Permit tie JJI!
CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
$� COMMUNITY DEVELOPMENT Permit #: ELR201000110
Ye Date Issued: 06/15/2010
TIGARD, 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 450
Subdivision: TIGARD TRIANGLE CENTER Lot: 0
Project: ACE American Insurance
Project Description: Low voltage for voice & data.
FEES
Owner:
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 Restricted Energy Permit 06/15/2010 $67.84
PORTLAND, OR 97224 12% State Surcharge - Electrical 06/15/2010 $8.14
PHONE: 503 - 624 -6300
Contractor:
NETVERSANT SOLUTIONS III LLC
9740 SW NIMBUS AVE
BEAVERTON, OR 97008
PHONE: 503 - 646 -0533
FAX: 503 - 641 -6613
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. ATTENT : Oregon requir- you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -001 hrough OAR 952 -001 0 .1. You maa • btain a copy of the rules or direct questions to OUNC by calling003.246.669• • 1.800.332.2344.
Issue By: £ ' Permittee Signature: e
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.
Electrical Permit Application FOR OFFICE USE ONLY
Of Tigard
City /
Y Received
IN Tigard Date/B i�� �' Permit No.:
�Q/O�G� /l0
a ' y -
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revew
Phone: 503.639.4171 Fax: 503.598.1960 Date/B Other Permit: hae.gUIQ Qe 7
TIGARD Inspection Line: 503.639.4175 Date Ready/By: runs 66 See Page 2 for
Internet: www.tigard or.gov Notified/Method: 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.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling 'g /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" "I 2" "I -3"
Job Job site address: � 7 VJW S p 9 , 1 <� r � 't e 100HP or more. occupancy.
Y� r i , 1 rs ❑ Six or more residential units. ❑ Recreational vehicle parks.
Cit /State /ZIP: p, -/. 1 �� 9 7 . 2 Z 3 ❑ Health -care facilities. ❑ Supply voltage for more than
` ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: /9eE / /I 7 m ,, f, Zn ❑ Service or feeder 600 amps or more.
S- 'Ant{ FEE SCHEDULE
Cross street /directions to job site:
Description 1 Qtr- 1 Fee. I Total 1 •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 1 68.54 4
Ea. add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
' DESCRIPTION. OF WORK (with above sq. ft.) 67 -84 2
Limited energy, multi - family
L / 67.84 2
Jte Vo / rte / g ¢ C V 9 , ,9-i6 CA OJe h { residential (with above sq. 0.)
!/ 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
Name: 401 amps to 600 amps 200.34 2
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
relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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
CI APPLICANT - ❑ CONTACT PERSON above service or feeder fee,
each branch circuit 7.42 2
Business name: B. Fee for branch circuits
without service or feeder fee, 56.18 2
Contact name: first branch circuit
Address: Each add') branch circuit 7.42 2
Miscellaneous (service or feeder not included)
City /State /ZiP: Each manufactured or modular
dwelling, service and /or feeder 67.84 2
Phone: ( ) Fax: : ( )
Reconnect only 67.84 2
E - mail: Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
Business name: v IC / V
/U E re s �-N Signal - Si circuits or limited -
n energy panel, alteration, or t/ / ��""ry
,
Address: 1 y o Sk) N I ►'►ihu s A ve 14 U e. extension. Describe: ' Page 2 G I f 2
City /State /ZiP: B ea ue 1 (- vi f c . 1 /o o S / Each additional inspection over allowable in any of the l above
e� Per inspection 66.25
6 - 0 , Phone: ) 6, 4 (. or 3 3 Fax: (s53, 6 e.{ 1 • 62 (Q Investigation per hour (I hr min) 66.25
CCB Lic.: 16( ) Electrical Lic.: C LE 11 1 Suprv. Lic.'. 710 1,eri Industrial plant per hour 78.18
�' om `' ....ELECTRICAL PERMIT FEES' y
Suprv. Electrician signature, required: Subtotal: (��, g
7! ,- --
Print name: (� �/ Date e' Plan review (25% of permit fe
(;)„..g._ ~ � I / 2: , ' Date 2_9/; State surcharge (12% of permit fee): Y•19
Authorized signature �
I /
) i ,,- ,,,�, TOTAL PERMIT FEE 75, 1`.6 / / This permit application expires if a permit is not obtained within 180
(
Print name: / Date:
,: ,x! , ; 4 . L'm i �S Z o� !. days after it has been accepted as complete.
• Number of inspections allowed per permit.
1.\ Building \Pei mils \ELC.PermitApp doc 10/01/09 440- 4615T(11 /05 /COM /\vEB