Permit _. ,.., ` CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
I Permit #: ELR2009 -00068
'' �
. • ,; COMMUNITY DEVELOPMENT Date Issued: 12/30/2009
T1GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 1 S 30/200 7100
Jurisdiction: Tigard
Site address: 7143 SW ASH CREEK CT
Subdivision: ASH CREEK ESTATES Lot: 4
Project: Ash Creek Estates
Project Description: Home theater & security systems.
FEES
Owner: Description Date Amount
ASH CREEK PROPERTIES LLC
12655 SW NORTH DAKOTA ST Restricted Energy Permit 12/30/2009 $67.84
TIGARD, OR 97223 12% State Surcharge - Electrical 12/30/2009 $8.14
PHONE:
Contractor:
GLOBAL SECURITY & COMMUNICATION
3212 MAIN ST
VANCOUVER, WA 98663
PHONE: 360- 693 -1900
FAX: 360 - 906 -9692
Type of Use: SF
Class of Work: NEW
Total Number of Systems:
Audio & Stereo: Y
Security Alarm: y
Garage Door Opener: N
HVAC: N Total $75.98
Vacuum System: N Required Items and Reports (Conditions)
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 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
IssuedBy:/L1/�57Q Permittee Signature: a/1l 4 ('7 0 Al
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 603.639.4176 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.
12/30/2009 WED 9:02 FAX 360090069692_Gl Security 2001/003 •
. lI� EC. a_VED
Electrical Permit Application FOR OrFI U SF ONLY - _ '�, . °.
lTE C 3 0 2009 „t .s:., . >..- .. �... _
' 'V • • • ', .. : • ' Received �i 4 ,9t A
' , 'ij C of Tigard Date /I3 bi 6 I 'mint No.: Gr �f y �
11 - ' 13125 SW Hall Blvd„ Tigard, 0,111- T W ' A RD Plan Review r 9 �
Phone: 503.639 4171 Fax: 50 Date /l3 Other I'crtnil /b' ��f! C Qd
T GA RDO Inspection Line: 503.639.41 w UILDI G DIVISION Dale Ready /13y: 3m is: El See Page 2 for
A :.. -- 7, Internet: www.tigard- or.gov Notified /Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
[ New construction ❑ Addition /alteration /replacement Picase check all that apply (submit 2 sets of plans wJilents checked below):
E ❑ Service or fccdcr 400 amps or more ❑ Building ovcr three stories.
Defnol It ton ❑ Other: where Ilse available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
--- Icss to ground, or exceeds 14,000 ❑ Commercial-use agricultural
eii- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other insiallatioos. buildings.
Q MuIti- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger scpa:ately derived system.
JOB SiTE INFORMATION AND LOCATION El Addition of new motor load of
Job no.: Job site address: 7 l (5 ..... S te" /`'1 Sn (/F e t e C4" IOO t[i'or more. occupancy.
n ❑ Six or more residential unus. ❑ Recreational vehicle parks.
City /State /ZIP: ( (/ �\ 0 (" ' 1 n 0 3 ❑ llealth -care at i lies. ❑ Supply voltage for more than
°{ ll ❑ Hazardous locations. 600 volts nominal.
U
Suite /bldg. /apt. no.: Project name: (. /_11)(X>f 'lt� S
❑ Service or feeder 600 amps or more.
'�! FEE SCHEDULE
Cross street /directions to job site: Description I Qlv. 1 Ice. ) Tota1 1 '
New residential single -or multi - fancily dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. R. or less 168.54 4
Ea. add'I 500 sq. 1t. or portion 33.92 I
Tax map /parcel no.: _ Limited energy, residential
67.84 2
DESCRIPTION OF WORK (with above sq. 11.)
` r Limited energy, multi - family 67.84 2
� e( t I� p d �'`y(vu pv y l t �Q residential (with above sq. 11.)
(� ) 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 kiss 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 1 68.54 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,
7.42 I 2
each branch Circuit
Business name: 13, Fee for branch circuits
Contact name: ividtont scrvicc or feeder fee, 56.18 2
first branch circuit
Address: Each add'l branch circuit 7.42 2
Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or nodular 1
dwelling, service and /or feeder 67.84 2
Phone: ( ) Fax:: ( ) Reconnect only 67.84 2
E -mail: Pump or in•igation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
I II Signal ciicuil(s) or limited -
Business name:
( tSb� I Se < _ e� Vim= energy panel, alteration, or /
(� extension. Describe: Page 2 ' 2
Address: 3 2 (2 i-1 S
City /State/ZIP: Cvwi' �` O • )3 Each additional inspection over allowable in any of the above
— Per inspection 66.25
Phone: ( O ) • j - X Fax: (1kt7) qO6 j 5 '2 Investigation per hour (1 lirmin) 66.25 ___
CCB Lie.: 6� S Electrical Lic.:a6- / /c /t Suprv. 5207 L i- industrial plant per hour 78.18
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: f L Subtotal: I l? ?Py
Print name: aL't S k ,,p ., Date: 1240 0 0 9 Platt review (25% of permit fee):
�./ �� State surcharge permit fee): ,
Authorized signature: / TOTAL TAL PEERMIT FEE: .? S 10 ✓
_"
This permit application expires if a permit is not obtained within 180
Print name: ,„l Date: 1 2 - .3O - 0_ / da after it has been accepted as complete.
. Number of inspections allowed per pcnrn.
id milling /l'crmits`liLC t'crmitApp doc 10,01/09 •140-4615'
12/30/2009 WED 9:03 FAX 3609069692 Global Security 2002/003
Electrical Permit Application - City of Tigard /
Page 2 - Supplemental Information 1 /� C
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: ` ' .. .
Fee for all residential systems combined........ $67.84
Check Type of Work Involved:
Audio and Stereo Systems*
Burglar Alarm
_ Garage Door Opener
❑ Heating, Ventilation and Air Conditioning System*
Vacuum Systems*
Li Other:
COMMERCIAL WORK ONLY::
Fee for each commercial $67.84
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
_ Clock Systems
Data Telecommunication Installation
n Fire Alarm Installation
IJ HVAC
U Instrumentation
❑ Intercom and Paging Systems
- 1 Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting`
n Protective Signaling
U Other
Total number of commercial systems:
: licenses are required. Licenses are required
for all other installations
hiSuilding \'omits \IiLGPcnnitApp,doc 10.01/09
01/05/2010 TUE 9:31 FAX 3609069692 Global Security VI 001 /002
E 22O0R - oaC(0 8.
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JAN 05 2010
,.40, Request for Perrnit Action
ZIGA•RD
— CITY OF TIGARD
. BUILDING DIVISION
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: !kJ ,-
j _ Applicant ❑ Contractor n City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) G b J (`
�cupt
Mailing Address: 32 A' c 4
City/State /Zip: U OksKjAk. W N Q. o0 .
Phone No.: ( U) f 4C � " pia
'LEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): •
64 CANCEL PERMIT APPLICATION.
,° (Ei 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( aa9 0006g
Site Address or Parcel # : ] I "1 5k) I Sk Cr eek C - {
Project Name: (),)l/d„)00,1 1 YlorvteS 4 Gee k_ ES`Oes
Subdivision Name: Lot # :
EXPLANATION: 4tiide0 Gt, p4 4-,,,_ c l eoc, G: $d /)I
S --_ /4--- Date: ) – S7 .
Print Name: i exk—
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.
•
� t t,r . a r,! n4 f r n, h ' .' k -� .i .w
� M1 s �r ,� � , � . �. ± =FOR OFFIGE.USE ONLY t .. , a , �.,,. , r'r�;?x'.,..'� . �.�; �,�r l �,, . •
Rte to Sys Admin: Date By .Rte to Bldg Adniin:; . Date / ,y/e) By '7
• Refund Processed: Date / / / // : ;tir/e Invoice Processed: Date By
Permit Canceled: Date / •/ B �f�, arcel Ta• Added: Date B .
Receipt # Date ' Met od Amount $
:\ Building \Forms \RegPermitActioii.doc Rev 07 /26/07
• CITY OF TIGARD RECEIPT
V
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 176515 - 01/08/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2009 - 00068 $ - 60.78
Total: $ -60.78
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 110331 DHOWSE 01/08/2010 $ -60.78
Payor: Anthony J Gomez, Global Security & Commu
Total Payments: $ - 60.78
Balance Due: $60.78
•
Page 1 of 1
CITY OF TIGARD RECEIPT
. SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 176425 - 12/30/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2009 -00068 Restricted Energy Permit 2200000 -43103 $67
ELR2009 -00068 12% State Surcharge - Electrical 1003100 -24001 $8.14
Total: $75.98
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 110331 DHOWSE 12/30/2009 $75.98
Payor: Anthony J Gomez, Global Security & Communication
Total Payments: $75.98
Balance Due: $0.00
•
Page 1 of 1
r' •
• City of Tigard, Oregon G 13125 StiV Hall Blvd. ° Tigard, OR 97223 •
.R
January 8, 2010
Global Security & Communication
3212 Main St.
Vancouver, WA 98663
Attn: Jeff Isaak
•
Re: Permit No. ELR2009 -00068
Dear Mr. Isaak:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 7143 SW Ash Creek Ct.
Project Name: Ash Creek Estates
Job No.: - N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $60.78.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as work was completed under MST2009- 00183, all
encompassing. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
. Sincerely,
r
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds \Administra tion \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard - or.gov • TTY Relay: 503.684.2772
City of Tigard
T L G A R D Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Global Security DATE: 1/8/2010
3212 Main St
Vancouver, WA 98663 REQUESTED BY: Dianna Howse
Attn: Jeff Isaak
TRANSACTION INFORMATION:
Receipt #: 176425 Case #: ELR2009 -00068
Date: 12/30/09 Address /Parcel: 7143 SW Ash Creek Ct.
Pay Method: CreditCard Project Name: Ash Creek Estates
EXPLANATION: Per applicant's request as the work was covered under MST2009- 00183.
'REFUND. INFORMATION:
pee Desciiption.From'Receipt . Revenue Account No. Refund
Exatnjile:.: [BUILD1 Permit Fee • Example: 245- 0000 - 432000 $'Amount
Restricted Energy Permit 2200000 -43103 $54.27
12% State Surcharge 1003100 -24001 6.51
TOTAL REFUND: $60.78
APPROVALS:
If under $5000 Professional Staff _ • i; �•
If under $7,500 Division Manager
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY • • • • .
Refund Request Reviewed: Date: /,� / Q By: i1t
Case Refund Processed: Date: A /t) By: '
I: \Building \Refunds \RefundRequest.doc 04/13/09