Permit Support Document (40) 0 f ,
City of Tigard • COMMUNITY DEVELOPMENT DEPAITT IST �' ' RECEIVED
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.goCI YOFTIGARDDIVISION
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: (1 Owner ❑ Applicant X Contractor ❑ City Staff
Check V)one G
REFUND OR Name:
INVOICE TO: (Business or Individual) it =�/� . - 4 S C,,/7 .rem
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
V_ CANCEL/VOID PERMIT APPLICATION.
• REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0. INVO OR FEES DUE (attach case fee schedule and provide explanation below).
si
MOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: E Lc- z 25/g --c C .. 3 g
Site Address or Parcel #: 9E 71 S4/ /1,',s- 4 A2-ci ,
Project Name: 6 r A) ` /A : F,,--,
Subdivision Name: Lot#:
EXPLANATION: ,A /t-,`o le— r ,T— Aapp /'c 2T s
/csae E.e— Ze,i6= c .3 S`"
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Signature: ,- Date: g -,z_--7-/
Print Name: ,tits-r- S Ai ,;
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• Not more than S0%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date / By ( fr
Refund Processed: Date ,V,.J,/14- Invoice Processed: Date A2 Ar--- By,
Permit Canceled: Date 4142-h, BParcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.d'oc
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Electrical Permit Application I l i i FOR OFFICE USE ONLY
_._ i
Cit ofTigard
(1 Received ermit#:
v 13125 SW Hall Blvd.,Tigard,OR 97223 ��iI i }}r' DateBy: r 1� 7 ri ...2.c/ d5—yd,
g ( Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 V I Date/By: 1 f ` Related Permit#: Ailipav` ,� /
Inspection Line: 503.639.4175 C y - Ready Daib„ : 7 Juris: ®/See Page rfor
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T[GAR[3:', Internet: www.tigard-or.gov ` i):, ' ' Notified/Method: _ Supplemental Information
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❑New construction ®Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
El Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
/�fr� f% TEG '�fO:*,:*rOti)Nr i / flf AO exceeds 10,000 amps at 150 volts or
❑Floating buildings.
❑ 1-and 2-family dwelling ®Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 ['Commercial-use agricultural
amps for all other installations. buildings.
El Multi-family ❑Master builder ❑Other: 0 Fire pump. ❑Installation of 150 KVA or
Vr S5Z ;'jfi��� FORMAONAND040N ���/ i som El Emergency system. larger separately derived
❑Addition of new motor load of system.
Job#:311180019 Job site address:9677 SW Washington Square Rd 100HP or more. ❑"A","E",`°1-2","1-3",
City/State/ZIP:Tigard,OR 97223 ❑Six or more residential units. occupancy.
Y g Recreational vehicle parks.
ID facilities. ❑
Suite/bldg./apt.#: Project name:Din Tai Fung ❑Hazardous locations. ❑Supply voltage for more than
['Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: rr
r ��� `t%r ESID ,
1
Description
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'l 500 sq.ft.or portion 33.92 1
f,,ff,/ /,moi' '✓ t'�f" i`1�f ,' f� ,'d,�'.%(+.�;
� G,,,,,, r ;;v/.,,,. 1 Limited energy,residential
(with above sq.ft.) 75.00 2
Din Tai Fung-tenant improvement for restaurant in Washington Square mall. Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
, Renewable Energy ❑ See Page 2
tf � ®iPRPERTYrWEy � / I ;: ` A „1
,,.....,,,,.„.,,,,,,,,e,„, , r ” Services or
feeders installation,alteration,and/or relocation
Name: 200 amps or less 3 100.70 302.10 2
Address: 201 amps to 400 amps 2 133.56 267.12 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
f 1Mr y f 13"21024;
f F F` j E,G F" PE Yy f y s, Branch circuits–new,alteration, extension,per or panel
'. A.Fee for branch circuits with
Business name: above service or feeder fee, 102 7A2 756.84 2
each branch circuit
Contact name: B.Fee for branch circuits without
Address: service or feeder fee,first 56.18 2
branch circuit
City/State/ZIP: Each add'1 branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax::( ) Each manufactured or modular '
dwelling,service and/or feeder 67.84 2
Email: Reconnect only 67.84 2
r m.77 ''r / r , f ,(j'..'„ /„ i f r,,., ' f /YPump or irrigation circle 67.84 2
Business name:IES Commercial-contact: Matt Saager Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy ® See Page 2 75 2
Address: 16135 SW 74 Ave panel,alteration,or extension.
City/State/ZIP:Tigard,OR 97224 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:(503)310-5111 Fax:( ) Investigation(1 hr min) 90.00/hr
Email:matt.saager@iesci.net Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: 118452 Electrical Lic.: C448 Suprv.Lic.: 4911S specifically listed(1 hr mm)
Su rv.Electrician signature,required: � �`� ��''� ��0 ��fERNIIT � � �=°''f'ff�'�'' i
P g 9 Subtotal: 1401.06
Print name: Corey Baysinger eeize7 *is, D : 07-30-18 ®Plan Review Required(25%of permit fee): 350.27
I I State surcharge(12%of permit fee): 168.13
Authorized signature: TOTAL PERMIT FEE: 1919.46
This permit application expires if a permit is not obtained within 180
Print name: Matt Saager Date: 07-30-18 days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:\Building\Permits1ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(11/05/COM/WEB
•
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
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RESIDE IA O f0 44
sE,,y,..rFr.,r„r;.,.>
Description I Qty. I Each I Total
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 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
❑ Garage Door Opener*
>100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
❑ 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(/z hr min)
COMERC`IJWa / 1oue , itt
% r j
Subto
Fee for each commercial system: $75.00 allowe al(Enter on Page 1):
* Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
® Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:\Building\Permits\ELCPermitApp_ELR_ERE.doc Rev 06/17/2015