Permit t„
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:. ; ' Community Development "
?% Request for Permit Action
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TO: CITY OF TIGARD 0* 1\G \ �� �
Building Division Services Coordinator G, A�N
13125 SW Nall Blvd., Tigard, OR 97223 01‘.‘. Phone: 503.718.2430 Fax 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner [I Applicant Z ❑ City Staff
(eherr nne)
REFUND OR Name: •
INVOICE TO: (A' ^ inc+r'-+rin(liniduaO J OL Sen CI r;c,
Mailing Address: vitgi9 s& valt 2 &) TPA)
V 1
' / Cit /State /Zip: Yi Lf U� I (� ie
1 Od- ir,� Phone No.: (` a ) lDcie'3417
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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 L C 2-0f01 ` oor(( j
Site Address or Parcel #: C o (a F20 SW gtd 1,1,Y,x, LP i i bS
Project Name.. Re eel Exch t
Subdivision Namc: TOLGI l 1 C Cocecv w C Ceinten. Lot #t: 002_
0 CAI.) CE -& )
Signature: Q J I Date: z�•� I09)
Print Name: `` Cr. � n�n � (Ma()
sthavactbs
1. The fl:reeror .r. E finding Official may aardiorin the refund nr..
a) any Fen which waa aconeotudy peal or collected.
b) nut mate dun NA ache land ute apt±licntion fee when an Apuliaotiun is aithdatwn or troweled befate any review effort lens bran invaded.
c) not truxe than sn% ark land uee applicaenn Gee Few imlued permits.
dl oat more don R0y lithe building plan 'c v he when an application u canceled before any plan review Orrin hie been expended.
:) not mute r?.on Mh riche b uilding uarr..ir ice roc irowd permit? }vino a, rosy inrrectipn raciness,
2. Refunds will be returned Ire the origin' P$a in rhos arrow method in which pigment wan rewired. iced. Pkape allow 1 weds Far roaming refund".
)i2 OFFICE 1. ;!-.1. 11i';i1.\
Rte en Sva Admm: Date :1 [alIME',Pll %a Dace 3h7, : : B' wig
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Refund Processed: Date 3ff0, O i� Invoice Processed: Date 8
Permit Canceled: Date 3 O, IEZ;la Parcel T • Added: are B
Rece • t #0 - Date /ri/lj
l'111uilding \Fowls tegPceniiAchun. -. ' • 11 /26/07
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City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
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T I GARDY{
March 4, 2008
Johansen Electric
10948 SE Valley View Terr
Happy Valley, OR 97086
Attn: Charlynn Leifsen
Re: Permit No. ELC2007 -00761
Dear Ms. Leifsen:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 6650 SW Redwood Ln., 105
Project Name: Realty Exchange
Job No.: N/A
Refund: ❑ Check # in the am ount of $ .
® Credit card "return" receipt in the amount of $138.33.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely, •
Dianna Howse
Building Division Services Coordinator
Enc.
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I: \Building\ Refunds\ Administration \LtrRefund- CancelPennit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
•
: , City of Tigard
T I G A R D 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: Johansen Electric DATE: 3/3/08
10948 SE Valley View Terr
Happy Valley, OR 97086 REQUESTED BY: Dianna Howse
Attn: Charlynn Leifsen
TRANSACTION INFORMATION:
Receipt #: 2007 -5009 Case #: ELC2007 -00761
Date: 11/9/07 Address /Parcel: 6650 S\V Redwood Ln., 105
Pay Method: CreditCard Project Name: Realty Exchange
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
[ELPRMT1 ELC Permit 220 - 0000 - 431510 $128.08
[TAXI 8% State Surcharge 100- 0000 - 207020 10.25
TOTAL REFUND: $138.33
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager
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
Case Refund Processed: I Date: I .3/_/(..:._V. I B I r-
I: \Building \Refunds \RefundRcquest.doc 05/23/07
17 1111 CITY OF TI.GARD 2/29/2008
13125 SW Hall Blvd. 10:52:234'M . •
Tigard, OR 97223 503.639.4171
TIGARD
Receipt #: 27200700000000005009 )/2/6-C-/p I.Z—
Date: 11/09/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELC2007 -00761 [ELPRMT] ELC Permit 220- 0000 - 431510 160.10
ELC2007 -00761 [TAX] 8% State Surcharge 100- 0000 - 207020 12.81
Line Item Total: $172.91
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
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CreditCard CHARLYNN LEIFSEN - DEB 842493 Fax 172.91
JOHANSEN ELECTRIC INC
Payment Total: $172.91
cltrropi.pt Page I of I
Er CITY OF T1.GARD 3/4/2008` _
13125 SW Hall Blvd. 10:07:06AM
Tigard, OR 97223 503.639.4171
TIGARD
Refund Receipt #: 27200800000000000695 / /t 7'2-S ..5
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Date: 03/04/2008
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
• ELC2007 -00761 Reversal - [ELPRMT] ELC Permit 220-0000-431510 (128.08)
ELC2007 -00761 Reversal - [TAX] 8% State Sure 100- 0000 - 207020 (10.25)
Line Item Total: ($138.33)
Refund:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Credit Reversal JOHANSEN ELECTRIC INC. 842493 Fax (138.33)
Refund Total: ($138.33)
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CITY OF TIGARD ELECTRICAL PERMIT
IN is
9 PERMIT #: ELC2007 - 00761
COMMUNITY DEVELOPMENT DATE ISSUED: 11/9/2007
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 2S112DA -01400
SrfE ADDRESS: 06650 SW REDWOOD LN 105 ZONING: I -
SUBDIVISION: PACIFIC CORPORATE CENTER LOT : 002 JURISDICTION: TIG
PROJECT: REALTY EXCHANGE
Project Description: TI
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: 12 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:
PACIFIC REALTY ASSOCIATES JOHANSEN ELECTRIC INC
15350 SW SEQUOIA PKWY #300 -WMI 10948 SE VALLEY VIEW TERR
PORTLAND, OR 97224 CLACKAMAS, OR 97015 -000
Phone: Contact #: PRI 503 - 698 -3417
FAX 503 - 698 -2486
FEES
Description Date Amount Reg #: ELE 3 -243C
IELPRMTI ELC Permit 11/9/2007 $160.10 LIC 51539
[TAXI 8 %State Surcharge 11/9/2007 $12.81
SUP 2053S
Total $172.91 REQUIRED ITEMS AND REPORTS
This Permit is issued subject to the regulations contained in the Tigard Muniapal 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 rules a set o in • = 952 - 001 -0010 through OAR 952 -001 -0100. You may obtain copies of these rules or direct questions to OUNC at
503.246.66 or 1.800. .2344.
Issued B /i , (f_.A,/4_,!)-1(i Permittee Signature. / d—c_--
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: . / #A_ 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.
. - I . //,
Electrical Permit AppaECE,
1111: UI. , I( I : 1 NI. ,,\
City of Tigard u Received
l ig 13125 SW Hall Blvd., Ti �T V 9 LUU I �� // i, Permit No.: EL1 , oO7,607
0 Tigard OR 9 Plan Review
Phone: 503.639.4171 Fax 50 598. ]960 Nazi Other Permit
I , , -,: I., Inspection Line: 503.639.0 I v 1f e 1 1� � Pte,
Internet www t -or. Jl 1 1111. Nate ReedyBy.
B NOtIfieNMethad
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rFIV i111h ,t i , u p ZEtit 1f1 '01 aaa�1`:ilffi �yJ i n �''' S CI fo s'�i• .- va1 I l its
i ric.::I�.: f �• udnv: J.-kaArl >-. �, r
❑ New construction ® Addition/alteration/replacement Please check all that apply (submit1 sets of
❑ Demolition ❑ Service or feeder 400 plans wfgva �� below):
c � 0 Other: �[ or more ❑ Building over three :reties.
Vii. , r `1j , 'llr SS }' l.s -'u s c ' I ' "Ac feu :: mazer a�r Ii1TRIL _ IporZ'Jtttl�' where the available 0sa fault outtat ❑ Marinas ®d boatyards.
rEm:`..l K;r'„ 1; � it +:•t a .. c;.�: •1 r; + t (3 < exceeds 10,000 amps : - �u Li} cni�'. Wtlia�rcd� 'C1eiLu:... *$rlecr �P ❑ Floating buildings.
❑ 1 -sad 2 - family dwelling ® CommerciaUindusnial ❑Accessory building less to groat orGxc 14.000 ❑commercial- useagrinilmral
amps For all othermetaWtieu. buildings.
❑ Multi - family ❑ Master builder ❑ Other. ❑ Fire pump. ❑ Installation of 75 KVA or
"1; � 1 ��eajat y.- caasgrl + Fat
r �r. l ` ". : c::: ri " i.:;: I n i r 7 w , n 1 I r �, u - a 'c
O i o �� ... (� �' [ Mt ❑ ergeAaS' tY�'+n• larger eeperetnly dwived s
'` �. ,fi,lfs -n�i� �ti;u3:�t�o_ -La:.� � + � ��itL1��, "cm.
n �� � r � �•� 6dtirlt �; ❑ Ad ditioe ae oew m otor load of ❑ -A" , •E•• "1.2 - "1 -3
Job no.: Job site address: ) KW Kid �ilanr i ❑ a
f 5 10011 or metro. occupancy. y.
six or more residential units. ❑ Reeetienal vehicle padts.
City /State/ZIP: ❑ Health -care ihatities. 0 Supply voltage for more than
❑ Hamrdoaa bcationa 600 volts nominal.
Suite/bldg./apt no.: ! Q fi 1 Project name: �l �X�d G ❑ service or
7 fonder 600 am or rranro
F; t{ rl!I! ; r . 1 .�:. � � s ,
t
Cross streeG'directions to job site: ,: i�l;;, i��tWtr +'ialNl��,:ks`c;,!:!,.;,i ° z. 18',:: s
_ natatadm am Ra Total •
New residential single- or multi - family dwelling unit
Includes attached garage.
Subdivision: 1 Lot no.: 1,000 sq. ft. or less 145.15 • 4
Tax map /par ccl no.: Ea add'l 500 sq. ft. or portion 33.40 1
' l - + *i;; ?'. a -�, ,nmw rtim cu r• -ra!n +� ,q r� rn Limited energy, residential
a. . ' kiagii;Eh l '!11Li :�i: � ' 4 ±� :t. .:._� "ice r R.:':I SI IK 1- ' fbised' i (with above seta It -) 75.00 2
r
� D rt . r .../. f �,, n�� L Limited rst energy, multi- family
e ai f / 'a'l T residential (with above sq. ft) 75.00 2
Services or feeders Installafio alteration, and /or relocation
,. +; �` +,' id a ax�r;w'pr ":.z�lE:up a t.. 1f ' IIv �r o t R 200 amps or less ' 80.30 2
i
.:... - 11 . Ill z i!�K ulG li �i Y .! 0 �.� f t
• ‘--P-4_/9- � ;;��;r�i.la COW' ; 201 amps to 400 snips 106.85 2
Name: — PA-e_ i i l C LTV 401 amps to 600 amps 160.60 2
Address: l - 601 amps to 1,000 amps 240.60 2
Over 1,000 amps or volts 454.65 , 2
City/State/ZIP: Temporary services or feeders Installation, alteration, and/or
I ) relocation
Phone: ( ) Fax: ( 200 amps or less 66.85 l 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.3 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, r panel
5~ _ A. Fee for branch circuits
i� ���� 1f��,, �� ���� °I1 I Pl ':.. I� ��� r a:;- 1pu,+. � „ fi�
;` mi f°> 1_MP :Il:i ilM ' ii ..:!: O N: tar 1 5 -i-lij ar Mss t, T�(1� a above service or feeder fee,
uc• d a,.�i,tfJSr'a. e 6.65 2
Business name: Johansen Electric Inc. each branch circuit 12. 1 q •Qd
B. Fee for branch circuits
Contact name: Charlynn Leifsen without service or feeder fee,
first branch circuit 46.85 2
Address: 10948 SE Valley View Teri. Each add'I branch circuit 6.65 2
City/State /ZIP: Clackamas, OR 97086 _Miscellaneous (service or feeder not included)
Each manufactured or modular
90.90 i
503 698 - 3417 dwelling, service ar d/or feeder
Phone:
(503) I Fax: (503) 698 -2486 Reconnect only .
E -mail: Johansenelectr msn.com y 66.85 2
Ia ,, , a :y y 'p� _ s� f Pump or irrigation circle 53.40 2
i:i ?:. = r:'?, 'n1hH, '. °! I iF :.I��:,:; '.i h ir bsillf�l INELE C L Sign or outline ling r 53.40
2
Business name: Johansen Electric Inc. Signal circuit(s) or limited -
energy panel, alteration, or
Address: 10948 SE Valley View Terr. extension. Describe: Page 2 2
City / State/ZIP: Clackamas, OR 97086 . Each additional inspection over allowable in any of the above
Phone: (503) 698 -3417 I Fax: (503) 698 - 2486 Per inspection 6250
Investigation per hour (I hi' TRW 62.50
CCB Lic.: 51539 I Electrical Lic.: 3-243C I Suprv. Lic.: 2053S Industrial -last • rhour 73.75
Suprv. Electrician si elute, Illllglrr' :� 1.11 !s7,t 7I. i TI i' !'110'T° r�� / I ' n/
gn required: 6 / ' tal ::.. a . /), / Dls.,t
`` (J �l �'11d �! Subtotal: / �n. ��
Print name: Carl Johansen Date: Plan review (25% o permit fee):
Authorized signature: 1 I 4�
/� State surcharge (8% of > /2,0/
J it fee):
TOTAL PERMIT FEE: 1 q
Print name: Charlyna Leifsen I Date: / b i - y This permit apptIcaden expires if a permit b not obtained within In / �/ /✓ / days ate It bas beta accepted as eoenplete-
r: SaiklinalPemitslELC- PereaitApp.the 05/23/06
• Number of inspections allowed par permit.
440.461 ST( 11/0S/COW WEa
T • d Xdd 13r I3Sd-i dH WdBE : T L002 60 AolJ