Permit , CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
% COMMUNITY DEVELOPMENT Permit #: ELR201000144
T i G A� R 0 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/09/2010
Parcel: 1S136DB00201
Jurisdiction: Tigard
Site address: 11565 SW PACIFIC HWY
Subdivision: Lot: 0
Project: CHASE BANK
Project Description: Security alarm.
Owner: FEES
FRED MEYER STORES, INC Description Date Amount
BY NICKEL & COMPANY LLC, STORE #375, PO Restricted Energy Permit 08/09/2010 $75.00
BOX 35547 12% State Surcharge - Electrical 08/09/2010 $9.00
PHONE:
Contractor:
ADT SECURITY SERVICES INC
2815 SW 153RD DR
BEAVERTON, OR 97006
PHONE: 503 - 469 -7212
FAX: 503 - 469 -7114
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: 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: Y
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 co • of the rules - direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
7 I
Issued By: .di— — i` i Permittee Signature: -- j
410
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.
PZ679% , 11 Cev'y 9 p-- // q# �ai t r n s► Y ';r,
Electrical Perrrrii Application - ti ( 5 ' r • k, F O R.FIGE IJSE ONLI rm ,. r4*µ+(
�' City of Tigard t 5 - 03 -y "�.•
6 9-7N ReceiDate /ved / IU 5 �
i 4 ': � By: Permit Nu.:
> ° 13125 S W Hall Blvd., Tigard, OR 97223
I. g" Plan Review
_< . . Z " Phone. 503.639.4171 Fax 503.598.1 F ° cc‘\,
+ 1 ' w.• Date /13v:
Other Permit:
„ '` '"A Ins Line: 503.639.4175 Q 6. --:9 f Date Ready /13y: lrw' ® See Page 2 for
TIGAR'D; �h "w. +O Notified Method: 1-14 Supplemental Information
+tnOtiv s•rtl Internet: www.tigard- or.gov A 1
TYPE OF WORK 10 PLAN REVIEW
f 'r.1' k(�V ( ) Please check all that apply (submit o plans 2 sets darts w/ items checked betoiv):
❑ New construction ® Addition /alteration /re la nAgit 1 a 1 400 \ J� k 1 V r nv l\S1u � 4 ❑ Service or feeder 400 amps or mire •' ❑ Building over three stories
❑ Demolition ❑ Other: a ci t\\G X1 where the ava ilable fault current ❑ Marinas and boatyards. .
CATEGORY OF CONS'I'RU� Ib
.x sa, .d N • exceeds 10.000 amps al 150 volts or ❑ Floating buildings.
less to ground. or exceeds 14.0011 ❑ 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. ❑ Installati(in of 75 KVA or
❑ Emergency system. larger separately derived system
JOB SITE INFORMATION AND LOCATION ❑ Addition anew motor load of ❑ .4 . 1.. 1 - 2"."I - ".
3 •10011P or mare. occupancy.
Job no.: -5 Job site address: //31/5" See) 4¢e /3/G �ja/�
/-� ❑ Six or more residential nits. ❑ Recreational vehicle parks.
City/State/ZIP: - /1 D D q 7.2 a 3 ❑ health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
> 3 ['Service or feeder 600 amps or inure.
Sui /bldg..apt. no.: Project name: C ff/� S � N�
FEE SCHEDULE
Cross street /directions to job site: Description 1 QIP. I Fee. 1 T 1 •
Nov residential single- or multi-family dwelling writ.
Includes attached garage.
Subdivision: lot no.: 1,000 sq. ti. or less 168.54 4
La. add'1 500 sq. II. or portion 33.92 I
Tax map /parcel no.: Limited energy, residenlial
67.54 2
DESCRIPTION OF WORK _ (wide above sq. ft.)
4 k (?g ^ Limited de m (, with above s
! q. ft.) 67.84 -
� ,� L // /19 � vi— (lvith ahoy (I.
��'���+++"' Services or feeders installation, alteration, and /or relocation
A ,..0......../#' .• i , / / � 4 1 200 amps or Tess 1 100.7(1
❑ PROI'EK'I'1` OWNER / / tENANT 2U I amps t., 400 amps 1 33.56 3
401 amps In 600 amp. 300.34 2
None:
- -- 601 amps to 1,000 amps 301.04
- Address: : Over 1.000 amps or volts 55226 '
Temporary services or feeders installation, alteration, and /or
City /State /Ll1': relocation
Phone: ( ) -- Fax: ( ) 2(10 amps or less 59.36 1 1
201 amps to •00 amps 1 25.06 1 2
Owner installation: This installation is being made on property that I own which is not
—
4(11 amps to 599 amps 1 63.54 1 2
intended for sale, lease, rent, or exchange, according to ORS 447, 440, 670, and 701.
Branch circuits - new, alteration, or extension, per panel
Owner signature: Dale: : \. Fee for branch Citcuit„Yi r/t
above see: ire or feeder lee.
❑ APPLICANT LR- '6)NTACT PERSON each branch circuit 7.42 2
Business Ha H. Fee for branch circuits air/mu
/ N service or feeder fee. first
56.18
4E
Contact name: . 1�4U� branch circuit
leach add'I branch circuit 7 -42
Address: Miscellaneous (service or feeder not included)
Each manufactured or modular --1
City /State / dwellin', service and /or lee(ier 67.84 _
(� Reconnect only 67.84 2
Phone: (4 3) 1 " 7c —J Fax: ( )
Pump or trrigauc circle 67.54 '_
E Sign or outline lighting 67.34 2
CONTRACTOR Signal circuit(s) or limited - enemy —
Business name: ART SECURITY panel, alteration, or extension. I Page 2 67.3 -t _
Each additional inspection over allowable in and of the abuse .
Address: 2815 SW 1531at 1)R Additional inspection (1 hr min) 66.25/hr
Investigation (1 hr min) 66.25/ hr
City /State /`LIP: BEAVERTON OR 97006 —
Industrial plant (1 hr min) 78.18/ hr
—
Phone: (503) 969 -7699 Fax: (503) 469 -7114 Inspections for which no lee is 90.001 hr
•speeitically listed ('' /, hr min) ,
CCB Lie.: 59944 Electrical Lie.: 26209CLE Suprv. Lie.: LEA389 ELECTRICAL. PERMIT FEES
Subtotal: 67.84
. Suprv. Electrician signature. required: -
Plan review (25 of permit fee):
Print name: KEN KRAUS Date: State surcharge (I2 %ofpermit fee): 5.14
TOTAL PERMIT FEE: 75.98
Authorized signatute:W (/ 37/6 This permit application expires if a permit is not obtained within IRO 1
days after it has been accepted as complete.
Print name: Dale: , Number of inspections allowed per permit.
I :$uilding1Permits, 1i1 c i'erniltApp.doc 1 0 , 0 1 , 0 9 440 -•16 I5T(I I .'0(461 501-))
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: •
Fee for all residential systems combined $67.84
Check Type of Work Involved:
I Audio and Stereo Systems*
I Burglar Alarm
I -1 Garage Door Opener*
Ideating, Ventilation and :Air Conditioning System*
L —I Vacuum Systems*
I I Other: - - -- _
COMMERCIAL WORK ONLY:
Fee for each commercial $67.84 •
system
(Slit•: OAR 9!S- 309 -0000)
Check Type of Work Involved:
:Audio and Stereo Systems
Boiler Controls
(:loci: Systems
Data Telecommunication Installation
Fire Alarm Installation
h I- ! \': \C
Instrumentation
Intercom and Paging Systems
Landscape Irrigation Control*
I 1 Medical
• I I Nurse Calls
Outdoor Landscape Lighting*
Protective Signaling• •
Other •
•
Total number of commercial systems: I
' *No licenses are required. Licenses are required •
for all other installations
'.•dfuildingTermils• liLC -Pei milApp.doc 10'01'0`1