Permit 111 CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
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c : COMMUNITY DEVELOPMENT Permit #: ELR2010 -00066
T [GAkD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 04/27/2010
Parcel: 2S101 AC00400
Jurisdiction: Tigard
Site address: 7095 SW GONZAGA ST
Subdivision: Lot: 0
Project: WILLAMETTE DENTAL
Project Description: Burglar /fire alarm system combo
FEES
Owner:
NATIONAL SAFETY COMPANY Description Date Amount
17010 SW WEIR RD Restricted Energy Permit 04/27/2010 $67.84
BEAVERTON, OR 97007 12% State Surcharge - Electrical 04/27/2010 $8.14
PHONE:
Contractor:
STANLEY CONVERGENT SECURITY
SOLUTIONS INC
15495 SW SEQUOIA PKWY STE 100
PHONE: 503 - 968 -3353
FAX: 503 - 968 -3398
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: N 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: 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 '• : cor•ance ■ 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
day ATTENTION: Oregon :w •w - s you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
9 - 001 -0010 through OAR 952 11 -0100. Y• may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: _ e i�. �L _ Permittee Signature: 41
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.
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Electrical Permit Application gg rec'ei'ved "' °I ()IZf()I I I CI (i,1 ()ll t,,,.;n ` r 4o i.,Y I y ,
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.,1 City of Tiga Date /B : y zZ /o 17. - Permit No.� /o -UDOc,k
I' - . V 13125 SW Ha Blvd., Tigard, OR 97223 Plan Review
'I' ' ' a , Phone: 503.639.4171 Fax: 503.598.1960 APR , 21 2010 Date Other Permit: /0S1,2,0 /O DUO
` 1.'1. . x R.1', Inspection Line: 503.639.4175 Date Ready /By: NM 63 See Page 2 for
Internet: www.tigard- or.gov R� CITY OF TIGARD Notified/Method: Supplemental Information
TYPE OF WOIJILDINU 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
❑ 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
JOB SITE INFORMATION AND LOCATION • ' ❑Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: I Job site address: c 7 / S !mot/ G G 100HP or more. occupancy.
- t c R y ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: �)' W V c 2 �� ❑ Health-care facilities.
El Supply voltage for more than
7 ❑Haza rdour Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: tJ I I I K ,,,.. +C 1 4 4 ( ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I
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. 11. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential 67.84 2
DESCRIPTION OF WORK . • (with above sq. ft.)
Limited energy, multi - family 67.84 2
C roce y o 130 `- y £ �‘ re A-'C r AN S y S d-4.-t-- residential (with above sq. ft.)
l Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER ❑ TENANT - 201 amps to 400 amps 133.56 2
/ 401 amps to 600 amps 200.34 2
Name: V im' f (' G tot C+.44_ �-P A..1 c 601 amps to 1,000 amps 301.04 2
Address: "7 0 95" S c 6 C� h .Z tis 5 Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: 'if 5 4 r cL 0 (2 q .- _237
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 1 own which is not
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 - I ❑ CONTACT PERSON above service or feeder fee 7.42 2
• each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
manufactured Each
City /State /ZIP: • dwelling, serviceand/or feeder 67.84 2
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited-energy / C G
Business name: S / ..., j co N t / €ate S CC/-! T j� _p anel, alteration, or extension. / Page 2 C 7. 1 2
J Each additional inspection over allowable in any of the above
Address: / -(-'G( 9 .s --- ' ' eti S'.-e , Oe ' L u / 0 0 Additional inspection (1 hr min) 66.25/ hr
Investigation (1 hr min) 66.25/ hr
City /State /ZIP: �t
d I"'} / s "t O P Q ( 7 a F Industrial plant (I hr min) 78.18/ hr
Phone: ( ' 6 - 3$ 3� I Fax: (5 2 ) 9E� - 3 3 7 � j Inspections for which no fee is 90.00 / hr
b/' i „,,-1pccifically listed (/: hr min)
CB Lic.: 16 / . - 62 Electrical Lic.:37 io S ye L uprv. Lic.: eeff e.&104 • ELECTRICAL PERMIT' FEES
P " Subtotal: 6 7 . y
Suprv. Electrician signature, required: t'1 66 ___ Plan review (25% of permit fee):
Print name: 1 / vf�— Date: e. / - / 0 State surcharge (12% of permit fee): F, /y
TOTAL PERMIT FEE: 75 ??
Authorized signature: This permit application expires if a permit is not obtained within 180
/ days after it has been accepted as complete.
Print name:
e - 5 ,� v�Jv0 Date: q 2 f — 0 * Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 10/01/09 440- 4615T(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:
❑ 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 $67.84
system
(SEE OAR 918- 309 -0000)
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
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
p Other Act/AG- 1.4/e / Cd/
Total number of commercial systems: /
*No licenses are required. Licenses are required
for all other installations
I:\ Building \Permits\ELC- PermitApp.doc 10/01/09