Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
II in
COMMUNITY DEVELOPMENT Permit #: ELR2012 -00285
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/27/2012
Parcel: 2S109DA17000
Jurisdiction: Tigard
Site address: 15425 SW SUMMERVIEW DR
Project: Stonebridge Homes NW Subdivision: ARLINGTON HEIGHTS NO.3 Lot: 99
Project Description: (1) low voltage for Audio, and Data wiring
Contractor: ROOM SERVICE AUDIO & VIDEO SYSTEMS Owner: STONEBRIDGE HOMES NW
10120 SW NIMBUS AVE C#1 4230 GALEWOOD ST, #100
PORTLAND, OR 97223 LAKE OSWEGO, OR 97035
PHONE: 503 - 598 -7380 PHONE: 503 - 387 -7577
FAX: 503 - 598 -7381
FEES
Description Date Amount
Specifics: Restricted Energy Permit 12/27/2012 $75.00
12% State Surcharge - Electrical 12/27/2012 $9.00
Type of Use: SF
Class of Work: ALT
Total Number of Systems:
Audio & Stereo: N
Security Alarm: N
Garage Door Opener: N
HVAC: N
Vacuum System: N
Other: N
Other Desc: Total $84.00
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 Ce er. Those rules are set forth in OAR
952- 001 -0010 through OAR 92 -001 -0 90. You may / o J btain a copy of the rules or direct questions to OUNC by calling 503.2 .1 87 or 1.800.332.2344.
Issued By: e l)+ 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:
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• hOI2 OFl I( 1: l til: O \l.l
lig RECEIVE Received )p
City of Tigard Date/By: (a 1 a 1 //4_ Permit No.�� _ p va�5�
1 3125 SW Hall B lvd., Tigard, OR 97223 DE 2 7 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 O 2 Date/By: Other Permit:
l - l G R l) Inspection Line: 503.639 Date Ready/By: r�uri ® See Page 2 for
Internet: ww.tigard- or.gov CITYOFTIGAR I Notified/Method: ([ r°
w Supplemental Information
TYPE OF WO I & UII.DING DIVISION 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.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
5 8:t 1- and 2- family dwelling ❑ 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 ", "l -2 ", "l -3 ",
i n
t.' no.: 3 j Job site address: 1 S S SW Si) nt.' l 1 � j Six or or more. occupancy.
�J I L `�Q ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: U` q I "7 41,2-'3 ❑ Health -care facilities. ❑ Supply voltage for more than
v v ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: P roject name: 5 1 tv -6A t_ ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: 4_,..t N �� (-ii Lot no.: S 1 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 ( 7500 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi- family 75 00 2
t b 2 -ki �,7 � L- L%Z- t IV f'7 residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
A t PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 46 KJ -g (2--i., 0/ 1-y g g Ai' W 601 amps to 1,000 amps 301.04 2
Address: k 2 &A7 5 ...s0 - / 60 Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State /ZIP: L,..-A te... O Sw t'() 0 relocation
Phone: ( , 51,, 3 3 g 7 - c") Fax: ( ) 200 amps or less 59.36 l
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
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: B. Fee for branch circuits w i t hout
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)
City/State/ZIP: Each manufactured or modular 67.84 2
h 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: I z- UW< 5 ti�Vtic. e 7"�7� (q t),`'- 1,-0 panel, alteration, or extension. Page 2 2
Each additional inspection over al owable in any of the above
Address: l 6 1 ZO 9,,--L5 rN 1 rVl. - Bt, g t1 - , ( Additional inspection (1 hr min) 66.25/ hr
�
( NQn n Investigation (1 hr min) 66.25/ hr
City/State /ZIP: `> _ _l 7 2'l3 Industrial plant (1 hr min) 78.18/ hr
Phone: ( 503) cil & .�'7 38-0 Fax: ( S - 4 8 - - 73 8' { Inspections for which no fee is 90.00 / hr
specifically listed (V2 hr min)
CCB Lic.: q (, 3.13 Electrical ' : aS
g'�lor Suprv. Lic.: Lt J 3- 4 ELECTRICAL PERMIT FEES
Subtotal:
Suprv. Electrician signature, required. \ Plan review (25% of permit fee):
Print name: '170 V. 1 Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE: gt
Authorized signature:
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
Number of inspections allowed per permit.
I:\Building\Permits\ELC- PermitApp.doc 07/01 /10 440- 4615T(I1 /05 /COM/WEB
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:
;0 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 systems: t
*No licenses are required. Licenses are required
for all other installations
1:\Building\Permits\ELC- PermitApp.doc 07/01/10