Permit Support Document CITY OF TIGARD
ELECTRICAL PERMIT
11111v ® Permit#: ELC2014-00711
1 +� COMMUNITY DEVELOPMENT �
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/11/2014
T F{''�� Parcel: 2S101 DC00200
Jurisdiction: Tigard
Site address: 13535 SW 72ND AVE 110
Project: Umpqua Bank Subdivision: 72ND BUSINESS CENTER Lot: 13
Project Description: Install power and lighting circuits for TI as per plans. 1/13/15,reprinted to correct suite address to 110.
Contractor: ERTELL ELECTRIC LLC Owner: PNWP LLC#2
PO BOX 279 BY PACIFIC NW PROP LTD PTNSP
FOREST GROVE,OR 97116 PO BOX 2206
BEAVERTON, OR 97075
PHONE: 503-841-4511 PHONE:
FAX: 503-359-5652
FEES
Quantity Description Date Amount
10 crt Branch Circuits wo/Purchase 12/11/2014 $122.96
Specifics: Service or Feeder
1 ea 12%State Surcharge- 12/11/2014 $14.76
Type of Use: COM Electrical
Class of Work: ALT 45 Misc Administration Fee 01/13/2015 $45.00
Type of Const:
Occupancy Grp:
Total $182.72
Required Items and Reports(Conditions)
This perm issued subs-• to the regulations contained in the Tigard Municipal Code, State of OR Specialty Codes and all other applicable law. All work will
be do in accordance with ap roved pl..s. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
day . ATTENTION: Oregon law r=. ires you • follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
95 -001-0010 through OAR 952-00/0090. Y_l tain a copy of the rules or direct questions to OUNC by calling 503.232.19 74..8�0.33 .2344.
/ 1 �
sued By: / «�'� Permittee Signature:
f 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.
pplCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
TIGARD 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 121 City Staff
Check(1)one
REFUND OR Name: l
INVOICE TO: (Business or Individual) -
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑ CANCEL/VOID PERMIT APPLI : ION.
❑ REFUND PERMIT F . ach copy of original receipt and provide explanation below).
❑ INVOICE F• ' ES DUE (attach case fee schedule and provide explanation below).
❑ RE Id i I /REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit #: ei-C c9O/`/-00 7//
Site Address or Parcel #: /3 53 5 ,,, LA..) 7 a - '6.- cT--"*I/O
Project Name: tb-//4Q/4 fi• Z,4 )4
Subdivision Name: /� Lot#:
EXPLANATION: IL ,t3 rt f►CTO2) fr 1 17 C ih4 t3 et,E- `du 1 T(--
iik i i--I /oo lb. 110. ialOthf. c, ATS77L€ S d4 P■Vb v,J
�r_ I PT (07 4 •e°
Signature: L , ,.,,, z_ . = Date: //;//5`
Print Name: gi ,47>9,-t./5A /
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.
FOR OFFICE USE ON 1.1
Route to Sys Admin: Date By Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Building\Forms\R(xi Perm;t:\etion_092314.doc