Permit IN N �� CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
` COMMUNITY DEVELOPMENT Permit #: ELR2011 -00189
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/18/2011
Parcel: 2S110DCO2200
Jurisdiction: Tigard
Site address: 15570 SW PACIFIC HWY
Project: Safeway Subdivision: 1997 -016 PARTITION PLAT Lot: 2
Project Description: Low voltage for HVAC
Contractor: HVAC INC Owner: TRC MM LLC
5188 SE INTERNATIONAL WAY 5973 AVENIDA ENCINAS STE 300
MILWAUKIE, OR 97222 CARLSBAD, CA 92008
PHONE: 503 - 462 -4822 PHONE:
FAX: 503 - 462 -6555
FEES
Description Date Amount
Specifics: Restricted Energy Permit 08/18/2011 $75.00
12% State Surcharge - Electrical 08/18/2011 $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 a rdance 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. ATTE TION: Oregon aw r - - .ir. u to follow the rules adopted by the Oregon Utility Notification Center. Those rut- are forth in, OAR
952- 001 -001 through OAR 952 -10 1090. u ay obtain a copy of the rules or direct questions to OUNC by calling 503.232. l 87 or 1 t600.332.. 4-
Issued B\..11 • Permittee Signature: 7 J _ ..
■ OWNER INSTALLATION ONLY 1\ ,
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 RECEIVED FOR OFFICE USE ONLY
City of Tigard AUG , Received
at�e/By m�� PermitNo.: e449 -
q 13125 SW Hall Blvd., Tigard, OR 97223 20 10 Plan Review
Phone: 503.639.4171 Fax: 503.598. Datetsy: Other Permit:
Inspection Line: 503.639.4175 G� - TIGARD Date Ready/By: Juris: El See Page 2'for
TI c ARD
Internet: www.tigard-or.gov B UI LDIN G DIVISIO
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
❑ 1- and 2- family dwelling Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family 0 Master builder ❑ Other: El Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND. LOCATION, ❑ Emergency system. larger separately derived system.
0 Addition of new motor load of ❑ "A ", "E ", "l -2 ", "1 -3 ",
100HP or more. occupancy.
Job no.: 475 Job site address: /SO ®j �� D Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: G� V / , ` ❑ Health -care facilities. ❑ Supply voltage for more than
�6 s t�� / 7.� 7 ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: cSGh/r # 7i. ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: _ Description I Qty. I Fee. I Total l
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Tax map/parcel no.: Ea. add] 500 sq. ft. or portion 33.40 1
Limited energy, residential
DESCRIPTION OF WORK ' - - (with above sq. ft_) 75.00 2
Limited energy, multi-family 75.00 2
/2 /DF 10AZ /4 S) G it/&J residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
'77e' �7e 7 7 200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT • 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 _ 2'
601 amps to 1,000 amps 240.60 ' 2
Address: Over 1,000 amps or volts 454.65 _ .2
City /State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
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, 6.65 2
�J each branch circuit
Business name: rS a, // • B. Fee for branch circuits
Contact name: ,RAGiti /72 ��_
without service or feeder fee, 46.85 2
first branch circuit
Address: $5 s G _/� 4447 L a/49, Each Ilan branch (service circuit 6.65 2
Miscellaneous (service or feeder not included)
City /State /ZIP: AyfjL" e.A6-- OR- 972a.0 Each
ling manufactured
and/or feeder 90.90 2
Phone: ) 44 .. IT7-7.- Fax: : 3 461? . ��5� Reconnect only 66.85 2
E -mail: 7 /kg o hvae/rleorp Cd m Pump or irrigation circle 53.40 2
CONTRACTOR , Sign or outline lighting 53.40 2
Business name: Signal circuit(s) or limited -
energy panel, alteration, or
Address: _itAll'i extension. Describe: Page 2 2
City /State /ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lie. : 97 Electrical Lie.: Suprv. Lic.: u03 Industrial plant per hour 73.75
n / ELECTRICAL PERMIT- FEES _
Suprv. Electrician signature, required: G k,gfci i( e Subtotal: "7:5" Print name: �b�� -�7 KK rn`, 1{X7n/ �1� — Date: Plan review (25% of permit fee):
/ State surcharge (12 % of permit fee): y,
Authorized signature: /ao / TOTAL PERMIT FEE: , 7
This permit application expires if a permit is not obtained wrthi 180
Print name: p4/ �eiziEz Date: 00/ days after it has been accepted as complete. 0 '
s Number of inspections allowed per permit.
I: \Building \Permits \ELC- PermitApp.doc 05/23/06 440- 4615T(1 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:
n Audio and Stereo Systems*
D Burglar Alarm
O Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
n V • acuum 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
n Boiler Controls
n C • lock Systems
n Data Telecommunication Installation
F ire Alarm Installation
HVAC
n Instrumentation
n I • ntercom 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
C\ Building \Permits \ELC- PermitApp.doc 03/23/06