Permit CITY ®F TIGARD ELECTRICAL PERMIT NA'AI'7' T
I
COMMUNITY DEVELOPMENT Permit #: ELC2010 -00203
•
I GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/28/2010
T
Parcel: 2S102BD00600
Jurisdiction: Tigard
Site address: 12725 SW PACIFIC HWY
Subdivision: Lot: 0
Project: Adrangi
Project Description: (2) branch circuits for repair work.
Owner: FEES
ADRANGI, FARID Quantity Description Date Amount
4289 ORCHARD WAY
LAKE OSWEGO, OR 97035 2 crt Branch Circuits 04 /28/2010 $63.60
wo /Purchase Service or
PHONE: 503- 719 -2174 Feeder
1 ea 12% State Surcharge - 04/28/2010 $7.63
Electrical
Contractor:
POSITIVE ENERGY ELECTRICAL
CONTRACTORS LLC
PO BOX 871543
PHONE: 360 - 885 -4479
FAX: 360 -326 -1918
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $71.23
Required Items and Reports (Conditions)
This permit '. • - • ••' to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be don= in accordance with a. • oved 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 - q ' -s . ou to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 01 -0010 through OAR 952 -001 -' 0. You ay obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Iss ed By: (1 � � ' � .e 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' , ,1111 §. `. M ' ` .....__ — 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.
Er City of Tigard
T I G A RD 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: ACH - Tim & Mindi Brizendine DATE: 10/20/2010
17047 SW Barcelona Way
Beaverton, OR 97007 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 177724 Case #: ELC2010 -00203
Date: 4/28/2010 Address /Parcel: 12725 SW Pacific Hwy
Pay Method: Check Project Name: Adrangi
EXPLANATION: Per applicant's request as work done by another contractor under separate permit.
Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 _ $ Amount. •
Electrical Permit 2200000 -43103 $50.88
12% State Surcharge 1003100 -24001 6.10
TOTAL REFUND: $56.98
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager /
If under $25,500 Department Manager ..------ .4 / /z /%
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY,
Case Refund Processed: I Date: I 1Q/2�(0 1 By: ,
1: \ Building \ Refunds \RefundRequest.doc x 09/01/2010
FROM BR 5035308268
7 -01 -2010 3 :41 PM P.1
06/29/2610 97 :48 5835981969 CITY TIGARD PAGE 01/01
. ^� ; Community Development
pment
Request for Pemtlit Action
TO: CITY OF TIGARD
Bedding Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Flta :503.598.1960 wravw.tigard- or..go.•
FROM:
FR env) ❑ Owner D Appbcant
(check
� Con tractor 0 City Staff
REFUND OR Name
INVOICE TO: cr3tt 'i rn *3 . p� t zt, , Ad►'�.
Mailing Address: 1 - 7 0 7 $ . 1 A , 'Aar c do tut k f
a
City/State/Zip: . �
Phone No.: ,503 — 7 9 — 7
_
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓);
CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES- (attach receipt, if available).
O INVOICE FOR FEES DUE (attack rase fec scbcdulc and explain REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: LC.
Site Address or Parcel #: 97
Ptojctt Nam
Subdivision Name: r...
Lot #:
EXPLANATION: '
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c) net num !hen a" ortbc laud t.4: ggnhcocon lee for issued permit%
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z. Refund. will be Ktwr an die 1 P fl a impatient
was ve tient requests.
y o No . m the MIK MIN' in which ysytn t od phase allow 1 - 2 wcelta For psoes n$ refund..
1 bale
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Permit Canceled: a Date
MfaXIMIIM Date �� , : .. T .: Added: Date 13 ,
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To: Electrical Permits Page 2 of 2 2010 -04 -28 19:59:19 (GMT) 13603261918 From: Lisa Thompson
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City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
r
October 28, 2010 .. .
ACH - Tim & Mindi Brizendine
17047 SW Barcelona Way
Beaverton, OR 97007
Re: Permit No. ELC2010 -00203
Dear Sir /Ms.:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12725 SW Pacific Hwy
• Project Name: Adrangi
Job No.: N/A
Refund: ® Check #67469 in the amount of $122.00 ($56.98 + $66.01).
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as work was done by another contractor under separate
permit. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
y +
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds\ Administration \LtrRefund- CancelPerrnitdoc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • • www.tigard- or.gov • TTY Relay: 503.684.2772
•
7I1 CITY OF TIGARD RECEIPT
n
Q 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
j2 P(A,
Receipt Number: 180161 - 10/28/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2010- 00203 $ -56.98
Total: $ -56.98
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
- Check 67469 DHOWSE 10/28/2010 $ -56.98
Payor: ACH - Tim & Mindi Brizendine
Total Payments: $ -56.98
Balance Due: $56.98
Page 1 of 1
Ill CITY OF TIGARD RECEIPT
, If
C . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
e /6= ihp9't__
Receipt Number: 177724 - 04/28/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2010 -00203 Branch Circuits wo /Purchase Service or 2200000 -43103 $63.60
Feeder
ELC2010 -00203 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 6623 DADAMSKI 04/28 /2010 $71.23
Payor. ACH - Tim & Mindi Brizendine
Total Payments: $71.23
Balance Due: $0.00
Page 1 of 1