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Permit
CITY OF TIGARD ELECTRICAL PERMIT 11 4- COMMUNITY DEVELOPMEN Permit #: ELC2011 00171 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/05/2011 Parcel: 2S102CD02706 Jurisdiction: Tigard Site address: 9695 SW OMARA ST Project: Worley Subdivision: Lot: 0 Project Description: Remodel 3 bathrooms. Contractor: OWNER Owner: WORLEY, MARTHA W 9695 SW O'MARA TIGARD, OR 97223 PHONE: PHONE: 503 - 639 -6563 FAX: FEES Quantity Description Date Amount 3 crt Branch Circuits wo /Purchase 04/05/2011 $71.02 Specifics: Service or Feeder 1 ea 12% State Surcharge - 04/05/2011 $8.52 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $79.54 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 - •rdance wi 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. AT NTION: Oregon -w eq ire- ou to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 -001 - 010 through OAR 952- ei ou may obtain a copy o he rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issue. By: K 0,1 U Permittee Signature: !y • OWNER INSTALLATION ONLY The installation is being made on K / � property I own is not intended for sale, lease or rent. �, D ^f . OWNER'S SIGNATURE A ac.CI r Date: ��01/vw . ?c it 1 a 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 USE ONLY City of Tigard Received it S/; // ,L„ i Permit No. eL ,g0 / / - DD / 7/ I N I • 13125 SW Hall Blvd., Tigard, OR 97223 plan Review Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit: I It ;1 R I Inspection Line: 503.639.4175 Date Ready/By: furls: ® 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 El- 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 ", "l -3 ", Job no.: Job site address: ' . 94 5' Q',(f Jr oo more. occupancy. / ❑ Six o or r more residential units. ❑Rec creation. eational vehicle parks. City/State/ZIP: --- / i + OA_ a 3 ❑ Health -care facilities. ❑ Supply voltage for more than � 0 Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total 1 A New residential single- or multi - family dwelling unit. Al • t0 ff 17QiPon/ l d Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4 Tax map /parcel no.: Ea. add'l 500 sq. ft. or portion 33.92 1 Limited energy, residential 75.00 DESCRIPTION OF WORK (with above sq. ft.) L �j Limited energy, multi- family 75.00 2 rliyrlo del 6t 7 raw* S. residential (with above sq. ft.) 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 Name: ,f j� boor-ley 401 amps to 600 amps 200.34 2 601 amps to 1,000 amps 301.04 2 Address: r//_�S- SGp ©( Sr. Over 1,000 amps or volts 552.26 2 City/State/ZIP: I�� Temporary services or feeders installation, alteration, and /or / t.a.ys( relocation Phone: ((() ‘a,9 _ 653 Fax: ( ) 200 amps or less 59.36 1 400 201 amps to 4 amps 125.08 2 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 168.54 2 401 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. `� /211-406111-r Branch circuits- new, alteration, or extension, per panel JC 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: c B. Fee for branch circuits without C � s q U- service or feeder fee, first ( 56.18 c6.11 2 Contact name: branch circuit Each add'l branch circuit .2-.. 7.42 / q.$ry 2 Address: Miscellaneous (service or feeder not included) Each manufactured or modular 67.84 2 City/State /ZIP: 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: panel, alteration, or extension. Page 2 2 1 Each additional inspection over allowable in any of the above Address: ,r f Additional inspection (1 hr min) 66.25/ In w jt J Investigation (1 hr min) 66.25/ hr City/State/ZIP: Industrial plant (1 hr min) 78.18/ hr Phone: ( ) Fax: ( ) Inspections for which no fee is specifically listed (Yz hr min) 90.00 / hr CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: 7/..0.. Plan review (25% of permit fee): .---- - Print name: Date: State surcharge (12% of permit fee): Q• 5-A TOTAL PERMIT FEE: 7.5 f Authorized signature: This permit application expires if a permit is not obtained within 180 Print name: Date: days after it has been accepted as complete. Num of inspections allowed per permit. I:\ Building \Permits\\ELC- PermitApp.doc 07/01 /10 440-4615T(11/05/CODA/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: n Audio and Stereo Systems* n Burglar Alarm n Garage Door Opener* ❑ Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* n Other: COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: n Audio and Stereo Systems ❑ Boiler Controls n Clock Systems n Data Telecommunication Installation n Fire Alarm Installation ❑ HVAC ❑ Instrumentation n Intercom and Paging Systems n Landscape Irrigation Control* n Medical ❑ Nurse Calls n Outdoor Landscape Lighting* n Protective Signaling n 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 Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.055 (4)) This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be license with the Construction Contractors Board. I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. ,l/ta./ / t Oar k Print Name of Permit Applicant &(/41 Signature of Permi+��pplicant Date t% ' Permit #: t Lt'1 Am-00164 4 LkCi'o /l 00/7/ x/95 .w 0'H4 cr. s ddress: :411/,7_,,r7,,,..,::::,..:-_-;,—,4,,,,,...i, Issued b Date: 7/��/�/ E _ This Copy for Permit Offices 7 „ 1f I].lCj/ l_zo City of Tigard October 20, 2011 Martha W Worley 9695 SW O'Mara St. Tigard, OR 97223 Re: Permit No. ELC2011 -00171 Dear Ms. Worley: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: • Site Address: 9695 SW O'Mara St. Project Name: Worley Job No.: N/A Refund Method: ® Check #204333 in the amount of $63.64. ❑ Credit card "return" receipt in the amount of $ Note: Please allow 2 -5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account "deposit" receipt in the amount of $ Comment(s): Per applicant's request as scope of work changed; replaced only switch plates; 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 i a gn idaidf, eidi rigarcloar on 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard- or.gov I 41 City ®f 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: Martha W Worley DATE: 10/18/2011 9695 SW O'Mara St. Tigard, OR 97223' REQUESTED BY: Dianna Howse Applicant TRANSACTION INFORMATION: Receipt #: 182026 Case #: ELC2011 -00171 Date: 4/5/2011 Address /Parcel: 9695 SW O'Mara Pay Method: Check Project Name: Worley EXPLANATION: Per applicant as scope of work changed; replaced only switch plates. Refund 80% of permit fees. •�- -•,. .`tom'., _ == .� . t,t;• ;.I `4' �RE'F �,�•;;�:= =< <' -, - s'V+ ...I..r .,> - :•Y: — - `' — S• - ,,�,,,,, • p., .� • ,p -,; - ' °Reyeaue�'Accoiint�No: - '�,Refundi`: -��. of s , • �''?C1111 c' s e... =Bud` ":1?erriit`F' �e • � °�f. >• � ``zam l'• - �..._ - `(��..., .. ..�?g - ........ � ......... 'S::Y`• -.., s -� ;E p e:1,2306�OQ�431;04':•`;;.`. .- .,:�..�oPt;t;.` ": , Electrical Permit Fee 220 - 0000 -43103 $56.82 12% State Surcharge 100 - 0000 -24001 6.82 TOTAL REFUND: $63.64 APPROVALS: ( f 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'._TIDEMARK`SYSTEIV_I .M•INIST•RATION:.U;SE ONV Case Refund Processed: I Date: I /0/20/ I By: I 1: \Building \ Refunds \RefundRequcst.doc x 09/01/2010 1111 II CITY OF TIGARD RECEIPT a 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 184296 - 10/20/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2011 - 00171 $ - 63.64 Total: $ -63.64 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 204333 DHOWSE 10/20/2011 $ - 63.64 Payor: Martha W Worley Total Payments: $ - 63.64 Balance Due: $63.64 Page 1 of 1 r • CITY OF TIGARD RECEIPT I, t 2 13 125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 182026 - 04/05/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2011 -00171 Branch Circuits wo /Purchase Service or 2200000 -43103 $71.02 Feeder ELC2011 -00171 12% State Surcharge - Electrical 1003100 -24001 $8.52 Total: $79.54 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1032 DADAMSKI 04/05/2011 $79.54 Payor: Martha W Worley Total Payments: $79.54 Balance Due: $0.00 / ✓ Page 1 of 1 1 a ° Community Development Request for Permit Action TIGARD TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW 1 -Tall 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: (Business or Individual) :- I `c y '1 6 , U) . (X 0 I- / (_'f Mailing Address: q6' CI � •J c L% c_. " y f I a . -rez-- ..- Cit /State /Zip: / ii e» 4 (6) /C 6 / 7 - �.2- 3 Phone No.: LS C' 3 4- 9 -- 6 c- PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ �NCEL PERMIT APPLICATION. ©. REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: L 6 .. .R / / C3 c / j / Site Address or Parcel #: ,.5 4' 47 4 C! < lr'' /2,: i/ e< Project Name: ,7 /, Subdivision Name: , / Lot #: EXPLANATION: %2C n r`= ems' . ip r cl / .1'-, d n e , 7 . Signature: ,�i 2 2,L) 2�� ' Date: cT /�� (/ //, Print Name: / U) . LWW i --I-:r Refund Policy 1. The Director or Building Official may authorize the refund of: • a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building 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 issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date its 4 ' • B E Rte to Bldg Admin: Date .. �® B Refund Processed: Date /n i Lc /i By ''' -, Invoice Processed: Date • By Permit Canceled: Date lt,Ac ,/ By Parcel Tag Added: Date By Receipt # Date • ! Method Amount $ I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07