Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
1 ` 1 .' a COMMUNITY DEVELOPMENT Permit #: ELR2010 00151
T I G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/12/2010
Parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 200
Subdivision: TIGARD TRIANGLE CENTER Lot: 0
Project: CNA Insurance
Project Description: Low voltage for CCTV
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 Restricted Energy Permit 08/12/2010 $75.00
PORTLAND, OR 97224 12% State Surcharge - Electrical 08/12/2010 $9.00
PHONE: 503 - 624 -6300
Contractor:
CONVERGINT TECHNOLOGIES
16575 SW 72ND AVE
PORTLAND, OR 97224
PHONE: 503 - 228 -8522
FAX: 503 - 228 -8521
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 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 acc• - = - .. • 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. ATTE ION: Oregon la requir-. you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -00 0 through OAR 952 -00 0 0 •. Yo m , obtain a copy of the rules or direct questions to OUNC by calling 503.246 -.:x : or 1.800.332.2344.
Issu. • By: ri milli-- 1. I�1—.. L .d Permittee Signature: / • 7 ��il %% - - - --
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 f, ... FOR OFFICE USE ONLY
City of Tigard Date/By: a Iv li Permit No.: E be) - •00 /5/
Nu 13125 SW W Hall Blvd., Tigard, OR 97223 Plan Review /1� Q� �9
' C Phone: 503.639.4171 Fax: 503.598.1960 Date/By:
Permit: /o�c� r
T I G A R D Inspection Line: 503.639.4175 Date Ready/By: Juris: RI See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction p 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 14 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.
A
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
/r1h 100HP or more. occupancy.
Job no.: Job site address:
I,,? y1 � b�/ �'t� /kw/ ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: / va/ g 9/,2,;23 ❑ Health-care za Hazardous fcation ❑ Supply voltage for more than
❑ Hazardous locati 600 volts nominal.
Suite/bldg. /apt. no.: Project name: C/v 4 ❑ Service or feeder 600 amps or more.
5-7:-. FEE SCHEDULE
Cross street/directions to job site: Htin fem Description I Qty. I Fee. 1 Total 1 •
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'l 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
Limited energy, multi - family
1 - , d, �' /1/e vs' j� .4,/ni 4 " Y�c /f7�ro I/:rlAc, residential (with above sq. 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 1 ❑ CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'/ branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
, _ Signal circuit(s) or limited -
Business name:
IQNI/C' i s' % /erA, /Gi,7,i f 22 f- energy panel, alteration, or
,,.� extension. Describe: / Page 2 'S' 2
Address:
/4 S� y1 ,4 v�,
City/State/ZIP: i7 / � Each additional inspection over allowable in any of the above
ty r �r�' �� % '�y Per inspection 62.50
Phone: c,.; ( ? 7 7 3: 2 2 Fax: ( 3') ' ���/ Investigation per hour (1 hr min) 62.50
CCB Lic.: / %g7 C� Electrical Lic.: ./ a Suprv. Lic `2gC _LM Industrial plant per hour 73.75
/ / ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: :1 ! Subtotal: 75 CO
Print name: Date: T
Plan review (25% of permit fee): d—'
� ' / rJ/ yierft U hhe State surcharge (12% of permit fee): , to
Authorized signature: �. ` 6a TOTAL PERMIT FEE: $ it , GCS
Print name: Date: This permit application expires if a permit is not obtained within 180
,e"r I/a/ 14017h /�� //D days after it has been accepted as complete.
4
* Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440-4615TO I /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:
1 COMMERCIAL WORK ONLY:
Fee for each commercial $75:00
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
n Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
D . Instrumentation
❑ Intercom and Paging Systems
❑. Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls •
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*NO licenses are required. Licenses are required
for all other installations
I:\ Building \Permits\ELC- PermitApp.doc 03/23/06