Permit a CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
° COMMUNITY DEVELOPMENT
. Permit #: ELR2010 -00056
°
T I G ltiA 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 04/02/2010
Parcel: 2S 101 AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 460
Subdivision: TIGARD TRIANGLE CENTER Lot: 0
Project: AM Trust North America
Project Description: Low voltage for HVAC
FEES
Owner:
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 Restricted Energy Permit 04/02/2010 $67.84
PORTLAND, OR 97224 12% State Surcharge - Electrical 04/02/2010 $8.14
PHONE: 503 - 624 -6300
Contractor:
PROTEMP ASSOCIATES INC
9788 SE 17TH AVE
PORTLAND, OR 97222
PHONE: 503 - 233 -6911
FAX: 503 - 238 -9767
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: N Fire Alarm: N
HVAC: Y Instrumentation: N Total $75.98
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: 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 rough • ' 95 .01 -:100. You may obtain a copy of the rules or direct questions to OUNC by calling 503. 46.6699 or 1.800.332.234 .
Issued = _ _ / Permittee Signatu_
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 Application FOR OFFICE USE ONLY
City of Tigard R Date/B e : A ro • Pennit No.: C
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
N... Phone: 503.639.4171 Fax: 503.598.1960 Date /B : Other Permit:
T I G A R D Inspection Line: 503.639.4175 Date Ready /By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov Notified /Method: Supplemental Information
TYPE OF WORK 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
❑ 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
J013 SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A". "E ",' 1 -2 "I -3 ",
Job no.: 9770 Job site address: 12909 SW 68 PKWY 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: TIGARD OREGON 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: 460 Project name: AMTRUST ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. 1 Fee. 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
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
(with above sq. fl.) 67.84 2
DESCRIPTION OF WORK ( q•
Limited energy, multi - family 67.84 2
RELOCATE THERMOSTATS residential (with above sq. ft.)
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
' 401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps [0 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
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: PROTEMP ASSOCIATES B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: BRUCE BUTNER branch circuit
Each add'I branch circuit 7.42 2
Address: 9788 SE 17 AVE Miscellaneous (service or feeder not included)
City/State/ZIP: /State /ZIP: PORTLAND Each manufactured or modular 67 84 2
tY dwelling, service and/or feeder
Phone: (503 - ) 519 - 6199 Fax: : (503) 238 - 9767 Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: SAME AS ABOVE panel, alteration, or extension. 1 Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
CitylStatelZlP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed CA hr min)
CCB Lic.: 38868 Electrical Lic.: 261063 Suprv. Lic.: 2613 ELECTRICAL PERMIT FEES
Subtotal:
Suprv. Electrician signature, required: o
.�j Plan review (25% of permit fee):
Print name: MONTY SCHROEDER Date: 4/2/10 State surcharge (12% of permit fee):
TOTAL PERMIT FEE:
Authorized signature:
� This permit application expires if a permit is not obtained within 180
Ad days after it has been accepted as complete.
Print name: BRUCE BUTNER Date: 4/2/10 * Number of inspections allowed per permit.
I: \Building \Permits \ELC- PermitApp.doc 10/01/09 440- 4615T(1 /05 /COM'WEB