Permit u CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
IIIIII 11 : COMMUNITY DEVELOPMENT Permit#: ELR2012 -00198
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/22/2012
Parcel: 2S 103AA00101
Jurisdiction: Tigard
Site address: 10865 SW WALNUT ST
Project: Fowler Middle School Subdivision:)0 SUPPLEMENTAL PLAT NO.1: ANNE Lot: 7 -6
Project Description: Low voltage for HVAC wiring
Contractor: AZIMUTH COMMUNICATIONS INC Owner: TIGARD - TUALATIN SCHOOL DISTRICT
PO BOX 508 ATTN: BONITA MAPLETHORPE
WILSONVILLE, OR 97070 6960 SW SANDBURG ST
TIGARD, OR 97223
PHONE: 503- 639 -0110 PHONE: 503 - 431 -4000
FAX: 503 - 639 -0115
FEES
Description Date Amount
Specifics: Restricted Energy Permit 08/22/2012 $75.00
12% State Surcharge - Electrical 08/22/2012 $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 'ssr.el 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 accordance wi - - .proved • ans. 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 la re• 'fires you to follow the rules adopted by the Oregon Utility Notification ter. Those rules are set forth in OAR
952- 01 -0010 through OAR 952 -00 .090. o '`- obtain a copy of the rules or direct questions to OUNC by calling 503.23 .1 87 Ur 1.800.332..23344.
Issued By: — / Permittee Signature: / 1
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 A li IVED FOR OFFICE USE ONLY
Received �p
City of Tigard Ott Date/By: i � / . i Permit No.: E,_, ' f ‘ 2,- 0 0 � / g
• 13125 SW Hall Blvd., Tigard, OR V7h3 2 2 i 1 ' / Plan Review
II Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit:
TI G A R D Inspection Line: 503.639.4175 CITY OFTIGARD Date Ready/By: luris: 63 See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: Supplemental Information
TYPE OF WORK 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 derived system.
/ ❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "I -3 ",
Job no.: Job site address: f ) g(S S W toa i h dl s ? Six or or more a residential units. ❑ Recreational 0 or al vehicle parks.
City/State /ZIP: ^ G ^,,� `� O r n 2 2 ❑ Health-care facilities. ❑ Supply voltage for more than
I J "+ e� ' ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: ( er yvi 5 ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Q19. 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
Ea. add] 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Pi lJ4 Limited energy, multi - family 75.00 2
�- O 't' t ( Cc( f e s 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: ( ) 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
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee,
first branch circuit 46.85 2
Address: Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
t T Signal circuit(s) or limited -
Business name:
z! , M.,,4 �25 rYt „, d r , t ca �lcif $ C in C. energy panel, alteration, or
Address: extension. Describe: Page 2 2
95 yo S w 1,Ja(OA t\it � �, ,
City/State /ZIP: To Q L - I - i n Q r 9 3 0 4- z, Each additional inspection over allowable in any of the above
/ / Per inspection 62.50
Phone: ( S03 ) C p -6170 Fax: b� '
3 ) , Q-U /
jr Investigation per hour (I hr min) 62.50
CCB Lic.: )t)5/ ' Electrical Lic.: 36- 9 Ye[ 6 Suprv. Lic.: 23 )2(4_7A Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
,--
Print name: J re i-4- U1 S er Date: 8- z 2- ZcY 2 Plan review (25% of permit fee):
_ State surcharge (12% of permit fee):
Authorized signature: ` TOTAL PERMIT FEE:
Print name: gee J L per Date: 2 This permit application expires if a permit is not obtained within 180
1- 01 5 y ? J / 2 days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440-4615T( I I /05/COM/WEB
Electrical Permit Application - City of Tigard •
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
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*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑. Other:
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
. HVAC
❑; Instrumentation
❑ Intercom and Paging Systems
❑: Landscape Irrigation Control*
❑: Medical.
❑ Nurse Calls ,
❑ Outdoor. Landscape Lighting*
❑; Protective Signaling.
❑. Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1:\Building\Permits\ELC- PermitApp.doc 03/23/06