Permit IA
` CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
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10
< _ COMMUNITY DEVELOPMENT Permit #: ELR2009 -00278
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08!27/2009
:TIGARD Parcel: 1S135AB01003
Jurisdiction: Tigard
Site address: 10300 SW GREENBURG RD 380
Subdivision: Lot: 0
Project: Maxim Healthcare
Project Description: Low voltage for data telecommunications.
Owner: FEES
LINCOLN CENTER LLC Description Date Amount
BY SHORENSTEIN PROPERTIES LLC, 555 Restricted Energy Permit 08/27/2009 $75.00
CALIFORNIA ST 49TH FL 12% State Surcharge - Electrical 08/27/2009 $9.00
PHONE:
Contractor:
MT HOOD ELECTRIC INC
PO BOX 1270
WELCHES, OR 97067 -1270
PHONE: 503 - 622 -1305
FAX: 503- 925 -3525
Type of Use: SF
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: N Boiler Controls: N
CCTV: N Clock Systems: N
Data & Telecommunications: y Fire Alarm: N
HVAC: N Instrumentation: N Total $84.00
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N
Required Items and Reports (Conditions)
Nurse Calls: N Protective Signal: N
Security Alarm: N Other: N
Other Desc:
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 - cordance 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 - re. ' es ou to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -'4010 through OAR 952 -01 -r 00. ma obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699,r 1.80> 32.2344.
� ,/ /,
Iss -d By: t \ ' 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 503.639.4175 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.
Electrical Permit Application_ OR OFFICE,USE ONLY
D ECEIVED
City of Tigard
4 .
.7 09 Permit No.: `� OY.( / '� a� U
' - ..
Date/By:
Received
'� 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phon 503.639.4171 Fax: 503.598.194 G 2 7 20 09 Date /By: Other Permit:
[ IGARD Inspection Line: 503.639.4175 Date Ready /13y: Juri_' 0 See Page 2 for
Internet: www.tigard-or.gov CITY OF TIGARD Notilied/Method t de Supplemental Information
TYPE OFWVkDING DIVISION PLAN REVIEW
Please check all that apply (submit 2 sets of plans w /items checked below)* New construction El 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 O. Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE, INFORMATION AND LOCATION
Addition of new motor load of ❑ "A' , "E ", "I -2 ", "I -3 ",
x �!• , / '+ 100HP or more. occupancy.
Job no.: Job site address: 1 t�(� W ls7 22V1 bU f ❑ Recreational vehicle parks.
,( A ❑ Six or more residential units.
City /State /ZIP: pQ�^` // Q7 rf� ❑ Health-care facilities. ❑ Supply voltage for more than
� / t` ✓ c 4 ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: ZS° Project name: / cw a t (A re ❑ Service or feeder 600 amps or more.
Cross street /directions to job site: t / ( FEE SCHEDULE
J Description I Qtr. I Fee. I Total 1
New residential single - or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
' c - r 41 uN /f2 1 T /� koo Limited energy, multi-family s i ly
/ / c �' `
SCR � P CQ a residential (with above sq. ti. ) 75.00 2
Services or feeders installation, alteration, and /or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 16(1.60 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,
each branch circuit 6.65 2
Business name: B. Fee for branch circuits
without service or feeder fee,
Contact name: 46.85 2
first branch circuit
Address: Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
90.90 2
Phone: dwelling, service and /or feeder
( ) Fax: ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
I fT
C ONTRACTOR . Sign or outline lighting 53.40 2
Business name: (
�'7 / , Hoop c / ecc 4 T ,. Signal circuit(s) or limited-
energy panel, alteration, or 75
Address: po, f & x ' 4270 extension. Describe: I Page 2 2
City/State /ZIP: te) -� t al) 6
?707 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( S). 3) 50 -f3 OE Fax: (SO �) s - s,9,& Investigation per hour (I hr min) 62.50
CCB Lic.: / 47 640 Electrical Lic.: J —577 C Suprv. Lie.: 4 <. S Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required:
Subtotal: 7cS,0(>
Print name: Main 6Y2.veo Date: Plan review (25% of permit fee):
/ State surcharge (12% of permit fee): 9.00
Authorized signature: "TOTAL PERMIT FEE: 8 t
{ c� /y This permit 1 /J /` applicatiays a on it h expires as i f a permit is nut obtained within 18t) Print name: 7,--/--a f L .... e � � 2 , Date: r/ .. 6 Q 7 d been accepted as complete.
* Number of inspections allowed per permit.
I \ Building \ Permits \ELC- PenntApp.doc 05/23/06 440- 4615T(I I /05 /COM /WEB
ElP ctrical 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*
n Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
n 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
n Boiler Controls
n Clock Systems
Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
n Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
n Medical
n Nurse Calls
n Outdoor Landscape Lighting*
n Protective Signaling
I Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1: \13w Iding \Perntiu \81.C- PermitApp.doc 03/23/06