Permit ELECTRICAL PERMIT -
C I TY OF T I GA R D RESTRICTED ENERGY
,11i1 DEVELOPMENT SERVICES PERMIT #: ELR2005 -00039
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/2/2005
SITE ADDRESS: 11308 SW 68TH PKWY 1ST FL PARCEL: 1 S136DA -00100
SUBDIVISION: ZONING: MUE
BLOCK: LOT: JURISDICTION: TIG
Project Description: SIS Cube remodel - voice & data. Job # 69327.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: X NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: : HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
BENENSON 68TH PARKWAY OREGON ELECTRIC CONST /GROUP
KEY LLC, THE 1010 SE 11TH AVE
BY FIRST AMERICAN TAX VALUATIO PORTLAND, OR 97214
WORCESTER, MA 01615
Phone: Phone: 503 535 - 2652
Reg #: LIC 203
SUP 4460S
FEES ELE 26 -95C
Description Date Amount REQUIRED ITEMS AND REPORTS
[ELPRMT] ELR Permit 3/2/2005 $75.00
[TAX] 8% State Surchar€ 3/2/2005 $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 within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires
you to follow 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 copies of these rules or direct questions to OUNC at (503) 246 -6699.
Issued by � 1, 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'N DATE:
LICENSE NO:
Call 639 -4175 by 7:00 P.M. for an inspection needed the next 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.
03 -02 -05 10:31 AM eaVEA , i ni< 5032313587 T -687 P.001/006 F -745
L'•IeCtxlcai Yermn •
,,,,,
City of Tigard 2 2 00e� 301 0S -P61C- Permioso.:V(�IKT ad e259
13125 SW Hall Blvd., Tigard, OR 972214 pR Plan Review e> Perm;t:
Phone: 503.639.4I71 Fax: 503.598.1960 {. 1! ;" Daze/By:
Inspection Line: 503.639.4175 OF TIG A e -- ' ! _;, Date Ready/By; 55 See Page 2 for
Internet: www.citibard.or.us CITY --ii• � i(1 Notified/Method: ) I G Supplemental Information
BU Itk : 1 .. PLALN REVIEW .
• ❑ New construction ► Addition/alteration/:teplacement Please cbeek all that apply:
❑ Dcmolitiam ❑ Other ❑ice over 225 amps. comm'l ['Hazardous location
❑Service over 320 amps — rating ❑Buildng over 10,000 sq. ft,
C ATEGORY OF CONSTRUCTION , of 1 and 2 family dwellings 4 or more new residential
•
❑ 1- and 2 -family dwelling ® Commercial/mdust ial ❑ Accessory building ['System over 600 volts nominal units in one structure
re
❑Multi- famr7y ❑ Haslet builds ❑ Other ❑� over three stories []feeders, 400 amps or more
Doccupant load over 99 persons ❑Manufacatrcd structures or
JOB SITE INFORMATION AND .LOCATION ❑ Egress/lighting plan ❑ RV�
p
Job no.: 69327 Job site address: 11308 SW 68th Parkway n ''�`o facility
-
Submit 2 sets of plans with any of the above.
City/State/ZIP: Tigard, OR 97224 yam, - The above are not applie:able to temporary construction service.
P ee _ q / Strite/bldg. /apt no.: I Project name: (J Dg FEE* SCHEDULE 1 QM 1 Fm. 1 rota i
Cross street/directions to job site New residential single- or multi family dwcirmg unit.
Includes attached garage.
1,000 sq. 8, or less 145.15 4
Subdivision: l Lot no.: Ea. add' 500 sq. R or portion 33.40 . 1
Tax map el - Limited energy, residcatial , 75.00 2
Limited energy. non - residential 75.00 2
DESCRIPTION OF WORK . Each manufactured or modular _
Low Voltage / Voice & Data . 5./ 5 8 6 0�£ dwelling, service and/or feeder 90.90 _ 2
Services or feeders instaiation, alteration, end/or relocation
200 amps or less 80.30 2
® PROPERTY .OWNER • . I • • ❑ TENANT 2 amps, to 400 amps 106.85 - 2
401 amps to 600 amps 160.60 2
Name: Providence Health System 601 amps to 1,000 amps 240.60 2
Address: 11308 SW 68th Parkway Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State/ZIP: Tigard, OR 97224 Temporary services or feeders tunseapoeion, alteration, and/or
Phone: (503)216-0012 Fat: (503)216 -0014 relocation
200 amps or less 66.85 1
Owner installation: This installation is being made on property that 1 own which is not 201:w,ps to 400 aatps _ 100.30 2
intended for sale, lease, lent, or exchause, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps - 133.75 2 .
Owner signature: _ Date Brunch +dr is — new, alteration, or extension, per panel
Et APPLICANT ' • • : 1 .. , ❑ Do1V1'ACI' PERSON . A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: Oregon Electric Group branch circuit
--' a Fcc for branch circuits
Contact name: Kyle Cooper withowrservice or feeder fee.
Address: 5000 NE Columbia Blvd each branch circuit
46.85 2
Each add't branch circuit _ 6.65 2
City/State/ZIP: Portland, OR 97218 Miscclhtneow (service or feeder not inc
Phone: (503)849 - 2169 1 Fax:: (503) 535 - 2810 Pump or irrigation uncle 53 2
Sign or o utline lighting 53.40 2
E - mail: kylecgdsg- group.com Sigtlnl circuit(s) or limited- ov
el alteration, or
CONTRACTOR eta Describe: Voice/data ( Page 2
Business name: Oregon Electric Group
Address: 1010 SE llth Ave _ Each additional inspection over allowable in any of the above
- Pcr inspection 62.50
City /StataZIP: Portland, OR 97214 Investigation per hour p e5- min) 62.50
Phone: (503) 2349900 1 FaX: (503) 535 Industrial plant per hots _ 73.75
_ELECTRICAL PERMIT FEES* .
CCB Lic.: 203 I Electrical Lic.: 26 -95C Suprv. Lie..: 44605 Subtotal 2 s - v
Suprv. Electrician signature, required: ����1// Plan review (25% of permit lee)
�[/ State surcharge (8% of permit fcc) C - t "
Print name: Date:
TOTAL PERMIT FEE 'r / - `—'
.Authorized signature: 0.44/1.,,,,,,, Tre permit application expires ifa permit b not obtained within 180
days alter It has been accepted as complete
Print name: I Date: • Fee methodology set by Tri- County Building Industry Service Bond
•• Number of inspection) eer ocmut allowed.