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Permit (124) REC El City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT`V 1 9 2019 CITY CF "I€GARD Request for Permit Action BUILDING DIVISION TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD V 0 I Building Division D 13125 SW Hall Blvd.,Tigard,OR 97223 ///O/z Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner 12pplicant LRritractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual)fit , I1/43 c XL. r t7/rt c.. Mailing Address: tiAtt) City/State/Zip: 1`?C4. oojs Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): [� CANCEL/VOID PERMIT APPLICATION. a REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: y c CL_cam., .. ' P_L-Q,ZC `t; "js Site Address or Parcel #: r � b �" npg Project Name: 1� S ga � E k Subdivision Name: Lot#: EXPLANATION: bt,;:stY kP� ( cC`:ei\e 5 c() �" � VAC -\ -�: T.�' u .c �J Signature: Date: 1 6,A-- lQ— Zo t oik Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 67,e 3. S7 e. //' — 6.S/ ,s /• l0 3 /SSr� 6ti Or/s /y 25 f- 7, ,fS FOR OFFICE IISE ONLY Route to Sys Adtnin: Date By Route to Records: Date 9 Z/ '; Refund Processed: Date ,�//;7%r By ,' / Invoice Processed: Date By Permit Canceled: Date'p0/2.c, j j By / Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_2051 .doc a . . TIGARD City of Tigard January 28, 2020 Rudnick Electric Signs 1400 SE Township Rd Canby, OR 97073 Re: Permit No. ELC2019-00580 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 15700 SW Upper Boones Ferry Rd Project Name: Best Western Plus Job No.: N/A Refund Method: ® Check#234514 in the amount of$60.78. ❑ Credit card"return"receipt in the amount of$ 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 job was cancelled. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, ,. )5 (Pv472417'z--- 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: Rudnick Electric Signs DATE: 1/17/2020 1400 SE Township Rd Canby, OR 97073 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 425670 Case#: ELC2019-00580 Date: 9/5/2019 Address/Parcel: 15700 SW Upper Boones Ferry Pay Method: CreditCard Project Name: Best Western Plus EXPLANATION: Per applicant's request as customer cancelled job. Refund 80%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Electrical Permit 220-0000-43103 $54.27 12%State Surcharge 100-0000-24001 6.51 TOTAL REFUND: $60.78 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: 9j/ -1 By: ' I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT )1 s 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T[GARD Project Name: Best Western Plus Site Address: 15700 SW UPPER BOONES FERRY RD tJ-® Receipt Number: 436197 - 09/03/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00580 $-60.78 Total: $-60.78 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 234514 DHOWSE 09/03/2021 $-60.78 Payor: Rudnick Electric Signs Total Payments: $-60.78 Balance Due: $60.78 Page 1 of 1 CITY OF TIGARD RECEIPT 1111. lQ a 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TfCAR`EDI 1 Project Name: Best Western Plus Site Address: 15700 SW UPPER BOONES FERRY RD Receipt Number: 425670 0 09/05/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00580 Sign or Outline Lighting 220-0000-43103 PO `344 $67.84 • ELC2019-00580 12% State Surcharge- Electrical 100-0000-24001 /0 //, $8.14 .,, Total: $75.98 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 5527083 PUBLICUSERO 09/05/2019 $75.98 Payor: Total Payments: $75.98 Balance Due: $0.00 Page 1 of 1 IN 1 ' CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit#: ELC2019-00580 T f[;A po 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/05/2019 Parcel: 2S112DD01000 Jurisdiction: Tigard Site address: 15700 SW UPPER BOONES FERRY RD Project: Best Western Plus Subdivision: None Lot: None Project Description: Sign lighting for(1)wall sign. Contractor: RUDNICK ELECTRIC SIGNS LLC Owner: BHGAH TIGARD LLC 1400 S TOWNSHIP RD 5895 JEAN RD STE 100 CANBY, OR 97013 LAKE OSWEGO, OR 97035 PHONE: 503-263-3600 PHONE: FAX: 503-263-4617 FEES Quantity Description Date Amount 1 ea Sign or Outline Lighting 09/05/2019 $67.84 Specifics: 1 ea 12%State Surcharge- 09/05/2019 $8.14 Electrical Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Total $75.98 Required Items and Reports(Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires y-- to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 9 -001-00 . Yo 4,ay obtain a py of the rul-s or direct questions to OUNC by calling 5 . . 7 or 1.811 - ,, Issued By: 01 , Imo% Permittee Signature: OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale,lease or rent. ` — OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR.ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Electrical Permit ApplicationECEI�/ UG AUG �O� FOR OFFICE USE ONLY Received - CITY City of Tigard 1I OF TIGAR�' dE /II f 114 111 13125 SW Hall Blvd.,Tigard,OR 97223 aPlanReview f L J �f Phone: 503.718.2439 Fax: 503.598.1960 ateB : Related Permit#: ' , ' 0 '' „ )'" f Inspection Line: 503.639.4175 ,:d DateB Juris: ® See Page 2 for TIGARD p ��� -�rib(,NG DIVISI Ojotified/Method: Supplemental Information Internet www.tigard-or.gov p ' , ... -_. �....,. ;.a .. " € :, x = Via• ' .' 1+a rrNew construction I=1 Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked) ❑Service or feeder 400 amps or more ❑Building over three stones. ❑Demolition ❑Other: where the available fault current 0 Marinas and boatyards. _ :,.1 `; , ' �_$ exceeds 10,000 amps at 150 volts or ❑Floating buildings. 0 1-and 2-family dwelling, ommercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural amps for all other installations. buildings. ❑Multi-family ❑Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or i 6 5 I 2'.'-' ti' 1:-i):: : y :--1'-::-:-. ' :- ❑Emergency system. larger separately derived ❑Addition of new motor load of system. Job#: Job site address: l x) L) _3 _._(t_E 10OHP or more. ❑..A» E» «1-2» ..1-3„ City/State/ZIP: �-` ❑Six or more residential units, occupancy. ``J� ❑Health-care facilities. ❑Recreational vehicle parks. S 0Hazardous locattons. 0 Supply voltage for more than Suite/bldg./apt.#: Project name: �� �1�� t,�SL;� 0 Service or feeder 600 amps or more. 600 volts nominal. Cross street/directions to job site: Description Qty. Each Total 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 It s� ._ 1 _ :' Limited energy,residential b (with above sq.ft.) 75.00 2 �P('tILc1C C - t e f\ LA1: �i� Limited energy,multi-family residential(with above sq.ft.) 75.00 2 . - Renewable Energy 0 See Page 2 � - m$ Services or feeders installation,alteration,and/or relocation Name: 3(• Q --Vt „Ca 200 amps or less 100.70 2 Address: r C&-''''''n-(2--S 201 amps to 400 amps 133.56 2 l *4- � Com` I 401 amps to 600 amps 200.34 2 City/State/ZIP: c�6,>^ Vim` l Tv J s' 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 M Branch circuits-new,alteration,or extension,per panel `°� :;.- SV: A.Fee for branch circuits with Business name: C above service or feeder fee, vi71 G� i tit'.C' J1t� each branch circuit 7.42 2 Contact name: �;(2kJ ,L)Ae-,(e;'— B.Fee for branch circuits without , service or feeder fee,first 56.18 2 City/State/ZIP: �{ � Address: V- o SE I�,7x s Z-1 branch circuit /�, _ L,, �,i V1 cy 1 `5 Each add'l branch circuit 7.42 2 Miscellaneous(service or feeder not included) Phone:(5-G S) 7 ... SC. Fax: :( b3 ) 3-- LI(p,(-74- Each manufactured or modular 67.84 2 dwelling,service and/or feeder Email: Reconnect only 67.84 2 ` ` Pump or irrigation circle 67.84 2 Business name: • T'4 g g g ` lr � {7����\� � -Fl ��I„`e_ �� �� �i noroutlinli tm 67.Sd 2 �� K C Signal circuit(s)or limited-energy 0 See Page 2 2 Address: ,�C J E ,- - ,® Q� panel,alteration,or extension. City/State/ZIP: 0.,i,..... ._ + ` Each additional inspection over allowable in any f the above Additional inspection(1 hr min) 66.25/hr Phone:(sc;S) 'LLS 2 -- U Fax:(S-62)) C_cz —4-1(j7+. Investigation(1 hr min) 90.00/hr 's Industrial plant(1 hr min) 78.18/hr Email: - / I ;• ' t mfr�!�o IAf;;�t'C �'>1 Cf�1 - �tir �) t ((AR Inspections for which no fee is 90.00/hr CCB Lic.: 'j Electrical Lic.: LLSSuprv.Lic.: 25i CR s.ecificall listed '/z ,hr min �j .a II Suprv.Electrician signature,required: .'.�.�—- "`�-7-f ) Subtotal: t.....-A- ' m'- Print name: ''E'."1 tar` IC Date: --Z1-( l _❑Plan Review Required(25%of permit fee): State surcharge(12%of permit fee): Authorized signature: -- TOTAL PERMIT FEE: '_-. This permit application expires if a permit is not obtained within 180 Print name: C� ., f . � er 'r Z C( days after it has been accepted as complete. ‘,,A,,.., "' * Number of inspections allowed per permit. I:\Building\Permits\ELC_PermitApp_ELRERE.doc Rev 06/17/2015 440-4615T(11/OS/COM/WEB Electrical Permit Application-City of Tigard Page 2-Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: Fee for all residential systems combined: $75.00 y Renewable electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 _© 5.01 to 15 kva 133.56 _© n Audio and Stereo Systems* 15.01 to 25 kva 200.34 _© Wind •eneration s stems in excess of 25 kva: ❑ Burglar Alarm 25.01 to 50 kva III 301.04 _© 50.01 to 100 kva 552.26 _© ❑ Garage Door Opener* >100 kva(fee in accordance with OAR 918-309-0040 ■ 552.26 _© ❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva: System* Each additional kva over 25 III 7.42 _© ❑ Vacuum Systems* >100 kva-no additional charge - 0.0 _© Each additional ins i ection over allowable in an of the above: ❑ Other: =11-'• ach•additional inspection is ■ 66.25/hr chared at an hourl 1 hr min) Inspections for which no fee is ■ 90.00/hr _. s�ecificall listed(%hr min) oR,Oi 4, a f;S: 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 n Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation • ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* ❑ 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