Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
2.: COMMUNITY DEVELOPMENT Permit #: ELR2012 -00100
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/21/2012
Parcel: 2S102BD00701
Jurisdiction: Tigard
Site address: 12785 SW PACIFIC HWY
Project: Burgerville Subdivision:RTH TIGARDVILLE ADDITION, AMENC Lot: 8
Project Description: Install (2) thermostats to control 2 HVAC systems
Contractor: PORTLAND MECHANICAL CONTRACTORS Owner: BENNETH, CATHERINE MCNICOL
2000 SE HANNA HARVESTER DR 3830 ROBIN CREEK LN
MILWAUKIE, OR 97222 WEST LINN, OR 97068
PHONE: 503 - 656 -7400 PHONE:
FAX: 503 - 655 -0620
FEES
Description Date Amount
Specifics: Restricted Energy Permit 05/21/2012 $150.00
12% State Surcharge - Electrical 05/21/2012 $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: 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 $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 0 R • 52 -001 -0.90, You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
' 0 ) 4 4 PPv ell 9AL,
Issued By: I i 1 I 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.
05/16/2012 11:06 5036550 RF. 9e ECEIV Eli PMC GROUP PAGE 02/04 5i
Electrical Permit Application F(111 OFFICE 11SE ONLY _
' City of Tigard M AY 6 2012 Received 4I tobi Ur Permit Nof���'�_
w 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review ` ,(,,, d 01191.1.. D
Ic ' Phone: 503.718.2439 Fax: 503.598. egf 1(QF TIGRItD Date Other Penmt: �Xl
.f I C. A R ID Ins Line: 503 G DIVISI ® N Date Ready/By: orris: ® See Page 2 for
cd/bd Internet: www.tigard- or.gov BUILDIN Naha; -n6 Supplemental Information
c, Pease check all that apply (submit sets of plans s w/items .•..,..: . •
:. ,
Please
El New construction ® Addition /alteration/replacement arts w /i checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
, ,, ::..,, .:. • ;, ,::.;:' : t.:.: lid "' exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
,... .. , C
ON9'; , I.CI'I,'; ' ::
...;,.. ;■P:..•�r� .: -.:,:: ,• :.:,, ^,� "■_ •:� :: 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.
El Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB$'.S -I Nil tiiti4 *f i.biki4i∎rik_LOfrTT 1:: ❑ Addition of new motor load of ❑ "A "E••, "1.2 ", "1 -3"
100HP or more. occupancy.
Job no.: I Job site address: 12785 SW Pacific Hwy Recreational vehicle
❑ Six or more residential units. ❑ parks.
City/State/ZIP: Tigard OR 97223 ❑Health facilities. ❑ Supply voltage for more then
['Hazardous locations. 600 volts nominal.
Suite/bldg. /apt no.: Project name: Burgerville #45 Tigard ❑ Service or feeder 600 amps or more.
Cross street/directions to job site: Description 1 (Irv. I Fee. I Total 1 •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. R or leis 168.54 4
Ea. add'1500 sq. ft. or portion 33.92 I
Tax map /parcel no.: Limited energy, residential
.:.:- :. • , i.<�:, t,... / gabove sq. ft) 75.00 2
. : . ..
1 . .
.. ,..i-a3,,.. G'R V, ,: Nli � F.WOItiC'�,`:::.;;` ..;;: = ;,;::�.:,..:'.:'::- :::'.`'.; Limited energy, multi
75.00 2
Install (2) thermostats to control 2 HVAC systems. residential (with above sq. ft.)
Services or feeders installatton and/or relocation
200 amps or less 100.70 2
,.: ;: �::. r...r::: =.. ' :. :. •: amps to amps
201 400 133.56 2
401 amps to 600 amps 200.34 2
Name: Burgerville #45 601 amps to 1,000 amps 301.04 2
Address: 12785 SW Pacific Hwy Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State /ZIP: Tigard OR 97223 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 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
:::, . .,, .,. above service or feeder . ._.. _ 7A2 2
.. , .. .... .. a emce
:' ;''�'AP1Q7s3CANT'.:' :. : ;:.. '; : : ' ::� : CON IACT; PEtZSUN: :: each branch circuit
Business name: Portland Mechanical Contractors B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: Paul Hettervig branch circuit
Each add'I branch circuit 7.42 _ 2
Address: 2000 SE Hanna Harvester Drive Miscellaneous (service or feeder not included)
Each manufactured or modular 67.84 2
City/StateJZIP: Milwaukle OR 97222 dwelling, service and/or feeder
Phone: (503) 656 -7400 • Fax: : (503) 655 -0620 . . Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: paulh@pmc Sign or outline lighting 67.84 2
. ,...
,... , .. ; ,.. , .. , . _ .... . ..... Signal circuit(s) or limited-energy 2 15000
Business name: Same as above. panel, alteration, or extension. Page 2 _ 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (I hr min) 66.25/ hr
City/State /ZIP: investigation (1 hr min) 66.25/ hr
A
Industrial plant (1 hr min) 78.18 / hr
( )
Phone: ,v ( I Fax \V K Ins for which no fee is
`\� 1► specifically listed (f, hr mini 90.00 / hr
,
CCB Lie.: 151807 ( E Lic.: 3 483CLE Suprv. Lic.: 1 %31 ) .. ELECTRICAL PERMIT .BEES •• • :
Suprv. Electrician signature, requir ... ./J T a Subtotal: 150.00
�- Plan review (25 /o of permit fee):
Print name: Mav1L ...tm. i . Date: . c /G _ `� State surcharge (12% of permit fee): 18.00
Date c: TOTAL PERMIT FEE: 168.00
Authorized signartif" + 1 0) V
11 t4 / Thla permit application if e penult Is not obtained within 180
•% days after it has been accepted as complete.
Print name: Paul Hettery Date: • Number of inspections allowed per permit.
i:\ Building \Perminl2LC-PermltApp.doc 01/01/10 440- 4615T(11/05/COM/WE8
X /2-& z4)//' 67Z Ai/i Ta /9-",4 ie4L-Av7—
05/16/2012 11:06 5036550620 PMC GROUP PAGE 03/04
Electrical Permit Application - City of Tigard •
Page 2 Supplemental Information
LIMITED ENERGY PERMIT FEES:
$10ENTMVCOMONLY: ._ • •
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
0 Audio and Stereo Systems*
O Burglar Alarm
El Garage Door Opener*
0 Heating, Ventilation and Air Conditioning System*
El Vacuum Systems*
El Other
Fee for each commercial $75.00
system
(SEE OAR 918-309-0000)
Check Type of Work Involved:
O Audio and Stereo Systems
ID Boiler Controls
O Clock Systems
O Data Telecommunication Installation
El Fire Alarm Installation
Z HVAC
El Instrumentation
El Intercom and Paging Systems
O Landscape Irrigation Control*
0 Medical
El Nurse Calls
0 Outdoor Landscape Lighting*
0 Protective Signaling
El Other
Total number of commercial systems: 2
*No licenses are required. Licenses are required
for all other installations
lAlluildingTermits1ELC-PermilApp.doe 07/01/10
05/16/2012 11:06 5036550620 PMC GROUP PAGE 01/04
PLUMBING & MECHANICAL CONTRACTORS GROUP
FACSIMILE TRANSMITTAL SHEET
TO: FROM:
Debbie Stephanie Taylor
COMPANY: DATE:
City of Tigard 5/16/12
FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER:
503- 598 -1960 4
PHONE NUMBER: SENDER'S REFERENCE NUMBER
503 - 639 -4171 11704
RE: YOUR REFERENCE NUMBER:
Burgerville #45 Low- Voltage Permit
Application
❑ URGENT 0 FOR REVIEW ❑ PLEASE COMMENT ® PLEASE REPLY ❑ PLEASE RECYCLE
NOTES /COMMENTS:
Attached is a low- voltage permit application for Burgerville #45 at 12785 SW Pacific Hwy,
Tigard.
Please charge the permit fees to the Mastercard shown on the Credit Card Authorization
form.
Please fax the fee receipt for the permit to me at 503 - 655 - 0620.
iJ//° ertn / If you need additional information or have any questions, please contact me at 503417 -0320.
Thank you.
Stephanie
Project Assistant
2000 SE HANNA HARVESTER DRIVE • MJLWAUKIE, OREGON 97222 • PH (503) 656 -7400
FAX (503) 655 - 0620
CCB #151807 • WA #CCO1 PORTLMCO24KA