Permit v CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit #: ELR2011 -00074
T I G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/24/2011
Parcel: 2S113AC00101
Jurisdiction: Tigard
Site address: 16655 SW 72ND AVE 300
Project: Food Sales West Subdivision: PACTRUST BUSINESS CENTER Lot: 0
Project Description: Low voltage for fire alarm.
Contractor: T & L COMMUNICATIONS INC Owner: PACIFIC REALTY ASSOCIATES
PO BOX 87387 15350 SW SEQUOIA PKWY #300
2800 NE 65TH AVE SUITE A PORTLAND, OR 97224
VANCOUVER, WA 98661
PHONE: 360 - 737 -9725 PHONE: 503 - 624 -6300
FAX: 360- 737 -9648
FEES
Description Date Amount
Specifics: Restricted Energy Permit 03/24/2011 $75.00
12% State Surcharge - Electrical 03/24/2011 $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 ce 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. TENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -0 1 -0010 through OAR 95' -001 :.9. • may obtain a copy of the rules or direct questions to OUNC by calling 503.232. 87 or 1.800.332.2344.
Iss d By: l � // r 0 Permittee Signature: A — Alt —.I _ ' _.4 . _
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.
CITY OF TIGARD RECEIPT
.: _ ,
C . _ 13125 SW Hall Blvd.. Tigard OR 97223
503.639.4171
.TIGARD
0./ L
Receipt Number: 181914 - 03/24/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2011 - 00074 Restricted Energy Permit 2200000 -43103 $75.00
ELR2011 -00074 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
Check 5650 DADAMSKI 03/24/2011 $84.00
Payor: T & L Communications
Total Payments: $84.00
Balance Due: $0.00
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Page 1 of 1
CITY OF TIGARD RECEIPT
p . , 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
•
TIGAAD
Receipt Number: 182934 -• 06/21/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2011 -00074 C LEc /2/ Ce G '6/z//'7 oeoo «s'' 3 4e, o0
/z e ! Smiz .ca4 e f. � /no.3i� o ' 7o o/
.,:e0 $ s7.2o
Total: $ 47.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 202547 DHOWSE 06/21/2011 $ -67.20
Payor: T & L Communications
Total Payments: $ - 67.20
Balance Due: $67.20
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Page 1 of 1
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard Date/B ' _ Permit No.: i of o (
f / - 7 `Z
: - " 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review r'L'1� E"(
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:
TIGARD Inspection Line: 503.639.4175 Date Ready/By: Juris ' ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: i Supplemental Information
/ TYPE OF WORK PLAN REVIEW
❑ New construction N Addition /alteration /replacement Please check all that apply (submit 2 sets of plans w /items checked below):
ss �' ❑ 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.
�r' less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling �W CommerciaUindustrial ❑ 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 of system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 - ", "1 - ",
Job no.: Job site address: I,, ( � SS l� A ' ,Q I OOHP or more. occupancy.
(K/ ` n J�ti/ ` ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: 1 � q � / El Health-care facilities. ❑Supply voltage for more than
g p 3 � _ j - S s El Hazardous locations. 600 volts nominal.
Suite/bld /a t. no.: Project riame:. ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
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 168.54 4
- -- Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: _ Limited energy, residential
-D ° WORK (with above sq. ft.) 75.00 2
Limited energy, multi- family
-r(r-c A-'o- r, 1-----C residential (with above sq. ft.)
75.00 2
1� Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
t i1ifit PROPERTY )WNEI 0 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 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
a bove service or feeder fee,
❑` AiPI IC ANT ❑CONTACT PERSON 7.42 2
. _ each branch circuit
Business name: � �— L Cr)ilm,,,Vb\( (Ot/tS B. Fee for branch circuits without
service or feeder fee, first
Contact name: 1 � - 4.rry (1(./S(..%) l`e) branch circuit
) 56.18 2
O U C) � � t h _ 9o( ' C? 3 3 Each ellan branch circuit 7.42 2
Address:
1 a x �� v CJ ✓ Miscellaneous (service or feeder not included)
� (.�/ L21 Each manufactured or modular City/State /ZIP:
Uc hCO V ( L/ dwelling, service and/or feeder 67.84 2
Phone: ( j) S 1 Z S Fax:: (340) 3 7_ 1 q 8 Reconnect only 67.84 2
r Pump or irrigation circle 67.84 2
E -mail:
O a cc < e + ( - C t.'UtA V4, (J ✓p l at4 c cry S , COV,1 Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: anel, alteration, or extension. Page 2 2
Co - t,(, „h I c Gt,-�-(vLA Each additional inspection over allowable in any of the above
Address: P a 9, `) . c f� Additional inspection (1 hr min) 66.25/ hr
V A J / fo Investigation (I hr min) 66.25/ hr
City/State /ZIP:
V av� CO' vCr Industrial plant (1 hr min) 78.18/ hr
Phone: (// ) J - s-- 1 _ a] - 2__s Fax: (36o) - R3 - 7 - 16 ti 8 Inspections for which no fee is
specifically listed (A hr min) 90.00/ hr
CCB Lic.: r , --)--) - 7 Electrical Lic.:b 9LI L E Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: . Subtotal:
4.../....0 :►�. �1 _ Plan review (25% of permit fee):
Print name: L&rr n, , _ c-✓ I Date: 3.'2( I ( State surcharge (12% of permit fee): / w
t n l TOTAL PERMIT FEE: �X . .
Authorized signature �J r U
This p ermit application expires if a permit is not obtained within 180
Date: 3 Z -- \ days after it has been accepted as complete.
Print name:
L., r r', CJS ✓`..kk f Number of inspections allowed per permit.
I: \ Building \Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(I t /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*
n 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:
n A • udio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
n Data Telecommunication Installation
❑ Fire Alarm Installation
n HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
n L • andscape Irrigation Control*
n M edical
n Nurse Calls
❑ O utdoor Landscape Lighting*
❑ P rotective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\ Building \Permlts\ELC- PermitApp.doc 07/01/10
eiLe.4._.
05/11/2011 07:24 5035981960 CITY OF TIGARD PAGE 01/01
RECEIVE,'
II 1
• Community Development
jtequest for Permit Action MAY 11 2011
TIGARD CITY OF TIGARD
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW I-1a11 Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503,598.1960 www.tigard- or.gov
FROM: ❑ Owner [] Applicant ►% Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: 039s'ncv', ex Individual) 4 ��ja 40 , /A-)c
Mailing Address: S2 n. ' 2/O
City /State /Zip: , "'gib %o ,uE 2 7 0 2,7
Phone No.: S — 5 - 0 86
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
ch CANCEL PERMIT APPLICATION. 0 1 0
REFUND PERMIT FEES (attach receipt, if available).
INVOICE FOR FEES DUE (attach case fee schedule and explain below). �p f /
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). / /
Permit #: C j .. / `Zo l ,t✓ — 0 Q
Site Address or Parcel #: 69 S"S" �w 7 Z 4 S 3
Project Name: roo L to r
Subdivision Name: Lot #:
EXPLANATION: X14'1 -i i1 Af IT A'S 4t a 1 i •
4 era, , 1 r L ' -r //J '7 5f
Signature: 4 0.., , I/ m Date: Srl VI I
Print Name: .. /' iin o A)
Bd uar Policy `
1. The Director or Building Official may authc,rbw the refund of
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application feu when an apptcation is withdrawn or canceled before any .review effort has been expended.
c) not more than 80% of the land use application fee for issued perrnits.
ti) not more than 80% of the building plan review :fee when an application is csurcelcd hefore any plan review effort has been expended.
c) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the tame method in which payment was received. Ploise allow 1 weeks for processing refunds.
FOR O'F T( ..F. i i ONLY
Rte to S s Admin: Date B - Rte to Bld: Ad.min_ Date - iA2= B 14
Refund Processed: Date ; AMIE B , Invoice Processed: Date B
MM
Permit Canceled: Date . B , .!�� Parcel Ta_ Added: EMIIM1111. B •
Receipt # . 9/ IT ®v] Method 6'' Amount $ r i
1,\ Building \f orms \RcgPermitAcdon.doc Rev 07/26/07
• t.
Pq 5,
City of Tigard
June 16, 2011
•
T & L Communications
PO Box 87387
Vancouver, WA 98661
Re: Permit No. ELR2011 -00074
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 16655 SW 72 " Ave., Ste. 300
Project Name: Food Sales West
Job No.: N/A
Refund: ® Check #202547 in the amount of $67.20.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as property owner, PacTrust does not want fire alarm in this
tenant space. 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: \Buildin \Refunds4g tsW\ llakd ne�nigthod9iattegon 97223 ° 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard - or.gov
v l 1 iv
. 7 1 q
City Of Tigard
T [ G A RD 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: T & L Communications DATE: 6/10/2011
PO Box 87387
Vancouver, WA 98661 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 181914 Case #: ELR2011 -00074
Date: 3/24/2011 Address /Parcel: 16655 SW 72nd Ave., Ste 300
Pay Method: Check Project Name: Food Sales West
EXPLANATION: Per applicant's request as owner, PacTrust does not want fire alarm in this tenande
space. Refund 80% of permit fees.
� T .. .?r.— _ ''tip. .: '+ .:•':w :;r .'i�!r. ..?
ee. D'cscri 'ti' : z
ori;Erom:Recei''t�_ �T:
'04 fit
:, - - :Re n'
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'EX f 1
am
eiimut�rFee'
.
Electrical permit fees 2200000- 43103 $60.00
12% State Surcharge 1003100 -24001 7.20
TOTAL REFUND: $67.20
APPROVALS:
C )
If under $5,000 Professional Staff
If under $12,500 Division Manager
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
;.'FOR TI DEMARK+ SYSTEM ;ADMINISTRATION:USE:ONLY: `
Case Refund Processed: I Date: I 4/2 / /// J B
l: \Building \Refunds \lte fund Reg ucst.dc,e x 09/01/2010