Permit II CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
1,0
0 COMMUNITY DEVELOPMENT Permit #: ELR2010 00146
T 1 GA R D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/06/2010
Parcel: 2S 101 AC00400
Jurisdiction: Tigard
Site address: 7095 SW GONZAGA ST
Subdivision: NATIONAL SAFETY BUILDING Lot: 0
Project: WILLAMETTE DENTAL
Project Description: Stereo system.
FEES
Owner:
NATIONAL SAFETY COMPANY Description Date Amount
17010 SW WEIR RD Restricted Energy Permit 08/06/2010 $75.00
BEAVERTON, OR 97007 12% State Surcharge - Electrical 08/06/2010 $9.00
PHONE:
Contractor:
MUZAK LLC ,
12449 NE MARX ST BLDG 10
PORTLAND, OR 97230
PHONE: 503 - 554 -2594
FAX: 503 - 889 -3883
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: Y Boiler Controls: N
CCTV: N Clock Systems: N
Data & Telecommunications: N 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 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 952- 001 -0100. You may ob • a of the rules irec es ions o UNC by calling 503.246.6699 or 1.800.332 2344.
Issued B Q Permittee Signature: ') nQ -�-�-�
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.
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard i g ed . Permit No.: ; I , w_ Ili
13125 SW Hall Blvd., Tigard, OR 97223 E BIN " an Review
C Phone: 503.639.4171 Fax: 503.598.1960 Date /B : Other Permit:
T I G A R D Inspection Line: 503.639.4175 , Date Ready /B ® See Page 2 for
Internet: www.tigard-or.gov AL\ G O S 1 Notified/Method: Supplemental Information
TYPE OF WORK QFT1GAv PLAN REVIEW
( � q' i te1
- New construction ❑ Addition/alteration/replac�r+> tI �t � � V I;� Al P check all that apply (submit 2 sets of plans w /items checked below):
11JJ \IV ❑ Service or feeder 400 amps or more ❑ Building over three stories.
El 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 4 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 Toad of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
IOOHP or more. occupancy.
Job no.: Job site address:
104 Sty.) 6 Nitsp ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: "'R (rAO ' d 2 L` i 22-3 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name:k A.jtti d-IL A- ❑ Service or feeder 600 amps or more.
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 Tess 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
75.00 2
DESCRIPTION OF WORK ( with above sq. ft.)
(0 - -� V 8 .13--e3-t, SI 5 Limited energy, multi-family a e q. 75.00 2
�` residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER I ❑ TENANT • 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
ty 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 I own which is not
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ ' APPLICANT 1 ❑ 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 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67 84 2
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
Business name: panel, alteration, or extension. , Page 2 75 2
M/(�Z L Each additional inspection over allowable in any of the above
Address: 1'L K$2.. K$2.. � >
5 0 Sr Additional inspection (1 hr min) 66.25/ hr
Investigation hr min) 66.25/
City/State/ZIP: y a,�t s� DA- 9 - 1 - L3 a
.�,�
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) S5 t;_ 2 . , s 9 ./ Fax: (5o3 ) _5 — 1 i pc) Inspections for which no fee is 90.00 / hr
specifically listed ('/ hr min)
CCB Lic.: 1 th,1 cp Electrical Li - jpss ((Suprv. Lic.: 33.) LEA ELECTRICAL PERMIT FEES
Subtotal: i, ,‘")
Suprv. Electrician signature, required: - r Plan review (25% of pen it fee): 44
Print name: ?pa (_„ y u cL Date: ,�I6 / y State surcharge (12% of permit fee): n �N
{ 111 TOTAL PERMIT FEE: y .
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.
I:\ Building \Yermils \ELC- PermitApp.doc 07/01 /10 440- 4615r(11/05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
=`RESIDENTIAL W,ORB ONLY e
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
R'OMMERCIAL,W,ORK O Y W.,.... ,.,w..;, ,...; .,..,_
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
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ 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:\13uilding \Permits \ELC- PermitApp.doc 07/01/10
08706/2010 16:32 5032521109 PORTLAND PAGE 01/01
W7/ Clb/ zulla 14:1/ 5035981960 CITY OF TIGARD PAGE B1/01
• RECEIVED
1 -or, Communi.t Development
AUG 06 2010
. 1: ,, Request for Permit Action
"- V OFTICTARr)
TO: CITY OF TIGARD BUILDING DIVISION
Building Division Services Coordinator
13125 SW Hall BIvd., Tigard OR 97223
Phone. 503.718:2430 Fax: 503.598.1960 ant►w.tig eel -otgov
FROM: [] Owner [] Applicant E Contractor ❑ City Staff
(cheek ottc)
REFUND OR Name:
INVOICE TO: ahwIneu a: 44'664 Ctrt L.4,7-1.
Mailing Address; t.1....1/4 q N E
City /State /Zip: Po R T L }., d 2 7 i3 0
Phone No.: 0 3 - S - LSCt
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Er CANCEL PERMIT APPLICATION. ` fiat /JA
I RE.FVND PERMIT FEES (attach receipt, if available). 6 �D '`^'
0 INVOICE FOR FEES D[JE (attach case fee schedule and explain below).
o REMOVE CONTRACTOR FROM PERMIT (do not cat,.cel permit).
Permit #: ZO 1 0 OO l
Site Address or Parcel #: O S Std5
Project Name: ` t
Subdivision Name
Lot #:
ERPI.ANATION:
S EE , A l
Signature: • ! I . _ Aate:
a • • - 4...L its a
Print Name: 1
t. • ihc Director or Building Official may authoTbro the refund ofi
t) any fee which apps ctttaseaaaly paid or re+licctcd.
b) not more Than 80% oft c land me application tat shat an application ie withdrnvn or emmlcd bcfo:c arty rcvicw utiort hap been expended.
e) not more than 8I1% of the land um application fit fa iataied permit
not nom than 80^�F of the tiding plan tuvicw fcc when an aprlionion ip +nettled beRiro nn play rvView arum hap bona .
c'/ not more than AO% of Ma buikSnp permit fec ibr *Pucd pcnmitx pno tO any bitpectiOn tcquM ot.
a &Fond; will to fumed to the o igbral P. in the ht! same nurficai in Mich payment drnp received. Phase R1ivw i,2 weeks for procuring seamier.
Refund P Datc PI / p s Rte to Did IEta ' • DAte
d xocessed: Date ', ,r1-7A ,�. I ' '
�:• invoice Processed: Date
� ���
Fermi+ Cs added t Dote ,r�e yaW Pa f c
. , 4 Date / ¢1 T Added: Date
1Huuditta \Forrnc R .7•7-/C,
1 eaNnniateenn,,d. /fi'f Amount S ,tom, .,
Irr City of Tigard
T[GARD 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: Muzak LLC DATE: 10/22/2010
12449 NE Marx St.
Portland, OR 97230 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 178985 Case #: ELR2010 -00146
Date: 08/06/2010 Address /Parcel: 7095 SW Gonzaga St.
Pay Method: CreditCard Project Name: Willamette Dental
EXPLANATION: Per applicant's request as this is a duplicate permit. Refund 80% of permit fees.
REFUND INFORMATION: - .
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Restricted Energy Permit 2200000 -43103 $60.00
12% State Surcharge 1003100 -24001 7.20
TOTAL REFUND: $67.20
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager
If under $25,500 Department Manager /47/64. -,' - -
/G'/Z -ZA 0
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: 1 4fre/ /fit I By: I :ir 3
I: \Building \Refunds \RefundResuest.doc x 09/01/2010
dok '06,'q,c
City of Tigard, Oregon • 13125 SW Hail Blvd. • Tigard, OR 97223
Vi i.. )[ rba
October 29, 2010 - •
Muzak LLC
12449 NE Marx St.
Portland, OR 97230
Attn: William Higgins
Re: Permit No. ELR2010 -00146
Dear Mr. Higgins:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 7095 SW Gonzaga St.
Project Name: Willamette Dental
Job No.: N/A
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $67.20.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per appliant's request as this is a duplicate permit (see ELR2010- 00116). 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: \ Building\ Refunds\ Administration\ LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 e www.tigard- or.gov • TTY Relay: 503.684.2772
CITY OF TIGARD RECEIPT
q
1 E . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 180218 - 10/29/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2010- 00146 $ -67.20
Total: $ -67.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 184900 DHOWSE 10/29/2010 $ -67.20
Payor: Muzak LLC
Total Payments: $ -67.20
Balance Due: $67.20
•
Page 1 of 1
CITY OF TIGARD RECEIPT
_ . • 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIG,1
e2/ 6 A /44—
Receipt Number: 178985 - 08/06/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2010 -00146 Restricted Energy Permit 2200000 -43103 $75.00
ELR2010 -00146 12% State Surcharge - Electrical 1003100 -24001 $9.00
Total: $84.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 184900 BTAGGART 08/06/2010 $84.00
Payor: Muzak LLC
Total Payments: $84.00
Balance Due: $0.00
Page 1 of 1