Permit (16) INCITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
21 :' COMMUNITY DEVELOPMENT Permit#: ELR2017-00086
T[GA RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/24/2017
Parcel: 1S136DB00201
Jurisdiction: Tigard
Site address: 11571 SW PACIFIC HWY
Project: T-Mobile Subdivision: None Lot: None
Project Description: Data telecommunications system.
Contractor: FREEDOM CUSTOM COMMUNICATIONS LLC Owner: FRED MEYER STORES INC
6526 SW WINTERS RD STORE#375
CORNELIUS, OR 97113 1014 VINE ST
PROPERTY TAX 7TH FLOOR
CINCINNATI, OH 45202
PHONE: 503-544-1302 PHONE:
FAX: 503-359-5695
FEES
Description Date Amount
Specifics: Restricted Energy Permit 04/24/2017 $75.00
Type of Use: COM 12%State Surcharge-Electrical 04/24/2017 $9.00
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 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 ma ,.�'�� of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: agvfit-- ermittee Signature: .,., ..,_,,,,,_...„7„..___.„.„_.. _+
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 OFFI( I ISI, O 1.1
City of Tigard . ceived
g ate/By: Permit#:
114 41 13125 SW Hall Blvd.,Tigard,OR 97223 BECE3 V Plan Review
Ill Phone: 503.718.2439 Fax: 503.598.1960e.,4 Date/By: Related Permit#:
Inspection Line: 503.639.4175 p f1 t `Z) Ready Date/By: Juris: ® See Page 2 for
1 I C,A h D Internet: www.tigard-or.gov PR
\ fl N tfied/Method: Supplemental Information
TYPE OF WORK IV 0,r '..� ^) PLAN REVIEW
❑New construction 'Addition/alteration/re it
•1 14Ct t>vl, ,��l Please check all that apply(submit 2 sets of plans w/items checked):
❑Demolition ❑Other: ElService or feeder 400 amps or more 0 Building over three stories.
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ 1-and 2-family dwelling ,acommercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family 0 Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
Job#: Job site address: �'S 'w P., ,.. t C 0 Addition of new motor load of system.
4ivv`' 100HP or more. ❑"A" "E" "1-2" "1-3"
❑Six or more residential units. occupancy.
City/State/ZIP: '�� .cam l O 2 °-ZZ3Recreational vehicle
❑Health-care facilities. 0 parks.
t(� ❑Hazardous locations. 0 Supply voltage for more than
Suite/bldg./apt.#: Project name: la, 1- m600 volts nominal.
0 Service or feeder 600 amps or more.
Cross street/directions to job site: Ai vV "11 FEE SCHEDULE
1 Description I Qty. I Each I 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'I 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential 75.00 2
PATA (with above sq.ft.)
�� i Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
0 PROPERTY OWNER Renewable Energy 0 See Page 2
I 0 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 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
APPLICANT I .CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: f'2 �yN G t r '-A'1 c�Nh�1KN t< cii o.tis above service or feeder fee,
7.42 2
l�eseach branch circuit
Contact name: �'"
r3t�Q.L L. ��✓tNL' B.Fee for branch circuits without
/ service or feeder fee,first
t
Address: tint Sv%/ V J ...t. -f Eves Ut.b branch circuit 56.18 2
City/State/ZIP: Co.2a� L...s; - ct.—1 i i','7 Each add'I branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:(,3) S144. Goz— Fax: :(c03) ' -'9r, s-c.c,S Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: ('et011:14 CK , ,e_ oriA Q q A,t L L.ccA4 Reconnect only 67.84 2
CONTRACTOR �f Pump or irrigation circle 67.84 2
Business name:f pi cM 'i^ ,cam C AA"vNICA'il 454/5 Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy ,rte
Address: to 52,...k, ,,../ W,h S R�.-D panel,alteration,or extension. See Page 2 ZS 2
City/State/ZIP: C� H� Each additional inspection over allowable in any of the above
O i SW 35-0'. &-"K"-
13 Additional inspection(1 hr min) 66.25/hr
Phone:(SD}) .5-144. 13 pZ, Fax:(soy 350'. 6aK"- Investigation(1 hr min) 90.00/hr
,� 1 �lltL -c-M Industrial plant(1 hr min) 78.18/hr
Email: � c_`^-S T �cQ� �. x
Inspections for which no fee is 90.00/hr
CCB Lic.: ' 33 .Fel Electrical Lic.: t Fiji Suprv.Lic.: .e�or specifically listed(%hr min)
`� ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: G�.•5'/ Subtotal:
Print name: -..... ..¢-1—"''`i stvt4,.`Cr Date: lJ/Z�/20.r 0 Plan Review Required(25%of permit fee):
1{ G � State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE: i%�
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
* Number of inspections allowed per permit.
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Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE,
Fee for all residential systems combined: $75.00
Description f Qty. I Each I Total
y 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 200.34 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
n 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:
❑ Other: Each additional inspection is 66.25/hr 1
charged at an hourly(1 hr min)
Inspections for which no fee is 90.00/hr
specifically listed('h hr min)
COMMERCIAL WORK ONLY:
ELECTRICAL PERMIT FEES
SubtotalEnteron Page 1):
Fee for each commercial system: $75.00
y ; Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
n Clock Systems
Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
Fl 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.doe Rev 06/17/2015