Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
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COMMUNITY DEVELOPMENT Permit #: ELR2011 -00246
13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/09/2011
. G• Parcel: 1S136AD06000
Jurisdiction: Tigard
Site address: 11437 SW PACIFIC HWY
Project: Carl's Jr. Restaurant Subdivision: VILLA RIDGE Lot: PTS 1 -2
Project Description: Low voltage for HVAC
Contractor: ADVANCED HEATING & AIR CONDITIONING Owner: EJM PROPERTIES INC &
5825 SE FOSTER RD MAVERICK DECATUR GEORGIA LLC
PORTLAND, OR 97206 3633 E BROADWAY
LONG BEACH, CA 90803
PHONE: 503 - 774 -0161 PHONE:
FAX: 503 - 774 -4391
FEES
Description Date Amount
Specifics: Restricted Energy Permit 12/09/2011 $75.00
12% State Surcharge - Electrical 12/09/2011 $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 - .r.ance - 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. ATTErTION: Oregon la requi - you to follow the rules adopted by the Oregon Utility Notification Center Thos rul s are set forth in OAR
952- 001 -0011 through OAR 952 -001 0r -0. out obtain a copy of the rule or direct questions to OUNC by calling 503 7 or 41I`d 432.,44:.
Issued B ' 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 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 / I / i Permit No.: a e // " ( 0
° 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
• C : Phone: 503.718.2439 Fax: 503.598.1960 Date /By: Other Permit:
TI G A R D Inspection Line: 503.639.4175 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK 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 ❑ Mannas and boatyards
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 t ❑ 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 -2 ", "1 -3 ",
q 100HP or more. occupancy.
Job no.: Job site address: t f 37 �.� C , �/ GV 0 Six or more residential units. P
❑ Recreational vehicle parks.
City /State /ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than
/� ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: 0A- /G f. f$- ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total
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' 1 500 sq. ft. or portion 33.92 I
Tax map /parcel no.:
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
/� L energy, multi- family
CO Q L / /-2,_ �Q/L 4 --e- residential (with above sq. ft.) 75.00 2
Services or feeders installation, alteration, and /or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: 1 C CO ( 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( ) Fax: ( ) 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 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
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, 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'l branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 67.84 2
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: AD ✓�}� j € b (4 A-77 � r! " 4 /4/e panel, alteration, or extension. , Page 2 2
_ ` Each additional inspection over allowable in any of the above
Address: 5 6,9,5 ., 4.) rr 4. Additional inspection (1 hr min) 66.25/ hr
� 47 -,... 4 6 a 9 7 Investigation (1 hr min) 66.25/ hr
City /State /ZIP:
P yam/ /1 Industrial plant (1 hr min) 78.18 / hr
Phone: (b95' ) 774 - 0/z, / ' Fax: ( 5) 77`7 " #/9 / Inspections for which no fee is 90.00 / hr
specifically listed (%a hr min)
CCB Lic.: q96 , Electrical Lie.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: o Subtotal:
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE:
Authorized signature:
// This permit application expires if a permit is not obtained within 180
Print name: JC Date: days after it has been accepted as complete.
Number of allowed per permit.
1:\ Building \'ermits\ELC- PermitApp.doc 07/01/10 440- 4615T(11 /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
111 F Alarm Installation
HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ 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
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