Permit CITY OF TIGARD ELECTRICAL PERMIT
a. COMMUNITY DEVELOPMENT Permit #: ELC2012 -00355
T I GA R.D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/07/2012
Parcel: 1 S133DD08300
Jurisdiction: Tigard
Site address: 11624 SW 128TH AVE
Project: Locsin Subdivision:'ILLAGE AT SUMMER LAKE PARK NO. Lot: 120
Project Description: (6) branch circuits for kitchen remodel
Contractor: CANBY ELECTRIC INC Owner: LOCSIN, ARSENIO Z
790 S IVY ST 11624 SW 128TH AVE
CANBY, OR 97013 TIGARD, OR 97223
PHONE: 503 - 266 -7878 PHONE:
FAX: 503 - 266 -5543
FEES
Quantity Description Date Amount
6 crt Branch Circuits wo /Purchase 06/07/2012 $93.28
Specifics: Service or Feeder
1 ea 12% State Surcharge - 06/07/2012 $11.19
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $104.47
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OAR 5 - 001 -009 You may o fain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
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Issued By: Permittee Signature: Ql't 't-f- 8 PLJ `4 T7i) k.
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for the next available Inspection date.
This permit card shall be kept In a conspicuous place on the job site until completion of the project
Approved plans are required on the Job site at the time of each Inspection.
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:..ELectrical Permit APPlicatiol O \ jF 1 , roR OFFI( :L USE OIrL>,'
4 r• Received City of Tigard . Datp/B : -e I /� - penr,it No � /_ -
i• • : 13 L25 SW Hall Blvd., Tigard, ()R 97223 SUN 0 5 2012 Plan R _ . •
.•Phone• 503.6394171 Fax: 503.598.1960 p�.: - (Anse I'crmit: •
T I i . A It I) % •'lnspectinn Line: 503.639,417$ • Date Re dy/)3y: s • El Sec Page 2 for • •.. • •
Internet: www.tigurd-or.gov CITY'OF TIGT1r ii . I+ fotified/method: 1 Supptemmtal tttoemadon '
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❑ New c.oriStruction IV Addition/al teration/replacement Plesffie dieek all that apply (submit ? sere of plum wlitenrs checked below):
0 Service or feeder 400 amps or more Cl nuiiding over 01 smriea. '•
Q Demolition ID Other: where the available fault current ❑ Marinas and boatyvds .. .
.a;ra d.,at r a "'r' : 5 027 7 .rr „ • . . e cr "T+ r ; n,47D'ri'rt o 7I5,..i • } 2,` i..', - . .
hR. i 11pF µ ••, ;Y Y a 6 r m 6.'"7 n r o, ,- e ' = I I' n M U . ,,, : l : r '1 exceeds 10.000 amp; at 150 roll:: (Ii ❑Floating buildin
! fiiL. ,Ltaz:e.':1:1.1.` . '., •Al ∎ •,. ±!"' v" _. ,. , ±1: EA1�1 k i'..1 'l �i:�"G '. u: ! '
' � ' �« l ess to ground. or exceu 14 ❑ Commercial-use IlgI1C0I :
• •• t7k 1- laid 2=f roily dwelling 0 Commerciul/industriat ❑ Accessory building. amps for all other installations. buildings.
C]Multi= family ❑ Master builder 0 Other: • ❑ Fire pump. ❑ installation of 7s KVA ar .. .
o
r ri r �. +r , , v;yvq� :i .,,� r +d' i rr, J ❑ Emergency system. larger separately do ivod system
,;6i)i'���i! r7 r, ' � fi ,w . : ,, (r. '.4 � . 'X'F� - e • . h`i'F,'
.M1 ; i1 } I,.n4 ; 4 ki n S >)t :11 01'i 'LI ".i t z- •t I Ili r`�✓i .red
45; -� _ - . - ., °. "•/? 1 ' �. ( ^ r .n 2• rpi.Ib � �r'::4 ' moor Itsxt of [] "5", "1-2", «t_a«
IsUr. :J.{iifrl�1li:,is. , , _ - CU:.:._:,.:' '� .ji; {R_dlx:r:� J t,�e a,, ❑ Addition Of new m
; •Job no:: Job site address: ] J 4 ' l JA` fi 10011P or morn. nccupa 1 Cy'
!� J t0 1 ,� W (alt. '/�l tr � ❑Six or more residential units. ❑ Recreational vie parks...
; `. City/SttitC,/ZI13: t I C l L.2-_ .. t. .: El Healtb-wre raciIiie. ❑ tiukn,ly w et y( e fur more than
1 ` , ❑ Hazardous locations. 600 volt. nominal; • •.
• 0.: Project name: or fodder 600 am
Sui /bld n I 0 s of more. p
I
CroSS street/d to job site: r........,.
....... .... ,
+� � ; �? { nil. ; . 1' �J :�
nCQiWtCa Qty. Fee. .'tOtat
. New residential single- or multi - family dwelling unit
•
r Indudes attached garage ...
Subdivision:,' f bat no -: • 1,000 sq, ft. or Icss 168.54 4 .
"Tax•mgp/parcel no.. J Ea. add'1500 sq. ft. or portion 33.92 • .1
(with above sa. R.)
��a, F�rtrt77rr ,1rt rr;wr T ,- Limit energy, residential 67.84 2
k i } I'�M;`' a f A 7 P ' 1 �"1:�''ifil A 'i.I� ,
µ �" a , a h i V e t, � ,. •
k.+1 b / Limited energy, multi - family 67.84 2
I't , residential (with share sq. a.) �.._ _
S ervices or feeders installation, al and%or relocation
d i kv7: :;?y`f :f; - ' i. ¢?{ "'�'»r :a, r, r "� - ir, • - 200 amps or less 100.7!) 2
;i9�
: -1 "; ti,. o F,�,l�e. �� vd 1 y vs :,,;: ; . r o, - 133.56 2 •z n 'j 7' r. ya 3` w.
: s, li'i +�.. :51ie.,A *, -e�. +` • a :r : • �. �.,'� . k �,,�[6:P:+" - A>Rd° ;:.. ''" 201 amps t 40 0 amps
,N 401 am to 600 amps _200.34 2
ar rbe: ... . .. _ ..
. : 601 amps to 1,000 amps 301.04 • 2 '
Address: Over 1,000 amps or volts 552.26 ••2
City /State/ZIP: . Temporary services or feeders Installation, alteration; and/or • : . .
relocation •
1;4one :.( ) I Fax: ( ) • 200 amps or less 59.36 1
O wne r installation: This installation is being mode on property that Town which is.not 201 amps to 400 amps 125,08 2 .
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. signtlitti'c: - Date: . • • .
g: . . r : ''I :i i ., ,' °' <' q iw cnn�J(r i x: ;r :,.: ; ;; Y'c r;ti r A. FCC for branch circuits with
et. 'f;'(ri; : <.' )4eie o ,( 's i I J ys3 '` , fi f,° 7 lC - "- .I. •�.. �,, ,rr i ��,�: • above service or feeder fee,
7 42 . 7 . :
.
each branch circuit
Business name: ' • B. Fee for branch circuits
6x 9
COritlidnaTO: �� first beseech circuit without service or feeder fee, 56.1$ 2' •
Address :. • Each add'I branch circuit 7.42 3Tip 2
„' ^-- Miscellaneous (service or feeder not included) .
:City /State/ZZ1P:
• Each manufactured or modular 67.84 2
• o ne: dwelling, service and/or feeder
Ph (: ) . • _ _. _ ^ � Fax ' ( )
Itmonnect only 67.84 ••4
E-mail'; Pump or irrigation circle 67.84 2
r, ,I x.
1� � 4 Cr,Y,?;P�'" `�'(• ,w,,;t',1x. :.y :i :..;3a ' Th�'� a'�a��„� Sign or outline lighting - ,..,._, 67.84 2
Signal cireuit(s) or limited
` l3tisiness • i
energy panel, alteration, or
Address: extension. Describe: Page 2 2
City /State/ZlP: Each addition-al liisrection over allowable in any of the above
Phone: . - --- r - Per inspection 6
( ) t4ty �� ( ) min', per hour (I hr i:', 66.25
' CB Lie.: 0407 ( J,iattric il I .ic,•r6.-1 I XG S rv. l.ic.: 1 S Industrial plant per hour I 7K. I8
. :s . 'Rl(. :A 1. PEFL FEES lig.41Nttligg.li
Suprv. Electrician signature, required: _ Subtotal. q 3
Print name: Date: flan tcvicw (25% 01 ;■omit tee):
State surcharge (I 21'. t+I permit fee): I , 7_
Authorized signature:: lOT,\l PIiltn41TFEE' I a 0151 ,g+.
-
This permit applicatius expire if a permit is not obtained within 180
Print name: - _� _ Dale: days idler it has II, 'n ;teccptel as cumplcte.
' Number ol'ur.peemo :I)l a.... .,,
1 :113uiIdil,glFamit l.C•I' : :r: ddAl:l , d„c Inn iuor 44r1..tai ST( II tuS /COM(WEll
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TIGARD
City of Tigard
August 22, 2012
Canby Electric
Attn: Douglas Onion
790 S Ivy St.
Canby, OR 97013
Re: Permit No. ELC2012 -00355
Dear Mr. Onion:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11624 SW 128 Ave.
Project Name: Locsin
Job No.: N/A
Refund Method: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $83.57.
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): Per applicant's request refund 80% of permit fees as job was canceled.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Building \Refund\ ,i bi ile tstrelan•elifirgib l�'
, o,bn 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
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: Canby Electric DATE: 07/26/2012
Mtn: Douglas Onion
790 S. Ivy St. REQUESTED BY: Dianna Howse
Canby, OR 97013
TRANSACTION INFORMATION:
Receipt #: 187081 Case #: ELC2012 -00355
Date: 06/07/2012 Address /Parcel: 11624 SW 128th Ave.
Pay Method: CreditCard Project Name: Locsin
EXPLANATION: Refund 80% per applicant's request as job was canceled.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Permit Fee 220- 0000 -43103 $74.62 /e5
(e
12% State Surcharge 100 - 0000 -24001 8.95 p.. , c 2�
TOTAL REFUND: $83.57
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager 1 1444
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: f 9 /2— B : oa
I: \Building\ Refunds \RefundRcyuest.doc x 09/01 /2010
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• .• . • City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ..
•. . a RECEIVED
Request Permit•Action , . •
• '. ' -,•,,,A-p,'D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503,718.2439 w■vw.tig1.1141/473_v 4 7'21?
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, . .• . CM' OF TIGARD
TO: CITY OF TIGARD BUILDING DIVISION
Building Division Services Supervisor
13125 SW Ball Blvd Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-cr.gov
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FROM: • ,
n owner 0 Applicant 34 Contractor J ( 11y Staff
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(cbcck one)
' • REFUND OR Name:
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• . • , INVOICE TO: (Bi.,4-,,,,, or Individual) CO-14 E).e.c.:,,,, , (_,.. • . • •
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• , . Mailing Address: • 79D S- .r. 1/ -.)--' -
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.. . . City/State/Zip: 19
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• Phone No.: (5 b3 7,b E :20.1'S_ .
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1.): . .
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CANCEL/VOID PERMIT APPLICATION. . . • .
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. ' REFUND PERMIT l'IJES (attach copy of original receipt and provide explansti( in below).
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. . Li INVOICE FOR FEES DUE (attach case. fee schedule and provide explanation below).
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ID REMOVE,/REPCI LA CONTRACTOR ON PERMIT (do not cancel permit).
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Permit . 11: 0-1(... 7_,() • — 00 C---5 .•
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Site Addtess or Parcel #: I ) .,2 q ,s:ti )7_,A, Avt _
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Project Name: Ley c_s,,,..
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Subdivision Name: V114 : L Lot j/ :
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' - EXPLAN.AT1ON: (0 ( 3L -4, t5t C ) Ci1,14711-P--/h, 7 ,' .T .
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ir, '4- 1A-41 eh-- b, tA-L ..: ______ _ ..._ . _ . •
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Date:
Signature: ( 4 -. .100 ___L_ —
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Print Name: ..
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gs:clif.iil ;Viz
1. 'ow D,,,,,,,,,,„ it wa atith,,tim Chi: refund of
a) any lei:- xhich ma., errinicol.lily laud or (nIleeted,
I)) not till)1 l (11 MT ■ .: 111c land IN: illplicalion fec when an applitzLtion is wilhdrawn or canceled before in■• rt% ic..v. ' ' , - ' I. I a t'li 4..A
1 ) ,,,,, mon d,,,, my ., ,,i th land n applicannn ice for issukli perinitt:.
( 1) .1 ,,,,,,,: i h, o , ; .,; ii,, h plan ic vi k m fee WIILII an application ii: canceled lwcofc any pian revie , I I I 'l I ''' ' ' " . ' i it
i /Lill ,0 .. ■ , 1 i , t.' I niltlog p( rMit fee for nirued peraitE prior to any int;pcction rcyuLstt;
2. li \,:t1 In' triuna.d lc, I I, ,,,i Payer in the snme incthotl in Which payment was P.:ccivttd. Pleas( , 1110% 1 , I ii. , ■•., • -: . :, ,, k.... ,C.ild:
..FOR OFFICE' USE ONLY ,
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, R I l' Sy S Al.1111111: ' );I I (' , At /0...... ,. ilv IMP Rte. to Tild tnin: Dnte
__ Procc..ssta.1 ; ! /on _,./..7,71,,p— _ liy irly Invoicet Processed: _Dtitt.: ‘ .. !iv
Pt-Twit Canceled. ., I ';oi• „eV:71, 7--1 . 0:Ai , _, Intattd . 1)ac:_. be ...... .
b ,. 1/4 ,. , ill i i j ! ! ).1!.. _ \ _ _ c_e___ Aouti:
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Id WdS17:170 ?TO VT 'unf 217SS99Z2OS : "ON 3N0Hd 3NI 3Ial3313 AEINUD : WONd