Permit q CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
e • COMMUNITY DEVELOPMENT Permit#: ELR2012 -00153
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/23/2012
Parcel: 1 S136DB00201
Jurisdiction: Tigard
Site address: 11565 SW PACIFIC HWY
Project: Chase Bank Subdivision: 2000 -025 PARTITION PLAT Lot: 2
Project Description: Low voltage for security system.
Contractor: TYCO INTEGRATED SECURITY LLC Owner: FRED MEYER INC
2815 SW 153RD DR STORE #375
BEAVERTON, OR 97006 1014 VINE ST
PROPERTY TAX 7TH FLOOR
CINCINNATI, OH 45202
PHONE: 503 -469 -7206 PHONE:
FAX: 503 -469 -7114
FEES
Description Date Amount
Specifics: Restricted Energy Permit 07/23/2012 $75.00
12% State Surcharge - Electrical 07/23/2012 $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: N Instrumentation: N
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N
Nurse Calls: N Protective Signal: N
Security Alarm: N Other: Y 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 = . • • - •._ ' h 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. : ' ENTION: Oregon 'w re• ' -s you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-0 1 -0010 through OAR 952 -1 r0 ay obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.33 2344.
A �� /
I sued By: Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on properly 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 503.839.4175 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 Application FOR OFFICE USE ONLY
City of Tigard ;_ MOM PestNo.: ft I2 2e f /S3
• 13125 SW Hall Blvd., Tigard, OR 97223 Plan y� �/
` • Phone: 503.639.4171 Fax: 503.598.1960 DaldBy: Other Permit: ta�/ag..QQD/9ff
T I a :, t: - Inspection line: 503.639.4175 Dace Ready/By: lms RI See Page 2 fur
Interact: www.ligard.or.gov Notified/Method: Supplementallnformatlon
• - 7' - = - _ _ _ jitieti VYtitdC:' _ '- __ . "7 -':_ . PLAN REVIEW - - . •
❑ New construction ❑ Addition /alteration/replacement Plum clock all that apply (suhmit a scts of plans cr:iteml s checked below):
� ❑ Service or feeder 400 amps or more ❑ Building over rupee stories.
❑ Demolition ❑
wham de:mailable taedicmart ❑ Mammas and boatyards.
- • - CATEGORY . OF CONS1RUC17Ol Q: - . - - osowds 10.900 amps at 150 volts or ❑ Floating buildings.
MB to ground or exceeds 14.000 ❑ Ctunm actal -here agricultural
❑ 1- and 2- family dwelling pCommervial industrial ❑ Accessory building amps for an otherinstaltemom. buildings.
❑ Multi- family ❑ Master builder ❑ Other. ❑ Fire pump. ❑ Irsraladon of 75 KVA or
JOB SITE INFORMATION- AND LOCATION O F m ' "A", E"."1 2 ","1 -3 ". system
- :' -� � � - � - ❑ Addition of new motor loo! of ❑ °A ". "E". °I -2 ". °I -3 ^.
CS 100 more. occupancy.
Job no. �s /0 ../ I lob site address: / /SOS 6W Ate, � t/ ��
❑ Six or more residential units. O Recreational vehicle parka.
City /State/ZIP: 774^ 4 de d' Qua a73 0 Health-care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: I Project name: e///¢,SE 7/9N /( 0 Service or feeder 600 amps or more.
tions to job site S FEE:SCHE r . i
Cross street/directions
om /D e /- 29 F!) /i / E ye A , me sa scion 1 Qty. I Fee. I Total I •
New residential single- or multi- family dwelling unit.
- Indades attached garage.
Subdivision: I Lot no.: 1,000 sq. h. orless r 168.54 4
Tax map/parcel no .: Ea. add'l 500 sq. R. or portion 33.92 1
P Limited energy, residential
__ 7x00 2
= DESCR�I ION. OF WORK (with above sq It)
Limited energy' tmultr -randy 75.00 2
e5 - ,/ vet y 5/S Tc/1/ residential (with above sq. f.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
- -❑ . PROPERTY OWNERr:.: :: _ .: . . ❑ TENANT . • .. , 201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
601 amps to 1.000 amps 301.04 2
Address: Over 1,000 amps or volts 55226 2
City/State/ZIP:
Temporary or feeders installation, alteration, and/or
Phone: ( ) I Fax: ( ) 200 amps or less 1 5936 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that 1 own which is not
intended for sale, (ease, rent, or exchange, , according to ORS 447, 449, 670, and 701. 401 amps to 549 amps 16854 2
Branch deceits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for (ranch circuits wish
above seance or
1: . .APPLICANT - I ` . ; - ': " --- : CONTACT. PERSON -: _ - ;_ - each branch circuit 7.42 2
Business name: B. Fee for branch circuits without
service or feeder few first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZI P:
Earl manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) I Fax: : ( ) Recent only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
...• . • . - . ' :. . CONTRACTOR : ... • •:.r ..: ,' . . ... • Signal circuit(s) or limited-energy •
Z
? T 5 6 / T edd,grvr t7 .. Pal, aeraion, or extension_ I Page 2 I 2
Business name ve /�t fCt tR t f
' � Each additional inspection over allowable in any of the above •
Address: 6 " $ (, f) /6-3 --bg £.Le... Additional inspection (I hr min) — 1 6625/ hr
City/State/ZIP: "66W iI�n TOA) Ox- T 70o 6
Investigation (1 hr min) 6625/ hr
Industrial plant (I hr min) 78.18 / hr
Phone: (5,3) V4, 9- 7„2 0 0 I Fax: ()3) y69 71/4' Inspections for which no fee is 90.00/ hr
j Surv . Lic.: 377 liste d CA hr min) CCB Lic.: / 7/ D I EI 1 Lic.:c 2Z 0 C m ELECTRICAL: •ir fob/ Subtotal:
pr
Suv. electrician signature, required: • .,-
Pharr review (25% of permit fee):
Print name: b/ /,d r-//4 Date: y3//2 State surcharge (12% ofperntit fee): q. 00
Authorized signature: TOTAL PERMIT FEE O!. 06
Thu permit application expires if a permit Is not obtained within 180
Print name: I Date: • days after it bat been accepted as complete.
Number of inspections allowed per permit
I:■Buildiolpermits1ELC- PamitApp.doc 07/01/10 440.46151(111O5IQOMIW®
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for a ll residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
p Heating, Ventilation and Air Conditioning System*
C J Vacuum Systems*
❑ Other:
CCIM IERCL L WOR ` O3N i .. _ :: _
Fee for each commercial $75.00
system
(SEE OAR 918- 309 - 0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
Instrumentation
0 Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
U Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
Other _ / 1/2/ re .h &W f5 y sec oe ry $ys%£/17
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1: Build'mgwamhAELC- prnnimpp.doc 07/01 /10