Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
$ ' COMMUNITY DEVELOPMENT Permit#: ELR2016-00001
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/21/2016
Parcel: 1S134BC00401
Jurisdiction: Tigard
Site address: 12442 SW SCHOLLS FERRY RD
Project: Providence Medical Group Subdivision: GREENWOOD TERRACE CONDO Lot: 17
Project Description: HVAC low voltage for RTU replacement.
Contractor: AMERICAN HEATING INC Owner: PROVIDENCE HEALTH SYSTEM-OREGO
5035 SE 24TH AVE ATTN: REAL ESTATE&CONSTRUCTION
PORTLAND, OR 97202-4765 4400 NE HALSEY BLDG 2 STE 190
PORTLAND, OR 97213
PHONE: 503-239-4600 PHONE:
FAX: 503-239-7038
FEES
Description Date Amount
Specifics: Restricted Energy Permit 03/21/2016 $75.00
12%State Surcharge-Electrical 03/21/2016 $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: 0 Fire Alarm: 0
HVAC: 1 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. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obt. .copy o - les or direct questions to OUNC by calling 503.232.1987 or 1.80
.332.23 .
Issued By: i' ��,. w= Permittee Signature: '/?`
/�
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 Application FOR OFFICE USE ONLY
Received ���
City of Tigard Date/By: I Z///V 451 Permit No.: 0L402,0lb••,,(, 1toic)I
,71 0 13125 SW Hall Blvd.,Tigard,OR 9722 Plan Review
C Phone: 503.718.2439 Fax: 503.598.1960Date/By: Other Permit: aDllo—(xxu3
TI GARD Inspection Line: 503.639.4175 . .,, 4 g 116 Date Ready/By: Ju�ris: � RI See Page 2 for
Internet: www.tigard-or.gov Notified/Method: /-�-f'P Supplemental Information
1 TYPE or W0 . , N , . PLAN REviEw.
❑New construction ®Addition/alteratio t •:< Please check all that apply(submit 2 sets of plans w/items checked below):
❑Service or feeder 400 amps or more 0 Building over three stories.
El Demolition 1=1 Other: rwhere the available fault current ❑Marinas and boatyards.
": A F O iif,;tF e0r4S1 Iwcnoi exceeds 10,000 amps at 150 volts or 0 Floating buildings.
` -> less to ground,or exceeds 14,000 0 Commercial-use agricultural
❑ 1-and 2-family dwelling ®Commercial/industrial 0 Accessory building amps for all other installations. buildings.
❑Multi-family 0 Master builder ❑Other: ❑Fire pump. 0 Installation of 150 KVA or
0 Emergency system. larger separately derived system.
JOBS E.Ii?iFO ATION AND LOCATION+, ❑Addition of new motor load of ❑"A","E","1-2","1-3",
100HP or more. occupancy.
Job no.:215624 Job site address:12442 SE Scholls Ferry Rd ❑Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIP:Tigard OR 97223 ['Health-care facilities. ❑Supply voltage for more than
0 Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name:Prov Scholls RTU-3 Replac ❑Service or feeder 600 amps or more.
FEE SCHEDULE'
Cross street/directions to job site: Description I Qty. I Fee. I Total
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']500 sq.ft.or portion 33.92 1
Tax map/parcel no.: Limited energy,residential
DESCRIPTION (with above sq.ft.) 75.00 2
OF';WORK
Limited energy,multi-family 75.00 2
low volt wiring and T-stats residential(with above sq.ft.)
Renewable Energy 0 See Page 2
Services or feeders installation,alteration,and/or relocation
0 PROPERTY OWNER, - 0 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
10 APPLICANT ' El'CONE'ACT' PERSON A.Fee for branch circuits with
above service or feeder fee,
7.42 2
Business name:American Heating Inc. each branch circuit
B.Fee for branch circuits without
Contact name:Brandon Hutchinson service or feeder fee,first 56.18 2
branch circuit
Address:5035 SE 24th Ave. Each add']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
Business name:American Heating Inc. Signal circuit(s)or limited-energyl 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 Lie.: 33135 Electrical Lie.: 26993CRE Suprv.Lie.: 2640LEB specifically listed('/2 hr min)
EI " RtOIIy PERMIT.FEES-:-
Suprv.Electrician signature,re uSuttal:
Print name: T Steve Young te:/a.,.a)•/s
Plan review(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE:
Print name: Brandon Hutchinson Date:
/�•�V ,/5 This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:\Building\Permits\ELC_PermitApp_ELR_ERE.doe Rev 05/21/2013 440-4615T(11/05/COM/WEB