Permit ACI,A7.95 CITY OF TIGAR® ELECTRICAL RESTRICTED ENERGY PERMIT
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COMMUNITY DEVELOPMENT Permit #: ELR2010 -00046
Date Issued: 03/24/2010
tTiGAAL? 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 25101 DD00101
Jurisdiction: Tigard
Site address: 6975 SW SANDBURG ST 160
Subdivision: Lot: 0
Project: Serenity Tallative Hospice
Project Description: Low voltage for voice /data.
FEES
Owner:
WESTON INVESTMENT CO LLC Description Date Amount
2154 NE BROADWAY, STE 200 Restricted Energy Permit 03/24/2010 $67.84
PORTLAND, OR 97232 12% State Surcharge - Electrical 03/24/2010 $8.14
PHONE:
Contractor:
HASTINGS COMMUNICATIONS INC
10015 SW STEEPLECHASE CIRCLE
BEAVERTON, OR 97008
PHONE: 503 - 789 -5852
FAX: 503- 524 -5678
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: Y 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: 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 a - • - - 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. AT NTION: Oregon la ire s u to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -001 1010 through OAR 952 -001 - 00. You may btain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
(
Permittee Signature:
Iss ed By: ,
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 'ss s , OR I lu tl t)iN�l ,st x
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Received { /� O / �` n � `to - 4 4
City of Tigard Re eiv : d O' �� Permit No.: C I. OrCJ �( /
11
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit:
TI(. i 1. u'. iss Inspection Line: 503.639.4175 Date Ready /By: Jur ri ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method. rte 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.
Tess to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling J'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 ", "I -3 ",
Job no.: Job site address: `�, / 100HP or more. occupancy.
97�JW SGtl�1��(// / ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: Qt J ❑ Health-care facilities.
0 l oca ti ons. ❑ Supply voltage for more than
l 600 volts nominal.
I
Suite /bldg. /apt. no.: Project name: S�� / T f !� 77 v e gse ❑ 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
67.84 2
DESCRIPTION OF WORK • • (with above sq. ft.)
Limited energy, multi - family 67.84 2
I. r7 t4J V n / ✓e j r residential (with above sq. 11.)
I Services or feeders installation, alteration, and /or relocation
200 amps or less 100.70 2
.0 .PROPERTY OWNER • ❑ 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
City/State/ZIP: Temporary services or feeders installation, alteration, and /or
n 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
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 ❑ 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)
Ci City/State/ZIP: Each manufactured or modular
ty dwelling, service and/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 / / 7 _t�
Business name: panel, alteration, or extension. ` Page 2 L / 2
s rr .t15 (f�rNn1v.! t crr nn c �rf C • Each additional inspection over allowable in any of the above
O ./Address: / 00/ ,S S W s� Dip k ,,,A,24,_ 6 >G /F Additional inspection (1 hr min) 66.25/ hr
0o /� (� pp Investigation (1 hr min) 66.25/ hr
City /State /ZIP:
i/4 6 /� / 70 v L Industrial plant (1 hr min) 78.18/ hr
Phone: (5 73) SLci Si 76 Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed (%: hr min)
CCB Lic.: /3/ 9 7 ? Electrical Lic.:3y_ 1092ce Suprv. Lic.:/ 3 osG . ELECTRICAL PERMIT ,FEES
Suprv. Electrician signature, required: - Subtotal:
Plan review (25% permit 6 7� g�
y mit fee): --1
Print name: �� yi'GA_ A , s D e: 3 2 y... /v State surcharge (12% of permit fee): t../ 4
TOTAL PERMIT FEE: 7 5 1 9 g
Authorized signature:, -
4. This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name:g L.4 / - '71r _ r t Date: 3-2Y- / 0 • Number of inspections allowed per permit.
'J'
1:\Buildingermits \ELC- PermitApp.doc 10/01/09 440- 4615T(It/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
n Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
n Other:
■..COMMERCIAL WORK ONLY:
Fee for each commercial $67.84
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
n Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
n HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
n Medical
n Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
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