Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
Irk •%. COMMUNITY DEVELOPMENT Permit #: ELR2009-00355
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 12/10/2009
T[ G A R D Parcel: 2S 102 BA02000
Jurisdiction: TIG
Site address: 12353 SW GRANT AVE
Subdivision: Lot:
Project: Sprint Wireless
Project Description: Install restricted energy for wireless antenna.
FEES
Owner:
R & R REED DIVISION Description Date Amount
2808 NE MLK, STE C Restricted Energy Permit 12/10/2009 $67.84
PORTLAND, OR 97212 12% State Surcharge - Electrical 12/10/2009 $8.14
PHONE:
Contractor:
BERGELECTRIC CORP
6026 NE 112TH AVE.
PORTLAND, OR 97220
PHONE: 503 - 255 -1818
FAX: 503 - 255 -1919
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 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 thro gh OAR 952-001-0100.
-0 010 ��
0. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: CC. t r L.0 . )0 Perm itteeSignature.
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' 0 0 Apr? Date:
LICENSE NO.
CaII 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.
. - DEC.10 -2009 09:08 From: 5032556633 To:5035961960 P. 1'3
Electrical .Permit Application FOR OFFICE L.SL ONLY
City of Tigard — I
41 13125 SW Hull Blvd., Tigard, UK97223 f1 PlanRcvicw - dti v• y
ti ['hone: 503.639.4171 Fax: 503.s98.196IDE C 1 0 2009 Datc1B : i rL
'
TIGARD)
Inspection Line: 503.639.4175 Drnc Rendy /Lty Z S. Peg 2 for
I nternet: www.tigard- ur.gnv CITY OF T1GARD Notified/Method: ___- I Supplemental Information
TYrE t) ,�
,ld� P '
.Ps ' 5: ; I . c ' ,, ruarN RcvrO'< '4 ' .,
0 New construction ® Addition/alteration/replacement Please check all that apply (suhmil 2 sets of plans whtems checker( below).
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other:
where the available fault current ❑ Mamie: and boatyards
' C@TE(,ORY OF CONS1 R" iir1ION ; -' " ,'` j t•±. ` ' '`= cxcecds amps at150,•oltxnr 0Flontingbuildings.
less to ground, or exceeds 14,000 ❑ Coum,cteial -use agricultural
0 1- and 2- family dwelling ® Commercial /industrial ❑ Accessory building amps for all other installations. building,
❑ Multi- tamil ❑Masterbuilder ❑ Other: El Fire pump. C Installation of75KVAor
"---�"7-'T= 0 Emergency system(. larger separately denved system
JOB SITE INFORMATION ,AND UOCA'I'ION ❑ A iditinn pf'new mnlor kcal of
Job no.: 11862.26 Job site address: 12353 SW Grant Ave y 100HP or morc. txzttpnnoy.
❑ Six or more rnsulenttal unit:,. ❑ Recreational vehicle pinks.
City /State /Z!I': Tigard, OR 97227 1 ❑ Health-care facilities. 0 tinpply voltage for more than
^ ❑ 1 t:v n'daus lac:dt ,,, . G00 Vohs 11001;1191. Suite/bldg./apt. no.: Project name: E1.A. Os". t. Tlg wr tt \ / \-- El Service or f 600 nmps in more
Cross street/directions to job site! yy..JJ " -;(1 FI?f SCIIF.DTTLE
-. ()merit,' ion i Qtr I F. 1 Total j .
Ncw residential single -or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. tt, or Icss 168.50 4
_ - _-- Ea. add'( 500 sq. R. or portion 33.92 1
Tax map /puree( no.: Limited energy, residential
': DESCKIR'I'I ;0F 'WORC1H ' , ' 0 r :P,V }t ^ ( 1 : (with above sq. ti.) 67.154 2
r t
Install wireless antenna's. Limited energy. multi 67.84 2
residential (with above sq. tl.)
Services or feeders instnllation, alteration, and/or relocation
200 amps Or less 100.70 2
0 PROPERTY; :OWNER' + ' '' R ' 119 "1'ENAN I xN =' 201 amps to 400 amps 133.56 2 • •
Name: 401 amps to 600 amps 200.34 2
„ — - 6(11 amps to 1,000 amps 101 114 2
Address:
Over 1,000 amps or volts 552.26 2
City /State /ZII': Temporary services or feeders lustallation. alteration. and /or
relocation
Phone: ( ) Fax: ( ) 200 amps or less - 59.36 1
I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.11R 2
intended for sale, lease, rent, or exchange. according to ORS 447, 449, 670, and 70I. 401 amps to 599 amps 168.54 2 l
Branch circuits - new, alteration, or extension, cr panel
Owner signature. Date: '�
-• - A. Pee for brunch circuits with
• "® APPI,ICAINT . 0 ,.CON'I'ACI PF;R8ON, " above service or feeder roc, 7.42 2
each branch circuit
Business name: Bergelectric B. Fcc for branch circuits •
without Service Or feeder fee.
Contact name: Jason Hayes 56.18 I 2
first branch circuit
Address: 6026 NE 112 Ave Each add'I branch circuit 7.42 ! 2
Miscellaneous (service or feeder not included)
City /State/ZIP; Portland, OR 97220 Each manufactured or Tn duIar
67,84 2
dwelling, service and /or feeder
Phone: (503) 255 -1818 Prtx::(503) 255 -1919 Reconnect only 67.84 2
E-mail: jhayes(t4bergelectric.com Pump tic irrigation circle 67.84 2
(301V13(ACI'OR ,"?.".1 ,t .f Sign or outline lighting 67.84 2
Business name: Bergelectric Signal circuir(s) or limited-
energy panel. alteration, or
Address: 6026 NE 112 Ave. T extension, Describe: 1 Page 2 ('7 2
City /Start /Z1P: Portland, OR 97220 Each additional inspection over allowable in any of the above
Per inspection 66.25
!'hone: (503) 255 -1818 Fax: (503) 255 -19 (9 Investigation per hour (1 hr min) 66.25
CCLI Lic.: 110521 Electrical Lic.: 37-682C ,S Iprv, Lic.; 5485S industrial plant per hour 78.18_
. - ". rELECTRICAL "'PERMIT - FEES ' 7 '
Suprv. Electrician signature, reqtaireibq Subtotal: (7.84
•
Print name: Ken Fill , Plan review (25% of permit fee):
ps Date: 12/10/09
- ----, State surcharge (12% of permit fee): 8.14
Authorized signature: - - TOTAL PERMMI FF11: 75.98
Print name:.fason 1 (ayes b � �'l /10/09 This permit application expires if u permit ix not obtained within 180
- ` days after 11 1125 been accepted ax complete.
• Number of inapections allowed pet pennd.
I PermitApp dnc 1)1(11 /1` 440.40151(111115 /1 OM,WFR
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