Permit �,: ; CITY OF TIGARD
ELECTRICAL RESTRICTED ENERGY PERMIT
•'�` ' °- COMMUNITY DEVELOPMENT Permit #: ELR2010 00269
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/03/2010
Parcel: 2S112DC00500
Jurisdiction: TIGARD
Site address: 15895 SW 72ND AVE 250
Project: Diagnostic Male Medical Subdivision: OREGON BUSINESS PARK III Lot: 40
Project Description: Low voltage for fire alarm.
Contractor: STANLEY CONVERGENT SECURITY SOLUTIONS IN' Owner: PACIFIC REALTY ASSOCIATES
15495 SW SEQUOIA PKWY STE 100 15350 SW SEQUOIA PKWY #300
PORTLAND, OR 97224 PORTLAND, OR 97224
PHONE: 503 - 968 -3353 PHONE: 503 - 624 -6300
FAX: 503 - 968 -3398
FEES
Description Date Amount
Specifics: Restricted Energy Permit 12/03/2010 $75.00
12% State Surcharge - Electrical 12/03/2010 $9.00
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: y
HVAC: N Instrumentation: N
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N
Nurse Calls: N Protective Signal: N
Security Alarm: N Other: N Total $84.00
Other Desc: 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 - • . - • ith 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. A NTION: Orego - , - • 'res you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -01 -0010 through OAR • ' 2 -0 .090 You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
it
I ued By: Perm ittee signat►�e�i / o -- ., _
7
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 the next available inspection date.
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 F_OR OFFICE USE ONLY
City J Rece
Ci of Tigard
q � �j ea 0 /6—c D k
•J g � r Date By: �i� �� wl "' Permit No.:
1 1111 '� 1 3125 SW Hall Blvd., Tigard, OR ' 2p3 ,I' Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit:
4 � =° �� Internet: www.tigard- or.gov
Inspection Line: 503.639.4175 Date Ready /By: Ju See Page 2 for
TIGARD. p DEC 2010 ns: 0 Notified/Method: Supplemental information
t�
' ,` : A ,, ,TYPE OF n{� V �ipyff,e�t � OF rIGA " • (` ` PLAN REVIEW , g z
❑ New construction ® Addition /aliEl�Citjr i pTia rnU VN 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.
111 Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
- CAT 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 ® Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE eiNFO I _ OCATION _ ° ° ❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "1 -3 ",
.`,• ... :,. s
IOOFIP or more. occupancy.
Job no.: Job site address: 15895 SW 72ND ❑ Six or more residential units. ❑ Recreational vehicle parks.
❑ Health -care facilities. ❑ Supply voltage for more than
City/State/ZIP: 97224 ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: 250 Project name: DIAGNOSTIC MALE MEDICAL ❑ Service or feeder 600 amps or more.
.t I EEE S '"*0.0LEr `r , f .. < ,'',; A,
Cross street/directions to job site: Description I Qty I Fee. I Total i *
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'l 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
75.00 2
'° - .t. � , DECRIP_ TION .�OF' WORK „..,:;,: "'. . . t � (with above sq. ft.)
5' .;
INSTALL ONE STROB AND TWO HORN STROBES ON EXISTING FIRE Limited energy, multi - family 75.00 2
residential (with above sq. 0.)
SYSTEM Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
P i ' TEN ANT'; . ' - e :a' 201 amps to 400 amps 106.85 2
®P;ROPEBTY� OWNER , . � ;' ^ -' ❑
401 amps to 600 amps 160.60 2
Name: PACIFIC REALITY ASSOSCIATES 601 amps to 1,000 amps 240.60 2
Address: 15350 SW SEQUOIA PARKWAY Over 1,000 amps or volts 454.65 2
Temporary services or feeders installation, alteration, and /or
City/State /ZIP: PORTLAND, OR 97224 relocation
200 amps or less 66.85 1
Phone: (503)624 -6300 Fax: (503)624 -7755 201 amps to 400 amps 100.30 2
Owner installation: This installation is being made on property that 1 own which is not -
401 amps to 599 amps 133.75 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. Branch circuits — new, alteration, or extension, s er panel
Owner signature: Date: A. Fee for branch circuits with
r r above service or feeder fee,
6.65 2
' ;® APPLIC - ® CONTACT'PERSON - . -
• each branch circuit
Business name: STANLEY SECURITY SOLUTIONS B. Fee for branch circuits
without service or feeder fee, 46.85 2
Contact name: GARY TAUSCHER first branch circuit
Each add'l branch circuit 6.65 2
Address: 15495 SW SEQUOIA PARKWAY, SUITE 100 Miscellaneous (service or feeder not included)
City /State /ZIP: PORTLAND, OR 97224 Each manufactured or modular 90.90 2
dwelling, service and /or feeder
Phone: (503) 968 - 3355 Fax: : (503) 968 - 3398 Reconnect only 66.85 2
Pump or irrigation circle 53.40 2
E-mail:
Sign or outline lighting 53.40 2
0 . CONTRACTOR - :.'
- Signal circuit(s) or limited -
Business name: STANLEY SECURITY SOLUTIONS energy panel, alteration, or
extg'sion. Describe: ` Page 2 2
Address: 15495 SW SEQUOIA PARKWAY, SUITE 100 Aa Ai-A¢M
Each additional inspection over allowable in any of the above
City/State /ZIP: PORTLAND, OR 97224 Per inspection 62.50
Phone: (503) 968 -3355 Fax: (503) 968 -3398 Investigation per hour (1 hr min) 62.50
Industrial plant per hour 73.75
CCB Lic.: 161567 Electrical Lic.: 37 -1054 Suprv. Lic.: a ELE(1RICA -. PERMIT FEEB..' i.
Suprv. Electrician signature, required: Subtotal
Plan review (25% of permit fee):
Print name: STEVE MOREHOUSE Date: 12/03/2010 State surcharge (12% of permit fee):
Authorized signature: 0
- P 2 7 , " i0 TOTAL PERMIT FEE: % .60
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
1. \Building \ Permits \ELC- PermitApp.doc 05/2:/06 440- 4615T(11 /05 /COMMB1
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL° WORIK` ONLY3 v 4 ', ,
Fee for all residential systems combined $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
. COMMERCI ORPoNI:Y:` . m , ;:' .' ;. ' , `,: `1
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
n Data Telecommunication Installation
Fire Alarm Installation
n HVAC
❑ Instrumentation
n Intercom and Paging Systems
❑ Landscape Irrigation Control*
n Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
C \Building \Permits \ELC- PermitApp.doe 03/23/06