Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
Request uest Permit Action
• „pAzo....1 .!
(i A lr i) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ,. City Staff
(check one)
REFUND OR Name: n
INVOICE TO: (Business or Individual) /�—
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
•
%..r 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 PEERMIT (do not cancel permit).
Permit #:
Site Address or Parcel #: 75 / ( , ) ,3* -- 1 R 2T Ho 11 774
f
Project Name: I / OU i 7)O 6.4-1 s
•
Subdivision Name: /J//q Lot #: /J /f}
EXPLANATION: L2'- P Q►- P 7 7j °4 /65/42:0 LI D E/2_,
•
Signature:
; Date: AO / �-
Print Name: 1 ?We E . 4Di9 - I
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
{ 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 retumed to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
f '
FOR OFFICE USE ONLY
Rte to S s Admin: Date olzr Rte to Bld: Admin: Date - B
Refund Processed: Date ,/`M111 B 'fa Invoice Processed: Date B
Permit Canceled: Date M® B A i /AMI Parcel Ta_. Added: Date B
,Recei.t # Date Method Amount $
I:\ Building \Forms \ReqPermitAction.doc Rev 05/25/2012
V ®I 0 ?/s,ohi
Electrical P Applicatio E1 r D FOR OFFICE USE ONLY
Received ,r
City of Tigard r 2 5 201 Date/B lC/ A /� . //1�D /a. -a) e9 ,/
° 13125 SW Hall Blvd., Tigard, OR 972 T Plan Review . / way !ti w T
C Phone: 503.718.2439 Fax: 503.598.1960 .�+� ! �nD�� DatDate/By: !!r PM t i Permit No.: Other Permit:
T I G A R D
Internet: ww Inspection Line: 503.639.4175 CITY �' 11GI11W Date Ready By: /o / � % l lnforma ion „
�,1,a S. Sup Page 2 for
tV.tigard - OrgOV Non .7G � l.T'� lementa
BUILDING DNISIO „ „■Io�,,, � ,fl„"..,, .
TYPE OF R ' O R K q - - , , , , , � � ` RE 1 y '
❑ 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
❑ 1- and 2- family dwelling ® Commercial/industrial El 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
El Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", 'l -2 ", "I -3 ",
Job no.: WIN23_KK Job site address:;14<artmouth Rd 100HP or more. occupancy.
El Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard, OR 97223 750/ ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: - Project name: WinCo Foods Store No. 23 ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Corner of SW 72 " Ave. & SW Dartmouth St Description I Qty. I Fee. I Total I •
New residential single or multi - family dwelling unit.
South of SW Pacific Hwy Includes attached garage.
Subdivision: - Lot no.: - 1,000 sq. ft. or less 168.54 4
Ea. add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: - Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
Addition of receptacle for connection of Kettle Corn sales. residential (with above sq. ft.)
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
Name: WinCo Foods LLC (David Van Etten) 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: 650 N. Armstrong Place Over 1,000 amps or volts 552.26 2
City/State /ZIP: Boise, ID 83704 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (208)377 -0110 Fax: (208)672 -2146 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 ® CONTACT PERSON above service or feeder fee 7.42 2
each branch circuit
Business name: Cushing Terrell Architects Engineers B. Fee for branch circuits without
service or feeder fee, first I 56.18 56.18 2
Contact name: Todd Poirier branch circuit
Each add'l branch circuit 7.42 2
Address: 1185 Grove St. Miscellaneous (service or feeder not included)
Ci /State /ZIP: Boise, ID 83702 Each manufactured or modular 67.84 2
h dwelling, service and/or feeder
Phone: (208) 336 - 4900 Fax: : (208) 343 - 3531 Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: toddp @ctagroup.com
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited - energy
Business name: Out To Bid rT----~ panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: 3 x Additional inspection (I hr min) 66.25/ hr
r l
City/State/ZIP: t Investigation (1 hr min) 66.25/ hr
-- - - - -�•- �►�S `TiEj,j. r Industrial plant (l hr min) 78.18/ hr
Phone: Fax: (20.% ' °tr e l i 7 Inspections for which no fee is 90.00/ hr
- � specifically listed ('/ hr min)
CCB Lie;_. — f - t - O I Electrical Lie.: Suprv. Lie.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: 56.18
Plan review (25% of permit fee): - 14-95 Ca'''
Print name: Date: State surcharge (12% of permit fee): 6.74
TOTAL PERMIT FEE: X699'•
Authorized signature: This permit application expires if a permit is not obtained within 180 ��ISS..f�� p
Z
days after it has been accepted as complete. El . !
Print name: Date: • Number of inspections allowed per permit. l
I:\ Building \Permits\ELC- PermitApp_doc 07/01/10 440- 4615T( I I /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:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
n 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
n Boiler Controls
❑ 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: _
*No licenses are required. Licenses are required
for all other installations
1:\ Budding \Pcrmits\ELC- PemutApp.doc 07/01/10
RE CC
D
CUSH ING
UT BCfrynn,
TRANSMITTAL LETTER G DFVIS O
PROJECT: WinCo Foods Store 23 PROJECT REF.: W1N23 KK
7501 Dartmouth St
Tigard, OR 97223 DATE: 10/24/12
If enclosures are not as noted, please inform us
TO: City of Tigard immediately.
Permit Center Building
If checked below, please:
13125 SW Hall Blvd
Tigard, OR 97223 ® Acknowledge receipt of enclosures.
Attn: Permit Tech. ❑ This is for your information.
(503)718 -2439
FROM: Todd Poirier
WE TRANSMIT: ® Herewith ❑ Under Separate Cover Via:
❑ In Accordance With Your Request:
FOR YOUR: ® Approval ❑ Distribution To Parties ❑ Record
❑ Information ❑ Review & Comment ® Use
The Following: ® DRAWINGS ❑ SHOP DRAWINGS '
❑ OWNER COMMENTS ® OTHER (� �s 3 " , r()
P
��' Ov "1 t me'
V
IN
COPIES DATE DESCRIPTI( 2 pppJ I CTION
(2) 10/24/12 Drawings e,, f P E
(2) 10/24/12 Specs r" P 1J E
(1) 10/24/12 Electrical Permit Application Form E
Action A. Action indicated on item transmitted. D. For signature and forwarding as noted below under REMARKS.
Code B. No action required. E. See REMARKS below.
C. For signature and return to this office.
COPIES TO: (with enclosures)
ZFile ❑
ZWinCo ❑
REMARKS:
Please see the attached drawings and specs for the Electrical permit plan review process. The scope of
work is to add one electrical receptacle on the outside of the existing front elevation.
Thank you,
- Todd Poirier (208) 577 -5676
CTA Architects Engineers
1185 Grove Street Boise, Idaho 83702 208. 336. 4900 Fax: 208. 343. 3531
http://www.ctagroup.com E -mail: boiseinfoCctagroup.com