Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit #: ELR2012 -00238
13125 SW Hall B lvd., Tigard OR 97223 503.718.2439 Date Issued: 10/16/2012
T [ GARL� Parcel: 1 S136DB02600
Jurisdiction: Tigard
Site address: 11201 SW 72ND AVE
Project: McDonalds Subdivision: AZOIC TERRACE Lot: 1
Project Description: (1) low voltage for wireless headset installation
Contractor: 1ST Owner: STEWART /BARI PROPERTIES LLC
8340 MILLSION RD., STE. B4 STEWART TRUST
PRAIRIE VILLAGE, KS 66206 BY US BANK
BOX 64142
ST PAUL, MN 55164
PHONE: 913- 652 -7000 PHONE:
FAX: 913- 381 -2819
FEES
Description Date Amount
Specifics: Restricted Energy Permit 10/16/2012 $75.00
12% State Surcharge - Electrical 10/16/2012 $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: Y 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, 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 OAR 952- 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Aalat bitted Permittee Signature: OA jPPLIG4T
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 ApplicationREC IvE I FOR OFFICE 1 SE C1 L 1
City of Tigard O CT 5 2012
Received /Oh< � itNo.: C�- .WIa'`�
!PI
'"
I I 13125 SW Hall Blvd., Tigard, OR 97223 Plan Rorie„
Phone: 503.718.2439 Fax: 503.598.1�� DateB e
. Other Perm,
TI G A RD Inspection Line: 503.639.4175 1 1 T� Date Ready/By: 1 j . El See Page 2 for
Internet: www.tigard -or.gov B { D `+tG Notified/Method: ( Supplemental Information
TYPE OF WORK Vi 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.
I- and 2-family dwelling Commercial/industrial ❑ Accessory building pep re. ground, or exceeds 14,000 ❑ commercial use agricultural y g ® rY g amps for all other msm0ations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fue pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of 0 "A ", "E", "1 -2 ", "1 -3 ",
Job no.: Job site address: 11201 SW 72id 0 Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIP: Tigard, OR 97223 ❑ Health-care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: Project name: McDonalds ' ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Ole. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. at or less 168.54 4
Ea. add'l 500 sq. tt or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. R) 75.00 2
Limited energy, multi- family 75.00 2
Wireless Headset Install residential (with above sq. IL)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER ( ® TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: McDonalds
601 amps to 1,000 amps 301.04 2
Address: 11201 SW 72nd Over 1,000 amps or volts 552.26 2
City/State/ZIP: Tigard, OR 97223 relocation services or feeders installation, alteration, and/or
Phone: (503) 670-0608 I Fax: ( ) 200 amps or less 5936 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 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, 7.42 2
each branch circuit
Business name: 1ST B. Fee for branch circuits without
service or feeder fee, first
56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: 8340 Mission Rd, Ste. B4 Miscellaneous (service or feeder not induded)
Each City/State/ZIP: Prairie Village, KS 66206 l manufactured or modular �` 67.84 2
tY g d service and/or feeder
Phone: (913) 652 - 7000 I Fax: : (913) 381 - 2819 Reconnect Only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: accounting @istservice.com Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: 1ST
panel, alteration, or Sion. 1 Page 2 7500 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 6625/ hr
City/State/ZIP: Investigation (1 hr mm) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) I Fax: ( Willi" ) Inspections for which no fee is 90.00/ hr
I 1 1 secifically listed ('f, car mm)
CCB Lic.: 197079 � Electrical Lic.: CLE318 6 ' ( Suprv. Lic.: 18938) ELECTRICAL PERMIT FEES
Subtotal: 75.00
Suprv. Electrician signature, required: o
Plan review (25% of permit fee):
Print name: t • t ".lJ►'l.r Date: State surcharge (12•% of permit fee): 9.00
• TOTAL PERMIT FEE: 84.00
Authorized sign. 0# ' ' ∎∎ / This permit application expires if a permit is not obtained within 180
V - - days after it has been accepted as complete.
Print name: Date: • Nlrmber of inspections allowed per permit
I:\ Buildin a\Permits1ELC- PermitAnn.doe 07/01/10 4404615Tf1I /05 /C.OM/WER
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
El 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 system
*No licenses are required. Licenses are required
_or ail other installations
I:\ Building \Permits\ELC- PermitApp.doc 07/01/10