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Permit IN CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT COMMUNITY DEVELOPMENT Permit #: ELR2012 -00084 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/08/2012 Parcel: 2S102BD00701 Jurisdiction: Tigard Site address: 12785 SW PACIFIC HWY Project: Burgerville Subdivision:RTH TIGARDVILLE ADDITION, AMENC Lot: 8 Project Description: (2) low voltage systems, data and paging. Contractor: CONNECTIONS NORTHWEST INC Owner: BENNETH, CATHERINE MCNICOL 604 NW 133RD CIRCLE 3830 ROBIN CREEK LN VANCOUVER, WA 98685 WEST LINN, OR 97068 PHONE: 360 - 518 -2868 PHONE: FAX: 360 - 574 -0049 FEES Description Date Amount Specifics: Restricted Energy Permit 05/08/2012 $150.00 12% State Surcharge - Electrical 05/08/2012 $18.00 Type of Use: COM Class of Work: ALT Total Number of Systems: 2 Audio & Stereo: N Boiler Controls: N CCTV: N Clock Systems: N Data & Telecommunications: Y Fire Alarm: N HVAC: N Instrumentation: N Intercom/Paging: Y 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. ATTENTI • • . e - . on law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -001' rough OA <52 -r • - 1190. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued ' _ / t 4 A.ii � � Permittee Signature: 1 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 603.639.4176 by 7:00 a.m. for the next available Inspection date. This perk 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. e r - r - y b a /4 -2b 5/8 g cad 6 , 4Ao j ,2.4ao85/ 4". i , LECTRICAL PERMIT APPLICATION �ttZ? iityt -egad; Oregon - Bureau of Development Services � r 1900 SW 4th Avenue, Portland, Oregon 97201 • 503-823-7363 • TTY 503 -8234868 • www.portlandoregon.gov/bds Type of work This permit application expires if a permit is not obtained within 180 days after it has been accepted 0 New construction n ' ddition /alteration/replacement as complete. 0 Demolition 0 Other: - Plan Review Category of construction Please check all that apply 0 & 2 family dwelling T 6(gtmerciaUndustrial 0 Accessory building 0 Fire pump 0 Building over three stones U Multifamily 0 Master builder 0 Other: ❑ Emergency system ❑ Service or feeder 600 amps 0 Addition of new motor load of or over Job site information and location 100 HP or more U Commercial use agricultural Job no.: Job address: ) a, RS s'U! e Acz F (- ) , 4/ - ❑ Patient area health care facility buildings U City /State/ZIP: ' r 16 r r � 2 9'72->3 / U Hazardous locations separately derived system t larger separately derived Suite/bldg. /apt.no.: 'Project name: Bv14-4 s 0 Recreationalvehicle parks O 'A','E','1- 2,'1 -3' occupancies Cross street/directions to job site: 0 Marinas and boatyards 0 Service or feeder 400 amps 1 or more where the available U Floating buildings no. fault current exceeds 10,000 Subdivision: Lot no. Tax map/parcel 0 Six or more residential units amps at 150 volts or less Description of work (example: 3 circuits for basement receptacles) U Supply over600 volts nominal to ground, or exceeds 14,000 amps for all other 1 / CA T,5f CAB ❑ Voluntary plan review installations �� G7.. w , ( •, Submit 2 sets of plans with any of the above. Provide RS Permit no. Fee Schedule • Property owner • Tenant Descri.tion Qty. 0 Total la Residential single or multifamily dwelling unit. Name: • E -mail: Includes attached garage. 1,000sq. ft. orless - -Q Address: Each added 500 sq. ft. or portion -M . - City /State/ZIP: Limited energy, residential - -© Limited energy, multi-family - 0 _ B Phone: IFAX: Services or feeders installation, alteration, and/or relocation Owner Installation: This installation is being made on property that I own, which is not intended for sale, lease, rent, 200 amps - $130 — or exchange. 201 to 400 amps IME EMI -© Owner si • nature: Date: • 401 to 600 amps MI EEEI El - ■ Contractor • Subcontractor • 601 amps to 1,000 amps - EMI - © vo ' yT � .I • Over 1,000 amps or volts -© Business name:cp�J�/L= �,77ppS /U E -mail: GS L Service Reconnect Only = gy Address: 6aq AA,,,, 133 GZR- -tc <cNNe4-rsouSNtw • C-O t" Temporary services or feeders installation, alteration, and /or relocation City /State/ZIP: f `f PcoU VOc_ (� A 986 8 S 200 amps or less — 360 — 518 , )- 868 J 360 -57 - 0 14 9 201 amps to600amps -M — Phone: FAX: � J 401 am9 to soo amps � M � Elec. lic. no. 4i.4" �2.,1 l 9 7// /o IccB lic. no. 1 (7t98 9 s/ri fig Branch circuits - new, alteration, or extension, per panel AFee for branch circuits with Metro or City lic no. service or feeder fee, each EMI 1 � �6 5 !Date: Supervising electrician _ branch circuit Signature, required: B for branch circuits without g q / service or feeder fee, first . $107 -© Print name: /3 n , • / / fwit C ce t.✓/ License no. 3 /ja 7 4 CA- branch circuit 64,b...414 Each additional branch circuit -� — Authorized signature: Miscellaneous (service or feeder not included) p Each manufactured or modular _ El Print name: &AR. Q L -cf 7 Date:,) r !g — dwellin. service and /or feeder • Applicant ■Contact Person Pump or irrigation circle - c_© • Sign or outline lighting - El Business name: Signal dreuit(s) or limited- energy - ri , : nel, alteration, or extension. ir� _ / c-' Contact name: Describe: Address: Hourly rate: - MI Each additional inspection over allowable in any of the above City/State/ZIP: Per inspection -EER - 1111 Phone: IFAX: Investigation fee -- -. Other -_ —M E -mail: Electrical permit fees' RS Combo Permit/No Fees Due El Subtotal 50 ' ` Plan review (25% of permit fee) ------ Residential Combo permit subcontractor submittals only can be faxed to 503 -823 -7693. State surcharge (12% of permit fee) a inspjiennitapp_elecnical 02/27/12 TOTAL PERMIT FEE In • • Requires Plan Review •• Number of inspections allowed per permit.