Permit ELECTRICAL RESTRICTED ENERGY PERMIT.
1 Y � ,r
CITY OF TIGARD
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COMMUNITY DEVELOPMENT Permit #: ELR2009 -00247
ii Date Issued: 08/04/2009
Ti kEt.D„ 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
� Parcel: 1 S135DD03703
Jurisdiction: Tigard
Site address: 11624 SW LOMITA AVE B -1
Subdivision: Lot: 0
Project: Park Place
Project Description: Install fiber optics for Verizon.
FEES
Owner:
1616 SHORELINE LLC & Description Date Amount
LOMITA WEST LP, PO BOX 15516 Restricted Energy Permit 07/31/2009 $75.00
FREMONT, CA 94539 12% State Surcharge - Electrical 07/31/2009 $9.00
PHONE:
Contractor:
PHONE:
FAX:
Type of Use: MF
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 $84.00
Intercom /Paging: N Landscape /Irrigation: N
Required Items and Reports (Conditions)
Landscape Lighting: N Medical: N
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 th oug OAR 952 - 001 -0100. You may obtain a op /� of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: `G. �1 1 X N Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property l 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.
- i„
.",ECFIVED
... ,
JUL 2 9 2009
Electrical Permit Application ' 0::,, ,, : , :: , ::...r.'.. , .::',
' , r w , +t
CITY OF TI ® ' r><c usE n .
, FUI2 U[ NLY ,
Cit of rlgatd � a �° Permit No,; • • t 13,(25 SW iidl l3(ul TI;i >rd. OR 9 311LDING,
Pion d . RI, r • , cc , 7
MirROYIC
1 a 0Iltor Pee,JI.
4 2 l Nh nic 5 171 Pits: 503.590.1960 OMNI!
(napts, 100 Line 503:639.4175 nate Reul Ai
1 • , • ( Y o 1��r) 0 See me Page nl z trot
internee ww
t tv.agitl'd�Un,gaV NOilfiedlMaLml: \ Supplenl tnfni•nmthm
TYPF ,Ot/ WORK PI,,to Rrvlrw.
rr New construction II Addition /n(teration /rcplact:lncnt - -. .. - Pic oe chock 81118 spiny (sobau ¢
t 2 .0 er1,1100 0,00 checked tWl UCIn0lih Otl ❑ Other: O Solo or (ceder 400 amps m mon: ❑ nulInin nv vitro:0 410r16'.
u'l+ero 2110: n. ila01c null curtcol 0 won:1$ and Nary:rah.
• .,'. CATEGORY •01' `CONSTRUCTION , ' '•'. '; c.m:oats 10000 amps ;4 150,' 2, r ( buildings.
i- and 2- Inln(1 dwelling Iczcu, ground.orexceedr14.0(10 (3Conlmorchrt.nro rtl
El y g [J:Comniercinl /industrini 0 . bnildin0t.
Gi Mttlti- ftltnity 0 Master builder ❑OIIICi'I 0 PiroNoy2. C( ln.r;dtnlimtof /tor
[) Cmttgm+ty sye tar r e nl het d erived s tint•
' ' JOB SITE. INFORMATION AND LOCATION be ,, (' ' y y;
.. ... ❑ Addilinu of uc n aenr Lludnl ❑•q "•yi' "i•1'••IJ ^,
Job no.: Job sic address; 11624 SW LOMITA AVE uHlHporroom. 1,<cnpa"cy.
ID SiX tx Moro rentivot o unite. 0 Ream:atonal vep(ele parks,
City/State/ZIP: TIGARD, OR 97223 LJHcahh•rvorncilities. 0Sow!) for nwretion
0 tia4, lucutiunc. GOO vnlls n01114101.
Suite /bldg./apt. no. Bi - BY Project name: PARK PLACE ID ScrviCO nrfecdcr600unipsor n,o,o.
..FreE SC11EDULr . .
Cross street /direelions to job site: _ ^ a a n, + l
1 1 O lv 1 I'm 1 ' noel
New resItlentlol single- or trn2llI- firnlIy dwell1 ig ual1.
incintio$ tttacllt+d garage
Subdivision: 102 110.: 1,000 Aq R. or loss 145.15 4
—
Tax nap/parcel Ito.: 11a. AV 500 q. It. or portion 33.40 I
° — ... Limited energy, rosidontlnl 75.00
DOSORIPT[ON 01' WORK (wait auto, ,q, Ii.)
INSTALL FIBER OPTICS. FOR VERIZON Li e''e'sy' Ilt 7100 2
r esiilcn(ial (woe olx+vd et.
Services or fectlers tnstatIntlon,oltcratlon, and/or relocation
200 otn n' or less 80.30 2
'Q PROPER'I'Y'OWNER • J :.. • ' []' TENANT ' ` '' , • •' 201 amps 10400 antes 106;85 2
Name: 401 amps to 6008 (1.4 1 (60.60 2
_____ 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or tint lo 454.65 2
City /State /ZIP: 'feinpovary:Serviees or terriers Installation, alter; Con, and /or
relocation
Phone: ( ) Fax: ( ) 200 amps o. less 66,85 1
_
_•,��
Owner installation: This installation is being made on property that 1 own which is not 201 amps to 400 1160 100.30 2
intended for sale, lease, rent, orexcltango, according 10 ORS 447, 449, 670, end 701. 401 tit ;is 10599 limps 133.75 2
Owner i i b nnr.ul'Cl 11101010 circuits -916w. ltlter:nioa,.or extenslea, per panel
— °- — -. Date:
A. i ce for branch elren(w t1-1111 r '
0 APPLICANT ' .- : '' :;1 ' ' . - Ej CONTACT PERSON ' ubovc'se vice or lccdcr leo, 665 2
each branch CitC1112
0)1510651 Kline: NORTH SKY COMMUNICATIONS, INC. 0. FCC t - ot- branch ehcuits
COntnct'. u�idroui service or feeder fee,
name: 2
ERIK SCHENCK lirstbrewhcircuit 46.85
Address: 11818 SE MILL PLAIN BLVD STE. 410 F,:ich 'l
lddbrunchcircuit [ 6.65"} 2
NUsccllatteous (service or feeder out iu chided)
coy /Sl8le/Z1P: VANCOUVER, WA 98684 Each niunulacinrcdormodulur 4090
Phone: (503) 969 7729 Fax: 866) dw ^- Ilinr, scrviccnnd /er( cctle'
t 452 4853 Reconucctonly 66.85 2
E.mad: rid or5.northskycomm,coin Pump orinigativucircle 53,40 2
CON'T'RA( TOR - • - Sign'orontlloc lighting 51.10 2
Bnuncs name: NORTH SKY COMMUNICATIONS, INC,
Signal pa nel , (a)rlitoitcd-
energy panel, alteration, or
Address: 11818 SE MILL PLAIN BLVD, STE 410 extension.De.<cribe: 1 rag 2 $75.00 2
CiIyIStateiziP: VANCOUVER WA 98684 finch nddltional Inspection over alto ,yi1Iein any ofllicabove '
Phone; ( 360) 254-6920 .. Per inspection G2.50
Fnx: ( > 1- 866 - 530 -4325, tuvevtignt(on per hour(1 or n,int 62:50
CC9 Lic.; 141 i 7 Blcuricn1 Lic•:17- 1,54CL D sally. Lie.: 173LEB 1n11uzuinlpl:mtp4' It01 ' 73:75
%�
" ' CI.Ie{1 ' RICAI. PERMIT FEES Suprv. Electrician signature, rY(ltlirctf: t.
Subtobd: 575.00
Print name: JACK CAGLE Date.: 7/29/09 plum re0i020 (25 of permit fee):
� f
State surcharge (12'7 of permit fco): $9,00
Autllolircd signature. g /�r� /".9., TOTAL PER tor PEE: ,'$4.00
Print nnmc: ETHAN A. DOLPH Date: 7/29/09 '11110 poi, dtu {rpth'ntlon uspl■vs If a moth Is not obinlucd watt 180
tiny% rifler 11 1120: boon nCCCultst a. tumplciv,
islutsOct. o1'hls n ,:icons 1410088 lkr frrnill,
Iaa nng in0WC■u1h11;1,p•0,:rnin0pp.,lnc 012)08 8/04610)1' Un.VCWIA'IlI1
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