Permit (49) City of Tigard • COMMUNITY DEVELOPMENT DEPARTME VFP
Request for Permit Action
TIGARD
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o�13125 SW Hall Blvd. . Ti and Ore on 97223 503-718-2439 www.tl an -or. o
TO: CITY OF TIGARD f t , `I T r4l1TIOTY
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
V 0 I
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov// ///!
FROM: ❑ Owner ❑ Applicant 14 Contractor ❑ City Staff `d)01
Check(✓)one
REFUND OR Name:
(.INVOICE TO: (Business or Individual) L GIS �h t C�
Mailing Address: ( 1 j -`j r,
City/State/Zip: < i eye`, &a.,_ —Z�S
Phone No.: 5 QQ , .-22 ' )(9 .4 3 C 4
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
r6- CANCEL/VOID PERMIT APPLICATION.
E 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#: 7,Q 6 - 0 0 3 6-,7 � 5f
Q L
Site Address or Parcel #: � � � � o 6 8�`' ���c'`-
Project Name: S e Ce. c
Subdivision Name: Lot#:
EXPLANATION: CA. ii....1ctiri d 113 0,- d Cfer to-.1/4e-'t
Signature: c Date: 0/571 6
Print Name: LA i I
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. c� hfe7 G/� Jr' /o a::
Y65' IF // .Y.$
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date // // /,,E) By 44
Refund Processed: Date ///il/k' B •- Invoice Processed: Date By
Permit Canceled: Date 4N/4 B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 2314.doc
-I' q
411
TIGARD
City of Tigard
November 14,2016
Charged Electric
Attn: Sean Randall
12175 SW Summer Crest Dr.
Tigard, OR 97223
Re: Permit No. ELC2016-00565
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13190 SW 68th Pkwy
Project Name: Tigard Corporate Park II
Job No.: N/A
Refund Method: ® Check#222901 in the amount of$465.38.
❑ Credit card"return"receipt in the amount of$ .
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 customer cancelled job. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
,<f):;; )f717-G71---"C--
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
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 for 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: Charged Electric DATE: 11/7/2016
Attn: Sean Randall
12175 SW Summer Crest Dr. REQUESTED BY: Dianna Howse
Tigard, OR 97223
TRANSACTION INFORMATION:
Receipt#: 405274 Case#: ELC2016-00565
Date: 8/1/2016 Address/Parcel: 13190 SW 68th Pkwy
Pay Method: CreditCard Project Name: Tigard Corporate Park II
EXPLANATION: Per applicant's request as job was award to another contractor. Refund 80%of permit
fees and retain plan review fees.
Lae) tler t w, � .. `.<.:.... � � s rt � .,a..�?flt .9n, " , ' x :i"
Electrical .ermit 220-0000-43103 $415.52
12%State Surchar:e 100-0000-24001 49.86
TOTAL REFUND: $465.38
APPROVALS: SIGNA�IRES/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 TIDEMARKSYSTEM ADMINISTRATION.USE Q 'Y;; ,
Case Refund Processed: Date: l///cf:/lcP By: .411//e•I:\Building\Refunds\RefundRequest.doc x 09/01/2010
yt CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2016 00565
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/01/2016
Parcel: 25101 DA00101
Jurisdiction: Tigard
Site address: 13190 SW 68TH PKWY
Project: Tigard Corporate Park II Subdivision: VARNS ACRES Lot: 9
Project Description: Building 2-(2)15.01 to 25 kva's for roof mounted solar photovoltaic system.
Contractor: CHARGED ELECTRIC LLC Owner: PACIFIC NW PROPERTIES LIMITED PA
12175 SW SUMMER CREST DR STERN FAMILY LIMITED PARTNERSHIP
TIGARD, OR 97223 STERN, HELEN R REVOCABLE TRUST
6600 SW 105TH AVE#175
BEAVERTON, OR 97008
PHONE: 503-380-4364
PHONE: 503-626-3500
FAX:
FEES
Quantity Description Date Amount
2 ea 15.01 to 25 kva 08/01/2016 $400.68
Specifics:
16 ea Each additional kva over 25 08/01/2016 $118.72
Type of Use: COM 1 ea 12%State Surcharge- 08/01/2016 $62.33
Electrical
Class of Work: ALT 1 ea Plan Review Electricial 08/01/2016 $129.85
Type of Const:
Occupancy Grp:
Total $711.58
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 rk is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Cen a Tho rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503. 8 or 1.8 .332.2344.
Issued By: _ ' ., 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.
I" Electrical Permit Application, i.o R o i 1.1( t: 1 SI. (1\1.1
Jy
City of Tigard � Date/By: 7f, , / Permit#: el-e,0/16 5-65—
13125 SW Hall Blvd.,Tigard,OR 97223 f Plan Review
L: Phone: 503.718.2439 Fax: 503.598.1960 Date/By: 7 S ho Related Permit Iguf'./ ,6-0Q�o�
Inspection Line: 503.639.4175 ? 1 Ready Da' : Juris:• , • ® See Page 2 for
i I A u l) Internet www.tigard-or.gov 3 i Notifi i i (6 G Supplemental Information
Please check all that apply(submit 2 sets of plans w/items checked):
®New construction 0 AdditiOr 6th 1tIA171XPplaCe(rient
El Demolition Other: 0 Service or feeder 400 amps or more El Building over three stories.
where the available fault current 0 Marinas and boatyards.
. ,.�.0 .-I :y '; t ,, 8 ! r .,„ ,..,x, _..,, ;_ , , exceeds 10,000 amps at 150 volts or ❑Floating buildings.
El1-and 2-family dwelling ®Commercial/industrial 1f less to ground,or exceeds 14,000 0 Commercial-use agricultural
0 Accessory building
F
❑Multi-family 0 Master builder 0 Other: m all other installations. buildings.
❑Fire re for pump. ❑Installation of 150 KVA or
, .. ❑Emergency system. larger separately derived
Job#: Job site address:13190 SW 68th ❑Addition of new motor load of system.
100HP or more. ❑"A""E" "l-2""1-3"
City/State/ZIP:Tigard Or 97223 ❑Six or more residential units. uPancY•
0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#:II Project name:Triangle Corporate 0 Hazardous locations. El Supply voltage for more than
o Service or feeder 600 amps or more. 600 volts nominal
Cross street/directions to job site:68th&1-5
Description .I.Qty. I Each 1 Total I�*
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#:
Ea.add'1500 sq.ft.or portion 33.92 1
. .. ., I 'ft':,,13. t 4*. .7333:3-„, ' r Limited energy,residential
install roof mount solar system (with above sq.ft.) 75.00 2
Limited energy,multi-family
75.00 2
residential(with above sq.ft.)
Renewable Energy 0 See Page 2
. alK , ,W -W • Services or feeders installation,alteration,and/or relocation
Name:Pacific NW Property Management 200 amps or less 100.70 2
Address:6600 SW 105th Ave 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Beaverton Oregon 97008 601 amps to 1,000 amps 301.04 2
Phone:(503)626-3500 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 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
a Branch circuits-new,alteration,or extension,per panel
°"' A.Fee for branch circuits with
Business name:NW Photon Energy LLC above service or feeder fee, 7.42 2
each branch circuit
Contact name:Kirk Cameron B.Fee for branch circuits without
service or feeder fee,first
Address: 10720 SW Moapa Ave branch circuit 56.18 2
City/State/ZIP:Portland Oregon 97219 Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:(503)703 4046 Fax::( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email:kirk@nwphotonenergy.com
Reconnect only
67.84 2
Za„� x , . Ni _ yu , .
Pump or irrigation circle 67.84 2
2
Business name: Photon Ene rT E 0 Flea-a_ Sign or outline lighting 67.84
Address:10720 SW a ve Signal circuits))or limited energy
0 See Page 2 2
p panel,alteration,or extension.
City/State/ZIP:Porti 1 .regon 97219 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:(503)71 -146 • Fax:( ) So 3 70..? 70',L Investigation(1 hr min) 90.00/hr
Email:kirk@nwphotonenergy.com Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: 18(g111 ,Electrical Lic.: ( 57 Suprv.Lie.:5-f s..c specifically listed 0 hr min)_,_
8:1334! t 3
Suprv.Electrician signature,required: �� Subtotal: .s29_ y
Print name: ce. 12t>n l)u(f Date: '7..(P_/ 0 Plan Review Required(25%of permit fee): /a v,
State surcharge(12%of permit fee): 4 o2 ,y,3
Authorized signature:
Liv...„....
TOTAL PERMIT FEE: ���, .5-,P
This permit application expires if a permit is not obtained within 180
Print name: le 2+L d Date: 7- ,/4days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:�Bwlding\Permits�ELC PermitApp_ELR am.doc Rev 06/17/2015 440-4615T(I I/05/COM/WEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
.. 4,y�„ORt7`l� s -
Description 1QtY• Each I Total I •
Fee for all residential systems combined: $75.00
Renewable electrical energy systems:
Check Type of Work Involved: 5 kva or less 100.70 2
5.01 to 15 kva 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 2 200.34 400.68 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301.04 2
50.01 to 100 kva 552.26 2
0 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 16 7.42 118.72 3
❑ Vacuum Systems* >100 kva-no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
❑ Other: Each additional inspection is 66.25/hr 1
charged at an hourly(I hr min)
Inspections for which no fee is
90.00/hr
specificallly listed(4 hr min)
COMMERCIAL W Subtotal(Enter on Page 1). 519.40
Fee for each commercial system: $75.00 Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
O Audio and Stereo Systems
❑ Boiler Controls
O Clock Systems
O Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
O Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
O Outdoor Landscape Lighting*
O Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:\Building Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015