Permit CITY OF TIGARD ELECTRICAL PERMIT
!, r q
I ; COMMUNITY DEVELOPMENT Permit #: ELC2010 -00187
Date Issued: 04/21/2010
1 GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S113AA00100
Jurisdiction:
Site address: 16358 SW 72ND AVE B4
Subdivision: Lot:
Project: Lindquist Glass
Project Description: (2) branch circuits for new LED sign.
Owner: FEES
PACIFIC REALTY ASSOCIATES Quantity Description Date Amount
15350 SW SEQUOIA PKWY #300
PORTLAND, OR 97224 2 crt Branch Circuits 04/21/2010 $63.60
wo /Purchase Service or
PHONE: 503 - 624 -6300 Feeder
1 ea 12% State Surcharge - 04/21/2010 $7.63
Electrical
Contractor:
EA MARTIN LLC
4233 SE 182 #202
GRESHAM, OR 97030
PHONE: 503 - 310 -9745
FAX: 503 - 658 -1935
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $71.23
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 R 952 -00 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. •
Issued By: '
Z l / 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.
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
V
c
October 28, 2010
E A Martin LLC
4233 SE 182nd, #202
Gresham, OR 97030
Re: Permit No. ELC2010 -00187
Dear Sir /Ms.:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 16358 SW 72 " Ave.
Project Name: Lindquest Glass
Job No.: N/A
Refund: ® Check #67489 in the amount of $71.23.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Work not allowed as service is crossing property lines and jurisdictional boundaries
to provide power to billboard in Tualatin. Refund 100% of permit fees per Building
Official.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
•
Enc.
I: \Building\ Refunds\ Administr ttion \LtrRefund - CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
Er i City of Tigard
T l G A R D 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: E A Martin LLC DATE: 10/20/2010
4233 SE 182 " #202
Gresham, OR 97030 REQUESTED BY: Dianna Howse
Debbie Adamski
TRANSACTION INFORMATION:
Receipt #: 177650 Case #: ELC2010 -00187
Date: 4/21/2010 Address /Parcel: 16358 SW 72 "d Ave.
Pay Method: Check Project Name: Lindquist Glass
EXPLANATION: Work not allowed; service crossing property lines and jurisdictional boundaries to
provide power to billboard in Tualatin. Refund 100% of permit fees per Building
Official.
,REFUND. INFORMATION: : - =': °' : _' .. :. - '
Fee Description. From Receipt Revenue Account No,.. Refiiiid
Exainpl'e; •B iildiri ':Permit l ee ;" Example; : 43104: `: ` ,: $ =Amount
Electrical Permit 2200000 -43103 $63.60 ✓
12% State Surcharge 1003100 -24001 7.63
TOTAL REFUND: $71.23
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager JJ
If under $25,500 Department Manager /b4,2.1/
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM,ADMINISTRATION
Case Refund Processed: I Date: I /C12 - 4:/F a' I By: I
1: \Building \Refunds \RefundRequest.doc x 09/01/2010
III CI
TY OF TIGARD RECEIPT
C . 1 3125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD rA Aid
Receipt Number: 180162 - 10/28/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2010 -00187 $ -71.23
Total: $ -71.23
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 67489 DHOWSE 10/28/2010 $41.23
Payor: E A Martin LLC
Total Payments: $ -71.23
Balance Due: $71.23
Page 1 of 1
l ig CITY OF TIGARD RECEIPT
i • 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIC,\ R.D
e, /6- � '9 4_
Receipt Number: 177650 - 04/21/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2010 -00187 Branch Circuits wo /Purchase Service or 2200000 - 43103 $63.60
Feeder
ELC2010 -00187 12% State Surcharge - Electrical 1003100 -24001 $7.63
Total: $71.23
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 2295 DHOWSE 04/21 /2010 $71.23
Payor: E. A. Martin, LLC
Total Payments: $71.23
Balance Due: $0.00
•
Page 1 of 1
Community Development
.
TI Request for Permit Action •
• TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: n Owner n Applicant n Contractor ig City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) &.)/7.
Mailing Address: I
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
N CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE, (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: [/C 0,20/o- OUf g 7
Site Address or Parcel #: /ev 35g o � w 7a °1 4-0 F
Project Name: h—I n>`r GZu 1 cr a L -4 5
Subdivision Name: 44" Lot #: A./4
EXPLANATION: L, r, AQ l T A2 r1,9 -ruk VA-$3 r- -,cn1. Nv
�u Ayr, AS 4 1 a PLe - A-Ir — //4-6 !Jar Z- Q u E6 7i77D .
Signature: Date: W.5 /4)
Print Name: —D //1f 4 7D4-44 ste, /
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more 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.Iand use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled 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.
FOR OFFICE USE ONLY
Rte to S s Admin: Date B Rte•to Bld; Admin: Date B
Refund Processed: Date B Invoice, Processed: Date B
Permit Canceled: Date B Parcel Ta. Added: Date B
Recei.t # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
r esCr,ar. rYat��'d' I 'wr 'R .71 Ip i� t o- it y r r a xv, a
Electrical Permit Application E �U , . t � `" ;L r i ,,' k 1, �' ' ' ° '
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'�, Received
Ol p T DateBy: 002///0 „4
- Permit No.:E LCo2OIO — (' (2 I�2
° 13125 3125 SW Hall Blvd., Tigard, OR 97223 APR . 2 20 Plan Review
' • °;'' Phone: 503.639.4171 Fax: 503.598.1960 DateBy: Other Permit:
rI IGi \ 1:'I)7 Inspection Line: 503.639.4175 CITY OF TIGAR �1 Date Ready/By: , g
luris: 63 See Pa e 2 for
Internet: www.tigard-or.gov BUILDING nivIs �111otified/Metho h Supplemental Information
' . TY PE OF WORK • PLAN REVIEW •
❑ New construction r2 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 0 Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling 0 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 ", "I -3 ",
Job no.: Job site address: / '1 I00HP or more. occupancy.
58 �- LLD 7c h ❑ Recreational vehicle arks.
�� `t ❑Six or more residential units. p
City /State /ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: N e ln.) L ` 5 1 � ❑ Service or feeder 600 amps or more.
J FEE SCHEDULE
Cross street/directions to job site: 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 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: -
Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 67.84 2
Limited energy, multi - family 67.84 2
k.Z.1■.D L 1 5 1 residential (with above sq. 0.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER • m TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: �� y S 6 S $ 601 amps to 1,000 amps 301.04 2
Address: 5o._ r.y`Q a s a 6 004 Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: relocation
( )
Phone: ( ) Fax: 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that 1 own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
E❑' APPLICANT . ❑CONTACT PERSON above service or feeder fee,
7.42 2
each branch circuit
Business name: 13. Fee for branch circuits without
service or feeder fee, first a) 56.18 , may p$ 2
Contact name: branch circuit J�
Each add'I branch circuit / 7.42 — 7 , y 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
Y dwelling, service and/or feeder
Phone: ( ) Fax: : ( )
Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR - Signal circuit(s) or limited - energy
�
/� 1 panel, alteration, or extension. _ Page 2 _ 2
Business name:
E / / ► Q c r I r Li- Each additional inspection over allowable in any of the above -
Address: -1) 33 &� 192 if ao2 Additional inspection (l hr min) 66.25/ hr
City/State /ZIP: G.,f,e 5 C� Ind p ant 1 min) 66.25/ hr
Industrial plant (1 hr min) 78.1181 hr
Phone: (5 ;) 31 0 (1 S Fax: (5tas )( 58-- 1 g3 j Inspections for which no fee is 90.00/ hr
specifically listed (%: hr min)
CCB Lic.:1 8 ciz -.2 Electrical Lic.lC_,(44.. Suprv. Lic. :53Vjc S ELECTRICAL PERMIT FEES •
Suprv. Electrician signature, required � jj
Subtotal:
i r 1' (� ,` Plan review (25% of permit fee))
:
Print name: e 1 c rn z-/-) h Date: — Z l _ / D State surcharge (12% of permit fee):
TOTAL PERMIT FEE: / 2.
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: • Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 10/01 /09 440- 4615T(t 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 $67.84
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $67.84
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
I Clock Systems
❑ Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
n Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1:\ Building \Permits\ELC- PermitApp.doc 10/01/09
d% fie.- 2c( cc,/ 7
City of Tigard, Oregon • 13125 SW Hal I Blvd. • Tigard, OR 97223
II •
October 28, 2010 •
E A Martin LLC
4233 SE 182nd, #202
Gresham, OR 97030
Re: Permit No. ELC2010 -00187
Dear Sir /Ms.:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 16358 SW 72n Ave.
Project Name: Lindquest Glass
Job No.: N/A
Refund: ® Check #67489 in the amount of $71.23.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Work not allowed as service is crossing property lines and jurisdictional boundaries
to provide power to billboard in Tualatin. Refund 100% of permit fees per Building
Official.
If you have any questions please contact me at 503.718.2430.
. Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
I: \ Building\ Refunds\ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
IN Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
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: EA Martin LLC
INVOICE TO: (Business or Individual)
Mailing Address: 4233 SE 182n #202
City /State /Zip: Gresham, OR 97030
Phone No.: 503 - 310 -9745
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL PERMIT APPLICATION.
® REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ELC2010 -00187
Site Address or Parcel #: 16358 SW 72 " Ave
Project Name: Lindquist Glass
Subdivision Name: Lot #:
EXPLANATION: Per Mark VanDomelen, Building Official, void and refund 100% of
permit fees. Work not allowed. Service was crossing property lines and jurisdictional boundaries
to provide p er to billboard located in Tualatin.
/
Signature: Y Date: 5/6/10
'bie Adamski
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 more 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 more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) 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.
FOR OFFICE USE ONLY
Rte to S s Admin: Date 6AltiriM,.B . jai Rte to Bld: Admin: Date , B b
Refund Processed: Date /0 2-4 i p B Invoice Processed: Date B
Permit Canceled: Date /6/241/0 B • %- Parcel Tag Added: Date By
Receipt # Date Method Amount $
l: \ Building \Forms \RegPemuvlction.doc Rev 07/26/07