Permit •
mto.y.ti• JF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit #: ELR200900339
`T 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 10/30/2009
,,,,.ate,,, o ,,, , Parcel: 2S101 DA00102
Jurisdiction: Tigard
Site address: 13221 SW 68TH PKWY 200
Subdivision: TRIANGLE CORPORATE PARK Lot: 2
Project: HealthNet
Project Description: Low voltage for HVAC wiring.
FEES
Owner:
GK TRIANGLE CORPORATE PARK III L Description Date Amount
PO BOX 2096 Restricted Energy Permit 10/30/2009 $67.84
WARREN, MI 48090 12% State Surcharge - Electrical 10/30/2009 $8.14
PHONE:
Contractor:
AMERICAN HEATING INC
1339 SE GIDEON ST
PORTLAND, OR 97202
PHONE: 503 - 239 -4600
FAX: 503 - 239 -7038
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 • • - - ith 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. , ENTION: Orego law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -0r 1 -0010 through OAR 95 ou may obtain a cop of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. ‘C g 1
Iss. ed By: Permittee Signature:
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.
p
EIeC •,p1TCat10II FOR OFFICE USE ONLY
. and Receive /J n _ _ L
h DateB /0 Q l Permit No.: �L p((.tJ _ �d`
• 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date/13y: Other Permit:
TI G A R D Inspection Line: 503.639.4175 Date Ready/By: ]uri IN See Page 2 for
Internet: www.tigard - or.gov Notified/Method: f Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction ddition/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
❑ Emergency system. larger separately derived system.
• JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 - ", "1 -3 ",
Job no.: Job site address: /3221 S fin/ 68 PIN)/ 10011P or more. occupancy.
❑
❑ Six or more residential units. Recreational vehicle parks.
City/State /ZIP: 779 4 ■ C7/ 7-722.3 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: liCGI, `J Nei- ❑ 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 145.15 4
Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
. DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
d W vO I fqy e — S71- � S
Limited ei energy, tial (with th above sq ft
/ I/ V f J + residential (with above s multi-family ft.) 75.00 2
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
. ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 1
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 PERSON ' above service or feeder fee, 6.65 2
/ /11 each branch circuit
Business name: A mer 1 C a/1 17'ea - /-� B. Fee for branch circuits
Contact name: oak from -/- / e t without service or feeder fee, 46.85 2
first branch circuit
Address: 6372 5 o� S --t-- Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: 0,--i- Jar) R 97202- Each manufactured or modular 90.90 2
dwelling, service and/or feeder
Phone: (503) 239- y *0 0 Fax: • (5 ) 23-70 5 g Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
• CONTRACTOR Sign or outline lighting 53.40 2
Business name: Hey Signal circuit(s) or limited -
�/'J' Gh /74 energy panel, alteration, or ^ �
Address: 133 6:7 5E 6/de a,,1 extension. Describe: J-- Page 2 ()7 t7
, g 2
City/State /ZIP: / (/r7/fh d D g ^7Z Q 2 Each additional inspection over allowable in any of the above
/� Per inspection 62.50
Phone: (503 ) 237 y6' 2c? Fax: (5 )237 703 8 Investigation per hour (1 hr min) 62.50
CCB Lic.:33)3 5 Electrical Lic.: 2 t / j?(A' Suprv.Lic.:2(,90 LE3 Industrial plant per hour 73.75
. ELECTRICAL PERMIT FEES
Suprv. Electrician signature, require ��1'� _ Subtotal: 7. g
Print name: T 5-1- Jer y j Date: to 2ci- 0I Plan review (25% of permit fee): �---
State surcharge (12% of permit fee): 3 . I y Authorized signature: TOTAL PERMIT FEE: 7 g . cm
This permit application expires if a permit is not obtained within 180
Print name: g,,-. �� Date: /0 -2e7 _01 days after it has been accepted as complete.
Number of inspections allowed per permit.
I.\ Building \Permits\ELC- PermitApp.doc 05/23/06 440-4615T(t t/05 /COM/WEB