Permit (81) CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
III /4
11 COMMUNITY DEVELOPMENT Permit#: ELR2016-00150
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/16/2016
C g A 1�,J 9 Parcel: 1 S 1260000300
Jurisdiction: Tigard
Site address: 9609 SW WASHINGTON SQUARE RD LO2B
Project: Shoe Mill Subdivision: None Lot: None
Project Description: Low voltage for HVAC.
Contractor: HVAC INC Owner: PPR WASHINGTON SQUARE LLC
5188 SE INTERNATIONAL WAY PO BOX 847
MILWAUKIE, OR 97222 CARLSBAD, CA 92018
PHONE: 503-462-4822 PHONE:
FAX: 503-462-6555
FEES
Description Date Amount
Specifics: Restricted Energy Permit 06/16/2016 $75.00
12%State Surcharge-Electrical 06/16/2016 $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. ATT ON: Ore• law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules -re set forth in OAR
952-001 010 through OAR 9
-0. -00*•. ou
may obtain a copy of the rules or direct questions to OUNC by calling 503.232.187 r 1.800..2344
Iss ed By: / 6( 1/A- Permittee Signature: ) $ •r\,)
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 wiz oI FI( II I SE Oy1.1
City of Tigard Received �p �" - _ -
DateB �` �Ip Permit No.: —I` /— /
III13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
t Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Other Permit: — I , Will
IIl l Inspection Line: 503.639.4175 Date Ready/By: 65 See 'age 2 for
Internet: www.tigard-or.gov Notified/Method: /` Supplemental Information
TYPE OF WORK PLAN REVIEW
❑New construction JR]Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked below):
0 Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition ❑Other:
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
I-and 2-familydwellingCommercial/industrialless to ground,or exceeds 14,000 0 Commercial-use agricultural
o 0 Accessory building amps for all other installations. buildings.
o Multi-family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 75 KVA or
❑Emergency system. larger separately derived system.
Ani7 JOB SITE INFORMATION AND LOCATION 0 Addition of new motor load of ❑"A","E","1-2","1-3",
Job no.. 4v" Job site address:tf \pi" '\ p(Qv 100HP or more. occupancy.
0 Six or more residential units. 0 Recreational vehicle parks.
ykCity/State/ZIP: �' {� (a `"� ❑Health-care facilities. 0 Supply voltage for more than
T
O / ❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.:�'a-8Project name: SV l C.. 'Y\'1 1 0 Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. I Fee. I Total 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'l 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
V 4 kC\IV. Cbl Nl \A) �Qx residential(with above sq.ft.)
75.00 2
IServices or feeders installation,alteration,and/or relocation
200 amps or less 100.70 2
0 PROPERTY OWNER 0 TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
City/State/ZIP: relocation
Phone:( ) Fax:( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation:This installation is being made on property that I own which is not
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168.54 2
Branch circuits-new,alteration,or extension,per panel
Owner signature: Date: A.Fee for branch circuits with
0 APPLICANT 0 CONTACT PERSON above service or feeder fee, 7.42 2
each branch circuit
Business name: \ip L, . .,0,(_.„ B.Fee for branch circuits without
/� service or feeder fee,first
Contact name,)('t,t _ }g,.!! 41L,e� branch circuit 56.18 2
`-"t+ IQ 17ttii1177 Each add'I branch circuit 7.42 2
Address: 1 O JCi .14A 4' t V) Miscellaneous(service or feeder not included)
City/State/ZIP: I R--)-6)11-)-- Each manufactured or modular 67.84 2
(``1 VV `�4 t/ dwelling,service and/or feeder
Phone:(Y)3)-4 o-}- \,( YYr Fax: :(5' 3) q ., Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E-mail: 'IX) d P ti V KC-AO UitY i N Sign or outline lighting 67.84 2
CONTRAC R Signal circuit(s)or limited-energy
Business name: \ C.A C. panel,alteration,or extension. Page 2 2
V Each additional inspection over al owable in any of the above
Address: j WO Additional inspection(1 hr min) 66.25/hr
C Investigation(1 hr min) 66.25/hr
City/State/ZIP: Industrial plant(l hr min) 78.18/hr
Phone:( ) Fax:( ) Inspections for which no fee is
�lV specifically listed(%z hr min) 90.00/hr
CCB Lic.:S 0-1 Electrical Lic.:1-j„-Sl l 1/l,I3
Suprv.Lic.: 1111. ELECTRICAL PERMIT FEES
asr.,,,,, Subtotal:
Suprv.Electrician signature,require • Plan review(25%of permit fee):
Print name: ill'\1\Q f k i i : 10 i``, I� State surcharge(12%of permit fee):
Authorized signature:
��- 9 TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
'` di ildays after it has been accepted as complete.
Print name (tip'
Date: f • Number of inspections allowed per permit.
I:1Building\Permits\ELC-PermitApp.doc 07/01/10 440-4615T(11/05/COM/WEB
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