Permit MAR. 31. 2015 8: 06AM 5032397038 NO. 1768 P. 1
RECeirrep City of T igard • COMMUNITY DEVELOPMENT DEPARTMENT
I Request for Permit Action MAR 31 ?Ol
5
t.D 13125 SW Hall Blvd.• Tigard,Oregon 97223 • 503-718-2439•
TO: CITY OF TIGARD \ittl D
Building Division
13125 SW Hall Blvd..Tigard,OR 97223 ? l /Oil"
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits(ct tigard-or.go. , 7
FROM: ❑ Owner 7-] Applicant ❑ Contractor ❑ City Staff
Check( )one
REFUND OR Name: ` l
INVOICE TO: (Business or Individual) h H,V)L.(1 LL-h Ir� .•�IVl 4
Mailing Address: 5 035 IA tZ
city/State/Zip: 964. 1 0-►
Phone No.: 5,c7 ';-361 440°
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (0):
❑ CAN OID PERMIT APPLICATION.
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#: R .O15 - 000 VI
Site Address or Parcel#: 1O t.&) 5t4 ��,r �, a )d
Project Name: C)kG
Subdivision Name: Lot#:
EXPLANATION: Cl Ss . A.,Li A'l G no ° uIf7c r ke
Signature: Date: 3-g1- 15
Print Name:
Egoirsiki
1 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 fern of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests, 75 Q,oD r /5 0-1)
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Route to -Admin: Date ERNE Route to Records: Date A7/tgEf✓,ir'��
Refund Processed: Date_ �ffin TAM Invoice Processed: Date g
Permit Canceled; Date 'jgi1 M�±rte •arcelT. Added: Date 1011
I:\Buff. g\Forms\RegParmitAttior,0.23 4.doc
311 . .
TIGARD
City of Tigard
May 7, 2015
American Heating
Attn: Brandon Hutchinson
5035 SE 24th Ave.
Portland, OR 97202
Re: Permit No. ELR2015-00089
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10250 SW Greenburg Rd., #101
Project Name: Bike Storage
Job No.: N/A
Refund Method: ® Check #217265 in the amount of$67.20.
❑ Credit card "return"receipt in the amount of$
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 building is pnuematic and no electrical is
required. 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
s " 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 fir 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: American Heating DATE: 4/30/2015
Attn: Brandon Hutchinson
5035 SE 24`''Ave. REQUESTED BY: Dianna Howse
Portland, OR 97202
TRANSACTION INFORMATION:
Receipt#: 200016 Case #: ELR2015-00089
Date: 3/30/2015 Address/Parcel: 10250 SW Greenburg Rd.#101
Pay Method: CreditCard Project Name: Bike Storage
EXPLANATION: Per applicant's request as building is pnuematic and no electrical is required. Refund
80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATrURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ON Y
Case Refund Processed: Date: c.S77 C� By:
I:\Building\Refunds\RefundRequest.doc s 09/01/2010
CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
1111 s COMMUNITY DEVELOPMENT Permit#: ELR2015-00089
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/30/2015
Parcel: 1 S135AB04500
Jurisdiction: Tigard
Site address: 10250 SW GREENBURG RD 101
Project: Bike Storage Subdivision: 1991-055 PARTITION PLAT Lot: 1
Project Description: Low voltage for HVAC
Contractor: AMERICAN HEATING INC Owner: LINCOLN CENTER LLC
5035 SE 24TH AVE BY SHORENSTEIN PROPERTIES LLC
PORTLAND,OR 97202-4765 555 CALIFORNIA ST 49TH FL
SAN FRANCISCO, CA 94104
PHONE: 503-239-4600 PHONE:
FAX: 503-239-7038
FEES
Description Date Amount
Specifics: Restricted Energy Permit 03/30/2015 $75.00
12%State Surcharge-Electrical 03/30/2015 $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 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. ATTENTI•• . • ••n law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-001. rough OAR •.2-001-.••0. You may yoobtain/a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800,332.2344.
✓V_ 4--
Issued : k4 Permittee Signature: _I l
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 A lic r- FOR OFFICE I.SE O\1.1
City of Tigard C D Received
EFS/WM..11 Permit No. 4 '„/ Yg
13125 SW Hall Blvd.,Tigard,OR MAD!; 0 2015 Plan Revie �1��a�iS �73
IN is Phone: 503.718.2439 Fax: 503.598.1 6tj Date/By: Other Permit: --CCn� tr ��
Ti GA 1'D Inspection Line: 503.639.417T/TM OF Date Ready/By: Juris. ® See Page 2 for
Internet: www.tigard-or.getArl,,O -...fr RD Notified/Method: Supplemental Information Div
iji BI TYPE OF WORK ION PLAN REVIEW
111 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.
LI 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 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system.
❑Addition of new motor load of ❑"A”,"E","l-2","1-3",
Job no.: 115105 Job site address: 10250 SW Greenburg Road l001IP 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.: 101 Project name:bike storage @ lincoln IV ❑Service or feeder 600 amps or more
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I 'totat I •
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision: 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 7500 2
low volt wiring and T-stats residential(with above sq ft.)
Renewable Energy ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
0 PROPERTY OWNER ❑ TENANT 200 amps or less 100.70 2
201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
Address: 601 amps to 1,000 amps 301.04 2
Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
Phone:( ) Fax:( ) relocation
200 amps or less 59.36 1
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: Branch circuits—new,alteration,or extension,per panel
® APPLICANT I ® CONTACT PERSON A.Fee for branch circuits with
above service or feeder fee,
Business name:American Heating Inc. each branch circuit 7.42 2
B.Fee for branch circuits without
Contact name:Brandon Hutchinson service or feeder fee,first 56.18 2
branch circuit
Address:5035 SE 24'h Ave. Each add'l branch circuit 7.42 2
City/State/ZIP:Portland,OR.,97202 Miscellaneous(service or feeder not included)
Each manufactured or modular 67.84 2
Phone:(503)239-4600 Fax::(503)239-7038 dwelling,service and/or feeder
Reconnect only 67.84 2
E-mail:b.hutchinson @americanheating.net Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2 i
Business name:American Heating Inc. Signal circuit(s)or limited-energy I See
panel,alteration,or extension. Page 2 2
Address:Brandon Hutchinson Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
City/State/ZIP:Portland,OR.,97202
Investigation(1 hr min) 66.25/hr
Phone:(503)239-4600 Fax:(503)239-7038 Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: 33135 Electrical Lic.: 26993CRE Suprv.Lic.: 2640LEB specifically listed(%]hr min) _
lirale/A.,{� ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: / Subtotal:
Print name: T Steve Young Date: , 25'LS Plan review(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: �� TOTAL PERMIT FEE:
�'r./f This permit application expires if a permit is not obtained within 180
Print name: Brandon Hutchinson Date: days after it has been accepted as complete.
Number of inspections allowed per permit.
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Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE
Fee for all residential systems combined ... $75.00 Description 1 Qt•. I Fee I Total I •
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
nBurglar Alarm Wind generation systems in excess of 25 kva:
25.01 to 50 kva 301.04 2
n Garage Door Opener* 50.01 to 100 kva 552.26 2
>100 kva(fee in accordance with 552.26 2
N ❑ Heating,Ventilation and Air Conditioning OAR 918-309-0040)
System* Solar generation systems in excess of 25 kva:
Each additional kva over 25 7.42 3
I I Vacuum Systems* >100kva—no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
n Other: Each additional inspection is 66.25/hr 1
charged at an hourly(1 hr min)
Inspections for which no fee is 9000/hr
specifically listed('/,hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system $75.00 Subtotal:
(SEE OAR 918-309-0000) Plan review,if required(25%of permit fee):
State surcharge(12%of permit fee):
Check Type of Work Involved: TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Audio and Stereo Systems days after it has been accepted as complete.
• Number of inspections allowed per permit.
I I Boiler Controls
n Clock Systems
n Data Telecommunication Installation
n F• ire Alarm Installation
n HVAC
n Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
❑ M• edical
❑ N• urse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
❑ Other
Total number of commercial systems: _
*No licenses are required. Licenses are required
for all other installations
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