Permit 1111 v CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
: COMMUNITY DEVELOPMENT Permit #: ELR2012 00261
TIGARD 13125 SW Halt Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/20/2012
Parcel: 1 S136AD06505
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Jurisdiction: Tigard
Site address: 10998 SW 68TH PKWY
• Project: Bailey - Golsan Building Subdivision: WAY LEE Lot: B
Project Description: Data telecommunications.
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• Contractor: ORE COM TELECOMMUNICATIONS LLC Owner: KEN GOLSAN
9828 E BURNSIDE ST STE 100 BAILEY GOLSAN LLC
PORTLAND, OR 97216 10998 SW 68TH PARKWAY
TIGARD, OR 97223
PHONE: 503 - 381 -7284 PHONE: 503 - 244 -0297
FAX: 503 - 953 -8501
FEES
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Description Date Amount
Specifics: Restricted Energy Permit 11/20/2012 $75.00
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12% State Surcharge - Electrical 11/20/2012 $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: Y 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: N Total $84.00
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Other Desc: Required Items and Reports' (Conditions) •
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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: 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' Date: / ( — 2_ — ! 2 _—
LICENSE NO.
Call 503.639.4176 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.
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Electrical Permit Application RECEIVE
Receiv
Plan Ci of Tigard
ermit No.'
131 Hall lvd., Tigard,OR 97223 N O NO V 0 2 12 n Review
// �D //a E� o�.? - Daa 6, '� C Phone: 503.718.2439 Fax: 503.598.1960 CITY OFT GARD Date/B
Iy: Other Permieupc:)0 47 �dd3/
I' 1 C. li u Inspection Line: 503.639.4175 w�{ ate Ready/By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov BUILDING DIVISIOt otified/Method: 776 Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction Additiort /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 / E1 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: /0 8 S k9 .4.6 r .e IOO or more residential Recreational
❑ Six or more residential units. ❑ R vehicle parks.
City/State /ZIP: Qd"aZ�t,q•v r �/'�1Z q' 7 Z ' 3 ❑ Haza Hazardous facilities.
❑ Supply voltage for more than
l� ❑Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: &1 f -G O (.5,40.1 ❑Service or feeder600 amps or more.
f` FEE SCHEDULE
Cross street/directions to job site: ( ? A.) Description I Qtv. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. R. or less 168.54 4
Tax map /parcel no.: Ea. add'I 500 sq. R. or portion 33.92 I
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi- family 75.00 2
D 1.J 1702-- C Lmio- vv' 66 14 .44 7 residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less • 100.70 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City /State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 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: 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: Miscellaneous (service or feeder not included)
Each manufactured or modular 67.84 2
City/State /ZIP: dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: O i� ,� , q ,/.iv44 —? � panel, alteration, or extension. Page 2 2
''( Each additional inspection over allowable in any of the above
Address: RS29 6 = _ g�� ,o/A- IF/073 Additional inspection (I hr min) 66.25/ hr
City/State /ZIP: c , Q � ' O/ 9 7 Z f /_ Industr p n (t (I hr min) 78.18/ hr
min) 66.25/ hr
e 1� Industrial plant (I
Phone: (S() 3) ' S 1 - 71 Li Fax: 5 ) 95 — SSo ( Inspections for which no fee is 90.00 / hr
specifically listed (%: hr min)
CCB Lic.: !S Z453 y Electrical Lic.341.6 aEj Suprv. Lic.: 3787 LEI3 ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: 7 /i // 10 f'IIl Subtotal: 75',
P lan review (25% of permit fee):
Print name: 015U1 L� Date: l I _? _ State surcharge (12% of permit fee): y, [11)
TOTAL PERMIT FEE:
f r , 01)
Authorized signature:
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: • Number of inspections allowed per permit.
I: \ Building \Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(11 /05 /COM/WEB
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Electrical Permit Application - City of Tigard' ` ' '
Page 2 - Supplemental Information t .
LIMITED ENERGY PERMIT FEES: � ' � l� ?-11'
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
la Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation •
❑ Intercom and Paging Systems
❑ • Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls • •
❑ Outdoor Landscape Lighting* •
❑ Protective Signaling •
.
❑ Other
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Total number of commercial systems: _
*No licenses are required. Licenses are required
for all other installations
1:\ Building \Permits\ELC- PermitApp.dac 07/01/10