Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
1111 COMMUNITY DEVELOPMENT Permit#: ELR2015-00192
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/19/2015
Parcel: 1 S134BC00500
Jurisdiction: Tigard
Site address: 12388 SW SCHOLLS FERRY RD
Project: McDonalds Subdivision: 1993-057 PARTITION PLAT Lot: 1
Project Description: Installation of low voltage data for POS
Contractor: VICTORY SYSTEMS LLC Owner: MCDONALDS CORPORATION(36-0105)
2050 BEAVERCREEK RD 101-313 PO BOX 182571
OREGON CITY, OR 97045 COLUMBUS, OH 43218
PHONE: 503-956-9801 PHONE:
FAX:
FEES
Description Date Amount
Specifics: Restricted Energy Permit 08/19/2015 $75.00
12%State Surcharge-Electrical 08/19/2015 $9.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio&Stereo: 0 Boiler Controls: 0
CCTV: 0 Clock Systems: 0
Data&Telecommunications: 1 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 is -. - •--ct 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 ordance with -••roved •tans. This permit will expire if work is not started within 180 days of issuance, or if work i- suspended for more the 180
days. A ENTION: Oregon la .uire you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-01 -0010 through OAR 952-1, 0090. Y. may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1• or 1.800.3•2.2344.
I-sued By: /� , ! / Perm ittee Signature: 4 " `:
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 ApplicanCEI S EP FOR OFFICE USE ONLY
City of Tigard Received Q y/,
//��tt``rr Date/B : O�� VJ Permit G��/S•C.( / /
13125 SW Hall Blvd.,Tigard,OR ATIG 1 9 ?1,09 Plan Review
II Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Related Permit t
Inspection Line: 503.639.4175
CITY(if J'i Ready Date/By: ions: ® See Page 2 for
T1GAR1) Internet: www.tigard-oegov GAR)) Notified/Method: SupplementalInfurmation
Ti P714MIC nr"+SION PLAN REVIEW'
❑New construction A Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w'items checked):
El Demolition ❑Other: ❑Service or feeder 400 amps or more ❑Building over three stories.
where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10.000 amps at 150 volts or ❑Floating buildings.
❑ 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 40 LOCATION ❑Emergency system. larger separately derived
Job#: Job site address: ' pQ �J ❑Addition of new motor load of system.
I 1i23001sv %1„,„+'s krll a 100HP or more. ❑„A E„ l-2 1.3„
City/State/ZIP: 1,24/ "►7223 0 ❑He It more facilities. units. occupancy.
/J j ❑Health-care facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#: Project name: MCOo,l/I Gt(S 1(6-62 ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description i Qtr. I Each I Total I .
New residential single-or multi-family dwelling unit.
Subdivision: I Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'I 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
(with above sq.ft.) 75.00
L V i�(1t(/1 ��rl`I►1 7 D Y p S Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Renewable Energy ❑ See Page 2
❑ PROPERTY OWNER ❑ TENANT Services or feeders installation,alteration,and/or relocation
Name: 200 amps or less 100.70 2
Address: 201 amps to 400 amps 133.56 , 2
401 amps to 600 amps 200.34 _ 2
City/State/ZIP: 601 amps to 1,000 amps 301.04 2
Phone:( ) Fax: ( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08
Owner signature: Date: 401 amps to 599 amps 168.54 2
❑ APPLICANT I ❑ CONTACT PERSON 1 Branch circuits-new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
each branch circuit
Contact name: B.Fee for branch circuits without
Address: service or feeder fee,first 56.18
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
2
dwelling,service and/or feeder 67.84
Email: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84
Business name: Vtch S 4.04 g (../..(', Sign or outline lighting 67.84 2
+ Signal circuit(s)or limited-energy '0 See Pa e 2 2
A Address: `�50 feet ,r e Ail (Q( - '3 3 panel,alteration,or extension. g ��J _
City/State/ZIP: 0 rG `o C r l 0 745 Each additional inspection over allowable in any of the above
C a Additional inspection(I hr min) 66.25/hr
Phone:(rj03) 't5( _ et,i r I Fax:( ) — Investigation(1 hr min) 90.00/hr
-Email: V I c S i�S fe wi S 1 f @ 6 f Ma i 1• c6 m industrial plant(1 hr min) 78.18/hr
¢ Inspections for which no fee is 90,00/hr
CCB Lie.: i l i 3 I Electrical Lic• L134o I Suprv.Lic.: 30 31(.0 specifically listed(��hr min)
` ELECTRICAL PERMIT FEES
Suprv. Electrician signature,required: �1.
Subtotal: 1 5
Print name: a4 LI(ttL I Date: g I tot 1 i 0 Plan Review Required(25%of permit fee): -
State surcharge(12%of permit fee): Ci Cx-:
Authorized signature:
TOTAL PERMIT FEE: t? �
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
'r Number of inspections allowed per permit.
I:Building'Permits\ELC_PennitApp_ELR_ERE.doc Rev 06/17/2015 440.4615W1/05/COM/WEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
y FEE SCHEDULE
Fee for all residential systems combined: $75.00 p
AL WORK ONLY: _ I Qty. l each 1 Total I *
0 Description
Renewable electrical energy systems:
Check Type of Work Involved: s kva or less 1 00.70
5.01 to 15 kva 133.56
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301.04
50.01 to 100 kva 552.26
❑ Garage Door Opener* >100 kva(fee in accordance
with OAR 918-309-0040) 552.26 2
❑ 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:
n Other: Each additional inspection is 66.25/hr 1
charged at an hourly(I hr min) _
Inspections for\o hich no fee is 90.00/hr
specilically listed i'_hr min)
"" ELECTRICAL PERMIT
COMMERCIAL WORK ONLY: Subtotal(Enter on Page 1): I
Fee for each commercial system: $75.00 ■ Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
n Boiler Controls
❑ Clock Systems
Data Telecommunication Installation
,,p(
❑ Fire Alarm Installation
n HVAC
1 1 Instrumentation
Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
Nurse Calls
l 1 Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems: I
*No licenses are required. Licenses are required for all
other installations
1:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015