Permit CIT OF T I GARD ELECTRICAL RESTRICTED ENERGY PERMIT
41 DEVELOPMENT SERVICES PERMIT #: ELR2005 -00103
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 5/12/2005
PARCEL: 2S 101 AD -02400
SITE ADDRESS: 12753 SW 68TH AVE ZONING: MUE
SUBDIVISION: WEST PORTLAND HEIGHTS LOT: 032 JURISDICTION: TIG
Project Description: Install limited energy for CCTV system.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: : HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER: CCTV X
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
GEORGE FOX UNIVERSITY GEORGE FOX UNIVERSITY
414 NORTH MERIDIAN 1101 VILLA ROAD
NEWBERG, OR 97132 NEWBERG, OR 97132 -1218
Phone: 503 -554 -2084 Phone: 503 -554 -2014
Reg #: ELE 36 -75C
SUP 3973S
FEES
Description Date Amount REQUIRED ITEMS AND REPORTS
[ELPRMT] ELR Permit 5/12/2005 $75.00
[TAX] 8% State Surchart 5/12/2005 $6.00
Total $81.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and
all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not
started w' • . • :0 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires
you • ollow rules a• • •ted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010
thr• ugh OAR 952 -001 -1 ' : •u may ob ain copies of these rules or direct • - lions to OUNC a 503.24 6699.
■
Iss d By: _ /� /L Permittee Signa • re: _ L
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'N 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.
EP>ical Permit Application FOR OFFICE USE ONLY
Cl of Tl aT� Received Pemut No.: /
`� g Date/B : ; / ; %. 1 Q 3
13125 SW Hall Blvd., Tigard, OR 97223 a Plan Review % , A
Phone: 503.639.4171 Fax: 503.598.1960 r \ O ' Date/By: Other Permit:
Inspection Line: 503.639.4175 v. J. Date Ready/By: J� ® See Page 2 for
� I. Internet: www.ci.tigard.or.us �� �� Notified/Method: a,. Supplemental Information
TYPEF WOE `V y PLAN REVIEW 1
❑ New construction ❑ Additio��n/al tioo • p1 l ement Please check all that apply:
❑ Other: 0./ \ ['Service over 225 amps, comm'I ['Hazardous location
❑ Demolition ['Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
CATEGORY CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential
❑ 1- and 2- family dwelling )0 Commercial/industrial ❑ Accessory building ['System over 600 volts nominal units in one structure
1:1 Multi - family ❑ Master builder 12 Other: ['Building over three stories ['Feeders, 400 amps or more
['Occupant load over 99 persons ['Manufactured structures or
JOB SITE INFORMATION AND LOCATION ❑Egress/lighting RV park
Job no.: Job site address: I a 753 O VV log` l -V� ❑Health -care facility ['Other:
n Submit 2 sets of plans with any of the above.
City /State/ZIP: rQ r -1- ( n c Q �Q q 7 a D 3 The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name:
\ FEE* SCHEDULE
Description I Qty. I Fee. I Total I ..
Cross street/directions to job site: K ( l u s e way -i'J / 5 1 ex, -1- New residential single- or multi- family dwelling unit.
{{��� y 1 / / Includes attached garage.
- gl 19 - t O /) ! a n ' D
uJ DO 1Q I I,O1ZY 4c Ii -T 1,000 sq. ft. or less 145.15 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 1
Limited energy, residential 75.00 2
Tax map /parcel no.:
Limited energy, non - residential 75.00 2
,/ DESCRIPTION OF WORK Each manufactured or modular
//
S //).400 00 I' 1 / o v tdoof .51e r ve, l (Q f-krk _ dwelling, service and/or feeder 90.90 2
�- Services or feeders installation, alteration, and/or relocation
e a-C ` LQifro / ?v/pft& f • 200 amps or less 80.30 2
PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: 6e01,,le fO X L)n I. vier j-f 4 601 amps to 1,000 amps 240.60 2
Address: 4) 4 ! V D r fl,, A l -I 1 G n Over 1,000 amps or volts 454.65 2
�t Reconnect only 66.85 2
City/State/ZIP: A) ember 0 4 97/ 3 Z Temporary services or feeders installation, alteration, and/or
relocation
Phone: (03 , 5 6 > - aQ Fax: ( 3) 45 - „,1-00 /
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 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT l ❑ CONTACT PERSON A. Fee for branch circuits with
f .
service or feeder fee, each 6.65 2
Business name: Geo (r y e 6 x �j, j VtcSt branch circuit
Contact name: if $ a n Co t Q f - l /
B. Fee for branch circuits
feeder ,/y / without service or fe fee,
1 � /� t / each branch circuit 46.85 2
Address: f2 r 5erv�Ges /s/oi Ai,, v/ //et `c Each add'I branch circuit 6.65 2
City/State/ZIP: /1)6. b De_ 7/.5 Z Miscellaneous (service or feeder not included)
Phone: (.5-)3 J ‘ / —ZO r Fax: : 6-z) 3 �G/ ) S l 7 /y Pump or irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E - mail: 5(0 P b e't1 0 ' a eo rate Pa >e , -ea u., Signal circuit(s) or limited-
CO1MACTOIV energy panel, alteration, or 00
ex�rtsi Qescribe: i ` Page 2 76' 2
Business name: ( 4 -x(/4/ w1-S/..� (�C V
Address: //// �� �� Each additional inspection over allowable in any of the above
7� pi-7 Per inspection 62.50
City/State/ZIP: /f,& z J t 6 q 7/3 �,__ Investigation per hour (1 hr min) 62.50
_ _2 Q � Industrial plant per hour 73.75
Phone: ( SS a n Fax: ( " i? _ v y C/
Cl � `� 7 / ELECTRICAL PERMIT FEES*
CCB Lic.: / /)709- -- Electrical Lic.: , _ 7 S-' Suprv. Lic.: Subtotal 7,5
Suprv. Electrician signature, required: Plan review (25% of permit fee)
/5/ LG�A
Print name:
State surcharge (8% of permit fee) (p .. D0
Date:
�(tS��(/ � �f TOTAL PERMIT FEE O v
Authorized signature:. / G/ � �/,/ �,i This permit applicat expires if a pe rmit is not obtain within 180
/ days after it has been accepted as complete
Print name: &saw (D r4( (y r / Date: I _,.. S • Fee methodology set by Tri- County Building Industry Service Board
7 ! ** Number of inspections per permit allowed.
is\ Building \Peemits\ELC•PermitApp.doc 12103 440-4615T(10 /02/COM/WEB
CIIY OFTIGARD ' , _
BUILDING DIVISION '�^ PERMIT #:
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: ELR200E�00103
Phone: (503) 639 -4171 :typical lei 5/12/2005
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 9/27/2005 TIME: 7:05AIN PAGE: 96
SITE ADDRESS: 12753 S1A/ 68TH AVE CLASS OF WORK:
SUBDIVISION: WEST PORTLAND HEIGHTS LOT #: 032 TYPE OF USE:
PROJECT NAME: GEORGE FOX UNIVERSITY
DESCRIPTION: Install limited energy for CCTV system.
OWNER: PHONE #:
CONTRACTOR: GEORGE FOX UNIVERSITY PHONE #: 503 -554 -2084
GEORGE FOX UNIVERSITY 503 - 554 - 2014
Inspection Request Scheduled For: Date: 9127/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
136 Low voltage 016422 -01 503-554-2084 Y
C Igo k
s U S A ICJ .;
PASS ❑ PARTIAL APPROVAL ❑ CANCEL 111 NO ACCESS
❑ ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: INQ' WS L Date: q EqUID Phone #: (503) 718-
Case Activity Listing 7/27/2007
CGEL/ 9:01:30AM
Case #: ELR2005 -00103
Assigned . Done Updated
Activity Description_ Date 1 Date 2 Date 3 Hold Disp To By By Notes .f
ELR1010 Application received 4/28/2005 None RECD MAIL 5/6/2005
DEB
ELR1020 Permit created 5/6/2005 None DONE DEB 5/6/2005
DEB
ELR1030 Check for parcel tags 5/6/2005 None DONE DEB 5/6/2005 Permit is in the pending bin awaiting
DEB new check in the correct amount.
Check #00158983, for $82.00 was
retumed by mail to Susan
Corbett- Furgal on this date.
ELR1280 Issue permit 5/12/2005 None DONE DEB 5/12/2005
DEB
ELR2135 Low voltage 9/22/2005 9/27/2005 9/27/2005 None PASS GN 9/27/2005 016422 - 01 503 - 554 - 2084 — VM -
STI Y
ELR1740 Case finaled 9/27/2005 None DONE GN 9/27/2005
GN
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