Permit ,, CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
"'! ! COMMUNITY DEVELOPMENT Permit #: ELR2012 -00027
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/09/2012
Parcel: 1S136AD06000
Jurisdiction: Tigard
Site address: 11437 SW PACIFIC HWY
Project: Carl's Jr. Restaurant Subdivision: VILLA RIDGE Lot: PTS 1 -2
Project Description: POS system.
Contractor: TRITON COMMUNICATIONS, LLC Owner: EJM PROPERTIES INC &
PO BOX 1091 MAVERICK DECATUR GEORGIA LLC
HILLSBORO, OR 97123 3633 E BROADWAY
LONG BEACH, CA 90803
PHONE: 503 - 615 -5800 PHONE:
FAX: 503 - 628 -5689
FEES
Description Date Amount
Specifics: Restricted Energy Permit 02/09/2012 $75.00
12% State Surcharge - Electrical 02/09/2012 $9.00
Type of Use: Investigation Fee (equals Electrical 02/09/2012 $75.00
Class of Work: Permit)
Total Number of Systems: Investigation Electrical 12% State 02/09/2012 $9.00
Surcharge
Audio & Stereo: N Boiler Controls: N
CCTV: N Clock Systems: N
Data & Telecommunications: N Fire Alarm: N
HVAC: N 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 $168.00
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 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 • 001 -0090. You may obtain a copy of the ruestions to OUNC by calling 503. .1987 or 800.332._2344.
Issued B Y '/ yam'- ��' • ee- 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 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 ,r
Date/By: ', Permit No.: P ' ■ =_ — ;--r
I lk '1 1 3125 SW Hall Blvd., Tigard, O' , ifr ° ➢ O'L ate /B Review ,
0 ,' ' Phone: 503.718.2439 Fax: 503.•''!:. 660 i% �' Date/By. Other Permit: Aa �1 // -0610
TIGARD Inspection Line: 503.639.4175 0 �� Date Ready /By: 0 See Page 2 for
Internet: www.tigard- or.gov �r(��� .4. Notified/Method i Supplemental Information
TYPE OF WORK . ..) PLAN REVIEW
® New construction ❑ Addition /alteration /r�bp }ce
= ' ment 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 ❑ Mannas 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.
/1137 ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: 4032 Job site address:V Pacific Hwy 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard, OR 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: Carl's Jr ❑ Service or feeder 600 amps or more.
,FEE .SCHEDULE,
Cross street/directions to job site: Description Fee.
p I Qty I 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'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
POS S Stem Install Limited energy, multi - family
75.00 2
y residential (with above sq. ft.)
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:
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
Temporary services or feeders installation, alteration, and /or
City/State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 l
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, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
El APPLICANT El 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)
Each manufactured or modular
City/State /ZIP: 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67 84 2
Pump or irrigation circle 67.84 2
E - mail:
CONTRACTOR Sign or outline lighting 67.84 2
Signal circuit(s) or limited- energy
Business name: Triton Comunications, LLC panel, alteration, or extension 1 Page 2 75 2
Each additional inspection over allowable in any of the above
Address: PO Box 1091 Additional inspection (1 hr min) 66.25/ hr
Investigation (1 hr min) l 66
City/State /ZIP: Hillsboro, OR 97123 7
Industrial plant (1 hr min) 78.18/ hr
Phone: (503) 615 - 5800 Fax: (503) 628 - 5689 Inspections for which no fee is 90.00 / hr
specifically listed (%2 hr min)
CCB Lie.: 154665 Electrical Lie.: 34648CLE Suprv. Lie.: 2826LEA ELECTRICAL PERMIT FEES
Subtotal
Suprv. Electrician signature, required: Plan review (25% of permit fee):
Print name: Aaron Van Fleet Date: 2/8/12 State surcharge (12% of permit fee): ��
awn 7.1- _ TOTAL PERMIT FEE: 4 / t
Authorized signature: 2t --------- This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Aaron Van Fleet Date: 2/8/12 * Number of inspections allowed per permit.
P\ Building \Permits\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*
Ti Burglar Alarm
n Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
Ti Audio and Stereo Systems
n Boiler Controls
n Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
n Instrumentation
Ti Intercom and Paging Systems
n Landscape Irrigation Control*
Ti Medical
Ti Nurse Calls
Ti Outdoor Landscape Lighting*
Ti Protective Signaling
NI Other POS
Total number of commercial systems: 75
*No licenses are required. Licenses are required
for all other installations
C \BuildingPermits\ELC- PermitApp doc 07/01/10