Permit •
City of Tigard Oregon • 13125 SW Hall Blvd. • • Tigard, OR 97223 „:1.20;!4 ��Y , nj% r aka
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August 20, 2007 's 4 "
Oregon Electric Group
845 NE Columbia Blvd.
Portland, OR 97211
Attn: Evalinne May
Re: Permit No. ELC2007 -00071
Dear Ms. May:
The City of Tigard has canceled the above referenced permits) and enclose a refund for the
following:
Site Address: 9000 SW Washington Sq. Rd.
Project Name: Clearwire POR 060
Job No.: 12349
Refund: ❑ Check # in the am ount of $ .
® Credit card "return” receipt in the amount of $69.38.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as work was not completed. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Permit Specialist
Enc.
1 \Budding\ Refunds \ Adrtunistranon \LtrRefund- CancelPemut.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
08/14/2007 15:33 5032470108 OREGON ELECTRIC GRPU PAGE 02
Building Division
Request for Permit Action or Refund_
City of Tigard y
TO: CITY OF TIGARD AUG 1 4 2007
Permit System Administrator CITYOI°'I•IDA
13125 SW Hall Blvd., Tigard, OR 97223 BUILDING DIVISION
Phone: 503.718.2430 Fax: 503.598.1960
FROM: ❑ Owner ❑ Applicant
® Contractor ❑ City ,Staff
(cheek one)
Name: Oregon Electric Group
V ® i (Business or Individual)
Mailing Address: 845 NE Columbia BIvd.
c' /24 /d 7 A ity /State /Zip: Portland, Or 97211
Phone No.: 503 -546 -6085
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
�1 CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ELC2007 -00071
Site Address or Parcel #: 09000 SW Washington Square Rd. Hotel
Project Name: Clearwire POR 060 /Job #12349
Subdivision Name: Embassy Center Lot #:
EXPLANATION: Nothing transpired on th job site. Permit was not used or needed.
There was no work done.
Signature: Date: 8/14/07
Evalinne May i\Ara
Print Name:
Refund Policy
1. The Building Official may authorize the refund of
a) any fee which was erroneously paid or collected,
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended
2. Refunds will be returned to the original Payer its the same method in which payment was received.
- FOR OFFICE USE ONLY
Rte to Sys Admin: Date B Rte to Bld: Admin: Date B
_ Refund Processed: Date By Invoi Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt #49-374 Date / a9 o 7 Method CC- Amount $ , ��, 7,Z
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08/14/2007 15:33 5032470108 OREGON ELECTRIC GRPU PAGE 01
Oregon Electric Group
845 N.E. Columbia Blvd.
Portland, OR 97211
Ph. (503) 969 -7510 Fax (503) 247 -0108
Fax Cover Sheet
To: City of Tigard Date: 8/14/07
Attention: Permits Refund Requests
Fax Number: 503 -598 -1960
From: Evai.inne May
Fax Number: 503 - 247-0108
Number of Pages Transmitted, Including Cover Sheet: 2
Comments: Please review this refund request and if you have any questions you may call
me at 503- 969 -7510. Thank you for your cooperation.
Sincerely,
Evalinne May
Oregon Electric Group
Wireless Division
Phone: 503- 969 -7510
FAX: 503 - 247 -0108
ate: 14 -Aug -07 I Time: By: Project:
il el
City of Tigard
TIGARD Tidemark Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Oregon Electric Group DATE: 8/20/07
845 NE Columbia Blvd.
Portland, OR 97211 REQUESTED BY: Dianna Howse
Attn: Evalinne May
TRANSACTION INFORMATION:
Receipt #. 2007 -376 Case #: ELC2007 -00071
Date: 1/29/07 Address /Parcel: 9000 SW Washington Sq Rd
Pay Method: CreditCard Project Name: Clearwire
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 0000 - 432000 $ Amount
[ELPRMT] ELC Permit 220 - 0000 - 431510 $64.24
[TAX] 8% State Surcharge 100 - 0000 - 207020 5.18
TOTAL REFUND: - �
APPROVALS: f ' Y
If under $500 Professional Staff
If under $7,500 Division Manager 61'
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
V' Case Refund Processed: I Date: I 002 By: I ° r ""
I \ Building \ Refunds \RefundRequestdoc 05/23/07
ill CITY OF TIGARD U /LV /LVV /
a 13125 SW Hall Blvd. 1 1:35:18AM „-
Tigard, OR 97223 503.639.4171
TIGARD
Refund Receipt #: 27200700000000003802 Vz- iLS
Date: 08/20/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELC2007 -00071 Reversal - [ELPRMT] ELC Permit 220 - 0000 - 431510 (64.24)
ELC2007 -00071 Reversal - [TAX] 8% State Surc 100 - 0000 - 207020 (5.18)
Line Item Total: ($69.42)
Refund:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Credit Reversal LAUREL A 015960 Fax (69.42)
SEMPREVIVO - OREGON
Refund Total: ($69.42)
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cReceipt rpt Page I of I
1111 CITY OF TIGARD 8/20/20D7
el
1 1 3125 SW Hall Blvd. 8 :20:39AM ' ,
Tigard, OR 97223 503.639.4171
TIGARD
Receipt #: 27200700000000000376 O/ 1E /A/'tz—
Date: 01/29/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELC2007 -00071 [ELPRMT] ELC Permit 220 - 0000 - 431510 80.30
ELC2007 -00071 [TAX] 8% State Surcharge 100- 0000 - 207020 6.42
Line Item Total: $86.72
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
CreditCard LAUREL A DEB 015960 Fax 86.72
SEMPREVIVO - OREGON
ELECTRIC GROU
Payment Total: $86.72
cReceipt.rpt Page I of
� ' CITY OF TIGARD PERMIT #: ELC2007 -00071
ELECTRICAL PERMIT
° . COMMUNITY DEVELOPMENT j DATE ISSUED: 1/29/2007
1
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 1S126BC
SITE ADDRESS: 09000 SW WASHINGTON SQUARE RD HOTEL ZONING: C -G
SUBDIVISION: EMBASSY CENTER LOT : JURISDICTION: TIG
Project Description: Electrical service for new collocation. Job No. 12349
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL/PANEL:
MANF HM/ SVC/ FDR: 601 +amps - 1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: 1 W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: >=4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
NESBITT PORTLAND PROPERTIES LLC OREGON ELECTRIC GROUP
2235 FARADAY AVE STE 0 1010 SE 11TH AVE
CARLSBAD, CA 92008 PORTLAND, OR 97214
Phone: Contact #: FAX 503 - 535 -2763
PRI 503 - 234 -9900
FEES
Description Date Amount Reg #: ELE 26 -95C
[ELPRMT] ELC Permit 1/29/2007 $80.30 LIC 203
[TAX] 8% State Surcharge 1/29/2007 $6.42 SUP 44605
Total $86,72 REQUIRED ITEMS AND REPORTS
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws.
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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center.
Those rule re set fo • in OAR 952 - 001 -0010 through OAR 952 -001 -0100. You may obtain copies a rules or direct questions to OUNC at
503.246.6 99 or 1 .800.3 .23 •
Issued B L i JV 2 / Permittee Sign e: ` _Alp
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'N: DATE:
LICENSE NO:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
' 007 06:44PM FROM -OR ELECTRIC SVC „, 5035352763 T -891 P.009 /010 F -468
A al Permit A I r licaLtuit s 1\p.
of Ti gar ll D c/B Q 04' fly PemitNa g , 7��07/
13125 SW Hall Blvd, Tigard, OR Plan Permit: Review Other p
Phone: 503.639.4171 Fax: 503 \v� 2' ^ 0 �fr+
Inspection Line: 503.639.4175 ,��`� �y
LO N. e yBY la Soo Page 2 for
Internet: www.cti.tlgardor.us `' 0 . Notified/Method � Supplemental tnformatine
�� PLAN REVIEW •
D Ald - Please check all that apply:
New construction a . 1 eat
,� ❑Saviceovcr225aanps , wmm'1 ❑Hazudous localiotl
• El Demolition ❑ ❑Service over 320 amps- rating ❑Butldng over 10,000sq. ft.,
CATEGORY OF. CONSTRUCTION • . . . of 1- and 2 -family dwelling 4 or more new residential
❑S over 600 volts nominal units in one structure
❑ i - and 2-family dwelling ®CommercisUindtistrial El Accessory building ID Building over three stories ❑Feeders, 400 amps or more
❑ Multi family ❑ Master builder 0 Other: ❑Occupant load over 99 persons ❑Manu8 cented structures or
• JOB SITE INFORMATION AND LOCATION ❑ Egretailighting plan RV park
�
Job no.: 12349 I Job site address: 9000 SW WASHINGTON SQUARE RD ❑Htstlth�atr facility ❑ Submit 2 sets of plans with any of the above.
City/ State/ZIP: TICARD, OR .97223 The above arc not applicable to temporary construction smite.
FEE' SCHEDULE •
Suite/bldg./apt no.: ( Project name: CLEARWIRE CELL TOWER
Disectulea 1 Q, For rota •.
Cross street/directions to job site: MIGHT BE SLIGHTLY ISOLATED New residential single- or multi- family dwelling unit.
Includes attached garage.
NEAR WASHINGTON SQUARE 1,000 sq. ft. or less 145.15 4
Subdivision: I Lot no .: Ea. =WI 500 sq. ft or portion _ 33.40 , 1
- Limited energy, residential 75.00 2
Tax map /parcel no.: Limited energy. non residential 75.00 2 •
DESCRIFFION OF WORK Each manufactured or modular
POWER TO NEW CELL TOWER dwellinp, service and/or feeder 90.90 2
Services or feeders installation, alteration, and/or relocation
200 amps or less i _ 80.30 $p ,30 2 -
Q PROPERTY OWNER I- ® TENANT . 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
��' 601 amps t
Name: �TCSC•rato 1,000 amps
.�Z. E.RWIR �,- �v....e.� COMMt �� ■ t ... C NC �� t � �� Jr, Jr, �. 240.60 2 54.65
Address: AA35 Ad gv� t C
Reconnect 0 o or vole 4 66.85 - 2 Ovcr
City/ State/ZIP: C'9RC D ( cif- 9 6 Temporary services or feeders Installation, alteration, and /or
relocation
Phone: ( ) J Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps _ 100. 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 13175 f 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT I El CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit _ B. Fee for branch circuits
Contact name: without service or feeder fee, 46,85 2
each branch circuit , -
Address: Each add'l branch circuit 6.65 2
City / State/ZTP: Miscellaneous (service or feeder not included)
Pump or irrigation curls 53.40 2
Phone: ( ) Pax: = ( ) Sign or outline lighting 53.40 2
E - mail: _ Signal circuit(s) or limited-
• CONTRACTOR energy panel, alteration, or
otension. Describe Page 2 2
Business name: Oregon Electric Group - -
Each additional inspection over allowable in any of the above
Address: 1010 SE 11th Ave
Per inspection 62.50
-
City/State/ZIP: Portland, OR 97214 Investigation pet' (1 hrmia) a 62.50
Phone: (503) 234 -9900 [ Fax: (503) 53S -2763 In�ial plant per how _ 73.75 -
ELECTRICAL PERMIT FEES'
CCB Lic: 203 Electrical Lic.: 2� ' - • • c.: 4460S Subtotal W • 30
Suprv. Electrician signature, required: �/ Plan review (25% of permit fee)
n r � , P State surcharge (8% of permit fee) (.0 . U AO
Print name: L �
/. / 4 te: TOTAL PERMIT FEE g (p ,1 p,
Authorized signature: ,,, r/
The permit application espins If a permit b not obtained within 180
�� days after it has been accepted as complete
Print name: 1 , d' � in 01/24/ — • Fee methodology set by Tri-County Building lnduxaService y Service Board
•” Number of unpaslona per permit allowed.
i ; \nwldiemPertniral-C- Permitaop•doe 12.03 44044615T(laroco IWm
b t-v C ss 61/44 �' ( . mot.•_ - 'flti Il L(0-)