Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
III a .: COMMUNITY DEVELOPMENT Permit#: ELR2009 -00154
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/05/2009
Parcel: 2S 113AA01100
Jurisdiction: Tigard
Site address: 16592 SW 72ND AVE, BLDG# B11
Subdivision: OREGON BUSINESS PARK I Lot: 0
Project: Spec Space
Project Description: HVAC
FEES
Owner:
PACIFIC REALTY ASSOCIATES Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY Restricted Energy Permit 06/05/2009 $75.00
#300 12% State Surcharge - Restricted Energy 06/05/2009 $9.00
PHONE:
Contractor:
OHAC INC
PO BOX 241
DUNDEE, OR 97115
PHONE: 503 - 538 -2953
FAX: 503 -691 -8556
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: N Fire Alarm: N
HVAC: Y Instrumentation: N Total $84.00
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N Required Items and Reports (Conditions)
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 0 952- 001 -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: I F/ `, Permlttee Signature: bN /919,4 /6�77e-
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 603.639.4176 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.
. .x
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
kBhA_ ��rc! trunu. .99;A1i"�fi.is.".- 1'u,'3.tC�.. L..._ L..n rfn S ilr.:.f alr(c1wJ_..p
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
[] Audio and Stereo Systems*
❑ Burglar Alartn
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Sy
❑ Other:
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 Telecor7:n ur: cation Installation
n F ire Alarm Installation
}VAC
❑ I nstrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape I fighting*
❑ Pruteciiv Sigtr ling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\B Hlldin gTermits PermitAno.dot )3!33/66
L0/90 3E d 9NIld3H N093d0 9558- T69 -E05 9b :ET 600Z/E0/90
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Community Development
Request for Permit Action
TIGARD • .
TO: CITY OF TIGARD JUL 1 3 2009
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223 CITY OF TIGARD
Phone: 503.718.2430 Fax: 503.598.1960 unvw.tigard- or.gov BUILDING DIVISION
FROM: ❑ Owner • ❑ Applicant ® Contractor ❑ City Staff
(check one)
REFUND OR Name: Oregon Heating & AC
INVOICE TO (Business or individual)
Mailing Address: P 0 Box 241
City /State /Zip: Dundee, OR 97115 •
Phone No.: 503 -538 -2953
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION.
• ® REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
Cl REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
. Permit #: ELR2009 -00154
Site Address or Parcel #: 7 572 Set.) 7 09-1 //
Project Name: 3 S • ec S • aces
Subdivision Name: Lot #:
EXPLANATION: job cancelled
I Signature: 4I tl Date: 07/13/09
Teres. Stupor
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% attic land use application fee when an application is withdrawn or canceled before any review effort has been a pended.
c) not more than 80" /n of the and use application fcc for issued permits.
d) nor more than 8O% of the building plan review fec when an application it canceled before any plan review effort hag been evpcnded.
e) not more than 8O% of the building permit fcc for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which paynu.oi was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE I1Si ONLY
Rte to Sys Adtain: Date • By Rte to Bldg rkdmin: Date - 7 O I By �� r
Refund Processed: Date , a 7 r B Invoice Processed: Date
Permit Canceled: Date a,? Vi.)9 Byj - - Parcel Tag Added: Date By
Receipt # • Date Method Amount $ _
1: \Bull din \Forms \Re tcv 07/26/(17
•
90/10 39tid EJNIlt13H NO93i'i0 9SS8- 169 -E09 bE :tt 600Z/E1/L0
City of Tigard, Oregon O 13125 SW Hall Blvd. 0 Tigard, OR 97223
• •
. . . .
August 27, 2009
Oregon Heating & AC
P.O. Box 241
Dundee, OR 97115
Attn: Teresa Stupor
Re: Permit No. ELR2009 -00154
Dear Ms. Stupor:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 16592 SW 72n Ave., B11
Project Name: Spec Space
Job No.:
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 applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
•
_
/ f ' `L
Dianna Howse
Building Division Services Supervisor
Enc.
I: \ Building \Rcfunds \ Administration \LtrRefund- Cancell'ermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 . • www.tigard- or.gov • TTY Relay: 503.684.2772
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1-2 weeks for processing.
PAYABLE TO: Oregon Heating & AC DATE: 8/20/09
P.O. Box 241
Dundee, OR 97115 REQUESTED BY: Dianna Howse
Attn: Teresa Stupor
•
TRANSACTION INFORMATION: /(0 9L
Receipt #: 173863 Case #: ELR2009 -00154
Date: 6/5/09 Address /Parcel: •1381VV 72nd Ave., B11
Pay Method: CreditCard Project Name: Spec Space
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
•
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD1. Permit Fee Example: 245- 0000 - 432000 $ Amount.
Restricted Energy Permit 220 - 0000 - 431510 $60.00
12% State Surcharge 100 - 0000 - 207020 7.20
TOTAL REFUND: $67.20
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager -
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
•
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY, • • .
Refund Request Reviewed: Date: P72. 2.-7/y %9 By: .
Case Refund Processed: Date: 6` , By: 't
I: \Building \Refunds \RefundRequest.doc 04 /13/09
CITY OF TIGARD RECEIPT
• IN
a 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 175009 - 08/27/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2009 - 00154 $ - 67 . 20
Total: $ -67.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 07395A DHOWSE 08/27/2009 $ -67.20
Payor: Teresa Stupor - Oregon Heating & AC
Total Payments: $ -67.20
Balance Due: $67.20
Page 1 of 1
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A. •
CITY OF TIGARD 6q;--07.-68 •
RECEIPT
a �c'�.ca 5
1 13125 SW Hall Blvd., Tigard OR 97223 C.
503.639.4171
• TIC
Receipt Number: 173863 - 06/05/2009
CASE NO FEE DESCRIPTION REVENUE ACCOUNT NUMBER • PAID
ELR2009 - 00154 _ Restricted Energy Permit 220 - 0000 - 43 $75.00
ELR2009 00154, • 12% State Surcharge - Restricted 100 -0000- 207020 $9.00
Energy
Total: $84.00
•
•
•
PAYMENT METHOD . CHECK.# CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT •
Credit Card . 07395A DHOWSE 06/05/2009 $84.00
.Payor: Teresa Stupor - Oregon Heating & AC
Total Payments: $84.00
Balance Due: $0.00
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Page 1 of 1
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90/Z0 39dd ONIlti3H N00360 9558- I69 -EOS OE:IT 6002/EZ/L0
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Electrical Permit Application . mu ()Fri( T. 'Isl.: ON1,1
Cl of Ti and Received / ti Permit No. !
'1 131 Hall Blvd., Tigard, O: Plan Re . rF' ✓� O� i a d / DQ1
� �w Plan Review /� A
_,,�6. Phone: 503.639.4171 Fax: 5 t .' ' , , I IVED Date./By: giber Permittelt 01 0I e e 24 •
1 .. ,: ; I Inspection Line: 503.639.4175 Date Ready/By: 6d See Page 2 for
Internet: www.tigard or.gov Notified/Method: 77 Supplemental Information
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` :- �..__ ,,- - `- ",_ :.... , k"1y w ti l. k'S 7'l : t. r . t \\ti - t.,, 'n� ,, pc•S, - „ .! B a 1 '�^ s ; : „ .. ;_ ;^' .i : x ,:\ �• ..
.. .. ._r :�... 1 F�"U.'..W:,..« ... z.« �.A.� . \. ..._ ,... ..1...a ) � Y • h". :»..1 � ) t ...,1...- ..•:t�.`•w ,:SIT......'::C...� 5 "1:....��...w �,'.U
❑ New construction ® Additi61 , "n eat Please check all that apply (submit 2 sets of plans w /items Checked below),
[ f j 14 / ❑ S or f 400 amps or m over ore ❑ Building ov three stories.
❑Demolition : ❑ pth$
j.D ■ b where the available fault current ❑ Marinas and boatyards.
l y2 , , Wit.VAti5. \ ' 1v ,V al\ b.. J c t ,, ' 1 !
� � i '� �� ? �� 1 , exceed; 10,000 amps at 150 volts or CI Floating buildings.
less to ground, or exceeds 14,000 ❑Commercial -use agricuhural
❑ 1- and 2 - family dwelling ® Comniercial/industrial El Accessory building amps for all other installations. buildings. •
0 Multi - family ❑ Master builder El Other: . ❑ 'Fire pump. ❑ Installation of 73 KVA or
larger separately derived system,
rn,ra. r. S, C .`� .
. , _.. n. 3 : ❑ Addition of new moan load of ❑ "A ", "E" "1-2” "1-3 ".
Job no.: 09 -0208 Job site address: 16592 SW 72° Ave 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City / State/ZIP: Portland, OR 97224 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: 3 Spec Spaces
❑ Service or feeder 600 amps or morx
r, y � 1 1, Y �'fl q \\ '' - � v , z..r :. • , f'\•,.n4y E .,,. ' T e y C.f -
Cross street/directions to job site: uescript i ? .g,..�r: ..t. . a . : , �. ::..; i.:.,..r.!. . <�w.:. , `"•�
o n qty r'ee total -
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 1
Tax map /parcel n0 Limited energy, residential
\: ;�s ''' ' i , {\ ` ? 75.00 2
...,i S z, :, _.�...fi, \` „... , u , -.,. w :. •!ti Ck .. .. _ .Y ,.,, ti , ar.._,._ , ._, :: � ?_,,w -....:,0.:::: (orith above s4. ft.)
11CVAC Limited energy, multi - family 7500 2
residential (with shove to. ft.)
Services or feeders installatioa and/or relocation
" < \ r ` y 200 amps or less 80.30 2
ti\ �.�; c_,S , °. , L , '"' ' I.. 201 amps 10 400 amps 106.85 2
._4.:.�:. ", i ....... ? � , ' : _- _......_.. max.
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 feed installation, alteration. and/or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I 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
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
A Fee for branch circuits with
` ` " w ` : j r ' ,f above service or feeder fee.
,..,.,: �`..- .`. ? ,;:. ....,_ ?.: ....). . Y ,. - ' „ r•>.i : M : z,zi,s..�ti ...r.,. :.: .r. ✓. . �.: .. ,,,,v. ;,..: .w.... ' _ - ....a,, 6.65 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fcc 46.85 2
fast branch circuit _
Address: Each add'! branch circuit 6.65 2
Miscellaneous (service or feeder not included)
• City /Statc /ZIP: . Each manufactured or modular
90.90 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
-
E -mail: Pump or irrigation circle 53.40 2
..-...,:.» 5 ....:... • :..,. 1MS 1'� iE\i ! .:..� ' � ) \ .. 1 K . r,i.� y � � , y i.i; :- lt Sign or O11C11nC lighting 53.4() 2
• ..x...:._ +ai \'l: ,. ..:, ..•.1.. Y.^^' � � -::: 1 `__.. .F1.....Mc:� �n Y. r..
Signal circuit(s) or limited-
Business name: Oregon Heating & AC energy panel, alteration or
Address: P O Box 241 extension, Describe: 1 Page 2 75.00 2
City/State/ZIP: Dundee, OR 97115 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (503) 538 -2953 Fax: (503) 6914556 . Investigation per hour (1 hr min) 62.50
CC13 Lic.: 172126 Electrical Lic.; LHR40 ;1 Suprv. Lic.: 1798LER Industrial plant per hour 73.75
ande Suprv. Electrician signature, regained: % -� 'r ,' 1tl., h; ,). _t.._? !cC... 4>
Subtotal 75.00 t/
Print name: CrregBoone i Date: 06 - - Plan review (25% of p ermit fe -
A � . State surcharge (12% of permit fee): 9.00
Authorized signature: �.1�'` TOTAL PERMIT FEE: 84.00 ✓
Print name: Teresa Stupor IMINI Date: 06-03 -09 This permit application expires if a permit is not iplete within 180
stays after it has been accepted as complete
V Number of inspections allowed per garnet.
1.1BuadilePvr nks N. ELC.PennitApp.doc osavo6 440- 4615T(1 vosicomnvi;B
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