Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
' COMMUNITY DEVELOPMENT Permit #: ELR2009 -00104
T t G A RD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/10/2009
Parcel: 2S113B000600
Jurisdiction: Tigard
Site address: 16580 SW 85TH AVE
Subdivision: SEWER TREATMENT PLANT Lot: 0
Project: Cleanwater Services
Project Description: Install limited energy for voice /data.
Owner: FEES
CLEAN WATER SERVICES Description Date Amount
2550 SW HILLSBORO HWY Restricted Energy Permit 04/10/2009 $75.00
HILLSBORO, OR 97123 12% State Surcharge - Restricted Energy 04/10/2009 $9.00
PHONE:
Contractor:
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: Boiler Controls:
CCTV: Clock Systems:
Data & Telecommunications: Y Fire Alarm:
HVAC: Instrumentation: Total $84.00
Intercom/Paging: Landscape /Irrigation: Required Items and Reports (Conditions)
Landscape Lighting: Medical:
Nurse Calls: Protective Signal:
Security Alarm: Other:
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 t roug OAR 954.001-0100. You ay o taii a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2 44.
Issued By:. (� L 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'N 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.
- RECEIVE ,
Electrical Permit Application FOIL OFFI(L 1 «II t,yl.)
1 a City of Tigard DateB `� I Permit No.: C eel O ,
• 13125 SW Hall Blvd., Tigard, OR 97223 APR 1 0 2009 Received
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960C APR
OF TIGARD Date/By: Other Permit:
T (.1 ,1z I Inspection Line: 503.639.4175 BUILDING DIVISIO I Date Ready/By: 7uris: El See Page 2 for
I Internet: www.tigard or.gov Notified/Method: T `(2 Supplemental Information
TYPE OF WORK PLAN REVIEW
Please check all that apply (submit 2 sets of plans w /items checked below):
❑ New construction ® Addition/alteration/replacement
❑ 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 INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "I -3 ",
Job no.: Job site address: 16580 SW 85 Ave. IOOHP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard, Oregon 97224 ❑ Health-care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: New Entrance gate ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Hall /85th 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'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
' Limited energy, multi - family 75 00 2
Reroute and re- terminate existing 50 pair Voice/Data phone cable residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: Cleanwater Services 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: 2550 SW Hillsboro Hwy Over 1,000 amps or volts 454.65 2
City/State /ZIP: Hillsboro Or 87123 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (503)681 -3600 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
Branch circuits- new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee,
each branch circuit 6.65 2
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'I branch circuit 6.65 _ 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular 90.90 2
Phone: dwelling, service and/or feeder
( ) Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Signal circuit(s) or limited -
Business name: Wel -Comm energy panel, alteration, or
Address: 6935 SW Molalla Bend Rd extension. Describe: Page 2 2
City /State /ZIP: Wilsonville, Or 97070 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (503) 936 -0367 Q. ( � • ■\ Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lic.: Electrical Lic.: 4333LEB Suprv. Lic.: Industrial plant per hour 73.75
43511 ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
Print name: Ryan Welsh Date: 10/10/09 Plan review (25% of permit fee):
State surcharge (12% of permit fee):
Authorized signature: A r-4_ TOTAL PERMIT FEE:
Print name: i � J q This permit application expires if a permit is not obtained within 180
�A A ) A �.r, `S �r-, Date: I lU O / days after it has been accepted as complete.