Permit EXPIREK-R ,, "''.'
Electrical Permit Application - -� , 9 F(1IR 01 I It I I til ONIA
4 f eceived c ►
IN 4 City of Tigard Date/By: / �4 D8 'I Permit No. C`�C �,,,dip• 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
III Phone: 503.639.4171 Fax: 503.598.1960 DateBy: Other Permit:
TI G A K D Inspection Line: 503.639.4175 Date Ready . �lud3 0 See Page 2 for
Internet: www.tigard-or.gov
i-� w� t AH�A� Notified/Method: 1 �n Supplemental Information
-
TYPE OF iWOR110.1 Q V!S r QN PLAN REVIEW
❑New construction ❑Addition/alteration/replacement PIe a 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 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.:409580 Job site address: 12785 SW Pacific Highway Six or or more. 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.: Project name: Burgerville ❑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: Lot no.: 1,000 sq.ft.or less 145.15 4
Ea.add'I 500 sq.ft.or portion 33.40 I
Tax map/parcel no.: Limited energy,residential 75.00 2
DESCRIPTION OF WORK (with above sq.ft.)
Limited energy,multi-family
Tenant buildout and remodel per plans 75.00 2
P P residential(with above sq.ft.)
Services or feeders installation,alteration,and/or relocation
200 amps or less Z- 80.30 /'t6�GD 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps Z 106.85 7/3,176 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 / 454.65 454`"12
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, cg f7C
Business name: Broadway Electric each branch circuit 6.65 ��1. 2
Y B.Fee for branch circuits
Contact name:Jeff Holmes without service or feeder fee, 46.85 2
first branch circuit
Address:626 SE Main Street Each add]branch circuit ( 6.65 j j 2
Miscellaneous(service or feeder not included)
City/State/ZIP:Portland,OR 97214 Each manufactured or modular 90.90 2
Phone:(503)234-6564 Fax: :(503)238-2098 Reconnect
dwelling,service and/or feeder
Reconnect only 66.85 2
E-mail:jholmes @cochraninc.com Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name: Broadway Electric Signal circuit(s)or limited
energy panel,alteration,or
Address:626 SE Main Street extension.Describe: Page 2 2
City/State/ZIP: Portland,OR 97214 Each additional inspection over allowable in any of the above
Per inspection 10; . + 62.50
Phone:(503)234-6564 Fax:(503)238-2098 Investigation per hoar(1 hr min) 62.50
CCB Lie.: 72942 Electrical Lie.: 37-546C Suprv.Lie.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: f Subtotal: J 441x,70
1 I
Plan review(25%of permit fee): 34,5,I E,
Print name: �V.� .�i Date: t--2._fti 09 State surcharge(12%of permit fee): /7.5,'Z$
Authorized signature: TOTAL PERMIT FEE: Zanl /4'
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
1.\Building\Permits\ELC-PermitApp.doc 05/23/06 440-46151(11/05/COWNEB /Jsr/'—d e
/ v I
(�f (f
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating,Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
LI Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ 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
Electrical Permit Application FOR OFFICE USE ONLY
Race/By: �� O E�.0 ZooB ��
City of Tigard may. Permit No.: G
III
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 �/ Plan Review I V/? Other Permit:
T I GARD Inspection Line: 503.639.4175 V- Date Ready/By: Juris 0 See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑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 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","I-2","1-3°,
Job no.: Job site address: 12:1%5 5 us PAc_ n,L g W I. 100HP or more. R c reation
Six or more residential units. ❑Recreational vehicle parks.
City/State/ZIP: ❑Health-care facilities. ❑Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name: ❑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: Lot no.: 1,000 sq.ft.or less 145.15 4
` Ea.add'l sq.ft.or portion 33.40 1
Tax map/parcel no.: .�
Limited energy,residential 75.00 2
DESCRIPTION OF WORK (with above sq.B.)
I Limited energy,multi-family
75.00 2
ij :L. `J a.i> ,..-d•.;‘,./r 3 a ",� V\ C.N residential(with above sq.ft.)
r�m \ E {L- V` . > Services or feeders installation,alteration,and/or relocation
W + 200 amps or less 3 80.30 Z4 b.90 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps LI 106.85 421.40 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 1451.Is' 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 ❑ CONTACT PERSON above service or feeder fee, 9 I 6.65 60s 2
each branch circuit
Business name: B.Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'l 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
Business name: Signal circuit(s)or limited-
energy panel,alteration,or
Address: extension.Describe: Page 2 2
City/State/ZIP: Each additional inspection over allowable in any of the above
Per inspection 10.%•016 1 62.50 1256
Phone:( ) Fax:( )
Investigation per hour(1 hr min) 62.50
CCB Lic.: Electrical Lie.: Suprv.Lic.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: I 79Q,6CJ
Print name: Date:
Plan review(25%of permit fee): 41j. ,b 5
State surcharge(12%of permit fee): 2i 4.a'7
Authorized signature: TOTAL PERMIT FEE: 2153, 12
Print name: Date: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:\Building\Permits\ELC-PermitApp.doc 05/23/06 440 3615T(t1/05/COM/WEB
Electrical Permit Application - City of Tigard
Page 2- Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined $75.00
Check Type of Work Involved:
n Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating,Ventilation and Air Conditioning System*
n Vacuum Systems*
n Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.0
system
(SEE OAR 918-309-0000)
Check Type of Work Involved:
n Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
n Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
n Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
❑ 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
Broadway Electric
624 SE Main Street
Portland, OR 97214
ATTN: Jeff Holmes
Date: Oct. 3, 2008
Project: Burgerville
12785 SW Pacific Hwy.
Tigard, OR
Dear Jeff,
The plan review for the above mentioned project was started on Sept. 30, 2008.
Correct information is required for the completion of the plan review.
Please submit the information requested below as soon as possible to facilitate the plan
review.
1. The information submitted on Sheet E-500 is inaccurate and/or incomplete.
Feeders are mislabeled.
2. The information submitted on sheet E-800 is inaccurate and/or incomplete.
Load calculations for Panels K1 and K3 are inaccurate.
Signed,
Gary Noble
Electrical Plans Examiner
City of Tigard, OR --N I
•
Phone: 503.718.2446 A l i—b.'
Fax: 503.624.3681
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;III • CITY OF TIGARD
Building Division
TIGARD 13125 SW Hall Blvd.,Tigard,OR 97223 503-639-4171
INVOICE
TO: Broadway Electric Customer ID: 72942
626 SE Main St. Invoice No.: INV2008-00019
Portland, OR 97214 Invoice Date: 10/24/08
Atm: Jeff Holmes Date Due: Upon Receipt
Case No. Site Address Subdivision Lot#or Project Name Amount Due
ELC2008-00548 12785 SW Pacific Hwy Burgerville $447.65
$ I 4 Di
/4 '2
Invoice Total: $447.65
® Please see attached fee schedule for description of fees due.
(Detach and return this portion with payment.)
Case No.: ELC2008-00548 Customer ID: 72942
Site Address: 12785 SW Pacific Hwy Invoice No.: INV2008-00019
Project: Burgerville Invoice Date: 10/24/08
Date Due: Upon Receipt
Invoice Total: $447.65
Amount Paid: $
Office Note: Please forward copy of receipt to Dianna Howse.
Please mail payment to:
City of Tigard,Building Division
13125 SW Hall Blvd.
Tigard, OR 97223
Attn: Dianna Howse
I:\Building\Accounting\Invoice.doc 04/06
CITY OF TIGARD 10/24/2008
111111 • Fees Associated With 9:24:34AM
I. 13125 SW Hall Blvd.
TIGARD Tigard,OR 97223 503.639.4171 Case #: ELC2008-00548
Fee Start End Revenue Created
Type Date Date Dept Description Account Number By Date Amount Due
PRMT 1/1/1990 12/31/2020 [ELPRMT] ELC Permit 220-0000-431510 GN 10/24/2008 1,790.60 1,790.60
PLCK 1/1/1990 12/31/2020 L[ELPLCK] ELC Pin Rev _ 220-0000-433040 GN 10/24/2008 447.65 �,447.65-
1
SUR1 12/31/2007 12/31/2020 [TAX] 12%State Surcharge 100-0000-207020 GN 10/24/2008 214.87 214.87
Total Due: $2,453.12
Page 1 of 1 CaseFees..rpt
C 11/19/2008
111 CITY OF TIGARD
_ 13125 SW Hall Blvd. i.49:04PM
Tigard.OR 97223 503.639.4171
TIGARD
Receipt #: 27200800000000003906
Date: 11/19/2008
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELC2008-00548 [ELPLCK] ELC Pin Rev 220-0000-433040 447.65
Line Item Total: $447.65
Payments:
Method Payer User ID Acct./Check No. Approval No. How Received Amount Paid
Check BROADWAY ELECTRIC DLH 9479 By Mail 447.65
Payment Total: $447.65
(Detach and return this portion with payment.)
Case No.: ELC2008-00548 Customer ID: 72942
Site Address: 12785 SW Pacific Hwy Invoice No.: INV2008-00019
Project: Burgerville Invoice Date: 10/24/08
Date Due: Upon Receipt
Invoice Total: $447.65
Amount Paid: $
Office Note: Please forward copy of receipt to Dianna Howse.
Please mail payment to: REG.It3E'. "
t p-- :, )
..
City of Tigard,Building `
13125 SW Hall Blvd. g Division
Pf 0!/ t c 2"--3
Tigard,OR 97223
CITY E AR€
Attn: Dianna Howse
9./..Ht r"t. tfr. nlol�?9P 181
I:\Bwlding\Accounting\Invoicc.doc 04/06
cReceipt.rpt Page 1 of I
' Community Development
Request for Permit Action
TIGARD
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name: ��
1 •DICE T I (Business or Individual) t /C
Mailing Address: 6 lQ `j L /4dii4 /5/
City/State/Zip: 474ØJ (2/G 17 / /
Phone No.: 3L/_ 1/51,V
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑ CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt,if available). w r,
INVOICE FOR FEES DUE (attach case fee schedule and explain below). LeIW6 /nl / SAS
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit#: t /�■08g�Dt
Site Address or Parcel#: /a 7 g s-- ; !Z Aft- mil
Project Name: - Y//
Subdivision Name: Lot#:
EXPLANATION: / X'A)5 A11 / / ei //i/�P
tP/Ai i‘ed' Atulyie't4,"
m A
Signature: Date: / 0/....a.„2141 g
Print Name: Gtirl' i 1,0a1.1-2.:" '
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'o 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.
d) not more than 80%of the building plan review fee 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 Sys Admin: Date By Rte to Bldg Admin: Date By
Refund Processed: Date By Invoice Processed: Date /0/19/0 t
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forts\RegPermitAction.doc Rev 07/26/07