Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
2 COMMUNITY DEVELOPMENT Permit It: ELR2012 -00131
Ti G AR. D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/26/2012
Parcel: 25101 DA00104
Jurisdiction: TIGARD
Site address: 13333 SW 68TH PKWY, STE# 010
Project: National American University Subdivision: VARNS ACRES Lot: 9
Project Description: Low voltage for HVAC
Contractor: HVAC INC Owner: TRIANGLE POINTE LLC
5188 SE INTERNATIONAL WAY 901 NE GLISAN ST, #100
MILWAUKIE, OR 97222 PORTLAND, OR 97232
PHONE: 503 - 462 -4822 PHONE: 503 - 297 -8791
FAX: 503 -462 -6555
FEES
Description Date Amount
Specifics: Restricted Energy Permit 06/26/2012 $75.00
12% State Surcharge - Electrical 06/26/2012 $9.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
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 $84.00
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, o if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Not Ce t= Th rules are set forth in OAR
952- 001- 0010 th - •AR 9
Permlttee Signature: x 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.19 • 1.;i .2344.
Issued By: . / I! /
y: _ J La : '
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.
Electrical Permit App 7"i I:OIZ OPFICE liSE ONLY
City of Tigard ' `•` Received 4 /. ("'" Permit No.: f V /,3/
13125 SW Hall Blvd., Tigard ] 9 plan Review
°: a Phone: 503.639.4171 Fax: 503.59 19'6 Date/B : Other Permit: W4 -00,3,.
TI G A R D Inspection Line: 503.639 p Date Ready/By: hais: ® See Page 2 for
Internet: www.tigard -or. • TI I t / (,3°- nGkpri Notified/Method: Supplemental Information
T l 0 Jitv PLAN REVIEW
❑ New construction , Addition/alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
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.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately "1 system.
o
❑ Addition of new motor load of ❑ "A ", "EE" ", " "11 -2 "", . "1 -3 ",
Job no.: Jo site address: 61)113 S' VA t� 1 iW Six o or more. Bey
more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: i'( ❑ Si or •' _ J ( � • ❑ Health-care facilities. ❑ Supply voltage for more than
�! _ _ _ _ rr , tea L " \ t ■ r 600 volts nominal.
0 Hazardous locations.
Suite/bldg. /apt. no.: 0(0 Project nam - . • 1 r / / t 1 ❑ Service or feeder 600 amps or more.
l "'.. FEE SCHEDULE
Cross street/directions to job site: . / ( ` /,• p - » Description I Qtr. I Fee. I Total I •
z�r� New residential single- or multi- family dwelling unit.
! t Includes attached garage.
Subdivision: G(/Jt 1/ii26/17 I Lot no.: 1,000 sq. ft. or less 145.15 4
Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
i ` , 1 \ J v Limited energy, multi - family 75.00 2
Vv w 1 residential (with above sq. ft.) _
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City /State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) I Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Branch circuits- new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 6.65 2
I 'n each branch circuit
Business name: V A V V V B. Fee for branch circuits
134
without service or feeder fee, 46.85 2
Contact name: ` first branch circuit
Address: l S ` Each add'l branch circuit 6.65 2
` Miscellaneous (service o feeder not included)
City/State /ZIP: i\\JVW l' - l e a' ( Each manufactured or modular
�
dwelling, service and/or feeder
90.90 2
Phone: Gb3 ) '4e' 4 J Fax: : (563) 46')...-- t STS
Reconnect only 66.85 2
E -mail: .1 b CA \tOrG 'AV pkk-t AL '2 r U1in Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Signal circuit(s) or limited-
Business name: Aj C�J /�J energy panel, alteration, or
Address: extension. Describe: I Page 2 2
City/State /ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lic.: So 'q( I Electrical Lic.: - 7 I (, f 1 Suprv. Lic.: 1,160 Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
�{ �/�,
Suprv. Electrician signature, required: Subtotal:
Mt�/ "' / 'U Plan review (25% of permit fee):
Print name: I r t 1 C 1 S l / i je Date: - I )� I State surcharge (12% of permit fee):
Authorized signature: 111.E . � TOTAL PERMIT FEE:
Print name: . � j1 r I t _ Thy permit application expires if a permit is not obtained within ISO
Date: ICJ days ys after r it t has been been accepted as complete.
• Number of inspections allowed per permit.
1: �BuildinglPermits�LC- PermitApp. X 3/06 440.4615T(I I /OS /COMIWEB