Permit •
a CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
.11 a • COMMUNITY DEVELOPMENT Permit #: ELR2010 -00231
T1 G A R D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/26/2010
Parcel: 1S135AB01003
Jurisdiction: Tigard
Site address: 10300 SW GREENBURG RD 487
Subdivision: LINCOLN ONE Lot: 0
Project: Farmers Insurance
Project Description: Low voltage for fire alarm
FEES
Owner:
LINCOLN CENTER LLC Description Date Amount
BY SHORENSTEIN PROPERTIES LLC, 555 Restricted Energy Permit 10/26/2010 $75.00
CALIFORNIA ST 49TH FL 12% State Surcharge - Electrical 10/26/2010 $9.00
PHONE:
Contractor:
SAFE TECHNOLOGY GROUP INC
6400 NE HWY 99 SUITE 375
VANCOUVER, WA 98665
PHONE: 360 - 699 -2130
FAX: 360 - 719 -1527
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 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 th • . ; •AR 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: � 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.
Electrical Permit Application FoR ()Hit]: I)SE oNi.v
Receive
I N
City of Tigard DateB : �Q ? /p � / Permit No.: f O�0
q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.639.4171 Fax: 503.598.1960 DateBy: Other Permit:
r I G n R D Inspection Line: 503.639.4175 Date Ready/By: Juris: HI See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction 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 ❑ 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
JOB SITE INFORM� N ND LOCATION ❑ Emergency system. larger separately derived system.
s�/ Q C1 ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
0 100HP or more. occupancy.
Job no.: Job site addre s: LS ( a (� ,�,. b /v2 ; ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: 'r
:54 fd _ " Jf ❑Health-care facilities. 0 Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: % 8 7 Project name: a 5 ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: 1,. /.GJ ( ( 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 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
-
Limited energy, multi - family
f w / w' r/it, residential (with above sq. ft.) 75.00 2
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
Temporary services or feeders installation, alteration, and/or
City/State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or Tess 59.36 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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
fa above service or feeder fee,
APPLICANT 1 ❑CONTACT PERSON each branch circuit 7.42 2
Business name: s4 , I �� 71 (05 / („ n (. B. Fee for branch circuits without
I ' service or feeder fee, first 56.18 2
Contact name: TA S� S a branch circuit
�"' ` e- Each add'I branch circuit 7.42 2
Address: L9 t o EC A ,9.) Miscellaneous (service or feeder not included)
Each manufactured or modular
City /State /ZIP: /
Uael (AM (irr I. A S' Gs" dwelling, service and/or feeder 67.84 2
Phone: ( 3L0) C._' - zi 3 O Fax: : (360) 7/e - ,'Sa -7 Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
CONTRACTOR Sign or outline lighting 67.84 2
Signal circuit(s) or limited- energy
Business name: „544 r"e(M tt D / As Oj G �,,,n L panel, alteration, or extension. Page 2 2
J / - Each additional inspection over allowable in any of the above
Address: (t I t)o N a fi q el Additional inspection (1 hr min) 66.25/ hr
7 / Investigation (1 hr min) 66.25/ hr
City/State /ZIP: V �0 (4),4- fVf ls' a g g (,S Industrial plant (1 hr min) 78.18/ hr
Phone: )bv (,qS _ a 130 (Fax: (3vo ) ')/ 5 , /3":2 Inspections for which no fee is 90.00/ hr
specifically listed (%2 hr min)
CCB Lic.: 1 73"7 3 1 Electrical Lic.: a C 75 Suprv. Lic.: ti,)7,2c,E.A. ELECTRICAL PERMIT FEES
Subtotal: 7t ill)
O
Suprv. Electrician signature, required: C
J Plan review (25% of permit fee):
Print name: J A 5 $' D ate: �Q ...-61.5-16 Plan
surcharge (12% of permit fee): �• 00
otA � TOTAL PERMIT FEE: Sff
Authorized signature:
This permit application expires if a permit is not obtained within 180
Print name: �Q Date: /0 = / days after it has been accepted as complete.
S y. Number of inspections allowed per permit.
I:\Buitding\Pmnits\ELC- PermitApp.doc 07/01 /10 440- 4615T(1I /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 $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:
COMMERCIAL WORK ONLY:.
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
I • 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
I:\ Building \Permits\ELC- PermitApp.doc 07/01/10
City of Tigard
TIGARD 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: Safe Technology Group, Inc. DATE: 11/23/2010
6400 NE Hwy 99, Ste. G375
Vancouver, WA 98665 REQUESTED BY: Dianna Howse
Attn: Jason Sweet
TRANSACTION INFORMATION:
Receipt #: 180092 Case #: ELR2010 -00231
Date: 10/26/2010 Address /Parcel: 10330 SW Greenburg, Ste. 487
Pay Method: CreclitCard Project Name: Farmers Insurance
EXPLANATION: Per applicant's request as no fire alarm was done. 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 ACU5.1
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 / /7 /f By: I .
I:\ Huildin,oto unds\ RcfundRc . ((9/01/2(1111
�� CITY OF TIGARD RECEIPT
.° II PI a 1 3125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
/" u «
Receipt Number: 180619 - 12/07/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2010-00231 $ -67.20
Total: $ -67.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 073914 DHOWSE 12/07/2010 $ -67.20
Payor: Jason D Sweet, Safe Technology Group Inc
Total Payments: $ -67.20
Balance Due: $67.20
c.
Page 1 of 1
Ihil CITY OF TIGARD RECEIPT
n
_ : 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGAR.D
2 /Z /C /,v
Receipt Number: 180092 - 10/26/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2010 -00231 Restricted Energy Permit 2200000 -43103 $75.00
ELR2010 -00231 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 073914 DADAMSKI 10/26/2010 $84.00
Payor: Jason D Sweet - Safe Technology Group Inc
Total Payments: $84.00
Balance Due: $0.00
Page 1 of 1
Community Development
I c � i.a Request for Permit Action nC
VED
N° V 4 2010
TO: CITY OF TIGARD CITY OF r
1131 ng H all Blvd., Tigard, OR 97223 scar BUILDIN DIVISION
Phone: 503.718.2430 Fax: 503.598.1960 www,tigard- or.gov I�N
FROM: ❑ Owner d Applicant 5 Contractor ❑ City Staff
(cheek one)
REFUND OR Name:
INVOICE TO: (Busing Or individual) , ( 11) , a ' Ca
3y r-y rte T12, s
Mailing Address: LO O NE }, C .3 k 37 T
Cit /zip: (k,; C e7 cA (/// l ,J/f 9 rf( ‘,
Phone No.: 3(14 ' (9`9 J - 1 3Q
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
r CANCEL PERMIT APPLICATION. VOID
REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FERS DUE (attach case fee schedule and explain below). /a /7/ 0
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit fit; EL-I a010 — OU X3
Site Address or Parcel 4: _1030 p () Gese / S -7
Project Naive: FAr' .ner'S 5(A. t C &
Subdivision Name: Lift col ii One lot #;
EXPLANATION: �/� aft;n�t wru�lc CAD
Signature: jn Date: //- '7- /C'
Punt Nam:
licfond Policy
1. The Director or Building Official may tutlhnrire the refund of
a) any fce which was erroneously paid or collected.
b) not more than 80% of the land use application fec when an spph ation is withdrawn or canceled before eny review effort has been expended.
c) not more than 80% of the land use application fec for issued pem its,
d) not mare than 80% of the building plan review fcc when an application is canceled before any plan review effort hint 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 t the original Payer in the carne method in which payment wee received. Please allow 1.2 weeks for procc gang ref
1 OIZ'•4 ) !
Rte to S s Admen; Date B
Rte to BEd. Adrrun: _ llate42 VAMP' B Processed: Dat a 7 . ! B
ERMIZIEMINI �'�� Invoice Procesaecl; Date
A
Mite Ir
I ParcelTa Added: Date B
� ,
Rccei. t # :Awn Date / A Metho. ( �. — Amount
l:\ Building Porma \RegPcmutAction.doc Rev ,7/26/07
3�; 90 les'y -; 6 ' CctL . 6,0 p /.�
:1 ' • Community Development r��
; ,\ ,; I , Request for Permit Action 1 EI VED
TO: CITY OF TIGARD
R/0 I/ It 2010
Building Division Services Coordinator BU/LO/A/ F " GAR
13125 SW Hall Blvd., Tigard, OR 97223 Oa DIVI
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard••or.gov
FROM: ❑ Owner [( Applicant 5 Contractor ❑ City Staff
(cheek one)
•
REFUND OR Name:
. INVOICE TO: (hluwtas of lttdiniduar) .Sc; -- e , , , , .
G
Mailing Address: L YOO NE Hwy q y Sup k 6,37S"
City/State /Zip: UG/) C ouw /.J4 9 g(, AS
Phone No.: 300 - CAC) - ? 130
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PINRMIT AP'PLICA'TION.
. REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR PEPS DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit it: Et-le aOl() - vO A31
Site Address or Parcel #: D30 56_1___ ) Vree, E era Cog 7
Project Name: Fa!•r.-er'S 5utj4 [ :e. _._.. _
Subdivision Name: L; n col 4 pee Lot #:
EXPLANATION: NO ' alarvt 144 C(p
Signature: g L peeh _ Date: /
Print Name: •Ta sLIA .S„ r v,P,r
•
Refunsladicy
1. The Director or Building OfRcial may authorise the refund of
a) any fee which was enormously paid or collected,
b) not more than 80% of the land use application fir when an application ie withdrawn or canceled before any review effort has been expended.
c) not more then 80% of the land use application fee for issued permits
d) not more than 80% of the budding 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 Mud permits prior to any impaction request..
2. Refunds will be returned to the original Payer in the same method in which payment was received please allow 1.2 steers for proving refunds.
('I d∎ itl:l 1C1! lHtil.t
Rto to S a Admin: Date B Rte to B • : Admin: Date,42 �•-, *i
Refund Processed: Dat �i 7 i••'� ��
—
rga,l Invoice Processed: Date
Permit Cancel, Date /� ; i g PParcel Ta : Added: Date B'
'
Recei• t #
dll Medici. L• C Amount $
1: \Building Porms \ReoPcmtaAction.doc R '7/26/07 . di) —
(:—q4 0 — 9e) 5/- eri-- - t
cL gl0' 002:5 1
City of Tigard, Oregon ® 13125 SW Hall Blvd. ® Tigard, OR 97223
®,� a
g rOSIV %
December 8, 2010 W I � ^, " s'
Safe Technology Group, Inc.
6400 NE Hwy 99, Ste. G375
Vancouver, WA 98665
Attn: Jason Sweet
Re: Permit No. ELR2010 -00231
Dear Mr. Sweet:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 10330 SW Greenburg, Ste. 487
Project Name: Farmers Insurance
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 applicant's request as fire alarm was not installed. 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- CancelPemut.doc 01/16/07
Phone: 503.639.4171 e Fax: 503.684.7297 e www.tigard- or.gov ® TTY Relay: 503.684.2772