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Permit RECEIVED l'i . , City of Tigard • COMMUNIIY DEVELOPMENI DEPARTMENT FEB 2 2015 N Request for Permit Action CITY OF TIGARD T 1 t,A R n 13125 SW Hall Blvd..• 'Tigard,Oregon 97223• 503-718-2439 •wlvw.tigard- {DING DIVISION TO: CITY OF TIGARD rit Building Division V 0 1 ‘1.1 13125 SW Hail Blvd,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov ,(p/4...4°. FROM: © Owner ❑ Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Do t:) 5.5— -_ Mailing Address: 2 p f f ll5 1,0 6�p'' Ay C.. � � City/State/Zip: T 5 ti d 2 ,-3_r - Phone No: S-03 —T3 .Y2---V7 PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓): e, CANCEL/VOID PERMIT APPLICATION - .'41IP REFUND 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#: EL e a o/y-004// Site Address or Parcel#: /514.5-DA- 06700 Project Name: ,3 , A _ Subdivision Name: / Lot#: n EXPLANATION: tV.J/ ito+ �p Cia i 1,,,, 1k. W iYi _. ha �ri�t,v.c/ Signature: 4 ,�_ �/ Date: / Print Name: I Refund Policy I The city's Community Development Ditectot,Building Official or City Engineer may authorize the refund ofi • 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. Air-74.4.46, _.,�" / • Not more than 80%of the application or petmit fee for issued permits prior to an inspection requests /2-C/onN 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 /QQ r 7a — Po .-5-4. 5 020• /y 42.a 1 — 9. _ FOR OFFICE USE ONLY Route to S s Admin: Date _ y— B -.1. Route to Records: Date _ 0� >tr- Refund Processed: Date. r fY Invoice Processed: Date 13.1 Permit Canceled: Date � celTa. Added: Date i:\BuikGng\Foans\RegPermitAction_I. 314.• • - A TIGARD City of Tigard February 26, 2015 Doug Ross 9240 SW 66th Ave. Tigard, OR 97223 Re: Permit No. ELC2014-00677 Dear Applicant: The City of Tigard has canceled the above referenced permits) and encloses a refund for the following: Site Address: 9240 SW 66th Ave. Project Name: Ross Job No.: N/A Refund Method: ® Check#216600 in the amount of$90.22. ❑ Credit card "return" receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit" receipt in the amount of$ Comment(s): 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 Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: Doug Ross DATE: 2/19/2015 9240 SW 66th Ave. Tigard, OR 97223 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 193530 Case#: ELC2014--00677 Date: 11/23/2014 Address/Parcel: 9240 SW 66th Ave. Pay Method: CreditCard Project Name: Ross EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees. REFUND INFOR1MATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 -$Amount Electric permit fee 220-0000-43103 $80.56 12% State surcharge 100-0000-24001 9.66 TOTAL REFUND: $90.22 APPROVALS: SIGNATURES./DATE: If under$3,000 Professional Staff 6 //:,7 If under$12,500 Division Manager If under$23,500 Department Manager If under$30,000 City Manager If over$50,000 Local Contract Review Board -• --FOR TIDEMARK SYSTEM ADMINISTRATION USE S LY Case Refund Processed: Date: _2 a6 id/ Or I:\Building\Refunds\RefundRequest.doc x 09/01/2010 11111 CITY OF TIGARD ELECTRICAL PERMIT s COMMUNITY DEVELOPMENT Permit#: ELC2014-00677 T[CARL) 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/25/2014 Parcel: 1 S 125DA00700 Jurisdiction: Tigard Site address: 9240 SW 66TH AVE Project: Ross Subdivision: 2006-073 PARTITION PLAT Lot: B Project Description: Replace service panel due to installation of new weather head and meter base. Contractor: OWNER Owner: ROSS, DOUGLAS LYNN DOUG ROSS 9240 SW 66TH AVE 9240 SW 66TH AVE TIGARD, OR 97223 TIGARD,OR 97223 PHONE: 503-936-8247 PHONE: 503-936-8247 FAX: FEES Quantity Description Date Amount 1 ea Services or Feeders-200 11/25/2014 $100.70 Specifics: amps or less 1 ea 12%State Surcharge- 11/25/2014 $12.08 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $112.78 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 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 the 180 days. ATTEN Oreg• law requires you to follow the rules adopted by the Oregon Utility Notification C-nter. Those rules - e set forth in OAR 952-001-0r r through OAR 95 01 - 0y1You may obtain a copy of the rules or direct questions to OUNC by calling 503.232. 7 or 1.800.332.2 -* Iss ed By: //s Permittee Signature: /r OWNER INSTALLATION ONLY The installation is being made on property I own h is not intended fo ,lease or rent. OWNER'S SIGNATURE �C i Date: //44—/ 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 City O Tigard # , Received ���� Permit#: tY f g DateB : /.(+7LILIiI`�5.1 f4/ /" Lb 67 ilh 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Phone: 503.718.2439 Fax: 503.598.1960 ) Date/B : Related Permit#: Inspection Line: 503.639.4175 Ready Date/By: Juris ® See Page 2 for I I G A R D Internet: www.tigard-or.gov (�, { ) Notified/Method: Supplemental Information j)++ 1ri r L TYPE OF Wblat7l}f',+TWIRIf f PLAN REVIEW ❑New construction tir Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked): ❑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. le I-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural amps for all other installations. buildings. ❑Multi-family ❑ Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived �� Job#: Job site address: A ii /O S + '` Y ❑Addition of new.motor load of system. [Y — 100HP or more. ❑"A","E City/State/ZIP: k ❑Six or more residential units. occupancy. ty �� 0.r O� �. ❑Health-care facilities. ❑Recreational vehicle parks. Suite/bldg./apt.#: Project name: (R ❑Hazardous locations. 0 Supply voltage for more than R`45s ❑Service or feeder 600 amps or more. 600 volts nominal. Cross street/directions to job site: Th_„j1)rs re eY-v, I L C� FEE SCHEDULE Description I Qty. I Each I Total I • New residential single-or multi-family dwelling unit. Subdivision: Lot#: Includes attached garage. Tax map/parcel#: 1,000 sq.ft.or less 168.54 4 Ea.add'l 500 sq.ft.or portion 33.92 1 DESCRIPTION OF WORK Limited energy,residential 75.00 2 }i- hl 1 (with above sq.ft.) W r ti 1`',e,� k Q0. h Ie_.J✓ E4.re- 1 fir emRAv— Limited energy,multi-family Co y J residential(with above sq.ft.) 75.00 2 GI PROPERTY OWNER ❑ TENANT Renewable Energy ❑ See Page 2 Services or feeders installation,alteration,and/or relocation Name: Dp R0 fy 200 amps or less I 100.70 j6,'�f 2 Address: 9� 4 s w//h�` 201 amps to 400 amps 133.56 2 7// Y n 401 amps to 600 amps 200.34 2 City/State/ZIP: -1--;5„...--,1 t!R 7'1 Ai�� 601 amps to 1,000 amps 301.04 2 Phone:(S3 ) Q3� _ y9. Y 7 Fax:( ) Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or Email: d D raS f 0--11.Q ya,he 1--t C. w relocation Owner installation:This irtitallation is being made on property that I own which is not 200 amps or less 59.36 1 intended for sale,lease,re or exchange,a rding to ORS 447,449,670,an 701. , 201 amps to 400 amps 125.08 2 Owner signature: Date: I/ /y 401 amps to 599 amps 168.54 2 pa-APPLICANT I lirCONTACT PERSON Branch circuits—new,alteration,or extension, set panel A.Fee for branch circuits with Business name: above service or feeder fee, 7.42 2 each branch circuit Contact name: B.Fee for branch circuits without service or feeder fee,first 56.18 2 Address: branch circuit City/State/ZIP: Each add'I branch circuit 7.42 2 Miscellaneous(service or feeder not included) _ Phone:( ) Fax: :( ) Each manufactured or modular 67.84 2 dwelling,service and/or feeder Email: Reconnect only 67.84 2 CONTRACTOR Pump or irrigation circle 67.84 2 Business name: Sign or outline lighting 67.84 2- Signal circuit(s)or limited-energy ❑ See Page 2 2 Address: panel,alteration,or extension. g City/State/ZIP: Each additional inspection over allowable in any of the above Additional inspection(1 hr min) 66.25/hr Phone:( ) Fax:( ) Investigation(1 hr min) 66.25/hr Email: Industrial plant(I hr min) 78.18/hr Inspections for which no fee is 90.00/hr CCB Lie.: Electrical Lie.: Suprv.Lie.: specifically listed(V:hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: Subtotal: W. .70 Print name: Date: ❑Plan Review Required(25%of permit fee): — State surcharge(12%of permit fee): 62.0 g Authorized signature: TOTAL PERMIT FEE: 0 a 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_ELR_ERE.docx Rev 04/21/2014 440-4615T(11/0S/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Description I Qty. I Each l Total I * Fee for all residential systems combined: $75.00 Renewable electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 2 5.01 to 15 kva 133.56 2 n Audio and Stereo Systems* 15.01 to 25 kva 200.34 2 Wind generation systems in excess of 25 kva: n Burglar Alarm 25.01 to 50 kva 301.04 2 50.01 to 100 kva 552.26 2 ❑ Garage Door Opener* >100 kva(fee in accordance 552.26 2 with OAR 918-309-0040) ❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva: System* Each additional kva over 25 7.42 3 Vacuum Systems* >100 kva—no additional charge 0.0 3 Each additional inspection over allowable in any of the above: Other: additional inspection is 66.25/hr 1 charged at an hourly(1 hr min) Inspections for which no fee is 90.00/hr specifically listed(%z hr min) , ELECTRICAL PERMIT FEES COMMERCIAL WORK ONLY: Subtotal(Enter on Page 1): Fee for each commercial system: $75.00 Number of inspections allowed per permit. (SEE OAR 918-309-0000) Check Type of Work Involved: n Audio and Stereo Systems n Boiler Controls Fl Clock Systems ❑ Data Telecommunication Installation n Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems n Landscape Irrigation Control* PI M• edical ❑ N• urse Calls n Outdoor Landscape Lighting* Protective Signaling n Other: Total number of commercial systems: *No licenses are required. Licenses are required for all other installations L\Building'Permits'ELC_PennitApp_ELR_ERE.docx Rev 04/21/2014