Permit 4
• CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
' .. a C OMMUNITY DEVELOPMENT Permit #: ELR2009-00189
.T 1 G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/20/2009
Parcel: 2S 101 AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 430
Subdivision: TIGARD TRIANGLE CENTER Lot: 0
Project: Reference Capitol Management
Project Description: Installation of voice and data.
FEES
Owner:
PACIFIC REALTY ASSOCIATES Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY Restricted Energy Permit 07/20/2009 $75.00
#300 12% State Surcharge - Electrical 07/20/2009 $9.00
PHONE:
Contractor:
SIMPLE SECURITY
4702 SW SCHOLLS FERRY RD., #196
PORTLAND, OR 97225
PHONE: 503 - 574 -2254
FAX:
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: Y 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: 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 accoi• - • ..proved 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. ATT- , ION: Oregon la re• -'res you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -001 *010 through OAR 952 -0r -1100 ay obtain a copy of the rules or direct questions to OUNC by calling 503.24 9 or 1.800.332.2344.
Is . ued By: ,■ , I v� L .4 Permittee Signature: n -
OWNER INSTALLATION ONLY I
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 Fc1R (11. ust: ONLY
R eceived t
City of Tigard � g / - �a
DateB Q (/ Permit No.: ��
a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review �
C Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit: /i ab f - t 1 //
I 1 G A 1t D Inspection Line: 503.639.4175 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
TYPE OF WORK • PLAN REVIEW
❑ New construction Addition /alteration /replacement 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 p Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
. ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: Job site address: 1 k it 100HP or more. occupancy.
1 q 5 . iA) - C� S r ark.t,uuy ❑ Six or more residential units. ❑ Recreational vehicle parks
City/State /ZIP: f, n 0 G 1-12. 3 ❑ Health -care facilities. 0 Supply voltage for more than
v'dC ` ❑Hazardous locations 600 volts nominal
Suite /bldg. /apt. no.: 4 2 Project name: g2feY.QN c4. c �. ❑ Service or feeder 600 amps or more.
� FEE SCHEDULE
Cross street/directions to job site: n 0041 rt.o� Description 1 Qty. 1 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.)
Limited energy, multi - family 75.00 2
D Ql'Gt- -1 V D ‘t ( e Ccc- V) 1.1 by residential (with above sq. ft.) _
Services or feeders installation, alteration, and /or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ 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 I
Owner installation: This installation is being made on property that 1 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 ❑ CONTACT PERSON • above service or feeder fee,
each branch circuit 6.65 2
Business name: B. Fee for branch circuits
without service or feeder fee,
Contact name: first branch circuit 46.85 2
Address: Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
. City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) - Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
• CONTRACTOR Sign or outline lighting 53.40 2
- p'� Z Z Q l
Business name: Signal circuit(s) or limited -
s i vtiP 1.e_ �j 1L c 1J r t Lr i J C - energy panel, alteration, or
extension�be r Page 2 2
Address: J
y03(.0 5 . IA) 5 c 1 �4I,I5 1'er v.y go 2 2 (Q '' I
City/State /ZIP: r DrT Ux vt, c (51 5 Each additional inspection over allowable in any of the above
i Per inspection 62.50
Phone: (5o3 ) 57./1 _ ZZ 5 'f Fax: (503 ) 2. y 5- ' qq S Investigation per hour (1 hr min) 62.50
CCB Lic.: t y zo i Q 7ctrical L ic.: 3 `1'(03 p GL4. Su rv. Lic.: �lq t r '� 4 Industrial plant per hour 73.75
r o ELECTRICAL PERMTT FEES
Suprv. Electrician signs e, r lred: -7/l Subtotal: 7..00
v g Plan review (25% of permit fee):
Print name: 0 u AA, e✓ Date: 20 x t 7.OJ I o Q
State surcharge (12% of permit fee): ! , O!.)
Authorized signature: TOTAL PERMIT FEE: g" i / .0C)
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
l:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440- 4615T(11 /0S /COM/WEB
Electrical Permit Application - City of Tigard ❑ Other
Page 2 - Supplemental Information Total number of commercial systems: _
LIMITED ENERGY PERMIT FEES: "No licenses are required. Licenses are requir
for all other installations
RESIDENTIAL WORK ONLY:
Fee for all residential systems $75.00
combined
Check Type of Work Involved:
n Audio and Stereo Systems"
❑ Burglar Alarm
❑ Garage Door Opener"
n Heating, Ventilation and Air Conditioning
System"
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK O NLY:
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
`0- Data Telecommunication Installation
n F • ire Alarm Installation
n H VAC
❑ Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control"
❑ Medical
n Nurse Calls
n O utdoor Landscape Lighting*
❑ Protective Signaling
: \ Building \Permits\ELC- PermitApp.doc 03/23/06