Permit 111 p CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT •
s . COMMUNITY DEVELOPMENT Permit #: ELR2012 00282
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/26/2012
Parcel: 1 S136DD03400
Jurisdiction: Tigard
Site address: 11740 SW 68 PKWY
Project: OR Med Assn Subdivision: WEST PORTLAND HEIGHTS Lot: 9
Project Description: (1) low voltage wiring
Contractor: AMERICAN HEATING INC Owner: HEALTH CARE ASSOCIATES LLC
1339 SE GIDEON ST 11740 SW 68TH PKWY
PORTLAND, OR 97202 TIGARD, OR 97223
PHONE: 503 - 239 -4600 PHONE:
FAX: 503 - 239 -7038
FEES
Description Date Amount
Specifics: Restricted Energy Permit 12/26/2012 $75.00
12% State Surcharge - Electrical 12/26/2012 $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 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: � lZ�C f=� Permittee Signature: 2 2 99 &" 14' d,-, s Ad5i6./
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 Application RECEIVE I FOR OFFICE USE ONLY
City of Tigard Received � � 4 r Permit No.: CL tit 1
1111 •
13125 SW Hall Blvd., Tigard, OR 97223 DEC 2012 Plan Review
l ((� oZ - ta d
Phone: 503.639.4171 Fax: 503.598.1960 I Date/B : Other Permit:
• 1 1 C. A IZ D
Inspection Line: 503.639.4175 CITY OF TIGAR i. i rwir. to See Page 2 for
Internet: www.tigard- or.gov
BUI L DING DNISI 11. _. i (( Supplemental Information
p.- . ; w >, e L t r , b -, ' a 0 4@i �6i.) . l Y i "" 7 A l a .g •i �,
. 'S= 7 3 6 ' °..� ' _ . . r • ''Y ES-? krGz :.� .,x�>_, f�_ ...` . ? �t3�. 5. s. .. .31: k C' ..:`,.n r 1,
❑ New construction C Addition /alteration/Ieplacement Please check all that apply (submit j sets of plans w /items checked below):
12 Demolition ❑ Service or feeder 400 amps or more ❑ Building owr three stories.
❑ Other: where the available fault current ❑ Marinas and boatyards.
: : • ' �F iC - ')! ` ?' exceeds round amps volts or ❑ Floating buildings.
sx c. .. , _ . sx a, Ag �s .., M j f ,._ ... less to ground, , or exceeds s 1 14,000 ❑ Commercial-use se a agricultural
❑ 1- and 2- family dwelling C Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
E s : , t ❑ Emergency system. larger separately derived system.
': ;: , . , JO * $ ,r :: r¢ iw ..'' }-foo ` ❑ Addition of new motor load of ❑ "A ", "E", "I-2 ", "1-3 ",
Job no.: I Job site address: 7 5 W G/ t/ �� �� Six or or mare. occupancy.
Q ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: 77 4 P D/` CJ 722 3 ❑ Health-care facilities. ❑ Supply voltage for more than
1 ❑ Hazardous locations. 600 volts nominal
Suite/bldg. /apt no.: I Project name: 2R /x4 cc ) 4 ss 0 G ❑ Service or feeder 600 amps or more.
a t + 1
Cross street/directions to job site: Description Qty. Fee. Total •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft. or less 168.54 4
Tax map /parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1
Limited energy, residential
..s ;. 4 c S r - is 67.84 2
_ r k u . s - ,4 -s I ' t ` b (6 aC s... 7, (with above sq. ft
/ v I -1-',A Limited energy, multi - family 67.84 2
e W i l I n q residential (with above sq. ft.)
J Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
F „ , , tA A „ . , 1. , % , gi ks . . --rf'g 201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( ) I Fax: ( ) 200 amps or less 59.36 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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
'; 3 .._,..'_ .4 , `,. _.'..'Z..` - .... s ttli 4 >il$( N; above service or feeder fee,
Y each branch circuit 7.42 2
Business name: A h'1 e r Ica r H eo -f - J t'1 B. Fee for branch circuits
Contact name: a r� G! a/1 C ' e S -F r' without
branch branch cir sc cir cuit or feeder fee, 56.18 2
Address: /33'f SE , i �e o n S '-j- Each add'l branch circuit 7.42 2
I c7-7o Miscellaneous (service or feeder not included)
City/State/ZIP: Po (' - ) a4 JJ C7 R C) 2 Each manufactured or modular
dwelling, service and/or feeder 67'84 2
Phone: (503 )231- 2 / / _ 0 0 I Fax: : (.5 g
Reconnect only 67.84 2
E -mail: Pump or irrigation circle 67.84 2
' { : .-''+k • . " ,Z .. - ! » _'o .- r g -yk5 `: u ` . k ` t , Sign or outline lighting 67.84 2
Business name:Am e ,-' / c �, H eR //] Signal circuit(s) r limited- I
energy panel, alteeration, or
Address: /331 5E 6, f d e O , S extension. Describe: Page 2 2
City/State/ZIP: �� r- 12.0 O/ ` 972 02 Each additional inspection over allowable in any of the above
Phone: ($03)2'3- 1-/(000 Fax: ($o3) Z3°1 -703 8
Per
ve 66.25
Investigation per hour (t hr min) 66.25
CCB Lic.: 33 13 5 Electrical Lic.:20 qq3 ow Suprv. Lic.: 2 GYO L. EQ Industrial plant per hour 78.18
Suprv. Electrician signature, re uir rtt•I`AI 'PEltM_a K. •�
Su
P q �� t---1 Subtotal.
Plan review (25% of permit fee):
Print name:T S fie. V e y (7 U v q Date: I 1 - State surcharge (12% of permit fee):
Authorized signature: -- /7/ 1.. ..r 4--- i / TOTAL PERMIT FEE: g1..t ro •
Print name: oy(` / /14,4/1 / 4 e -ter- Date:
This permit application expires if a permit is not obtained within 180
C �
� / days after it has been accepted as complete.
• Number of inspections allowed per permit.
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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
XHVAC
❑ 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
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