Inspection13125 SW Hall Blvd.
Tigard, OR 97223
City of Tigard
Location:
15350 SW SEQUOIA PKWY 100, TIGARD, OR,
97224
Record Type:
Commercial - Electrical
Inspection Type:
199 Electrical final
Result:
PASS- NoCofO
Comments:
Violation Summary:
Inspector
Tel: 503.718.2439
Inspection Date:
January 23, 2017 at 9:38:14
AM
Record ID:
ELC2016-00907
Inspector:
Jeff Grove
Contractor
To: Page 2 of 2 2016-12-02 16:20:17(GMT) 15039721861 From:Charlynn Leifsen
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 4 , , i 4, .;..in
Request for Permit Action orf: 04
7'11
Ti ciyi,fcry 15125S\\ Hall Blvd. •Tigard, Oregon 97223 - 503-718-2439 • 2.,:wkuita,c1W4,42,)".-. - '
manwmalmiliagememallnam°"'N°s2‘"wfmn UTT,,,,,,.r,, ` ,,r,.
TO: CITY OF TIGARD ''''''-'
Building Division - - -
13125 SA' Hall Blvd.,l'igard,OR 97223
Plaone: 503-718-2439 Fax: 503-598-1960 TigarciBuildingPermits@tigard-orgov
FROM: fl Owner —I Applicant R.Contractor fl Cit).,Staff
(Iva:(Z) ire
REFUND OR Name:
L .
INVOICE TO: csusincy:or I ndwIchr4 JO In WI se,r, ele erliC.,
Mailing Address: 1(9ticei SW G5A/e.,- *---. 3 I i
City/Stare/Zip: Let..e--e-' 11-1D3S--
._.1
Phone No.: ( p3) 1 Li'7- Z Cc,3
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
J CANCEL/VOID PERMIT APPLICATION. .
IffitNI )PERMIT FEES (attach copy of original receipt and provide explanation below).
..
\OICE FOR FEES DUE (attach case fee schedule and provide explanation below),
REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit #: e Lc2-01 6 -oc 6 ol
Site Address or Parcel#: 13 5) 54.0 Stetre,V0iit ) I W
Project Name: i 5:1- 1:-(DO( ka,411„..1A-Ler
Subdivision Name: Lot#:
........______
EXPLANATION: i\Je.e.dP e_e s -CiAr- A dL4 CIre 'ILI:•.Sre-
,e, -0,-Y— i ci aloiir...c.:dr _
Signature: Glit,...L}:---- Date:
Print Name: C.ir,04 tint) Lei-C.Se--",)
/', .9 40 _A
Refunci Policy
I. The city.;Community Develepmcnt Director,Building C)Iticial or Cite 1a-it:lint:et oar Authorize the refund cir: ii. ei/i efrliair-
Any Ceti which'teas erroneously paid of WileCtrd.
. . Not more that:80%of the:ippilcAtIon or plan rCTILIVe fee when an application is withdraW11 or 4311C0Cd 1)(fOre J:CArteNV CtiOrt
has been expendcd.
I) Not 1110r,than 80r,-0 o1 the application or pcnnit fee for issued permits prior to any inspection requests.
2. All refl.:n(15 will be returned to be original pai.er in the fonn of a checl-via US postal service. 5-3 . t/r2- ,E72-Alir
1 Please allow.3-4-weeks for processing rerun t-I requests. i zi, 24?
, 2 Y 1X470 -s-a,-Le24,7-4,ty-e-
e. c,,l- , ,F05'3, 2 -- -5'7 /
grOVPICE USE:-.ONLY": '''- : -': '........,— ....„•4
[ Route to Sys Acimin: Dater ilinimmri Ti.oute to Re.,,,,,d5:_Date /A„gdproi ' 7-29 :" .-?,,c____
....,
Refund Processed: Dat /2 A2 / By I7 Invoice Processed: Datc I By
,......__
I Perrnit Canceled: ...___Dtw.._Az "9- : MJ‘ ' Parcel Tap,/k dried: Day: 1 By
'7\iluildirlg\Forms\131Pern-a it Act r,r,..,0i)2 I.i.doc
:
TIGARD
City of Tigard
December 15, 2016
Johansen Electric
Attn: Charlynn Leifsen
16869 SW 65th Ave., #311
Lake Oswego, OR 97035
Re: Permit No. ELC2016-00907
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 15350 SW Sequoia Pkwy, #100
Project Name: 15`floor hallway
Job No.: N/A
Refund: ® Check#223265 in the amount of$59.84.
❑ Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 Trust account "deposit"receipt in the amount of$
Comments: Per applicant's request to refund permit fees for (9) branch circuits as only
(1) was required of the job. 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
INn
_ 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: Johansen Electric DATE:
12/12/2016
Attn: Charlynn Leifsen
16869 SW 65`''Ave., #311 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORMATION:
Receipt#: 407706 Case#: ELC2016-00907
Date: 11/29/2016 Address/Parcel: 15350 SW Sequoia Pkwy,#100
Pay Method: CreditCard Project Name: 1st floor hallway
EXPLANATION: Per applicant's request to refund permit fees for(9) branch circuits as only(1)was
required for this job. Refund 80% of permit fees.
REFUND INFOIATION
* ,sr r %S. �' 3P
ti W
fFciDescription From`Rect < ����� .o� � 7j 3 � , .re ' 'Paxiple."�u �eLlltF� y_py4 q.: f ,Electrical Permit
220-0000-43103 $53.42
12%State Surcharge 100-0000-24001
6.42
TOTAL REFUND: $59.84
APPROVALS: SIG ES 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 ADMINIS'T'RATION TJSE,ONLY
Case Refund Processed: I Date: j 0,/7
By: I ,6540"
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
TIGRRECEIPT
13125CITY SWOF Hall Blvd.,TigardAORD 97223
503.639.4171
TIGARD
lLE cA/6
Receipt Number: 408247 - 01/06/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2016-00907 kL-C, ? 1V/'T v20 —0000 - 3/0 3 .-3- $-59.84
/?-e740 e /o-v -oi 'o - gVaoi , y�
Total: $-59.84
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 223265 DHOWSE 01/06/2017 $-59.84
Payor: Johansen Electric
Total Payments: $-59.84
Balance Due: $59.84
Page 1 of 1
CITY OF TIGARD RECEIPT
i j 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Tfi;AItf7
Receipt Number: 407706 - 11/29/2016
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2016-00907 Branch Circuits wo/Purchase Service or 220-0000-43103 $122.96
Feeder
ELC2016-00907 12%State Surcharge-Electrical 100-0000-24001 $14.76
Total: $137.72
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 08571C PUBLICUSER107 11/29/2016 $137.72
Payor: charlynn Ieifsen
Total Payments: $137.72
Balance Due: $0.00
Page 1 of 1
To: Page 1 of 2 2016-12-02 16:20:17(GMT) 15039721861 From: Charlynn Leifsen
FAX COVER SHEET
TO
COMPANY
FAXNUMBER 15035981960
FROM Charlynn Leifsen
DATE 2016-12-02 16:19:52 GMT
RE Permitrefundrequest
COVER MESSAGE
Charlynn Leifsen
*Secreta ry/Treasurer*
Johansen Electric, Inc.
P (503) 747-2503 I F(503) 972-1861
http://www.johansenelectric.com
WWW.METROFAX.00M
Electrical Permit Application
City of TigardIII Received
111 13125 SW Hall Blvd.,Tigard,OR 97223 Date/By: Permit#:
Phone: 503.718.2439 Fax: 503.598.1960 Plan Review
Inspection Line: 503.639.4175
Date/By: Related Permit#:
TI G A RD Internet: www.trgard 39.41 Ready Date/By Juns
Notified/Method: See Page for
H 2
r.gov
Supplemental information
°`, ,: ' '' *.4.aF WORK .. 5; Ii'LAN REVIEW 3 ,
0 New construction 0 Addition/alteration/replacementapply(submit 2 sets of plans w/items checked):
,
Please check all that
0 Demolition 0 Other: ❑Service or feeder 400 amps or snore ❑Building over three stories.
` " where the available fault current
. 'ICTia(3O* OF CONSTRUUTiO1 r ❑Maag bd boatyards.
exceeds 10,000 amps at 150 volts or ❑Floatinting buildings.
❑ 1 and 2-family dwelling 0 Commercial/industrial 0 Accessory g buildin less to ground,or exceeds 14,000
❑Commercial-use agricultural
0 Multi-family ❑Master builderamps for all other installations. buildings.
❑Other: 0 Fire pump.
B SIT '` m ❑Installation at ly KVA or
� 0 A L� 110- r` ❑Emergency system. larger separately derived
Job#: 1 Job site address: ❑Addition of new motor load of system.
l OOHP or more. ❑°`A°° `E" "l-2""I-3>
City/State/ZIP: ❑Six or more residential units. occupancy.
Suite/bldg./apt. ❑Health-care facilities. ❑Recreational vehicle parks.
#: I Project name: ❑Hazardous locations. ❑Supply voltage for more than
Cross street/directions to job site: ❑Service or feeder 600 amps or more. 600 volts nominal.
Description i Qty. 1 Each 1 Total
T.
New residential single-or multi-family dwelling unit.
Subdivision:
I Lot#: Includes attached garage.
Tax map/parcel#: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
Limited energy,residential
(with above sq.ft.) 75.00 2
Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
❑:PIQI �? bWhfR: ,a ,. `•. d1iii Renewable Energy El See Page 2
Name: Services or feeders installation,alteration,and/or relocation
200 amps or less 100.70 2
Address: 201 amps to 400 amps 133.56 2
City/State/ZIP: 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Phone:( ) I Fax:
( ) Over 1,000 amps or volts 552.26 2
Email: Temporary services or feeders installation,alteration,and/or
relocatin
Owner installation:This installation is being made on property that I own which is not 200 amps or less
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 59.36 2
201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps
s 168.54 2
A* ,- tJ CO 'ACT r Branch circuits—new,alteration,or extension,per panel
Business name:
A.Fee for branch circuits with
above service or feeder fee,
Contact name: 4 , C (c, each branch circuit 7.42 2
B.Fee for branch circuits without
Address: — -5"/f r ` service or feeder fee,first
CF branch circuit 56.18 2
:f_— 7Each add'l branch circuit
7.42 2
/ �` r .7G t O _? r
Phone:( ) I Fax: :( ) Miscellaneous(service or feeder not included)
Each manufactured or modular
Email: dwelling,service and/or feeder 67.84 2
" cO Reconnect only 67.84 2
/ / - i Pump or irrigation circle 67.84 2
Business name: ` "
Sign or outline lighting 67.84 2
Address: ��� Signal circuit(s)or limited-energy
,
panel,alteration,or extension. ❑ See Page 2 2
City/State/ZIP: �� GCS 0 Each additional inspection over allowable in any of the above
Phone:( ) , C7 ((,e, r Additional inspection(1 hr min) 66.25/hr
Fax:( ) — Investigation(1 hr min
g ) 90.00/hr
Email: /....A. 'l5-<7 r fV Industrial plant(I hr min) 78.18/hr
CCB LiC.: Cl inspections for which no fee is
Electrical LiC.: I Suprv.LiC.: specifically listed(%Z hr min) 90.00/hr
Suprv.Electrician signature,required: I ICIRICA l I? �` . .';
Print name: Subtotal:
I Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE:
Print name: I This permit application expires if a permit is not obtained within 180
I Date: days after it has been accepted as complete.
uilding�Permits�ELC_PermitApp_ELR_ERE.doc Rev 06/I 7/2015
* Number of inspections allowed per permit.
440-461ST(]1/OS/COM/WEB