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Permit 12.1joi it 40 add 4v- - :' CITY OF TIGARD ELECTRICAL PERMIT , pi ... " - Q'' COMMUNITY DEVELOPMENT Permit #: ELC2009 -00607 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/10/2009 Parcel: 2S102AD02900 Jurisdiction: Tigard Site address: 12770 SW ASH AVE Subdivision: BURNHAM TRACTS Lot: 5 Project: City of Tigard - Dog Park Project Description: Change to "temporary service" of (1) 100 amp service for dog park lights on 11/18/09. Temp feeder added and paid for 12/1/09. Owner: FEES CITY OF TIGARD Quantity Description Date Amount 13125 SW HALL BLVD TIGARD, OR 97223 . 1 ea Services or Feeders - 200 11/10/2009 $100.70 amps or less PHONE: 1 ea 12% State Surcharge - 11/10/2009 $12.08 Electrical 1 ea Temp Services or Feeders - 12/01/2009 $59.36 Contractor: 200 amps or less NORTHSTAR ELECTRICAL CONTRACTORS 0 ea 12% State Surcharge - 12/01/2009 $7.13 19450 SW CIPOLE RD, STE 107 Electrical TUALATIN, OR 97062 PHONE: 503 - 612 -0840 FAX: 503 - 612 -0891 Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Total $179.27 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 -0100. You ma 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' Q Q CY 6 (10 I Date: LICENSE NO. 'C CaII 503.638.4175 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. CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit*: ELC2009 -00607 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/10/2009 Parcel: 2S102AD02900 Jurisdiction: Tigard Site address: 12780 SW ASH AVE Project: City of Tigard - Dog Park Subdivision: BURNHAM TRACTS Lot: 5 Project Description: Change to "temporary service" of (1) 100 amp service for dog park lights on 11/18/09. Temp feeder added and paid for 12/1/09. 4/20/11: REPRINT PERMIT TO CORRECT STREET ADDRESS. Contractor: NORTHSTAR ELECTRICAL CONTRACTORS Owner: CITY OF TIGARD 19450 SW CIPOLE RD, STE 107 13125 SW HALL BLVD TUALATIN, OR 97062 TIGARD, OR 97223 PHONE: 503 - 612 -0840 PHONE: FAX: 503 - 612 -0891 FEES Quantity Description Date Amount 1 ea Temp Services or Feeders - 12/01/2009 $59.36 Specifics: 200 amps or less 7 12% State Surcharge - 12/01/2009 $7.13 Type of Use: COM Electrical (manual) Class of Work: ALT Type of Const: Occupancy Grp: Total $66.49 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 0 95 j90. Y. u may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. C /97°/° _ /L' t9 7ct 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 503.639.4176 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 ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: ELC2009-00607 TIGtIRD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/10/2009 Parcel: 2S102AD02900 Jurisdiction: Tigard Site address: 12770 SW ASH AVE Subdivision: BURNHAM TRACTS Lot: 5 Project: City of Tigard - Dog Park Project Description: (1) 100 amp service for dog park lights Owner: FEES CITY OF TIGARD Quantity Description Date Amount 13125 SW HALL BLVD 1 ea Services or Feeders - 200 11/10/2009 $100.70 TIGARD, OR 97223 amps or less PHONE: 1 ea 12% State Surcharge - 11/10/2009 $12.08 Electrical Contractor: NORTHSTAR ELECTRICAL CONTRACTORS 19450 SW CIPOLE RD, STE 107 TUALATIN, OR 97062 PHONE: 503 - 612 -0840 FAX: 503 - 612 -0891 Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Total $112.78 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through e •r01 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: 4t / ` �� Permittee Signature: ••V /9 ( # 4 - 7 7 e' OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR. ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. J 'y NOV - 09 - 2009 MON 09:28 AM P. 001 Electrical ,Permit Application ,� • �v,, ' � FoR . u s o N 4 ' ^ 4 r` :. o .' .ill . 4ist;was..— a me d „ t. .w,,k ' : 9t�rr J Rccewed , I rn ceive J of A I e,n,ir Nu. GL v2 //1312$W hal Bl vdTigard, OR EC E ' Plan Review , / ; g Phone: 503,639.417 Fax: 503.5 1960 2 0 UO,;•r Permit J Datd TLGARt3 Inspection Line 503.631).417; Nov 0 D arr Ready /13y Iv , El See page z for t ..,..t :~+,r: I nternet: wwW. l 1gnrd- or.gav Notified /Muduu -_ �I SupplernentntInformation TYPE OF W �Y 0:: 1 1LaA��� _ PLAN REVIEW _ _ lI `5ti Ni. construction ❑ AdCltlion gt,' le • ' heck 111 Ihni nigh (submit a lets a phis w /items chtcknt below). ❑ ?CI'VCe of (ceder Pitt amps or :nitre ❑ !Wilding over Mee SEOriCS ❑ DC111olit1011 ❑ Other: — „her the „'alloblc twill current ❑ Mamas and boatyards ..CATEGORY OF CONSTRUCTION exceeds 10,000 amps al 150 volts or ❑ Floating buildings. less 10 ground, or exceedx I4,06O ❑ Compeer,ial -nie no,eulnn'nl ❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building mops For all other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Others ❑ Fire pump. ❑ loslnllarion of 75 KVA or ' . . . — ❑ Emergency system. larger separately derived system. J013 SITE INFORMATION AND LOCATION , 0 Addition of new motor load of ❑ "A "E ^k- 2' ","I -3'. Job no.: - -- Job site address: 1 61 - 7 70 �`� --------- 100HP or more. occupnncy. w ❑ Si., or Mora residm,tinl nnvs. ❑ Reefentional vehicle parks. City/State/ZIP: Tr 6 a�� r wp ❑ H fcci ❑ Supply vohlae for more than I . ` I ♦ ❑ r)ax: rdoue locations. . GOO volts nominal. SO /bldg. /opt. n0.: Project Ilan »e: ❑ Service or feeder 500 amps or more. - Hr. Cross street/directions to job site: 8/,8/, � ' 4 S r, {•J r 19 _5 )..,,. I� Dµ x riptieon �.,., 1 Orv. i Pce. 1 Torn, 1 • New residential single- or multi - fondly dwelling unit. 0 S)J ,0 1vt, ___ . Includes nttached garage. Subdivision: Lot no.: I 1.000 sq. ft. or less ( 145.15 f 4 Ea, add'I 500 sq. fl_ or portion 33.40 I Tax map /parcel no.: _ __ �Li,,,ited energy, residential 75.00 2 ;DESCRIPTION OF WORK (wall above so, IT) '" Limited energy. multi- family 75.00 2 ERM�i90 1 4-pit' .SL'��ht4 _residential (with above sq. ft.) Services or feeders Installation, alteration, and /or relocation — AO G r Ll Jfrs 2( amps or less 80.30 2 .. 201 amps to 400 amps 106.85 . • P><tOPFsRTY; OWNI R El TENANT - - - /GtO J ©.2 ' 4 T 176440 - - Name: Y 0 F �(I ramps to 600 snips 160.60 2 p -- 601 alnps to 1,000 amps . 240.60 . 2 Address: 7 �� 5 . , k , 6L v K2 Over 1,000 amps or volts I 454.65 2 City/State/ZIP: «� p Temporary services or feeders installation, alteration, and /or __ �`1") d , </ 7 . 2 7. 3 relocation 200 amps or less 66.85 ? I Phone: ($03 ) 63y c Fax: ( ) P Owner installation: This installation is being mpdc on property that 1 own which is not 201 amps to 400 amps 100.30 1 2 intended for sale, lease, rent, or exchange. accordine to ORS 447, 449, 670, and 701. 401 amps to 599 anws 133.75 2 Branch circuits - ne,v_alteration, or extension, per panel Ow'ller Signature: Date: A. I ee for branch circuits with 0 APPLICANT 1 1=1 CONTACT PERSON above service or feeder fee 6.65 each branch circuit Business name: B. Fee for branch circuits :•/r /,on, service or feeder fee, Contact name- 46 55 2 cog brooch clrcim Address: _ Each add•I branch circuit 6.05 _ - \Iisccllalleolls (service or feeder not included] City /State /ZIP: l-ach l»anutacturcd or modular 90 90 1 -- clw'rlline. service anti /or feeder Phone: ( ) { Fax: : ( ) _ Reconnect only M_ 66.85 2 r,-111/1i l' �� I'.ump or irrigation circle . 53.40 2 CONTRACTOR Slat Oroutiine lighting 53.40 . w 2 Business name: r !! 1 'i 2 01 circuits) or limited- NortbStar Electrical Contractors I i l . \ - 'rgy panel, alteration, or " r 1 Address: 19450 SW Cipole Rd. #107 \` \ •\ I extension. Describe Page 2 I 2 Tualatin, OR 97062 f ( - City /State /ZIP: (503) 612 -0840 Fax (503) 612 -0891 . L•{-I i `_ , a r' / 6Rett additional inspection over allowable in any of the shove j Lic #34-359C GG13 #90454 Metro #1911 •_ / ---' Per inspection 62.50 - . ., . .. • - - .. Phone: ( - ) • ,. eSligwt,nn per h u if { I 62.50 J I nv . a hr V B 1,1c.' 0 S Electrical Lic.: y �� 1 • . Plv, Lic,: Ind u;trirl pant per hour 73.75 -- — 1 — // L t,I TRICAL PERMIT FEES Q,.. j t tired: f �O /D ELECTRICAL L Suprv. Electrician sigma re, G . _ • _ �___. D I Subtotal: 'l ' • Print name; Date: / / 2- PIOilfcvieW /e of permit fee): I is . I • D . - • . - State surcharge ( 12% of permit tee): "' Y Authorized signoturc: TOTAL PERMIT FEE: 2.1iri 1 - This permit appli0nrinn expires if a permit is not obtained within 18 Print name: Date: day, lifter it has been acccptct.l its complete. ^ Nuin bei at' inspections allowed per moat. li , 176P e � 1 0 noding \Permi10G6C- Permi,A00.000 07/27/06 440 - 101 ST( 11/r)5ICOA11W1a 4te _____.. 'City of Tigard, Oregon ® 13125 SW Hall Blvd. • Tigard, OR 97223 - December 11, 2009 Northstar Electrical Contractors 19450 SW Cipole Rd., Ste 107 Tualatin, OR 97062 Re: Permit No. ELC2009 -00607 Dear Sir /Ms.: The City of Tigard has processed a refund for fees on the above referenced permit(s) for the following: Site Address: 12770 SW Ash Ave. Project Name: City of Tigard Job No.: Refund: 0 Check # in the amount of $ ® Credit card "return" receipt in the amount of $112.78. ❑ Trust account "deposit" receipt in the amount of $ Notes: Scope of work changed from service to temporary service. Refund 100% of service 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\ Adminis tration \LtrRefund- RefundOnly.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 . • www.tigard - or.gov • TTY Relay: 503.684.2772 • I. 14 City of Tigard TI G n R D Accela Refund Request This form is used for refund requests of land use, engineering and building application fees. Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be attached to this form. Refund requests are due to Accela System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow 1 -2 weeks for processing. PAYABLE TO: Northstar Electrical Contractors DATE: 12/11/09 19450 SW Cipole Rd., Ste 107 Tualatin, OR 97062 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt #: 175972 Case #: ELC2009 -00607 Date: 11/10/09 Address /Parcel: 12770 SW Ash Ave. Pay Method: CreditCard Project Name: City of Tigard EXPLANATION: Scope of work changed from service to temporary service. Refund 100% of service fees. REFUND INFORMATION: Fee Description From Receipt. Revenue Account No • Refund • - Example: .[BUILD] Peimit•Fee : • Example: 245 - 0000 - 432000 $ Permit Fee 2200000 -43103 $100.70 12% State Surcharge 1003100 -24001 12.08 TOTAL REFUND: • $112.78 APPROVALS: rr � If under $500(: Professional Staff Y�l If under $7,500 Division Manager If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board FOR ACCELA•SYSTEM ADMINISTRATION USE ONLY Refund Request Reviewed: Date: p a By: �1f t Case Refund Processed: Date: '.:A V 7 i% By: • " I: \ Building \Refunds \RefundRequest.doc 04/13/09 NOV - 1E - 2009 WED 09:07 AM P. 001 4rr..' _ .,_ _. , 1 11 Community Development /i1/1//1/14 Request for Permit Action TIGARD„ 7thlt/1)4.- rmt7 TO: CITY OF TIGARI) l:) O ��E Building Division Services Coordinator I �� � 13125 SW Hall Blvd., Tigard, OR 97223 VIOV 1 b ZOOS • • Phone: 503.718.2430 Fax: 503.598.1960 www.tigatd-or.gov FROM: ❑ Owner 4 " A pp licant El Contractor ii City Stag ' �G D V 01 (check onc) 8UI ° REFUND OR Name: INVOICE TO: (Business or Individual) AK nf rota - L.6 / 66 v Mailing Address: it? 'KO 3 Ce p,,LF A O 67 /D•7 City /State /Zip: 1I 4144 rot) B+� 9704A., Phone No.: . 3 -bl7 -D iN0 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓): • ' • ❑ CANCEL 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 #: 6 L C 2 9 01 n h' O'7 Site Address or Parcel #: 47 70 5' Li ) A 1.1V6 Tl6l4kq Q/Q 9 7 2 3 • Project Name: 6iTY ©d Thieitre0 - ri2 iteg- Subdivision Name: Lot #: EXPLANATION: G ifiil oL .t rrell PC4Ropt Y 5 •P / th t (.�rg 0 Ai 69nic TR 4.c . 7"1 ifAl S / T /lf0 L A a <y 72 0 e 6 /72ic • • Signature: r , `� a / f Date: f/ Print Name: ,t . aefund Policy 1- The Director or Building Official may authorize the refund of: a) any fee which war 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 e::pended. 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. y L l�_�. y n �v- ly7� i+, 5. t x. { I �. j r - r c- �_�. � . .3 ..7:7:11::.: . .., .:,; .fit, EL r t!tu z_ gia areigtC_l__,Lltil f)N1 Yip � , _-� c ' ;. 7 i ` Rte to Sys Adtnin: Date By Rte to Bldg Admire: Date 4)- /j 0 9 Bye-= . Refund Processed: Date ,e B Q A Invoice Processed: Date ' B Permit Canceled: Date / B "« Parcel T.: Added: Date B Receipt # Date • Method Amount $ I:`Building \ Forms \RegPermitAction,doc Rev 07/26/07 111 CITY OF TIGARD RECEIPT 4 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD n _ ( f': ' ti t s Receipt Number: 176276 - 12/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2009-00607 $ - 112.78 Total: $- 112.78 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 01536B DHOWSE 12/11/2009 $- 112.78 Payor: Kenneth E Murphy, Northstar Electrical Total Payments: $ - 112.78 Balance Due: $112.78 • • Page 1 of 1 CITY OF TIGARD RECEIPT g . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD /° --- Receipt Number: 175972 - 11/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2009 - 00607 Services or Feeders - 200 amps or less 2200000 -43103 $100.70 ELC2009 - 00607 12% State Surcharge - Electrical 1003100 -24001 $12.08 Total: $112.78 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 01536B DHOWSE 11/10/2009 $112.78 Payor: Kenneth E Murphy, Northstar Electrical Contractors Total Payments: $112.78 Balance Due: $0.00 Page 1 of 1