Permit (179) VOID
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City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMENT }�� ���7
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: I. Request for Permit Action
Try OF TIGARD
T l G A R D 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •1 AAA..t ter:- %s.i, C DIVISION
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: ❑ Owner 21<plicant ❑ Contractor 0 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) C £1 `S e r i c 01/4,,I
Mailing Address: .- x( 31 We Pre scc►-1-\-- Sr-, c'v -
City/State/Zip: Pc Y--1-`(A.1.-N r'.\ OR C1 ' 7-17
Phone No.: 503-2-0(0--7 ti Lt. l
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
EFUND 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#: Lc,' 2_1:7i (",e ' oaf. ,C)a,
Site Address or Parcel#: 1 01 (cs 0 ' .W S 0 oet rev._r I ka, . D r
Project Name: .I C3:2-49
Subdivision Name: Lot#:
EXPLANATION: je 1 c c tie);'l- V i 6A 1 I, e tit-c d�' a
i n t c 4'-i`i-w., -Po r tveSeltky, S-1 3 \\ in ek ci k.4 pros c rs cd on .1--
1 SD it ed r rick) peri ;4 Eie -2o( e.Oc a� pn Lir;
Signature: i,...s '- Date: C7//cj/j A
Print Name: (_i Ca 4,sit'_bb -02 6iec-irictal
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. y S. ` 6 ' /(i ' /_- `17
/ti . 3e) e'` #2 y , e'C-,
96 /4, 76 .c3 / '• '3
FOR OFFICE USE ONLY
Route to Sys Admin: Date q , 7 f By ,J, Route to Records: Date 9' /2- / B 7
Refund Processed: Date j jeBy r, Invoice Processed: Date By
Permit Canceled: Date ,,,,, By
IABuilding\Forms\RegPennitAction_09rt3/r14.d, By r Parcel Tag Added: Date
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TIGARD
City of Tigard
November 29, 2018
CR Electrical LLC
Atm: Lisa Webb
7131 NE Prescott St, Unit B
Portland, OR 97217
Re: Permit No. ELC2018-00602
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10760 SW Summer Lake Dr
Project Name: Dimaggio
Job No.: N/A
Refund Method: ® Check#230437 in the amount of$76.93.
❑ Credit card"return"receipt in the amount of$ .
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 permit was reapplied for under ELC2018-
00608. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
<P7(71—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
T I G A K D 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 forPermit 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: CR Electrical LLC DATE: 11/16/2018
7131 NE Prescott St, Unit B
Portland, OR 97217 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 419439 Case#: ELC2018-00602
Date: 9/13/2018 Address/Parcel: 10760 SW Summer Lake Dr
Pay Method: CreditCard Project Name: Dimaggio
EXPLANATION: Per applicant's request as permit was reapplied for under ELC2018-00608. Refund 80%
of permit fees.
C'^sa.aMt N ke ffi . q t k a . ?�d�� .a..,.wrrt
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,aas'� °m ��ea � oar �� xi` pro a �a6��•� ` �'� �,���.
Electrical Permit Fee 220-0000-43103 $68.69
12%State Surchar:e 100-0000-24001 8.24
TOTAL REFUND: $76.93
APPROVALS: SIG •TURE /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
n "
Case Refund Processed: Date: if 12 /,:` By �� '
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD ELECTRICAL PERMIT
• COMMUNITY DEVELOPMENT Permit#: ELC2018-00602
Date Issued: 09/18/2018
Tt[ AR13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1S133AD03500
Jurisdiction: Tigard
Site address: 10760 SW SUMMER LAKE DR
Project: DIMAGGIO Subdivision: AMART SUMMER LAKE Lot: 9
Project Description: Adding(5)branch circuits relocation of washer and dryer and added bedroom.
Contractor: CR ELECTRICAL LLC Owner: DIMAGGIO, LAURA&DAVID
5100 SE HARNEY DR SUITE 121 10760 SW SUMMER LAKE DR
PORTLAND, OR 97206 TIGARD, OR 97223
PHONE: 503-206-7441 PHONE:
FAX:
FEES
Quantity Description Date Amount
5 crt Branch Circuits wo/Purchase 09/13/2018 $85.86
Specifics: Service or Feeder
1 ea 12%State Surcharge- 09/13/2018 $10.30
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $96.16
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 01-0090. ou y obtain a cop of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: --Air L�'�'v Permittee Signature: L//e a75c -i
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 603.639.4175 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 1 OR UI 1 It.1. ( til:(1N1 \
SECity of Tigard P16 'j j > vea MA' ....011
Ilig • 13125 SW Hall Blvd,,Tigard,OR 97223 Plan Review
Phone: 503.715.2439 Fax: 503.598.1960 Date/B : 121212211
Inspection Line: 503.639.4175 `' Ready Date/By: ® H See Page 2 for
T t C:�[.L) Internet www.tigard-or.gov Notifed/Method: Supplemental Information
y
❑New construction ►.1 Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/tems checked):
❑Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition 0 Other: _ where the available fault current 0 Marinas and boatyards.
a $;"�'�� 'rpta s , T ��, @ � �" ,r" � � �'���x„,�.s fi � exceeds 10,000 amps at 150 volts or 0 Floating buildings.
El`'` '� �&9�� less to ground,or exceeds 14,000 ❑Commercial-use agricultural
1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or
taincy system. larger separately derived
. � I (? " � ilk'){± !� .w x, .. . ❑Emerge
❑Addition of new motor load of system.
Job#:18249 Job site address:10760 SW Summer Lake Dr, 100H1'or more. ❑ A, ,"l-2"•"1-3"•
13 Six or more residential units. occupancy.
City/State/ZIP:Tigard,OR 97 e.e ❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name: ❑Hazardous locations. 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: Zggr '° "
Description I Qty. 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'1500 sq.ft.or_, 'r,..>,.m . portly 33.92 1
1 ' 4 .. r�F. z ?":t!�'.? RX:+ , . ,.5.,.lei.'tlifse#.;c Limited energy,residential75.00 2
move washer and dryer and added bedroom (with above sq.ft.)
I Y Limited energy,multi-family 75.00 2
residentialwith above s .
( q ft.)
. = „ > Renewable Energy 0 See Page 2
; . 1 k. .( it, }. , . :. . ON - ``f
` Services or feeders installation,alteration,and/or relocation
Name: 200 amps or less 100.70 2
201 amps to 400 amps 133.56 2
Address: 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 I
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
Branch circuits—new,alteration,or extension,Qer panel
(!]�ioi-iLtct»T 4iiiij , -..-A,
. $ , Y . 0. 1GT 4,0$0*,,,,_ A.Fee for branch cine t;with
Business name:CR Electrical above service or feeder fee, 7.42 2
each branch circuit
Contact name:James Webb B.Fee for branch circuits without
service or feeder fee,first I 56.18 2
Address:5100 SE Harney Dr.STE123 branch circuit
City/State/ZIP:Portland,OR 97206 Each add'l branch circuit 4 7.42 2
Miscellaneous(service or feeder not included)
Phone:(503)7897385 Fax::( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email:james.electricaldesigninc@gmail.com Reconnect only 67.84 2
. •,,"e �
C, �R ' Pump or irrigation circle 67.84 2
Business name:CR Electrical Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy 0 Page See 2 2
Address:5100 SE Harney Dr.Ste123 panel,alteration,or extension.
Each additional inspection over allowable in any of the above
City/State/ZIP:Portland,OR 97206 Additional inspection(1 hr min) 66.25/hr
Phone:(503)2067441 Fax:( ) Investigation(I hr min) 90.00/hr
Industrial plant(1 hr min) 78.18/hr
Email:james.electricaldesigninc@gmail.com Inspections for which no fee is
specifically listed(%2 hr min) 90.00/hr
CCB Lic.: 214244 Electrical Lic.: C126 ic.: 5019S ,.
ELEG)<'R((CA .PERMIT 1 5
Suprv.Electrician signature,required: Subtotal:
Print name: Gary Sunford Date: 09/13/18 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: " + ' =
&....-i:___._.. TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within DSO
Print name: James Webb Date: Q9/13/18 days after it has been accepted as complete.
Number of inspections allowed per permit.
1:\Building)Permits\F.LC_PernutApp_ELR_ERE.doe Rev 06/17/2015 440-4615T(11/05/COM/WEB
f.
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
(� Each f T�..«.I
DneriptroR
Fee for all residential systems combined: $75.00 Renewable electrical energy systems:
5 kva or less 100.70 2
Check Type of Work Involved:
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 55226 2
❑ Garage Door Opener* >100 kva(fee in accordance
SS2.26 2
with OAR 918-309-0040)
p 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
7'{any specifically listed
(Yz hr min) r
Subtotal(Enter on Page 1):
Fee for each commercial system: $75.00 * 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*
❑ M• edical
❑ N• urse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems: —
*No licenses are required. Licenses are required for all
other installations
t:lauildinglPennits\ELC PemtitApp_ELR ERE.doc Rev 06/17/2015