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Permit CITY OF TIGARD ELECTRICAL PERMIT ' : COMMUNITY DEVELOPMENT Permit #: ELC2012 -00096 TIGAR.D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/10/2012 Parcel: 1 S136CD01002 Jurisdiction: Tigard Site address: 7906 SW PFAFFLE ST Project: Wenyi Jia Dental Office Subdivision: 2006 -016 PARTITION PLAT Lot: 3 Project Description: TI. This work is for space 7906 only. Contractor: FIVE STAR ELECTRIC, INC. Owner: PFAFFLE OFFICE, LLC PO BOX 555 PCCC LLC BANKS, OR 97106 915 NW TORREYVIEW LN PORTLAND, OR 97228 PHONE: 503 - 324 -0948 PHONE: FAX: 503 - 324 -0973 FEES Quantity Description Date Amount 1 ea Services or Feeders - 200 02/10/2012 $100.70 Specifics: amps or less 1 ea 12% State Surcharge - 02/10/2012 $12.08 ' Type of Use: COM Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $112.78 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 OAR 952- 001 -0090. You may obtain a copy • - • -. or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. 411111. - Issued By: Permittee Signature: /J 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. Fax: Feb 10 2012 03:23.m P001 002 Electrical Permit Application 1.ok oFFicF: I. 4F. tiN1.V City of Tigard RECEIVED Received Pei itrro,: 13125 SW Hall Blvd., Tigard, OR 97223 pi m • _ . - • Phone: 503.639.4171 Fax 503.598- 116E13 1 0 20i2 Dot= Other Permit: :: ; Z4P I8 — �O • )�d� Inspection Line: 503.639.4175 Date Ready/By: runs: QI See Page 2 for 1 . - d / Supplemental Information Internet www.tigard- or.gov r� Notified/Method: tal 1 �,k� .f, C _ ; �ry� � $ ;q . a . :o '� ';� v °'.'�v ,:7�„ �°� . �.: , ,. .�* "' ?�.� TIGARD 1:J" d; �:' g ! a 'J! (:N„ y�r CU, i t( � A 7 l i l�Yt� s : 7 , i 4 . ; t �wt _+ .41 : ' rt 1'1 4 : � « i k Y ' .' . � ':Z y « � T'1. a y �, t ` ; w4' " ..k <a', , n.- ew construction 0 Addition/alteration/replacement Please cheek all that apply (submit a sets of plane w /ioema chocked below): ❑ Semite or feeder 400 amps or more © Building over three starlet. a Demoi Lion ❑ Other: p _ cabers the available fault current D Marinas and boatyards. V.d^..,' P' "i;. , 4.�,,p ' r. .1 - .} .� �:a.:.,. �,, ,, ; rAccg 1000 am Floating Ina:Hugs ,.k. �rn s� ;.���T °'f 1 ': , .... / , y �r ,, , : i :a�i,;., : 7 sat 150 volts or ❑ P M. z .�.. � rw _4 ._ ., x � , ■:' �.. ' ' '''.', : .' ; ;,' � •'-'; , lus to ground, or exceeds 14,000 ❑ Caisy»eresal -one agricultural [] 1- and 2-family dwelling ' ominercial/industrial ❑ Accessory building amps for an other installations, buildings. ID Multi- family C} Master builder ❑ Other ©r;ra pump. 0 io:ssaUssioe of 75 KVA or 4 , ; .,, v. g. a .. „ „r. ...;,.... - U ; •„ w : • .,. - ergeaoy system, larger separately derived system. N �:n3 y„' � �;, d. : , 9 'l r , Et 3'' ;i' .., c y, • .T.1 ,. Y 1 ... ,!,rr . hy ', . : . . ' :: «E" "1-2", l_3•, , �,,,. , - e ,,,., . _ 41 Y . . , , . ::'6 ❑ Addition of 1WW motor load of © "A» Job site address: ' i N~ M1 1001 - P or more, ooertpan y. I — .gal S AL ' . i ❑ Six or more residential cart+:. 0 Reoreatioxial vehicle parks. ❑ Realtia -cme facilities. ❑ Supply voltage r more tbu City/State/ZIP: �\ a r 41 0 • ., i7 - . llaaardoua locations. 600 volts nominal. Suite/bldg. /apt no.: Project name: . ` a . D service or feeder 600 amps or more. „ ie ' �,an - - : � _ 0 : 4tg^r� �uxYf {r &.7 , , iv � '...,,,.;A,-.4:43J � x7 a :?, 'r'" M " ' Cr oss sheet /directions to job site: /4 't� (f e �" ' ` t ' - - .: , , t� r - - --- 1NeW. residential s or multi-family dwelling unit. • . ' Includes atta'c'hed garage. Subdivision; Lot no.: 1,000 sq, ft or less __ 168.54 J 4 - Ea. add'l 500 sq. ft. or portion 33,92 1 Tax map/parcel no.: Limited enemy, residential . •:'tS'i -v1.. ..�.. ..4u.'- ::% : Vi i ", !• v:R F(. =q•,f ,.ry 75.00 2 ,:;.,s ,:Iii-. : i , ., ., ;; v . 'l ac l rs ' , r i a :' a It -1 -1 r :.' y (with above Sq. ft) �� Limited energy, multi - family • Y Ill (. 7--) } residenMal t/1th above sq. ft) i 75 2 1T7• MMI! _ at �i,� �iR Services or feeders installation 1 alteration and/or relocation �1 ►�Art��� L'. � � �2 s•.�i��,_ 200iaxrtps or less � 00.70 _ y 0 2 q ^ , ws ;it� i„; : id i ` ; ° " 201 amps to 400 am 133.56 2 l ,F�. wti �,_. a,,,,t t''' Rw :1'sl: ¢ .. . k, " .Y : +n ; , z�' f p 401 amps to 600 amps • 20034 20034 2 Narne: amps to 1,000 amps 301.04 mm S5: 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 1 1 59.36 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2 irstended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2 Brunch circuits - new, alteration or extension, ear panel Owner signature Date: A. Fee for branch circuits with ' y c r � � „ r r . 4.'" 3 . , ,"' x fin' above service or feeder fee. .- , • ,'Y� A,-i a, , `" fa7 � a 'p' , ' 4 4 > = C ,. `�. -. s t.. . hliz < rl; : . E each branch circuit 7.42 2 Buse name: B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact nante: branch circuit — W-- ---- - — Each add'l branch circuit 7.42 2 Address: Miscellaneous (service or feeder not included) Ci /State /ZIP: Each manufactured or modular 67,84 2 tY dwall service and/or feeder - Phone: ( ) l Fax:: ( ) Reconnect only / II 67.84 2 111 Pump or irrigation, circle 67.84 2 g N , �`, . . " Sign or outline lighting 67.84 _ ' 2 „4 r t S 13~" .w ai. , ,. l ;y _ r J - „,,r0: " " � ..,_o ° . Signal circuit(S) or llmlted- energy 0 , el altered • or extension. P: _ 2 2 Business name: r1 qe (✓ e Y t G h situ- t � c • - - Each additional Inspection over allowable in any of tlteabov? Address. - 1 1t s sS' _ — ,Additional inspection (1 hr min) - I 66.25/ hr , ^'� i o Investigation (1 lit min) 66 - 25/ hr City /State /ZIP: . e, _ lridustxial plant (1 lrr min) 78.18! br Plvome: ( 5:)" ?)2, -094-g Fax: (S1),31 , N ( y C? 7 3 Inspections for which no tee is 90.00/ h specifically listed 14 h hr min r yS r CC)3 Lic.: Electrical Lic.: - * `� Suprv. Lie.: . 2�. ..S ,Ca ' r eSia _. _ 264,4�ae . ..: ..w ,.'tga _ : �/': ' Suprv. Elect rician 1 31 r equ it ed: Subtotal: r _�i Fl re view 2590 of •chili fee): ,w __ _ P r i n t name: c o r n. . , Date: r ) .- I 0 - 1 (9., State surcharge (12% of permit fee): TOTAL PERMIT P E: Authorized signature: TOTAL permit application expires if a permit is eat ohnaittod� - days after it has been accepted as CO is • Print name: Date:. " Number of iaspec6ons allowed per permit. , Q° / i )• ' - 7( r.'ldiesS a atBmnC- permitapp.doc o7 /01 /l0 4 0.4615r(i1 /05/COLr/WE5 ( I Ilh i:r, -,... i: _ ::, ,,-. I City of Tigard February 15, 2012 Five Star Electric Attn: Becca PO Box 555 Banks, OR 97106 Re: Permit No. ELC2012 -00096 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 7910 SW Pfaffle St. Project Name: Dr. Wenyi Jia Dental Office Job No.: N/A Refund Method: n Check # in the amount of $ . ® Credit card "return" receipt in the amount of $112.78. 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 $ . Comment(s): Refund 100% of permit fees paid as scope of work was added to existing permit ELC2012- 00030. If you have any questions please contact me at 503.718.2430. Sincerely, VC,fr " 1 r W - C----- Dianna Howse Building Division Services Supervisor Enc. is \Buildin \ReFundst3, LKA cenT adzci 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: Five Star Electric DATE: 2/15/2012 Attn: Becca PO Box 555 REQUESTED BY: Dianna Howse Banks, OR 97106 MAV TRANSACTION INFORMATION: Receipt #: 185509 Case #: ELC2012 -00096 Date: 2/10/2012 Address /Parcel: 7910 SW Pfaffle St. Pay Method: CreditCard Project Name: Dr. Wenyi Jia Dental Office EXPLANATION: Refund 100% of fees. Scope of work was added to ELC2012 -00030 where additional fees were collected. xmREEUND'INFOgMATION iK, _, -P ° . ` .. ,; .- x.,� : r.. ' ., V? . Z , } tx',+ w use -§ r a z ,^gin '°"4 Y<"r t s i Fee Description From Receipt°" �k E Revenue Account No t , dg to Refund ;„, Exam e ' - 2 r 1 , a 4 ` ; 7 , � 30 V F'C:i " ,r t k e ? i p Buildung,Perinit Fee, < r ... ,, EVainple :,' 0 0 0 0 43104 ;: $ ,! Electrical Permit Fee 220- 0000 -43103 $100.70 12% State Surcharge 100- 0000 -24001 12.08 �' TOTAL REFUND: �$t'18 APPROVALS: 1 /' �� f If under $5,000 Professional Staff . If under $12,500 Division Manager 1 _. 1 If under $25,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board SS < FORS- T AOSIINISTRATION` USE; O : LA ifteg Case Rfund Processed: Date: ,J2 / /S // - --By:- 1:ABuildin \Refunds \RcfundRcquest.doc x 09/01/2010