Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
1111 2 COMMUNITY DEVELOPMENT Permit #: ELR2013 -00162
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/09/2013
Parcel: 1 S 135BC00202
Jurisdiction: Tigard
Site address: 10763 SW GREENBURG RD 110
Project: Mattress Closeouts Subdivision: HILLSBORO Lot: PTS 1 -2
Project Description: Low voltage for HVAC
Contractor: WILLAMETTE HVAC LLC Owner: BELANICH, ROGER M
3075 SW 234TH AVE. #206 22020 17TH AVE SE #200
HILLSBORO, OR 97123 BOTHELL, WA 98021
PHONE: 503 - 259 -3200 PHONE:
FAX: 503 - 848 -2597
FEES
Description Date Amount
Soecittcs:, Restricted Energy Permit 07/09/2013 $75.00
12% State Surcharge - Electrical 07/09/2013 $9.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 0
Audio & Stereo: 0 Boiler Controls: 0
CCTV: 0 Clock Systems: 0
Data & Telecommunications: 0 Fire Alarm: 0
HVAC: 0 Instrumentation: 0
Intercom /Paging: 0 Landscape /Irrigation: 0
Landscape Lighting: 0 Medical: 0
Nurse Calls: 0 Protective Signal: 0
Security Alarm: 0 Other: 0 Total $84.00
Other Desc: Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordanr.. wi h approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. AT ON: Oregon :w requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules re set forth in OAR
952 -00 - 010 through OAR 952 -0 a 1 -. .' '. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800. .234
1
Is ued By: _AI" �� A. ! _..../ Permittee Signature:
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' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
Electrical Permit Application FOR OFFICE USE ONLY n n ecewed
City of Tigard ' Date/By: Q / 3 . ' Permit No.: L /C 4 Z'/ 3 eo 13125 SW Hall Blvd., Tigard, OR 972 Plan Review �i q 2_� 3 z
p
Phone: 503.7182439 Fax: 503.598.1960 Date/By: :
Other Permit: /` J 7
Inspection Line: 503.639.4175 JUL 9 2013 Date Ready /By: Juris: la See Page 2 for
TIGARD
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
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TYPE OF VI(4 T OFTIG" TIGARD PLAN REVIEW
❑ New construction ® Addition /alters � IV 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 El 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 E 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 ", "I -2 ' l -3
Job no.: I Job site address: 10763 SW Greenburg Rd IOOH more rest occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: Tigard, OR ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: HO I Project name: Mattress Closeouts ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: 1 Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 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
two thermostats residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: relocation
Phone: ( ) I Fax: ( ) 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 1 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 I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: same as below B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
Y dwelling, service and/or feeder
Phone: ( ) I Fax: : ( )
Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Signor outline lighting 67 84 2
CONTRACTOR Signal circuit(s) or limited - energy G t)
Business name: Willamette hvac LLC panel, alteration, or extension. I Page 2 7 2
Each additional inspection over allowable in any of the above
Address: 3075 SW 234 Ave Suite 206 Additional inspection (I hr min) 66.25/ hr
City /State /ZIP: Hillsboro, OR 97123 Investigation (I hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18 / hr
Phone: (503) 259.3200 1 Fax: (503) 848.2597 Inspections for which no fee is 90.00 / hr
specifically listed (%1 hr min)
CCB Lie.: 56951 Electrical Lie.: 34346CRE Suprv. Lic.: 4025LEB ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: 20,73te o al: — 7 5 •°�
Plan review (25 /o of permit fee):
Print name: mike sicard Date: 6/27/13 State surcharge (12 % of permit fee): ! •`0
^I A TOTAL PERMIT FEE: L/ Gb
Authorized signature: / jyf This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Michael Malstrom Date: 6/27/13
Number inspections allowed per permit.
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