Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
,11111 COMMUNITY DEVELOPMENT Permit #: ELR2011 -00070
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/22/2011
Parcel: 2S113AB00500
Jurisdiction: Tigard
Site address: 16083 SW UPPER BOONES FERRY RD 100
Project: Amedisys Subdivision: Lot: 0
Project Description: HVAC system.
Contractor: BELL MOUNTAIN ELECTRICAL TECHNOLOGIES LLC Owner: G &S FC LLC
PO BOX 895 516 SE MORRISON #100
BATTLE GROUND, WA 98604 PORTLAND, OR 97214
PHONE: 360 - 624 -1580 PHONE:
FAX: 360 - 666 -5053
FEES
Description Date Amount
Specifics: Restricted Energy Permit 03/22/2011 $75.00
12% State Surcharge - Electrical 03/22/2011 $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: N
HVAC: Y 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 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 OAR 952- 001 -0090. You m nhtaiaa co of the rue r direct questions to OUNC by * 87 or 1.800.332.2344.
Issued By: Permittee Signature: o r 1 f
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 FOR OFFICE t SE: O\1,1
City of Tigard . DateB Received \� '" Permit No.:
■ ,i - 7e)
/df/
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
s a Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit 614,9,9r, I j _ 0( )0s
TI G A R D Inspection Line: 503.639.4175 Date Ready /By: Juris ri , VI See Page 2 for
Internet: www.tigard - or.gov Notified/Method: � 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
ID Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
100HP or more. occupancy.
Job no.: Job site address: 16083 SW Upper Boones Ferry Rd ❑Recreational vehicle arks.
❑ Six or more residential units. p
City /State /ZIP: Tigard, OR 97224 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: 100 Project name: Amedisys ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street /directions to job site: SW Fanno Creek PI. & SW Up Boones Ferry Description I Qty. I Fee. I Total j *
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'! 500 sq. ft. or portion 33.92
Tax map /parcel no.: 2S113AB00500 Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family 75.00 2
rough in in three (3) tstat wires and two VAV boxes residential (with above sq. ft.)
l I Services or feeders installation, alteration, and /or relocation
-��I M / EZIS-Yrin 200 amps or less 100.70 2
0 PROPERTY OWNER ❑ 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
City /State /ZIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( )
Fax: ( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
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 7.42 2
each branch circuit
Business name:
B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each addl branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited - energy
Business name: Bell Mountain Electrical Technologies LLC panel, alteration, or extension. I Page 2 75.00 2
Each additional inspection over allowable in any of the above
Address: 23101 NE 246 Court PO Box 895 Additional inspection (1 hr min) 66.25/ hr
Investigation (1 hr min) 66.25/ hr
City /State /ZIP: Battle Ground, WA 98604 Industrial plant (1 hr min) 78.18/hr
Phone: (360) 624 - 1580 Fax: (360) 666 - 5053 Inspections for which no fee is 90.00 / hr
specifically listed (%z hr mm)
CCB Lic.: 176481 / �J Electrical Lic.: C700 / Suprv. Lic.: 5664S ELECTRICAL PERMIT FEES
Suprv. Electrici i' � e, require 7 , i 101113 Subtotal: 75.00
� ---+ Plan review (25% of permit fee):
Print name: Terry Carlson Date: 3 -22 -2011 State surcharge (12% of permit fee): 9.00
Authorized signature:
L„ J TOTAL PERMIT FEE: 84.00
T his permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Terry Carlson Date: 3 -22 -2011
` Number of inspections allowed per permit.
I:\ Building \Permits\ELC PermitApp. doc 07/01/10 440-461 5T( I I /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
I I 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
Fire Alarm Installation
® HVAC
❑ Instrumentation
n Intercom and Paging Systems
Landscape Irrigation Control*
Medical
Nurse Calls
I Outdoor Landscape Lighting*
I I Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
e\suiiaing\Permitg \ELc- r�aap.a« 07/01/10