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Permit CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: ELC201000500 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/15/2010 Parcel: 2S112DA00800 Jurisdiction: Tigard Site address: 15055 SW SEQUOIA PKWY 130 Subdivision: Lot: 0 Project: PacStar Project Description: TI Owner: FEES PACIFIC REALTY ASSOCIATES Quantity Description Date Amount 15350 SW SEQUOIA PKWY #300 PORTLAND, OR 97224 2 ea Services or Feeders - 200 09/15/2010 $201.40 amps or less PHONE: 503- 624 -6300 30 crt Branch Circuits w /Purchase 09/15/2010 $222.60 Service or Feeder 1 ea 12% State Surcharge - 09/15/2010 $50.88 Contractor: Electrical JOHANSEN ELECTRIC INC 10948 SE VALLEY VIEW TERR HAPPY VALLEY, OR 97086 PHONE: 503 -698 -3417 FAX: 503 - 698 -2486 Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Total $474.88 Required Items and Reports (Conditions) 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 copy of les or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: 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. • 4 , t g. 1 � y 'a City of Tigard June 2, 2011 • Johansen Electric Attn: Charlynn Leifsen 10948 SE Valley View Terr Happy Valley, OR 97086 Re: Permit No. ELC2010 -00500 Dear Ms. Leifsen: • The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 15055 SW Sequoia Pkwy, #130 • Project Name: PacStar Job No.: N/A Refund: ❑ Check # in the amount of $ . ® Credit card "return" receipt in the amount of $379.90. ❑ Trust account "deposit" receipt in the amount of $ . Notes: Per applicant's request as permit was not required. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor • . Enc. • I:\BuIdin lai+MinSWi Fltitil amceTig ti eiL n 97223 0 503.639.4171 TTY Relay: 503.684.2772 0 www.tigard - or.gov / 1 • • 11 ni ■ I. Community Development ' i1 ''F4 �. l ; : E; D Request for Permit Action 1AY CITY OF TIGARD TO: CITY OF TIGARD BU1LDINQDIVISION . Building Division Services Supervisor 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov FROM: ❑ Owner ® Applicant ® Contractor ❑ City Staff (check one) REFUND OR Name: Johansen Electric INVOICE TO: (Business or Individual) Mailing Address: 10948 SE Valley View Tens City /State /Zip: Happy Valley, OR 97086 Phone No.: 503 -698 -3417 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): . ❑ CANCEL PERMIT APPLICATION. VOID ® REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). (r /2 /f *Y" Permit #: • ELC2010 -00500 Site Address or Parcel #: 15055 SW SEquoia Project Name: Subdivision Name: Lot #: • EXPLANATION: Permit not needed • Signature:. l Date: 5/25/2011 Charlynn Leifsen Print Name: Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not snore than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not snore than 80% of the building plan review fee when an application is cancekd before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection. requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1.2 weeks for processing refunds. OIL 01 I !til ; (l \TI.1' Rte to Sys .Admits: Date By Rte to Bldg Admin: , Date - 1 // By -i" Refund Processed: Date 4o /2 //i By ; Invoice Processed: Date By Permit Canceled: Date �, /2.//f By :'�' • • arcel Tag Added: Date By Receipt # Date / Method _ Amount $ I:\ Building \Forms \RegPemvtAction.doc Rev 02/23/2011 • T ' d Xdd I3C213S131 dH Wd26 s E 1102 S2 ReW • 1 : 1 1111 . City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request. Refund requests are due to Accela System Administrator by Wednesday at 5:00 PM for processing by the following Wednesday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing. PAYABLE TO: Johansen Electric DATE: 6/2/2011 Attn: Charlynn Leifsen 10948 SE Valley View Terr REQUESTED BY: Dianna Howse Happy Valley, OR 97086 TRANSACTION INFORMATION: Receipt #: 179465 Case #: ELC2010 -00500 Date: 9/15/2010 Address /Parcel: 15055 SW Sequoia Pkwy #130 Pay Method: CreditCard Project Name: PacStar EXPLANATION: Per applicant's request as permit is not needed. Refund 80% of permit fees. REFUND INFORMATION: • . , Fee Description Frome_ Receipt Revenue Account Refund• Example:. Building Permit Fee .. Example: 2300000 -43104 • . $Amount Electrical Permit 2200000 -43103 $339.20 12% State Surcharge 1003100 -24001 $40.70 TOTAL REFUND: $379.90 APPROVALS: If under $5,000 Professional Staff If under $12,500 Division Manager Y` If under $25,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board FOR T IDEMARK SYSTEM•ADMINISTRATIONUSE • _ L Case Refund Processed: Date: rfQ B : �gr . l: Building \Rcfunds \RcfundRcqucst.doc x 09/01/2010 CITY OF TIGARD RECEIPT pl.. . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 182691 - 06/02/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2010 - 00500 $ 379.90 Total: $- 379.90 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 12507S DHOWSE 06/02/2011 $ 379.90 Payor: Charlynn Leifsen, Johansen Electric Total Payments: $ - 379.90 Balance Due: $379.90 • :I - , Accela System Administration "' Finance Department Request Date: 4 a / To: Liz Lutz Kathy Gende From: Dianna Howse/ . Re: Receipt #: t2 ? Y6,5 /1" 6 9 / • Please process this request as follows: _ Journal Entry (route copy of JE to Dianna Howse). • Reversal (fees have been reversed on . Revenue Account Report). • Credit Card Return (fees have been reversed on Revenue Account Report). __ Oth FEES .i Es3e C rea aAf Rc-d6--,✓vc -v— Thank you! -- I: \ Building \Forms \RteSlip- FinanceReq.doc • Page 1 of 1 11111 CITY OF TIGARD RECEIPT g 7 . 13125 SW Hall Blvd., Tigard OR 97223 • 503.639.4171 • TIGARD I Receipt Number: 179465 - 09/15/2010 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2010 -00500 Services or Feeders - 200 amps or less 2200000 -43103 $201.40 ELC2010 -00500 Branch Circuits w /Purchase Service or 2200000 -43103 $222.60 Feeder ELC2010 -00500 12% State Surcharge - Electrical 1003100 -24001 $50.88 Total: $474.88 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 24035S BTAGGART 09/15/2010 $474.88 Payor: Charlynn Leifsen / Johansen Electric - Total Payments: $474.88 Balance Due: $0.00 • • • • • • Page 1 of 1 Electrical Permit Aonlication ( 1'5 1 t, I: 1 fl 1 1 t 1. (,1: ()NI . 'I City of Tigard � �0�� tl� Permit No.: ( l 1 •••••00 13125 SW Hall Blvd., Tigard, OR Ali I Phone: 503.639.4171 Fax: 503.59 .1960 <,`? 1 c. Other Permit 1. : ; 1 , Inspection Line: 503.639.4175 c "'1 ` `♦ `'\ Date Ready/By: See Pegs 2 lbr Internet www.tigatd- or.gov Q' ' ' Notified/Method: SuppkmeesalInfmmatioo .,3,1 -i Ifl. ,. e.;"tr ;: ' .p9 (J,,ili farn+i "1. r a,^ u z a liFi'(Ale�i. lh'$! 1. 'p?f dr r,s} 7�`rl } }i'r' r r 4 l 1(I.ia P itir vimiiiri.,,'"' a ll) 11 , , 1.11 ;......1• -- s+', .: . ..:. .�i �f ! . :9�L1 f �a �:!., +1 e , ., .,. 11i, l , aisE . ii • r 1 at Jti.d'.-0 h 7'1 .usLr -, _S 1 el. :.lf:e "Lae 1 i, I u1M {,! t 1 1 SJ. IL - ' 1,11 d - ,_, 1, 1::1 New construction ® Addition/alteration/ , .i. 1. - ment Please cheek all data apply (gaunt a eels ofplans whtems cbeeked below): 0801 or feeder 900 amps or more 0 ❑ Demolition ID Other: where the available fault cuu entt ❑ Merin and boatyar syo t 4 t ( 1 .+K i1L1 au �- c�:. -r ir in7 ✓ . r .tug tar i Y"„J Ij11N(r.._' li�l� 7t ht':,,. et 170 vo lts or boil . ,!sli:r a ...ar.'rLl , ' I il ,1....' . } .S; ..+ r..r.un.iatw „ i:...) - i ..: I ..a s. :,�.�a r_ -. - �il . exceeds 10.000 amps xa ['Floating dings. lase to ground, m exceeds 14.000 ❑ Comamrcisl -use agricultural ❑ 1- and 2- family dwelling ® Commercial/industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi - family ❑ Master builder ❑ Other ❑ Fire P>mP. ❑ Insulation of 75 KVA or EZ m'. ¢: w,eu yvton te Ttra rt r• s an u }Scour F n r mrnluu ,, .:run{� , i s I IJ 1' 1' ` n ik 0 F�crgency 6) c1n. large' separately derived system. 11 ,�i t :Kt rt cy . ll 1 , 1 1 l � 1 L r iai(iil rr-T dl ; e. i Additiml o fnew motor load of "A ", "E", "1 -2 ", "1 -3 ", L S ii'M1l_DN.• ::::..8 s,. ialLui:•4 �.aruisYV rVlrt 'r, rrimiL........:.. •� i . u. >.,..: . -.._.. '. 1 loan., ❑ ❑ 1001IP or mom. Job no.: Job site address: 15055 SW S e• uo i s 130 ❑ Six or more residential runts. (3 Recreational vehicle pstica. City/State/ZIP: ❑ Health -care facilities ❑ Supply valtego for more than ID Hazardous locations. 600 volts nominal. Suite/bldg. /apt.no.: Ai Project name: PacStar ❑ Service or feeder 600 amps ar more. c' s mr h uar ..,.. tEdF'f 34.r 1 4 Cross st eet/direotions to job site: , Description oer. rea raw • , New residential single- or multifamily dwelling unit Includes attached garage. 5 .. ivision: Lot no.: 1,000 sq. ft. or less 168.54 4 Fa. add'i S00 sq. ft. or portion 33.92 1 Tax map/parcel no.: Limited energy, residential it 1 :p. J, r pr i i ff rr�t, y. ar sn.irq I r ta L ,lo Ia,�M�i Ihyi i l ` }I S r 75.00 2 t lI tgiiifll flit !ffn ii '`' i 1 ` ;.i4 i(.I 1i! r 3r ++ (with above sq. ft.) � s L1 _;!iaeuml .sul?..,�,ti r. , �.t.... .!_ :wets.' I' ,S. � e u.i.A). Limited energy. multifamily Tenant downs i ze residential (with above sq. fl.) 75.00 2 Services or feeders installation, alteration, and/or relocation , 200 amps or leas 2 100.70 201.402 Ill /l i 1 (1 r of t 'e l "'`r' ' t i il' ! ii i(i 1 Ij iitt , .+ ifi 350, ; ii Y d„ s 1 (' I lr 1�11ti'11`I 1 1 >I 201 amps to400 amps 133.56 2 I.i, tit lift...- 11141Q.Isek_.3;iYt� : :i. :l).: IIt ittaii .- zulSittiin miittlii .......,,.rdaiulo,.ovi :.1.. ... ...o : Name: 401 amps to 600 amps 200.34 2 601 amps to 1,000 amps 301.04 2 Address: Over 1,000 amps or volts 552.26 2 Temporary i services or feeders Installation, alteration, and/or City/State/ZIP: rei Phone: ( ) Fax ( ) 200 amps or lesss 1 122 59.36 1 Owner installation: This installation is being made oo property that I own which is not 201 amps to 400 amps 125.08 intended for sale, lease, rent, or exchange, according to ORS 447, 449.670, and 701. 401 amps to 599 antes 1 68.64 Branch circuits - new, alteration, or enteosloo. per panel Owner' signature: Date: A. Fee for breach circuits with 1 i4n'�i+ IE n •s.>r9i+ u I cMc « lr � +F t Ir u 41t'R'ni t�Al. }(�! I.IT I tlljr N>"It11151�, t above service or feeder 'xE ; �$ it (;ir DIY t <, Y. ,,e l c ny l ��. llltljl ei i _ `�1 A ,r 1 r L t , �. < �.. 7 each branch circuit 30 7.42 222.632 B . Fe vi for br Riede r fee . witkom Businessname: Johansen Electric service or feeder foe, fast 56.18 2 LC19 name: Chart Leifsen branch circuit Each add') branch circuit 7.42 _ 2 Address: 10948 SE Valley View Terr Miscellaneous (service or feeder not Included) an Each City / State/ZIP: Happy Valley, OR 97086 dwell ng. service and/or f 67.84 2 Phone:(503) 698 -3417 Fax::(503) 698 -2486 %Doormat only 67.84 2 Pump or irrigation circle 67.84 2 E -mail. •ir�i!•• e F t }r+ri I �crn , cv;•a>R,yl , �.v.q, 1= 1 v , , i7 i - rl ,.., Sign oroutlirm lighting 67.84 2 }1+ILrAdi .(i ,r u ` : ir � g ialllii r :isC' =F.0..i..3[Vi_ iti ins , f li 3 l l9l a l! irSi t1 signal circuits) or smiled -energy Business name: Johansen Electric panel, alteration, or extension. Page 2 2 Each additional Inspection over allowable in any of the abov Address: 10948 SE Valle View Terr Additional inspection (1 hr min) 6615/ hr City /State/ZIP: Ha • • Va 1 le , OR 97086 Investigation nd str p l (i hr min) 78.18/ hr Industrial plant (l ira min) 73.18/ hr Phone: (5 0 3) 698-3417 Fax: (5 0 3) 698-2486 inspections fbr which no the is 90.00/ la 'call listed /a hr min CCB Lic.. Electri Lic,. Su rv. Lic.: ;JD _ 1'1_i '�°.':'rr. -_ . �i iu �!arllrg+l 51539 •3 -243C P 2053S '= i�nl[��� *- _.:��:..i:! " ". ;;+�:�=:�,��;ti,'����Ir_;�..�1 Suprv. Electrician signature, required: / Subtotal: 424.00 i . . / _ ... • _ , . Plan review (25% of permit fee): , name: Carl Johan - - n / Date: 9/14/10 Statc surcharge (12% of permit fee): 5 0 . 88 Authorized signature: �' TOTAL PERMIT FEE: 4 7 4 . 8 B . „ . This permit application expires Ma permit is not obtained within t80 11 w,, days after it has been accepted es complete. Print name: Charlynn Leifsen /iimi Date: 9 / 14 / 10 • Number of inspections allowed per penult L IBmidinn\PaminlELC- PsmitApp.doe e7rotn0 440- 46131 (1itosicol.ewun a f ed. : 4 , rir?c..... 1 ' Xbd 13C213Sti1 dH W1718is :01 0102 bT des