Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT EXPIRED
: Request for Permit Action /%y//y
TI G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(1)gym.
REFUND OR Name: ��
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
i P ASE T: .� ACTION FOR THE ITEM(S) CHECKED (1):
0 CANCEL OID PERMIT APPLICATION.
V . I D PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: Eke 2c/ 3- OO �o Co 4`
Site Address or Parcel#: /o 35-0 6 C4f4gt.t -a & .
Project Name: a ct-sTA-' 1 S
Subdivision Name: I Lot#:
EXPLANATION: c/J c Li AL- '/2/d C,q-T/o�/ .2 1.J3
_ 1. /S a . cc l° L ' . •r e .. >:/J r - /. Ate
5 Et/E4Q-- /5-Ea , — • W. 57j °"' SF / ile /
Signature: ■ C� Date: /D/(y//f/
Print Name: / Cg4/f /47J 4/1-16A I
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
I OR OFFICE USE ONLY
Route to S s Admire: Date eAYE'I'IFp Route to Records: Date ld®2'M B V°Ma
Refund Processed: Date At �j By Invoice Processed: Date By
Permit Canceled: Date ite y//� By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 231 .doc
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard , Reccoecd ,
'I- i; i ii i' ' Datdill
t..-: " 13125 SW Hall Blvd.,Tigard,OR 97223 Y fi, .i,„i I T "-. ! RovY.'
opil „,,,,„„i 4,,,y.. ,,e1 ma No —;"' „
: 1hone 503.718.2439 Fax: 503.598.1960 Dine./By. "htliPiefmli C4),.10 13—
Inspection Line: 503 639 4175 Dale Ready/By hint la See Page 2 fur
I 1MARD
Internet: www.tigard-ot.gov tiny 4 251 Now.iimoh,,,i , f Supplemental information
TYPE OF WORK ,' PLAN REVIEW —I
0 New construction El Additionialteratii4 P.1enscCi,ack all that apply tsub;:i sets of plans vs/items checked below)
0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition 0 Other: 'Pill there the available fault current 0 Marinas and boatyards
CATEGORY OF CONSTRCCUION
ilkv,latig;N c 1,1)1(iNj.:ti IRsii..N
exceeds 10,000 amps at 150 volts or 0 Floating buildings
less to ground,or exceeds 14,000 0 Commercial-use agricultural
a I-;Ind 2-1amily duelling I2 Commerciallindustrial El Accessory building amps for all other UW303110115 buildings.
D Mtilliiirtimil) El Master builder 0 Other: OF"PumP. 0 Installation of 150 KVA or
0 Emergency system larger separately derived system
.1(111 Sill INFORM‘1 BIN AND LOCATION °Addition of DCW motor load of
—
occupancy
Joh no.: Job site address: 10350 SW Greenburg Rd
a sis 100HP or more Of more residential units 0 Recreational vehicle parks.
City/Stale/ZIP:Portland/OR/97223 0 Health-care facilities 0 Supply voltage for more than
0 Hazardous locations 600 volts nominal
Suite/bldg./apt.no.: I Project name:Gustav's El Service of feeder 600 amps ig mole
FEE SCHEDULE
Cross street/directions to job site: Derrriptier i Iv. I Fee. Tora_tl_i_i:
' New residential single.Or multi-family dwelling unit.
Includes attached garage. ..
Subdivision: 1 Lot no.: 1,000 sq.it.or less .,..._ 168.54 4
Ea addi 500 so it or portion i 33.92 1
Tax map/parcel no.: i
Limited energy:,residential
Ill s titirrioN oF WORK (with above sq. tt) 75,00 2
Limited energy.multi-film ily i
75 00 I
Install(2)Illuin i mit cti all signs to replace existing wall signs on South residential(With above sil It 1 -
--.._.—....
Renewable Energy_ i 0 See Pale 2
& East elevations Services or feeders installation.alteration,a ritl?or relocation
CD PROPERTY OWNER 0 TENANT 200 amps or less 100.70 2
, 201 amps to 400 amps 133.56 2
Name:tauten Foods,Inc
401 amps to 600 amps 20034 2
Address: PO Box 130 0 68 601 amps to 1,00 amps 301.04 2
Over!Jam amps or volts 552.26 2
City/State/ZIP;Portland/OR/97213 Temporary services or feeders installation,alteration,and/or
Phone:(503)249-0507 Fax:( ) relocation
200 amps or less 59.36 I
Owner installation:This installation is being made on property that I own which is not _..
201 amps to 400 amps 125 08 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701.
401 amps to 599 amps 168.54 2
Owner signature: Date: BratichcircLitts:new,alteration,or extension,per panel
El APPLICANT j_ i kl I 11 IC■r7\7 A 1-7,...t; or branch circuits with
above,service or feeder fee,
7.42 2
Business name: ES&A Sign&Awning each brunch circuit ,
B.Fee for branch circuits WilhOW
Contact name:Jenny Oberst service or feeder fee,first
56.18 2
branch circuit
Address:89975 Prairie Rd Each add'Ibranch circuit 7.42 _ 2
Miscellaneous(service or feeder not included)
City/State/ZIP: Eugene/OR/97402 —
Each manufactured or'nodular
67 84 2
Phone:(541)868-2389 Fax: :(541)485-5813 dwelling,service and/or feeder
Reconnect only 67,84 2
E-mail:joberst(a)esasigns.com
Pump or irrigation circle 67,84 2
CONTRACTOR . Sign or outline lighting 2 67.84 135,68 2
Business name:ES&A Sign&Awning Signal en:curds)or limited-energy See
panel,alteration,or extension. Page 2 2
Address:89975 Prairie Rd Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66,25/hr
City/StateiZIP, Eugene/OR/97402
Investigation()hr min) 66.25/hr
......._ ,........
Phone:(541)485-5546 Fax:(541)485-5813 Industrial plant(I lir nun) 78 I ft/hr
Inspections for which no lee is
CCB Lie.: 163470 Electrical Lie,: 20543 O.. Suprv.Lic.: 514-SIC specifically listed('4,hr min) 90.00/hr
—...-
ELECTRICAL PERMIT FEES
f __
-
Suprv.Electrician signature.required: 4 .
..,`Tx..... 6—s---.4? Subtotal. 135 68
Print natne: Gordy Roseboro Date: 10/28/13 Plan review(25%of permit fee):
State surcharge(12%of permit fee): 16 28
Authorized signature: TOTAL PERMIT FEE: 151 06
This permit application expires int permit is not obtained within 180
m
Print name: Jenny Oberst Date: 10/28/13 days after it ban been accepted as complete.
* Number of inspections allowed per permit.
I 111oildan41,Pcsmitsfir PermitApp_r.1..R..ERE due Rev 05/2 I/20i.) 440-4615111 I dArCONINVEll