Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
e • COMMUNITY DEVELOPMENT Permit #: ELR2010 -00179
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/09/2010
Parcel: 2S101 DA00104
Jurisdiction: Tigard
Site address: 13333 SW 68TH PKWY
Subdivision: FARMERS INSURANCE Lot: 0
Project: Triangle Pointe
Project Description: HVAC.
FEES
Owner:
TRIANGLE POINTE LLC Description Date Amount
901 NE GLISAN ST #100 Restricted Energy Permit 09/09/2010 $75.00
PORTLAND, OR 97232 12% State Surcharge - Electrical 09/09/2010 $9.00
PHONE:
Contractor:
HVAC INC
5188 SE INTERNATIONAL WAY
MILWAUKIE, OR 97222
PHONE: 503- 462 -4822
FAX: 503 - 462 -6555
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: Y 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 issuanc , or if ork is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification 3rlter. hose rules are set forth in OAR
952 - 001 -0010 through 0 • R 952-001-0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.24 36 0 0.332 2344.
Issued B ... - ..i Permittee Signature:
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 : FOR O11:1( E 1: 1: O N` 1.1
City of Tigard C� Received •J g �O Date/B : Ira Permit No.: L w� • a 13125 SW Hall Blvd., Tigard OR 9 �'� Plan Review
' C Phone: 503.639.4171 Fax: 503.598.1960 S OR
q Date/B : Other Permit:
T 1 G ;A 1: D Inspection Line: 503.639.4175 �D Date Ready/By: IA See Page 2 for
Internet: www.tigard or.gov `, O + l ` AS 1O Notified/Method: Supplemental Information
TYPE OF WOl `` PLAN REVIEW
❑ New construction Addltlon/alterati teplacement 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
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "I - ", "1 - ",
Job no.: 4 '13 Job site address: 1 333 J W Six or or more. occupancy.
�Q g ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: 1 c� V` ❑ Health-care facilities. ❑ Supply voltage for more than pvyri O � ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: t Project name: A ( �� i �V 0 D i v1 7 - ❑ ice or feeder 600 amps or more.
I_ FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. l 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'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Cp1n } , ,, n (/�' Limited energy, multi - family 75.00 2
NV Y `V V 1 V OV �/ _.. y S j - T residential (with above sq. ft.)
\ \\ I " {{"" •• Services or feeders installation, alteration, and/or relocation
pa-t.,(, S 200 amps or less 80.30 2
❑ PROPERTY OWNER 1 ❑ 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: J H SI/tl!/ B. Fee for branch circuits
Contact name: N ' i ( without service or feeder fee, 46.85 2
first branch circuit
Address: '- % .d � � ,_ at-,,,,,e, Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included) _
City/State /ZIP: MI 1 KT b� 1 Each manufactured or modular 90.90 2
�(� 5O1, I `w f dwelling, service and/or feeder
Phone: (`) 4 V I Fax: : x 10 Reconnect only 66.85 2
E -mail: e v V\,.) ( i ∎ 1� UV . lQ INN , Pump or irrigation circle 53.40 2
4 (� CONTRACTOR Sign or outline lighting 53.40 2
Business name: ` ) T /� Signal a or limited -
V y � V � energy p panel, alteration, or
Address: �(n,�� extension. Describe: ( Page 2 2
City/State /ZIP: �� V , / �/" Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) I Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lic.: SO U CV — ) I Electrical Lic.: A - 1 i LOSuprv. Lic. :3 QV) 1., 0:3 Industrial plant per hour 73.75
�� ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required ( z C i(j ` i „ ` C Subtotal:
�� .�, Q S i Date: a/ Plan review (25% of permit fee):
Print name:
I Y `t Vl, i l/ k 1 I c b State surcharge (12% of permit fee):
Authorized signature: I 1 TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Print name q 1 ' ' N Date: 9/1 days after it has been accepted as complete.
• Number of inspections allowed per permit.
11BuildingWermits\ELC- Permi pp.doc 05/23/06 440-4615T(I 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*
b. ea: -ntilatio d Conditioning Sys 7 *
❑ 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
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
El 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