Permit C ITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
AA DEVELOPMENT SERVICES PERMIT #: ELR2005 -00045
{III 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 3/15/2005
PARCEL: 2S 101 AD -03200
SITE ADDRESS: 12909 SW 68TH PKWY 450 ZONING: MUE
SUBDIVISION: TIGARD OFFICE BUILDING LOT: JURISDICTION: TIG
Project Description: Data /telecommunications
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:
PACIFIC REALTY ASSOCIATES ANDERSEN ELECTRIC LLC
15350 SW SEQUOIA PKWY #300 -WMI 9390 SE HIDE A WAY COURT
PORTLAND, OR 97224 GRESHAM, OR 97080
Phone: Phone: 503 665 - 4327
Reg #: ELE 3 -516C
SUP 4826S
FEES LIC 147561
Description Date Amount REQUIRED ITEMS AND REPORTS
[ ELPRMT] ELR Permit 3/15/2005 $75.00
[TAX] 8% State Surchart 3/15/2005 $6.00
[ELPRMT] Investigation 3/15/2005 $75.00
Total $156.00
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 9 - 001 -0100. You y obtain copies of these rules or direct questions to OUNC at 503 - 246 -6699.
Issued By: Permittee Signature: L1 -
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.
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: L_--iii IV ,.. ® FOR OFF1C:1- 1!SE ONLY
E► ,Perm Apptica I / Rtceived.L N sA s / A • 0012 !
Dat
g � eerm
131 . igard ` ` 1 plan Review Other Permit
ermit:
p one ., 3.63 4171 Fax: 5 3. 9 3. 13 1':: ti � i ' '. Date/I3 :
1nspeCtion Line: 503 Fax: 503.598.1960 '''' fm's: lL Da Ready/Sy: ® See Paget for
_ � 1 Supplements) Information Inte ne Line: .tiger onus CITY OF T -_i - 1 J NotIfteNMdhod:
. or nu
Internet: tvtvw.n.0 _ >: - . •; •'. _
51a s a utse. t 9 t._....•• YIaAN`:RF ? ? ::. "`:: :,' .
.:...:.'.'..;_ : ..,-- ::.:....... ::. ... that [
Tom':....,.'-:;' ..: :;:..• : -'.; :-:-..:•:.: _ .._..•:.:- ...�::
El New construction 0 Addition/alteration/replacement
Please check a ll apply:
wiring for tenant Sextriec o ver 225 amps cottrm'l ['Hazardous location
0 Demolition Other. Telecommunications wir
• ecommunin oo . f •.
® :..: ...:.....:...:..:..;:.:. []Service 320 - aZardO 10,0 sq
_ Slit 1
:.._;,_.::;: �:: ::. .:.....��:._......... ....... UL?1301st;; r:_::;. �'.' i:-; � .:``:.-:':.: :.:�: "r':' of �� milydwellings� 4ormorenewresidexttia
. _. -:. � :..:.:r .... , �:;::,:;,,:: �A� <.... votes nominal units in one structure
0 1- and 2- family dwelling 0 Comtnercial/mdustrial 0 Accessory building QSystcm over 600
0 M aster builder 0 Other: rod amps or r
❑ Multi-famil .:.....: .
.:.: C - :. .., .,,.., ::.:. • .: <:- ::.•..: O ad over 99 persons Butldin t o
_.... :.,_,.:.;.:- .._.:.;= .::':a.7: $:' • : 11! /11. . DRVpark or
� N' �;jkitTp: �IOC�'I7i0 �Egrcss/lighdng plan
:o: lob site address: 12909 SW 68 Parkway Suite 450 ❑Health facility
Job n i dd Submit 2 sets of plans with any of the above.
The above are not applicable to temporary construction service.
Ci /Statc/ZIP: Ti trd, OR 97223 .. -.... - - '
Universal Business lnsurancc ;;:;, : "' --
Suite/bldg./apt no.: 450 1 Project name: Trinity Dendrite COS. Pm. Tarot
Cross street/directions to job site New residential single- or ntotti- family dwelling unit.
• Includes attached garage. 1 4
1,000 sq. ft. or less 145.15
Lot no.: Ea. add'1500 so. ft. or portion 33.40'
Subdivision: Limited energy, residential 1111 75.00
Tax [trap /parcel no -: _ est 75.00 2
-:.. : S)P.F.iC .. . , Each t manufactured 0T modular
"a- o n o .. telecommunications :; Un iversal Business
Installation of tdetommanieations wiriagand jacks for Trinity dwelling, service and/or feeder 90.90 2
Insurance Suite 450 Tigard Triangle 12909 SW 68 Parkway Services or feeders installation, alteration, dlor relocation 2
200 amps or less 2
:,:_: 201 amps to 400 amps 106.85
['::1!1A1T „: r': ": 160.60
...:::. Oyyit►ER "� ;; `_:':: ; .::; : ': c: :' • � ... .... l amps q0 to G00 amps 2
::�, ..,:. �:, -�:. ::•.; : _. :::. , ,- ,.. .:.� .. ... : 14(1 60 2
.
Name: 601 amps to 1,000 amps 2
Ova 1,000 amps or volts 454.65 j
Address _
Reconnect only 66.85 ` 2
Temporary services or feeders installation, alteration, and/or
City/Statc/ZIP: relocation
--- F3x: ( )
Phone: ( ) 200 amps or less 66.85 1
100.30 2
Owner installation: This installation is being made on property that 1 own which is not 201 amps to 400 art>➢s 100. 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
401 amps to 600 apps 133.75
Date: Branch circuits -- new, alteration, or extension, per panel
.. .
Owner signature: ., . .:. -'-- A. Fee f branch circuits with
h 2
...::<. .. - 6.65
t" r feeder fee each
.. - ...... service o
Business name: T1)S TELECOM Lewis River Telephone Company, lire. g Fee for branch circuits
Contact name: Elizabeth Cerveny, g
General Manor er Eric McManus Network Sp. without service or feeder fee,
_ 46.85 2
Address: 210 E. 4 Street each branch circuit
E ach add'1 branch circuit 6.65 i 2
.Miscellaneous (service or feeder not included)
City/State!LIP: LaCenter, WA 98629 Pump a irrigation circle 53.40 _
1, n Phone: (360) 263 -7154 Ell
Fax:: (360) 263 - 1124 Sign or outline lighting 53.40 _Q
`(S�DJ or limited-
Signal circuit(s) limit
E-mail: elizabetb.eerveny @tdsteleeon tom } _.:.. energy panel, s) or limit or 2
. , .. ; �:: _EOrI'I>t,. R;- �: ':; :.;:.;•:. �. ,, -' torsion. Describe: Page 2
ca -:. .... ,[' / f/�r e ms ` ' k2
Business mime :. 4/7 0 2hJ r- !�- Each additional iospectton over altowabte (o auy of the above
Address: 9 3 `J C� S �� � - C'—� Per inspection 62.50 ` 1
• • * • investigation per h our ( in min
6230 1
City/State/DP: • _ i Industrial plmt
per hour 73.75
F S03 C6 8 33 / at FL <:# tIT M :, ::
So3 665 y32, .:
L. ..../9, 75 / El ectrical Lic.: • �5 /6, Su q - a6 s Sab,otal . - •tt�
Ccs c;�: /' '75 7 / ' � / b 1 Plan review ( o t p ermit fee)
Suprv. Electrician signature, required: ,. � Date: State surcharge (8% of permit fee) �I
TOTAL PERMIT FRE
i
Print name:/ �- .14 / - AT; 3 ��
T in
his permit application expires if a permit Is not obtained stela 180
Authorized signature: • � Date: days after it bar been accepted as complete
Print name:
Fes methodology act by 1'6- County Building industry Service Board /
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CITY OF TIGARD
BUILDING DIVISION PERMIT #: ELR2005 -00045
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/15/2005
Phone: (503) 639 -4171 A �
Inspection Requests (24 Hrs.): (503) 639 -4175 . 1!.
INSPECTION WORKSHEET FOR DATE: 3/16/2005 TIME: 7 :11AM PAGE: 30
SITE ADDRESS: 12909 SW 613TH PKWY 450 CLASS OF WORK:
SUBDIVISION: TIGARD OFFICE BUILDING LOT #: TYPE OF USE:
PROJECT NAME: TRINITY UNIVERSAL INSURANCE
DESCRIPTION: Data/telecommunications
OWNER: PACIFIC REALTY ASSOCIATES, PHONE #:
CONTRACTOR: ANDERSEN ELECTRIC LLC PHONE #: 503-665.4327
Inspection Request Scheduled For: Date: 3/1612005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
135 Low voltage 11 913-01 360- 263.1154 Y
Corrections /Comments /Instructions:
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*ASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: le�''`'' Date :, .5 -/'‘" C Phone #: (503) 718-