Permit ELECTRICAL PERMIT -
CITY TIGARD RESTRICTED ENERGY
DEVELOPMENT SERVICES PERMIT #: ELR2003 -00105
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/9/03
SITE ADDRESS: 11875 SW PACIFIC HWY PARCEL: 1S135DD -00900
W
SUBDIVISION: HOFFARBER TRACTS NO.2 ZONING: C -G
BLOCK: LOT: 021 JURISDICTION: TIG
Project Description: Installation of limited energy for data telecommunications.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: X NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: : HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
LEFEVER, GEORGE & TAMMY LJ MATTISON COMMUNICATIONS
11875 SW PACIFIC HWY 7021 SE 31ST
TIGARD, OR 97223 PORTLAND, OR 97202
Phone: Phone: 503 771 - 5708
Reg #: ELE 26- 849CLE
LIC 95742
MET 5872
FEES Required Inspections
Description Date Amount Low Voltage Inspection
[ELPRMT] ELR Permit 4/9/03 $75.00 Elect'I Final
[TAX] 8% State Tax 4/9/03 $6.00
Total $81.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and
all other applicable laws. 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 than 180 days. ATTEN • N: Oregon law requires
you to fol w_a leers adopted by the Oregon Utility Notification Center. Those rules are set forv'in GAR 952 -001 -0010 throuc •
_I sued by , ? , � �/, r te;! 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'N DATE:
LICENSE NO:
Call 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Electrical Permit Application FOR OFFICE USE ONLY
Received L g 2 Electrical o n� /
Date/By: y: 6 d/ Permit No.: C L�.,j0.00 — 00/0 C
City Ti and Planning Approval Sign
y g Date/By: Permit No.:
13125 SW Hall Blvd. Plan Riew Other �f, D_ D � y �� 9 �
Tigard, Oregon 97223 Date/By: Permit No. '
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use
Ira & Date/By: Case No.:
Internet: www.ci.tigard.or.us t I Contact J ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name/Method: / (A . Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous
Addition /alteration/replacement ❑ Other: location
❑ Service over 320 amps - rating of 0 Building over 10 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
❑ 1 & 2- Family dwelling igl,Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit _ sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: 1/R7 S S. a. -c Vie- /4w `') FEE* SCHEDULE
Suite #: I Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: .Zf/T E fL / 0 z 144 o-i kr E 5 Description Qty Fee (ea.) Total 1
Cross street/Directions to job site' New residential- single or multi- family per
' dwelling unit. Includes attached garage.
P Fa C ` a ,- ,e -, Service Included:
11��y 1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Lot #: Limited energy, residential 75.00 2
Subdivision: Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
Services or feeders - Installation,
alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTY OWNER I ❑ TENANT 601 amps to 1000 amps 240.60 2
Over 1000 amps or volts 454.65 2
Name: Reconnect only 66.85 2
Address: Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: 200 amps or less 66.85 1
Phone: Fax: 201 amps to 400 amps 100.30 2
❑ APPLICANT ❑ CONTACT PERSON Branch n circuits h amps 133.75 2
Branch c -new, alteration, or
Name: extension per panel:
A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 6.65 2
City /State /Zip: B. Fee for branch circuits without purchase of
service or feeder fee, first branch circuit 46.85 2
Phone: I Fax: Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: ' / Signal circuit(s) or a limited energy panel,
Business Name: J alteration, or extension age 2 2
�r97 ''Sor/ l�Mih0N11C'.1q-iou5
7 Description: G •
Address: 0.2 5- 01 s� 4�I , 'T74 -TI'S-
Each additional inspection over the allowable in an of the above:
City /State /Zip: ax-v— u@wID 0 2 , 5' 7 0 Z Per inspection per hour (min. 1 hour) 62.50
Phone: 5 -77/- -5670 8 Fax: 5o3 -? 7 / - 64in Investigation fee:
Other:
CCB Lic. #: 9S7ifZ Lic. # ev --g J t. p Electrical Permit Fees*
Supervising electrici Subtotal $ 70 e
signature required: Plan Review (25% of Permit Fee) $
y "34.1r/S o Lic. #' LE State Surcharge ep . 00
Print Name I �'� Z harge (8% of Permit Fee) $ TOTAL PERMIT FEE $ fs/ . oe
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms \E1cPermitApp.doc 01/03
Electrical Permit Application - City of Tigard
.Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
0 Audio and Stereo Systems* •
❑ Burglar Alarm
❑ Garage Door Opener
❑ Heating, Ventilation and Air Conditioning System
❑ Vacuum Systems
E] Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
0 Audio and Stereo Systems
0 Boiler Controls
0 Clock Systems •
El Data Telecommunication Installation
Fire Alarm Installation
HVAC
Instrumentation •
Intercom and Paging Systems
Landscape Irrigation Control .
❑ Medical
0 Nurse Calls
❑ Outdoor Landscape Lighting
Protective Signaling
n Other
Number of Systems . '
* No licenses are required. Licenses are required for all
other installations
i:\Dsts\Permit Forms\ElcPermitAppPg2.doc 01/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Rewested _ ° AM PM BUP
Q
Location 1 1 U 15 Suite MEC
Contact Person Ph ( ) PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation Access: ELC C
Ftg Drain ELR l J
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling L._ _
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
'ELECTRICAL
Rough -In
UG/Slab
F= Alarm
Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PART FAIL
SITE El Please call for reinspection RE: El Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date, � / ' Inspector Ext
Other: /
Final DO NOT REMOVE this inspection recor from the Job site.
PASS PART FAIL