Permit rr, +r- .
CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
. IN COMMUNITY DEVELOPMENT Permit #: ELR2009 -00141
T I GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 05/27/2009
Parcel: 2S112DD01600
Jurisdiction: Tigard
Site address: 15495 SW SEQUOIA PKWY 150
Subdivision: Lot: 0
Project: Acceleration Chiropractor /Dr. Adam Mohr DC
Project Description: TI - Low voltage for voice /data and protective signaling.
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY Restricted Energy Permit 05/27/2009 $150.00
#300 12% State Surcharge - Restricted Energy 05/27/2009 $18.00
PHONE:
Contractor:
CONNECTIONS NW INC A WASHINGTON CO
2501 NE 170TH CT
VANCOUVER, WA 98684
PHONE: 360 - 772 -0494
FAX: 360 - 326 -1586
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 Total $168.00
Intercom/Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N Required Items and Reports (Conditions)
Nurse Calls: N Protective Signal: Y
Security Alarm: N Other: N
Other Desc:
This permit i • subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work
will be one in accordan tqlth approv • plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more
the 80 days. ATTENTION: Ore on =w requir == you to follow the rules adopted by the Oregon Utility Notification Center. Those "rules are set forth in OAR
952 01 -0010 thro gh OAR 952-00,1100. • u • obtain a copy of the rules or direct questions to OUNC by calling 503.2.= 699 or 1.800.332.2 •
Iss d By: , \ - /d ' � `� 4 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'N Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
r• , tic
Electrical Permit Application FOR OFFICE l)SE ONLY
711 City of Tigard Received
a a ed 5 . n 7 Permit No.: ,� _ /
d
• 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review eq
Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit: s
T I G A K D Inspection Line: 503.639 Date ReadyB ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: , Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction ® Addition/alteration/replacement Please check all that apply (submit a 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
❑ I- 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 derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
f ool m or more.
Job no.: Job site address: 15495 SW Sequoia PKWY #150
El Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard, Oregon 97224 ❑ Health facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: 150 Project name: DR Adam Mohr D.C. ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Deseription I Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Tax map /parcel no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
Limited energy cabling for Telecom - Voice and Data residential (with above sq. ft.)
Limited energy cabling for Intrusion - Burg wiring Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: Pac Trust 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: ( ) 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
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
A. Fee for branch circuits with
® APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit
Business name: Connections NW B. Fee for branch circuits
Contact name: Gary Billett without service or feeder fee 46.85 2
first branch circuit
Address: 604 NW 133 Circle Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Vancouver, WA 98685 Each manufactured or modular 90.90 2
360 518 - 2868 Fax: (360) 574-0049 Reconnect t on service and/or feeder
Phone:
( ) ( ) 9 Reconnect only 66.85 2 -
E -mail: gbillett ®connectionsnw.com Pump or irrigation circle 53.40 2
CONTRACTOR _Sign or outline lighting 53.40 2
Signal panel, or limited -
Business name: Connections NW
energy panel, alteration, or
Address: 604 NW 133n Circle extension. Describe: A Page 2 2
City /State/ZIP: Vancouver, Wa 98685 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (360) 518 -2868 ( di 1 Fax: (360) 574 -0049 Investigation per hour (1 hr min) 62.50
CCB Lic.: 179928 f 1 1Electrical Lic.: CLE 143 Suprv Lic 8591J Industrial plant per hour 73.75 _
., I i I ELECTRICAL PERMIT FEES
Q
Suprv. Electrician signature, required: i4( Subtotal:
Print name: Tom Jensen V Date: 5 .— ( —p 9 Plan review (25% of permit fee):
/ 4 State surcharge (12% of permit fee):
Authorized signature: g / 4 / 1.1 TOTAL PERMIT FEE: K�� 40
Print name: Gary Billett f /1 4 Date: ✓ f �j - _ 77 This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
• Number of inspections allowed per permit.
1: \Buiiding'Permits6ELC- PermitApp.doc 05/23/06 440- 4615T(11/05 /COM/WEB
Electrical Permit Application - City of Tigard
•
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
f RESIDENTIAL WORK ONLY:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ H eating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ O ther:
COMMERCIAL WORK ONLY:
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
❑ H VAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ M edical
❑ N urse Calls
❑ Outdoor Landscape Lighting*
® Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\ BuildingWermits \ELC- PermitApp.doc 03/23/06