Permit CITY OF TIGARD ELECTRICAL PERMIT
Iii q
t ' - COMMUNITY DEVELOPMENT Permit #: ELC2011 -00295
1 3125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/02/2011
TIC' ARi Parcel: 1S136AD02301
Jurisdiction: Tigard
Site address: 10500 SW 71ST AVE
Project: Newsom Subdivision: VILLA RIDGE Lot: 3
Project Description: Electrical corrections required by electrical reconnect permit ELC2011- 00184.
Contractor: OWNER Owner: NEWSOM, JOSEPH & MIRIAM
10500 SW 71ST AVE
TIGARD, WA 98032
PHONE:
PHONE: 503 - 795 -4762
FAX:
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 06/02/2011 $100.70
Specifics: amps or less
3 crt Branch Circuits w /Purchase 06/02/2011 $22.26
Type of Use: SF Service or Feeder
Class of Work: ALT 1 ea 12% State Surcharge - 06/02/2011 $14.76
Electrical
Type of Const:
Occupancy Grp:
Total $137.72
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in - • • - -- with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. AT' NTION: Orego law =•uires you to follow the rules adopted by the Oregon Utility Notification Cente Those rules are set forth in OAR
952 -001 -r 010 through OAR 95.01 -00 0. •• may obtain a copy of the rules or direct questions to OUNC by calling 503.2 • 1.800.332.2344.
Issued ay: r Permittee Signature: . ..a.,
OWNER INSTALLATION ONLY
The installation is being made on property I ow. of intended for sale, lease or rent. OWNER'S SIGNATURE i Date: 6 t //t
t
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Applicatio � FOR. OFFICE USE ONLY
A ���� Y L� Received
Date/By: Permit No.:
11
13125 City SW of Hall Ti gard Blvd., Tigard, OR 97223 2 r a a Pl Review
Phone: 503.718.2439 Fax: 503.598.19 0 N Date/By: Other Permit:
TIGARD
Inspection Line: 503.639.4175 Date Ready/By: Juris: 171 See Page 2 for
Internet: www.tigard - or.gov CITY OF TIGARD Notified/Method: Supplemental Information
TYPE o$WilitiliNU DIVISION 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 - ", "1 - ",
Job no.: Job site address: /aspf s r7 �$� �� 100HP or more. occupancy.
❑
/ � y r� f 0 or more residential units. Recreational vehicle parks.
City/State /ZIP: i� OA? U `p /, 9 7 �� 2 0 Health - care facilities. 0 Supply voltage for more than
(J / C((/ / ✓ Hazardous locations. 600 volts nominal.
�
Suite/bldg. /apt. no.: Project name: 4/ f- -gnq ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. 1 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
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi- family
/! L C'h' (Q / C( rChalis residential (with above sq. ft) 75.00 2
Services or feeders installation, alteration, and/or relocation
CCV// 200 amps or less ) 100.70 /46?6 2
0 PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: �0<e k 3 Mi atyc
�m 601 amps to 1,000 amps 301.04 2
Address: 1O J 4t 7/ Sf v Over 1,000 amps or volts 552 26 2
Ci City/State/ZIP: Temporary services or feeders installation, alteration, and /or
ty � O/� e;2 972,23 relocation
Phone: (65) 7� 4/7a I ax: ( ) 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, r r exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, l er panel
Owner signature: " Date: A// A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 3 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 add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
ty dwelling, service and/or feeder
Phone: ( ) I 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
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) I Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed ( hr min)
CCB Lie.: 1 Electrical Lie.: I Suprv. Lie.: ELECTRICAL PERMIT FEES
Subtotal: / 9a, '
Suprv. Electrician signature, required: Plan review (25% of permit fee): .r--_'
Print name: I Date: State surcharge (12% of permit fee): / 7.
TOTAL PERMIT FEE: / 3 7 . 7 2
Authorized signature: ,
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: . / � `r 9JL Date: r� " — A / * Number of inspections allowed per permit.
■ C\Building\Permits\ELC- PermitApp.doc 07/01/10 440- 4615TO 1/05 /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*
❑ 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
n HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
L \Building\Permits\ELC- PermitApp doc 07/01/10
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:
City of Tigard
•
August 11, 2011
Joseph Newsom
10500 SW 71" Ave.
Tigard, OR 97223
Re: Permit No. ELC2011 -00295
Dear Mr. Newsom:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 10500 SW 71st Ave.
Project Name: Newsom
Job, No.: N/A
Refund: n Check # in the amount of $ .
M Credit card "return" receipt in the amount of $46.35.
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 $ .
Comments: Per applicant's request as scope of work changed. Retain fees for (2) branch
circuits plus 12% state surcharge, and refund 80% of balance of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
1:\suuld n \ReCurAiZi, sM h , a ii L aiizat agar ancgon 97223 ® 503.639.4171
TTY Relay: 503.684.2772 ® www.tigard- or.gov
!PI City of 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: Joseph Newsom DATE: 8/1/2011
10500 SW 71s Ave.
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 182690 Case #: ELC2011 -00295
Date: 6/2/2011 Address /Parcel: 10500 SW 71" Ave.
Pay Method: CreditCard Project Name: Newsom
EXPLANATION: Per applicant's request as scope of work changes. Refund 80% of permit fees.
tREF J:N_;D�IN'FORMAT:I`® N - � .,�.. �> .� ��;� -r -• �'�. -�, � ..,���.�t' :���:��*� b`�,;.::, �rtr.�_,.. �.,,. �;�:.>���
- - - a. .A,.P ;a��==r'S>�:+a rxwe`:y,,._ .,% �i; �r�,,_,; �. rF'.€ �,.-.-, a: ��i,`'. �' �": �d=• �; ��:'::: �. �=_, x. :,,,e.�.:��':a�- +:,��:�E;,s�€.: �5: �..,s- :�_,�:�! w.�,>a$'- _'�-��
- . nr : l „ ., �= k�,+",a�:° - , �t..a � °: ��r':�, . �,:,. , x"ru+,�a.,. �. �.�a..
4 Fee'�Descri phorr From Receipt ;��a � �;,�, „�.� , �., � Revenue..AccouritiNo. �� � � „���2 �� ,,Refiind� �, r
i . a . 'S ,r' F.: k �+ . ,. ,?'? < $d� -4��: i :.^ �. < 7 �?a a ..�� ff » a £ - .k4» , 1. ! `d '"6 x e' k s+ s 3 "ail x ` ' , 'S $' � . ,tN s 3 r. $`.r+, =”. '..�,
`Exam le' $MUg tk i OFee ` . , aikt _ Eaample•� 2300000 4310A , ���. $ Amount
�n _ p .� -- �- �.. an, Y.g ",r..+�s,.,,...,.,. �, . 't.', tta.. *. - '?+sin.., 3.. �`3�,r3a.,t��.4 €.:. �: R,..x..,.„.,:_c,
Electrical Permit Fee 220-0000-43103 $86'74 a ,
12% State Surcharge 100- 0000 -24001 " 7' 7 11.81
•
L REFUND: $.S5
�-- �, TOTA 76 .2,7
•
APPROVALS:
If under $5,000 Professional Staff
e —.. - -----
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
2 F r .` . y �`_ ff �.Vxi., t ' ;. � ;: ,� •�,..��.:e(+a�% s':`�e;':;.r' �,
,�,;,,' ,.,,. !. ,a FO,R'TI : ADMINISTRt1TIONV.WON.I Y - „ ,, �, , �
.
Case Refund Processed: Date: ,. 1.t,
”,
I ; \ Buildin \ Refunds \RefundRe x 09/01 /2010
11 III
Community Development \` F.
• Request for Permit Action
JUL � 9 2011
z [ GaRD CITY OF TIGA n
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: f Owner n Applicant n Contractor n City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) / <<11114
Mailing Address: / )5 s , ( .� J 7/6"-- d
Cit /State /Zip: 7 , 4 c?
Phone No.: — 7Q — 117‘,2
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL PERMIT APPLICATION.
REFUND RMIT FEES (attach receipt, if available).
• FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: a20 - oo
Site Address or Parcel #: los sev 7/ 5 4re J
Project Name: ��'�" "(
Subdivision Name: Lot #:
EXPLANATION: / cr Af O Q SE e (/) /2.4n/Cq
Signature: Date: 1 0? �(
Print Name:
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 S s Admin: Date B Rte to Bld• Admin: Date/ ,O' B ''j=11
Refund Processed: Date a /Aram G���, tzg Invoice Processed: Date B
Permit Canceled: Date / _. F .'/EMI Parcel Ta • Added: Date B
Recei.t # /f,2 f Date ��I' Method e` C.— Amount $ 3 7-1-
I: \Building \ Forms \RegPermitAction.doc Rev 07/26/07