Permit # ELECTRICAL RESTRICTED ENERGY PERMIT
q CITV OF TIGARD
: '. COMMUNITY DEVELOPMENT Permit #: ELR2010 -00134
(G AR D 13125 SW Hall Blvd., Tigard OR 97223 503,639.4171
Date Issued: 07/23/2010
�., Parcel: 2S102AA00906
Jurisdiction: Tigard
Site address: 12080 SW MAIN ST
Subdivision: Lot: 0
Project: Rite Aid
Project Description: Add (3) cameras and monitor to existing system in pharmacy
FEES
Owner:
BSM REALTY LLC Description Date Amount
3176 AMERICAN SADLER DR Restricted Energy Permit 07/23/2010 $75.00
PARK CITY, UT 84060 12% State Surcharge - Electrical 07/23/2010 $9.00
PHONE:
Contractor:
CHECKPOINT SYSTEMS INC.
8180 UPLAND CIRCLE
CHANHASSEN, MN 55317
PHONE: 971 - 212 -3779
FAX:
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: N Boiler Controls: N
CCTV: Y Clock Systems: N
Data & Telecommunications: N Fire Alarm: N
HVAC: N Instrumentation: N Total $84.00
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 through OAR 952- 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246. 9 or 1.800.332.2344.
Issued By: -��� �� Permittee Signature: r _
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.
F . , t tl '1 ! b �AV .
Electrical Permit Amalie pr. 1,7,_„,, �' :I f)R t l I CI t ISF ON
1111 City of Tigard 2 3 2010 DateB �3 a t'h Permit No. --• 0 /39' •
° 13125 SW Hall Blvd., Tig OR Plan Revi-
Other Permit:
0
Phone: 503.639.4171 Fax: 50 M 196p -, ., r , Date/B :
i i i A i:fi> Inspection Line: 503.639.4175 U b I , 11"' I 10/Ai Date Ready/By: Juris: ® See Page 2 for
- Internet: www.tigard- or.gov BU LDYNC DIVISION Notified/Method: 776-- 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 ,,Commercial/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 ", "l -2 ", "I -3 ",
Job no. : B�3 y Job site address: ! d ' 100HP or more. occupancy.
/� U Z t� {/V [/ ti W " /� �� / 0 or more residential units. ❑ Recreational vehicle parks.
ty
Ci /State /ZIP: /� elf /J J ❑ Health-care facilities. ❑ Supply voltage for more than
�/V �� C. //� G CY 7,9r El Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: / [� , �6' ❑ Service or feeder 600 amps or more.
�/ FEE SCHEDULE •
Cross street/directions to job site: 9 ! � Z Description 1 Qty. 1 Fee. 1 Total 1
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK . (with above sq. ft.)
Limited energy, multi - family 75.00 2
/1,09/721e--1,/ 4/2)/67 7 /v �r �i��� : resid (ith . ft.)
[ '"�� !"'� Services or ential
feeders above instal alteration, and/or relocation
Y ";IW 7,01 /. 200 amps or less 100.70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 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
tY relocation
Phone:( )
Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
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
❑ APPLICANT • ,'CONTACT •PERSON above service or feeder fee 7.42 2
• each branch circuit
Business name: 4 • • ' %" f C rfa •
i / ✓rt ,0/(1 B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
tY dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
' Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: 0, G ° Div 7, c.l y� rit4r / /V t' panel, alteration, or extension. Page 2 26� 2
Each additional inspection over allowable in any of the above
Address: f / .
�D j 4 f7 c, (ei- Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: //������ N �/ _ ?` Investigation (1 hr min) 66.25/ hr
LJ7� / �y -S 5 1 .312 Industrial plant (1 hr min) 78.18/ hr
Phone: Z /2, S : 1 Fax
Inspections for which no f is
( ) yd 90.00/ hr
specifically listed (' /: hr min)
CCB Lic.: /O Electrical Lic. :C Suprv. Lic. :( ` c J — Wore ' , . • iELECTRICAL PERMIT 'FEES
Suprv. Electric iiattfre, required : /� !? 9 p MA///' v Subtotal:
f;�f2�G` -� P review (25% of permit fee):
Print name: -j // S�(9 j Date: 7 /6 fi id _ State surcharge (12% of permit fee): 9. P
�`�� � 4 I TOTAL PERMIT FEE: y e p6
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date:
Number of inspections allowed per permit.
1:\ Buildineermits \ELC- PermitApp.doc 07/01 /10 440- 4615T(11/05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined .. $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems* .
❑ Other:
;COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
n Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentations
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical /
❑ Nurse Calls
❑ Outdoor Landscape Lighting* /v
P g g
❑ Protective Signaling ` J
N Other ( '/A'eI e C�V
Total number of commercial systems: /
*No licenses are required. Licenses are required
for all other installations
C\ Building \Permits\ELC- PermitApp.doc 07/01/10