Permit /1 C„/
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT (./
IN v o/ 7"
i al
Request Permit Action
q
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor VO I D
13125 SW Hall Blvd., Tigard, OR 97223 3/24//3 —
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 'Cit Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: f LC- 0 ( 3- — 00 7/ D
Site Address or Parcel #: / t4 6e,0 7`�' Apt -----
Project Name: \)02-16 / 7 rig_ r S
Subdivision Name: Lot #:
EXPLANATION: C 6„,,,,,, Nr 7 17) tJ2o,J6 /4D[7te_ 5S c5,0
A- PA LI C A- 1 OK) , P 2 D 3 e-r Pi c_T i , c 1 LLN/ 03 (..4 . C..(2). / 4vo4 el iJ t otJ -. __
Ot3 t 'a- _ Or E c-i . J) Le._ AS 2 2 e r-it,so • 41
Signature: 410 Date: /.. ..._-_ _
Print Name. fi? f 41 DR/11 (
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date ® mm Rte to Bld ! Admin: Date B .:'
Refund Processed: Date rZBEI B ; „_ - Invoice Processed: Date B
Permit Canceled: Date S - /3 By ..FT Parcel Tag Added: Date By
Receipt # Date Method Amount $
l: \Building \Forms \ReqPermitAction.doc Rev 05/25/2012
CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2012 -00710
Date Issued: 12/13/2012
TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503 718 2439 Parcel: 2S113AD01900
Jurisdiction: Tigard
Site address: 16640 SW 72ND AVE B10
Project: Veris Industries Subdivision: ROSEWOOD ACRE TRACTS Lot: D
Project Description: (2) 200 amp service and (10) branch circuits for machinery/equipment
Contractor: FARNHAM ELECTRIC CONSTRUCTION Owner: PACIFIC REALTY ASSOCIATES
PO BOX 7 ATTN N PIVEN
MCMINNVILLE, OR 97128 15350 SW SEQUOIA PKWY #300
PORTLAND, OR 97224
PHONE 503 - 472 -2186 PHONE
FAX' 503 - 472 -4042
FEES
Quantity Description Date Amount
2 ea Services or Feeders - 200 12/13/2012 $201.40
Specifics: amps or less
10 crt Branch Circuits w /Purchase 12/13/2012 $74 20
Type of Use: COM Service or Feeder
Class of Work: ALT 1 ea 12% State Surcharge - 12/13/2012 $33 07
Electrical
Type of Const:
Occupancy Grp:
Total $308.67
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 • ; 001 -00•0 You ay obtain a copy of the rules or direct questions to OUNC by calling 503 232 1987 or 1 800 332 2344
Issued By: 1 _ -ILl E� Permittee Signature: 4 A /9"// G. /
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.
From:FARNHAM ELECTRIC 503 472 4042 12/12/2012 17:15 #069 P.003/003
Electrical Permit Application — _ EIVED FOR OFFICE USE ONLY
e�!y
City of Tigard DEC 12 Received
UPI 2012 DateB : A�® / Permit No. Le,20 /2 'eo t/
13125 S W Hall Blvd., Tigard, OR 97223 p Plan Review
: 6 Phone: 503.718.2439 Fax: 503 -5 OF TIGARD Dare/B • Other Permit:
T , Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready /By: NM Supplemental See Page 2 for
Internet: www.tigard or.gov Nonfted•Method: Supplemental Information
- y - - %- i' - - i"''r: i''�3 m• ; - V' -..ya= liA-- _:�>>.•. _:1r�,� - 4,1_,, .,v - a-
_ - - - - ." -t a - , '.: Q -. - - -a -;
t', �- ^' y '- "r' -.k t �e $* r ,.. a
.. 181 ._- IFL� - N'i :-. "b,s �
❑ New construction Addition/alteration/replacement Please check all that apply (submit F sets of plans items checked below):
ns
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current
❑ Marinas and boatyards.
< _ z ,.- R., _ __ .._ _ - ; ,,f p „i,,r;•,.., >y " amps at 150 volts or ❑ exceeds 10,000 s Floating buildings.
o^ 7 3 7 . .t:., aom�t1Q, f,rtiz'.ex�k�'k� =aa; less to
ground or exceeds 14,000 ❑Commercial -use agricultural
❑, :- , n- , r a ,AZ 1- and 2- family dwelling C ommercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump ❑ Installation of75 KVA or
r - - ❑ Emergency system. larger separately derived system.
i. -,0 , .,.,.._w `v- ❑ Addition of new motor load of ❑ "A ", "E' "1 -2" "I 3"
Job no.: 005 Job site address: I ( 10 SW 72 Pat 8 - I D Six or residential units. ❑ Recreational vehicle parks.
City/ State/ZIP: .01' (>� a �� a 1 � ❑ Health-care facilities. ❑ Supply voltage for more than
"j ❑Hazardous locations. 600 volts nominal
Suite/bldg. /apt. no.: . -I l l Project name: Njeri5 lyta f I S c ❑ Service or feeder 600 amps or more. 4 f
Cross street/directions to job site: , De scription i Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1.000 sq. ft or less 168.54 4
Ea add'I 500 sq. ft or portion 33.92 1
Tax map /parcel no.:
Limited energy, residential
;� R r a I - 1 ;; '" '' rs, =y�Z;'- t*- � �` fj.1 ;! s�� " (with above sq. ft)
75.00 2
Limited energy, multi- family 75.00 2
I in sf a N ` ZOh/r f st t � � Ian Facto- (with above sq. ft.) t �+__� LL I / Services or feeders installation. alteration, and/or relocation
/ / tf • if t ( ' 2 w i V1u.f�- 200 amps or less 2 100.70 201.
gi � q ' VZit L�, ,� it !3,i1 201 amps to 400 amps 133.56 2
Name? ���{ y/ J {-�.' 401 amps to 600 amps 200.34 2
V v� p S r wr"S 1 t t
es 601 amps to 1,000 amps 301.04 2
Address: l (au 4 () SW 1214 Ave. 13 iD Over 1,000 amps or volts 552.26 2
Temporary City / State/ZIP: 170141a4/14 I At '172
relocation
or feeders installation, alteration, and/or
Phone: (1 ) S 5i ) LI 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 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
_': s" above service or feeder fee, 10 7 �. 20
-`?�;` �.'407 `s�:? e''� each branch circuit 7.42 74 2
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)
Ci / State/ZIP: Each manufactured or modular 67.84 2
ty dwelling, service and/or feeder
Phone: ( ) I Fax: : ( ) Reconnect only 67.84 2
Pump or imgation circle 67.84 2
E -mail:
- �%- ' x� « rte' "33 Sign or outline lighting 67.84 2
r_ -� ' '-' • �.° .s .�:��; rc3'" r,•. �� Signal circuit(s) or limited-energy
Business name: Far ham et p, - h c � s - �d, p j� panel, alteration, or extension. Page 2 2
"">r Each additional inspection over allowable in any of the above
Address: pp a px .7 n Additional inspection (I hr min) 66.25/ hr
City /State/ZIP: M r», Ville , Oil Q g712S' investigation (1 hr mm) 66.25/ hr
Industrial plant (1 hr min) 78.18 / hr
P e: (07, L S Fax: (603 A172 - 4042, Inspections for which no fee is
fically listed 0 hr min) 90.00 / hr
C CB Lic.: Electrical Lie.: prv. Lie.: .V f ` e r ( 1� t r -
A 4 . ..
Suprv. Electrician signature, required: '''"D I • 10/1' 1� Subtotal: 7j, (00
G Plan review (25% of permit fee):
Print name: 5.../eve Ktj•e(,,/ Date: 12 1124 1Z State surcharge (12% of permit fee): 5, -7
Authorized signature:
TOTAL PERMIT FEE: . (r2
This permit application expires it a penult Is not obtained within 11 80 1
Print name: Aim I3 14 D 1 • days b allowed has been accepted as complete.
M l Number of inspections allowed d per permit
I Budding \ Permits \ELC- Permit App doe 07/01 /10 440- 4615T(11/05'COM•WEB
From:FARNHAM ELECTRIC 503 472 4042 12/12/2012 17:15 #069 P.001/003
W IN FARNHAM ELECTRIC CONSTRUCTION
Serving the Community Since 1920.
SOLAR • AGRICULTURAL • INDUSTRIAL • COMMERCIAL • WINERIES • RESIDENTIAL
FAX COVER SHEET
TO: . (4 a 1 FAX: ^1 • -13 - - , •
ATTN: (� SL, J . DATE: 2 12. Z
FROM: � Qo �, _1C1 PAGES INCLUDING COVER: 3
RE: J
I� t_ ry uk P c>f i i c turn
�RGENT 0 FOR REVIEW 0 PLEASE REPLY 0 PLEASE RECYCLE
COMMENTS:
RiCae_____ati ma b AtAt n --{fit iS
has p n SY:cc( .5o a" r� r qe,,-�.
On � ¢_ 771414 Gov.
Asktu Om 1d
b 47z 218(4
• MCMINNVILLE 503.472.2186 • SALEM 503.581.6287 • PORTLAND 503.222.7138 • FAX 503.472.4042 • AFTER HOURS 503.434.5185
PO Box 7 MCMINNVILLE, OR 97128
PROUD MEMBERS OF NECA / IBEW