Permit 1 1 11 1111 o ° Community Development
T 1 c n ii D Request for Permit Action
REal
TO: CITY OF TIGARD - 0 1 2009
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223 • rric p TIG I A O
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard -or.g gIj1 LD ING
I
FROM: El Owner El Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) / 4
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
'E . 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 #: E j 2, COO 9 dU Aq 3
Site Address or Parcel #: ei 7 35 . �tO -j- T y L. k)
Project Name: A t.n-f-en e_ \I tip, G £
Subdivision Name: Lot #: ' g7"
/ '/
EXPLANATION: 0 2 � 6'rtb / 0 E 1' l ,.e f.. Eke.., 409 -. 0D`t
,/
Signature: / I
� _ , _ _ 4 _ . 1 ' • Date: 940/0?
Print Name: ( OA/ E /6.09
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b) not more than 80% of the land use application fec when an application is withdrawn or canceled before any review effort has been expended.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 fec 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 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 S s Admin: Date ' i Cle�� Rte tr , Admin: Date ! ?,...Irt■-�Lr /f/ /hi
Refund Processed: Date ,, ..- B . j7,1 Invoice Processed: Date By
Permit Canceled: Date 9 _ , 09 By d'"!' Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Fomu \RegPemmitAction.doc Rev 07/26/07
' Electrical Permit Application volz ol:l.lct: Hsi: o i.l'
Ci of Ti and • a i Received MOr ��
�' g I, 1 71 I I Permit No.:
. C a 13125 SW Hall Blvd., Tigari..... 2 Plan Review '
Phone: 503.639.4171 Fax:15 t 3 �S9 I I = ttt ��� Dates ,: Other Permit:
I' I C. A I: D Inspection Line: 503.639.4175 Date Ready/By: • / ate RI See Page 2 for
Internet: www.tigard- or.gov ,: .-,..j:1 Notified/Method: nu
Supplemental Information
TYPE ' `TtGABr) PLAN REVIEW
❑ New construction ® Addis' Vl � " s1 I loses Please check all that apply (submit 2 sets of plans w /items checked below):
17i UY�' ❑ 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 ❑ 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 ", "1 -3 ",
Job no.: Job site address: 9735 SW Shady Ln tooliPormore. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard OR 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: 200 Project name: Aesthetic Medicine ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. 1 Fm 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
Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family
Reconnect Condenser residential (with above sq. ft.) 75.00 2
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
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,
each branch circuit 6.65 2
Business name: same as below B. Fee for branch circuits
without service or feeder fee, I 46.85 2
Contact name: 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 90.90 2
dwelling, service and /or feeder
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name: Willamette HVAC Signal circuit(s) or limited -
energy panel, alteration, or
Address: 3075 SW 234 Ave Ste 206 extension. Describe: Page 2 2
City/State/ZIP: Hillsboro OR 97123 Each additional inspection over allowable in an of the above
Per inspection 62.50
Phone: (503) 628.6841 Fax: (503) 848.2597 Investigation per hour (1 hr min) 62.50
CCB Lie.: 56951 Electrical Lic.: 363 RE Suprv. Lie.: 4025LEB Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
Print name: Mike Sicard Date: 9/16/09 Plan review (25% of permit fee):
State surcharge (12% of permit fee):
Authorized signature:/ TOTAL PERMIT FEE:
This p ermit application expires if a permit is not obtained within 180
D ate: 9/16/09 Print name: Mike Sicard days after it has been accepted as complete.
• Number of inspections allowed per permit.
1: \ Building \Permits'ELC- PermitApp.doc 05/23/06 440.4615T(II /05 /COM/WEB