Permit • 1.
3 — o cl
v
e Building Division
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 4 City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
1 J/( 4-
® Mailing Address:
Cit /State /Zip:
SAY, '2 4 1 1 ----
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
14 CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ea ,Aco7 -Cp67 P, �� C �Ti07 L_. a-C
Site Address or Parcel #: / p 760 c LIP/ t 600/J6 IJ4/ & /69,
Project Name: ../..z.rt eok-P //
Subdivision Name: /3/4. Lot #: Ai/4
EXPLANATION: / } , 5 t J o / PA.N / 7 No /a A,e c7 65-D/ c %/o,J
eAt.D,T en-2b PAY h1e,JT A- Leff! -by tie ID Et, .
Signature: . . JC19 -�✓v�A �+a ---l. Date: jI/Y (07
Print Name: 70 th 6 t E /}7jIFN S ('IN 1
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fcc 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80° o of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) not more than 80% of the building permit fcc 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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date ' /y 07 By Rte to Bldg Admin: Date .3 0 74 e`) By " -
Refund Processed: Date „3 /y /O 7 By ,2)625? Invoice Processed: Date By
Permit Canceled: Date ,.5/2_1707 B -p -Parcel Tag Added: Date By
Receipt # 07- / /3q Date 3jny /C 7 Method C e_ Amount $
l:\ Building \Forms \ReypermitAction.doc Rev 05 /24/06
Iat
C ITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT PERMIT #: ELR2007 - 00072
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 3/14/2007
PARCEL: 2S 113AC -00600
SITE ADDRESS: 16760 SW UPPER BOONES FERRY RD ZONING: I -
SUBDIVISION: COUNCIL VIEW ACRES NO. 2 LOT: 044 JURISDICTION: DU
PROJECT: RICOM CORP
Project Description: Low voltage for data.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: X NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: : HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER: :
TOTAL # OF SYSTEMS:
Owner: Contractor:
SCHISLER FAMILY TRUST ASHLAN COMMUNICATIONS INC.
16760 SW UPPER BOONES FY RD 7534 N ELMORE AVE
TIGARD, OR 97224 PORTLAND, OR 97217
Phone: Contact #: PRI 503- 849 -9523
FAX 503 -286 -2158
Reg #: ELF CLE -33
FEES LIC 169323
Description Date Amount SUP LEB3333
[ELPRMT] ELR Permit 3/14/2007 $75.00
[TAX] 8% State Surcha 3/14/2007 $6.00 REQUIRED ITEMS AND REPORTS
Total $81.00
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 Notifi atin Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these
rules o irect ques''ns to OUNC at 503.246.6699 or 1.800.332.2344.
Issue By: // ' /�1A — % Permittee Signature: A / / :.
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.
ctrical Permit Application F OR OFFICE USE ONLY
d ce
Reive / 7 7—
City of Tigard Received / D/ I Permit No.: Et ^ .�� 1114 ° 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date /By: Other Permit:
TI G A R D Inspection Line: 503.639.4175 Date Ready /By: Juri HI See Page 2 for
Internet: www.tigard Notified/Method: ( ( Supplemental Information
TYPE OF WORK PLAN REVIEW
45--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 dwellingCCommercial /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 ", "1 -2 ", "I -3 ",
100HP or more. occupancy.
Job no.: Job site address:
/4 760 UD7pPi 8e Ar) //y ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: "l am . el , / ( ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: jeZ - I.-, ,. ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Deseriptloa • I Qtr. I Fee. I Total I •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Tax map /parcel no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
A i c 4 1 1; l a 7'; residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) 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 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel _
A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee,
each branch circuit 6.65 2
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( )
Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Signal circuit(s) or limited -
Business name: / 4/4 . , ‘ ( .M,4,44, 1 4 A f _Z e energy panel, alteration, or
extension. Describe: / Page 2 r� 2
Address: 7S % �/. / i iP / e / �)
City/State /ZIP: A7 t o / G - '7.7 /1 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (03 ) g y _ 9re, 3 Fax: ( ) Investigation per hour (I hr min) 62.50
CCB Lic.: / ”2 3 Electrical Lie.: a _ 3 Suprv. Lie.: /FQ_ _733..3 Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: ����_ Subtotal: 7s-
/ / , Date: Plan review (25% of permit fee):
Print name:
_ q,. �.3/ ®/>
State surcharge (8% of permit fee):
Authorized signature: — ��� TOTAL PERMIT FEE:
p)//).X,7 This permit application expires if a permit is not obtained within 180
Print name: fi ,
�r // -4;,/‘', Date:
, j days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440- 46t5T(t I /05 /COMIWEB
•
Electrical Permit Application - City of Tigard -
Page 2: - Suppkniental'Inforniation
LIMITED-ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: 1
Fee for all residential systems combined ... $75.00
Check Type of Work Involved: •
0 Audio and Stereo Systems* •
0 Burglar Alarm
•
11=I Garage Door Opener*
LI Heating, Ventilation and Air Conditioning System*
0 Vacuum Systems*
•
El Other:
•
I COMMERCIAL WORICONLY: 1
Fee for each commercial $75.00
system
• (SEE OAR 918L260-260) •
•
Check Type of Work Involved: •
0 Audio and Stereo Systems
0 Boiler Controls
El Clock Systems
Data Telecommunication Installation
0 . Fire Alarm Installation.
•
HVAC •
0 Instrumentation
'0 Intercom and Paging Systems
•
O _Landscape Irrigation Control* •
LI Medical
. Nurse Calls • • •
O Outdoor Landscape Lighting*
Protective Signaling;
LI Other
. : •
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other-installations • •
I: \Building \Permits \ ELC-PermitApp doc 03/23/06