Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
111 11- COM MUNITY DEVELOPMENT Permit #: ELR2009-00152
Dat Issued: 06/04/2009
T1GAR.D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 2S102BD02201
Jurisdiction: Tigard
Site address: 9984 SW WALNUT ST 11
Subdivision: Lot: 0
Project: Chalet Village
Project Description: Install fiber optics for Verizon.
FEES
Owner: Description Date Amount
CHALET VILLAGE LLC
TWO CENTERPOINTE DR STE 210 Restricted Energy Permit 06/04/2009 $75.00
LAKE OSWEGO, OR 97035 12% State Surcharge - Restricted Energy 06/04/2009 $9.00
PHONE.
Contractor:
NORTH SKY COMMUNICATIONS INC
11818 SE MILL PLAIN BLVD, SUITE 410
VANCOUVER, WA 98687
PHONE: 360- 254 -6920
FAX: 1- 866 - 905 -4907
Type of Use: MF
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: N Boiler Controls: N
CCTV. N Clock Systems: N
Data & Telecommunications. Y Fire Alarm: N
HVAC: N Instrumentation: N Total $84.00
Intercom /Paging: N Landscape /Irrigation. N Required Items and Reports (Conditions)
Landscape Lighting: N Medical' N
Nurse Calls: N Protective Signal: N
Security Alarm" N Other: N
Other Desc:
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 OA 52 -0 1 -0100. ou may obtain a copy of the rules or direct questions to OUNC by calling 503 246 6699 or 1 800 332 2344 , /
issued By: Permittee Signature: 4A1 �� eew" . "
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 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.
•
RECEIVED
Electrical Permit Application JUN 01 "2009 _ .. _ .. :; FOK:OFFICEI1SEONLY ..•, : < : :. .
..... City of Tigard . ..._ ; . .
sgY OF TIG ARD Lid 4 �, �nn.r r�,,.: - L , 0. 9 -r S:2_, c , X31 unc• ., SW Hall Blvd Tigard. 50 OR 1 plan Review
' 1 h1 G :tx: Oder Penal:.
inspection Line: 500.639 4175 �B ING DIVIS l Dala Ready/Br
:
fI GARU I 044 e
rme
I O Sppicentn L ror [mum: www.Ugmd -ut;ov Nullficdfhlcrhtxk Sulcmcnlnl lnfm•antlen
. .' TYPE Or WORK .• :+ • • .0 ., . . , . ••• PLAN RIiVIDW
❑ Newconstntcuon O Addi;ion /alterht ion /repincemcnt Pleaee check alll hal apply (submit 1 eels el rxane Wilmer clinked Selow)•
❑ Demolition ❑ UUleft ❑ Serviec or feeder dos any, or more ❑ anllrlitw oar II sde■lec
where dte wadable faull cumin 0 Mim we and buaty.uuls.
• +• . • , , C . CATEGORY or •CONS9'RUC'1'ION , • • , . exceeds 10,0410,unp1 di ISondts (] Pluming bulldinps.
❑ 1- and 2- 1'aldil dwelling leK maIvund. orcxcrcdr 14.500 CI Cunm erc l i:,u le eaten/
y g ❑ Com :ncrcinl /industrinl ❑ Accessory building amp for nil otlei installations. bwldingt.
O Multi- family [] Muster builder ❑ Wm: 0)ihn pony. ❑ Inanllnriun of 7S KVA or
- • • •• JOB SITE INFORMATION AND LOCATION Ofiu ergmuty systmn
larger >cpa,mely halved vocal].
• —'--) Q Addlbnn of new tmmor load of Q `A• , 'If ..•1.7^ "1.J'
Job no,: 1 Job site addtross: 9984 SW WALNUT lu°xr yr nmro. ueeup.mcy.
❑ 5k or more resktemiul ndrlt, Q Rceieaiiuuxl vcl+iele owes.
City/State/ZIP: TIGARD, OR 97223 O Hcnbh•carc faclptics. O surtply maonn
❑ Huadum ltealiunt. 61x0 Suite dcrrmtul.
Suite /bldg. /apt. 110.s:o7).t,an Pro name: CHA VILLAGE �_ ❑ scrvi.e nr feeder MOunto.ormime
• Cross street /directions to job site: PEE • SCIICDULI( ' '
M _ unerryntm, 1 ow. 1 Ile, I Tool 1 •
New residential single. or multl•famlly dwelling null.
Includes nllac garage,
Subdivision: 7 Lot no.: 1.000 sq. I). or leen 145.15 4
Tax nutp /parcel no.: hat. adrl'1500 set. Ii. or potion 33.40 I
(mired cnagY, tctiiie lint 75.00
DESCRIPTION OP WORK ' (with above n1. )
INSTALL FIBER OPTICS FOR VERIZON LII , ttld111- railllly 75,00 2 •
raislcatial (winl %.; eq. m.)
Scrvlcea or (coders InalnlIntlon Worn don, nud/nr telt:utl e
200 amps or less 80.30 2
.'❑ PROPERTY•'OWNER ' I , • • . 0' TENANT ' 201 mum to400limps 106.85 2
Name: 401 wisps to600 amps 160.60 2
Address:
— " 601 amps to 1,000 amps 240.60 2
Over 1,000 amps or volts 454.65 r 2
City /Slide/ZIP: Ywnrporery secvlcea or feeder* installation, alteration, and/or
relocation
Phone: ( ) I Fox: ( ) 200 amps or Iert 66 85 I
Owner InstullnQon: This insiallntion is being made on properythat. I own which is not 201 Drops 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: Brunch circuits - new, ulceration, or ex(enslmt, per panel
A. Fcc for broach ciwilit> with
: • • ❑ APPLICANT .. • • : "I • ' 0 CONTACT PERSON • above service or feeder fco,
665 2 •
Business name: each branch circuit
NORTH SKY COMMUNICATIONS, INC. B. Fee for brooch eircuils
Contnctname' ERIK SCHENCK without hervicc (ceder fee, 46.85 first branch circuit
Address: 11818 SE MILL PLAIN BLVD STE. 410 Each midi brunch cilcuit I - 6,65 - ----- 3
Miscellaneous (service or feeder not included)
City /Slate/ZIP; VANCOUVER, WA 98684 Each Inunufacturcd or modular
dw;lline, tcrviec nod /or feeder x'90 2
Phone: (503 ) 969 -7729 I Fax: : ( 866 ) 452 4853 Reconnect only 66.85 2
G•nlaiL mduor annorthskycomm.com Pump et litigation clinic 53.40 2
CONTRACTOR Sign or maim lighting 53.40 2
Businessmen e
: NORTH SKY COMMUNICATIONS, INC, nerrgy panelypan]t(`)orlimited.
ene, atiswiiun, or
Address: 11818 SE MILL PLAIN BLVD. STE 410 exleatien. Deceribe• 1 peso $75.00 2
City /Stalc/ZIP: VANCOUVER, WA 98684 End additional Mem:tion over ellownblo In an of the above •
Phone: ( 360> 254 -6920 I Fes: ( ) 1- 866 - 530 -4325 Per ins Iuvcsligndntln 62.50
lnrJwur(Il:rmitu 62.SI)
CCB Lic.: Electric Lic.. Stt nv. Lic.: dushia) plant per hour 73.75
14117 17 154CL� 173LEB In
• 'ELECTRICAL PERMIT REIN
Suprv. Electrician signnnnc, requited: Subwtnl: •
$75.00
Print m une: JACK CAGLE I Date: 6/1/09 PlDn re vinw (259h of permit fee):
State surcharge (12% of permit fco): $9.00
Authorized signature: X 0 /�O
' f q _ I TOTAL PERMIT prat: $84.00
Dale: 6/110 ' rhtsporml acdWth)oISO
Prim none: ETHAN A. DOLPH
days after It Lot been nccepkd on tmnpte .
> Number of lusriccdun, atluwed per pconll•
Ineumnngu 1 :,sr,p,ior 003310* 101 161415: UlvCoalnvr :u