 3 53.40 2 G co 0 Signal circuit(s) or limited - Business name: J ( 4 _ j / j e 4/ � energy panel, alteration, or Address: .. 5757 0 , '� A ), /� c CAN I A ( 'Q' q � 4 i � c t . d extension. Describe: Page 2 2 City/State /ZIP: 67c t O A G7L1 g' Each additional inspection over allowable in any of the above • 7 Per inspection 62.50 Phone: (SU 730,. i G Fax: ( • ) Investigation per hour (1 hr min) 62.50 CCB Lic.: E lectrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: �(� l Print name: Date: Plan review (25% of permit fee): ,p State surcharge (8% of permit fee): /, • O Authorized signature: i t ' c4h �� TOTAL PERMIT FEE: / 7 3.0- 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: \ Buildin g'Permits\ELC- PermitApp.doc 05/23/06 440- 4615T(11 /05 /COM/WEB