Permit 1 1 1 11 e Community Development
1. GAR Request for Permit Action
ID
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 A City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) , L C r c . i Q I U.rS
Mailing Address: vV `. `
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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 #: C \ C2 QOC ' 00 i 1, 0 .
Site Address or Parcel #: a30 PQC -C i, C ---kkUVI I 0 0
Project Name:
PQrtiltk. Bpwp/
Subdivision Name: __ Lot #:
EXPLANATION: U3 Or « cone l at r -L,c i Ci' oos;4)
tQ 2 c ko or rni - - 1 1./tic-,c --v
0_ 6nA -era \-or
Signature: Date:
Print Name:
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 / //9 477 By .r
Refund Processed: Date Air °f By .,7 Invoice Processed: Date 1 By
Permit Canceled: Date 4 0 r By„ ' — Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
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Electrical Permit Application
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W' City g C of Tigard �.i tO _ 1 `
Permit No. I ` Q . • • `
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13125 SW Hall Blvd., Tigard, OR 97223 x I n q _ 2009 Plan Review n
!i - -, „ C . Phone: 503.639.4171 Fax: 503.598.1960 2009 Date /B : 1 1 lf7tL) Other Permit: i . Ct136
r I � " Inspection Line: 503.639.4175 Date Ready /By: ®See Page 2 for
ii: El G A R DD: ; g g CI OF TIGARD
+ K Internet: www.ti ard -or. ov Notified/Method: 121 See Page Supplemental 2 information
TYPE O w LDING 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.
CA TEGORY 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
Job no.: Job site address: 16230 SW Pacific Highway 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: Tigard, Oregon ❑ Health -care facilities. ❑ Supply voltage for more than
• ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: 100 Project name: Panda Express ❑ Service or feeder 600 amps or more.
. FEE SCHEDULE '
Cross street/directions to job site: SW Pacific Highway and SW Durham Road Description 1 Qty. 1 Fee. 1 Total 1 •
New residential single- or multi - family dwelling unit.
Tigard Town Square Shopping Center 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.: 2S115BA02600 Limited energy, residential 75.00 2
DESCRIPTION OF WORK . . (with above sq. ft.) -
Limited energy, multi - family 75.00 2
Tenant Improvement for 2,000 sf restaurant in vacant building residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
°\ AO 200 amps or less 2 80.30 160.60 2
❑ PROPERTY OWNER El TENANT 201 amps to 400 amps 106.85 2
Name: Panda Express Inc. 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: 1683 Walnut Grove Avenue Over 1,000 amps or volts 454.65 2
City /State /ZIP: Rosemead, California 91770 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (626)799 -9898 Fax: (626)372 -8288 200 amps or less 66.85 I
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 ® CONTACT P ERSON above service or feeder fee 40 6.65 266.00 2
each branch circuit
Business name: Reiter Design Group Architects, Inc. B. Fee for branch circuits
Contact name: Scott A. Reiter without service or feeder fee, 46.85 2
first branch circuit
Address: 7965 SW Cirrus Drive Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City /State /ZIP: Beaverton, Oregon 97008 Each manufactured or modular 90.90 2
dwelling, service and/or feeder
Phone: (503) 574 -3036 Fax: : (503) 574 -2916 Reconnect only 66.85 2
E -mail: ScottRDG @aol.com Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 2 53.40 106.80 2
Signal circuit(s) or limited -
Business name: To Be Selected
energy panel, alteration, or
Address: extension. Describe: Page 2 2
City /State /ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75
• ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: 533.40
Print name: Date: Plan review (25% of permit fee): —1.1.1 5--
State surcharge (12% of permit fee): 64.01
Authorized signature: TOTAL PERMIT FEE: 4341:16..
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete. t�\
' Number of inspections allowed per permit. e1
1:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440- 4615T(11 /05 /COM/WEB
•
(- z l - /'
ilq Community Development
' 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 X City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) L crock e Q V I Lc r c
Mailing Address: ` -7
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): •
CANCEL PERMIT APPLICATION.
n 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 ■ C2 00q • 00 i to e)
Site Address or Parcel #:( . 2 0 1 P ` i- ,, C , w, 1 00
Project Name:
l TQYI tt BC B ptjzc �
Subdivision Name: Lot #:
EXPLANATION: W O(K cone W ' di. r 6LC OO ° 0 ,006 9
tc cu(c tx, Ic2 Q r term } � t lit- C --c)
Q 0 n Q -or
Signature: Date:
Print Name:
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.
'',I 1, � `'' , : �7 'l ",Q. KoF FT E*O•L3.r ( {
� ,, r' -., ,.,d t, I °rJ � .� d � ,. Y I'� !I _.. � US N t �., -1 L.��'i,1 .vl -. :6lil4 h4,. ;l ,. , ter 4 h
Rte to S s Admin: Date B Rte to Bld• Admin: Date %/ O B . r=
Refund Processed: Date EH Invoice Processed: Date B
Permit Canceled: Date i;J B ' ,SW! Parcel Ta. Added: Date B
Recei.t # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07