Permit (2). .
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ''''' '''''' ' ''' ' '(-)
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Request for Permit Action ucT b 2020
13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439• www.tigaid2:.;g1;T:i),'(N.11;IIPILISkrIi5N
TO: CITY OF TIGA.RD V 0 I D
Building Division
iqc7/'2o 406
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: Owner 0 Applicant D Contractor 0 City Staff
check(1)0m
REFUND OR Name: ty
INVOICE TO: Cfhnl"e36 or
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Mailing Address: (P61 it,) W610 4- via-?‹..e.....-
City/State/Zip: --rt tiNt... .) Om ot 7 0---3
Phone No.: a5 . .__TL c‘c) 7/4
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PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (I):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: • -1,,c, 1,0 Zio co I 0--1-
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Site Address or Parcel #: i Ai c..".3 6v0 VV\ N4-- --ce:vv--kc6
Project Name: W(1,1/4- 41)‘1, A.- 6.14.0-4;,,C...g_ VICNId .f?....e Ti-tei Subdivision Name: I•JI Lot#: ..---
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EXPLANATION: Pc D-P4t4\-P•sCle 04).6i.--
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Signa,ture: Ai. -NI tW Date ioJ7io
Print Name: l C-711-0 el tk--T
,. Refund Polig
1. The city's Communi . nt DirectOr,Budding Official or City Engineer may authorize the refund of
• Any fee which ., 'i cously 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 apphcation 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 tot processing refund requests. 67. er .--_cc.", Z„.7 _7 /3• -5.7
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. Route to Svs Admin: _ Date IMIN Et Route to Records: Date ,goznamor,
. • Refund Processed: Date ,,,2,,,,r, By)4 Invoice Processed: Date BIT
Permit Canceled: Date I 2,0 B. Parcel Tag Added: _ Date By
. , I:\Building\Forms\ReqPermitActionJ if. . ,
, „
111
TIGARD
City of Tigard
December 22, 2020
Garo Wright
6815 SW Walnut Ter
Tigard, OR 97223
Re: Permit No. ELC2020-00103
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 6815 SW Walnut Ter
Project Name: Wright
Job No.: N/A
Refund Method: ® Check#237605 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 permit was not required per PGE. Refund
80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Ornelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
III
: " 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 Garo Wright DATE: 12/9/2020
TO:
6815 SW Walnut Ter
Tigard, OR 97223 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 428274 Case#: ELC2020-00103
Date: 2/19/2020 Address/Parcel: 6815 SW Walnut Ter
Pay Method: CreditCard Project Name: Wright
EXPLANATION: Per applicant's request as applied as permit was not required per PGE. 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 lee. 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 D. L. Ornelc 4
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
Case Refund Processed: Date: ep 2/ By: 0
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
it 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Wright
Site Address: 6815 SW WALNUT TER •O_S
Receipt Number: 435834 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00103 $-60.78
Total: $-60.78
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237605 DHOWSE 08/13/2021 $-60.78
Payor: Garo Wright
Total Payments: $-60.78
Balance Due: $60.78
Page 1 of 1
II
CITY OF TIGARD RECEIPT
ris13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Wright
Site Address: 6815 SW WALNUT TER d 4/6 i J
Receipt Number: 428274 - 02/19/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00103 Reconnect Only 220-0000-43103 $67.84
ELC2020-00103 12%State Surcharge-Electrical 100-0000-24001 $8.14
Total: $75.98
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 7664 JDRINKWATER 02/19/2020 $75.98
Payor: Crystal Wright
Total Payments: $75.98
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD ELECTRICAL PERMIT
1 COMMUNITY DEVELOPMENT ELECTRICAL
ELC2020-00103
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/19/2020
T I G A R ID9 Parcel: 1 S125DA02400
Jurisdiction: Tigard
Site address: 6815 SW WALNUT TER
Project: Wright Subdivision: Lot:
Project Description: Reconnect only.
Contractor: Owner: WRIGHT, GARO&CRYSTAL L
6815 SW WALNUT TER
TIGARD, OR 97223
PHONE: 503-347-8028
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Reconnect Only 02/19/2020 $67.84
Specifics:
1 ea 12%State Surcharge- 02/19/2020 $8.14
Electrical
Type of Use: SF
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 p rmit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION. Ore!•- - require -•u to o ow the r s opted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through O 01-009• 'ou may o in a copy e s or direct questions to OUNC by calling 5 3.232.1987 or or/1.800.332.2344.
Issued By: , „ ttee Signature: l4I2 L1.4 t
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 503.639.4176 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 OFFICE USE ONLY
CityofTigard Received
g Date/B : � �7� f _
;�,. • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Date/B : Related Permit#:
Email: TigardBuildingPermits@Tigard-or.gov Ready Date/By: Juris: Ei See Page 2 for
l li.:1 PPInspection Line: 503.639.4175 Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑New construction 0 Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
❑Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition ❑Other: 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 0 Commercial/industrial 0 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
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
Cr ❑Addition of new motor load of system.
Job#: I Job site address:/�8) , 6- L,JCu-_]Put 'fl1' 100HP or more. ❑"A" "E"`9-2" "1-3"
City/State/ZIP: W� occupancy.e
- � _ a ❑Six or more residential units.
ty l� ��Z23 ❑Healtbcare facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#: I Project name: 0 Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I 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'1500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
�p� (with above sq.ft.) 75.00 2
l, w_r'�r frt rcr Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
Renewable Energy 0 See Page 2
1;:f PROPERTY OWNER i 0 TENANT Services or feeders installation,alteration,and/or relocation
Name: (yiur L, Clit I /�1 - 1 J') ,kr. - 200 amps or less 100.70 2
Address: (0 f.- 3/,_.0 tjal C "leer— 201 amps to 400 amps 133.56 2
` �-r 401 amps to 600 amps 200.34 2
City/State/ZIP:"r 1/c (p_� p/q 7 22 601 amps to 1,000 amps 301.04 2
Phone:(5� (�.7—C6UL-0 Over 1,000 amps or volts 1 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: QfJf(T 1 cr 5� J Lo r:t-I -t t o fir, relocation
Owner in`jallation:This installation is being 4nade on propertyYilat I own which is not 200 amps or less 59.36 I
intended for sale,1 e,rent,or exchange,according to ORS 447,449,670,iand 701. 201 amps to 400 amps 125.08 2
,Owner signature: fL,4 ita J �j{lc Date: -(2� I ZOZO 401 amps to 599 amps 168.54 2
APPLI ANT ❑ CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
each branch circuit 7.42 2
Contact name: ( ' rb �. ,, ,/ bB.Fee for branch circuits without
Address: 10�a`t'I S- `7 uD Cll !"1 l '/ ea or feeder fee,first
brannice ch circuit 56.18 2
EacCity/State/ZIP: l I� 6F__, ' t 7Zz-� add']branch circuit 7.42 2
CJ Miscellaneous(service or feeder not included)
Phone:(5—b3) (.�`) — rin s- Each manufactured or modular 67.84 2
�u dwelling„service and/or feeder
Email: c/j/ CIN 5 i_ L,ACTO �i'�}' J 7 '1 �. PLUS-ite..onnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy ❑ See Page 2 2
Address: panel,alteration,or extension.
City/State/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) Investigation(I hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lie.: I Electrical Lie.: I Suprv.Lie.: specifically listed(Y2 hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required:
Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: (/ (i-� y TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 1S0
Print name:'Orli
e]- jjilL i.A Date: cl2_6 l w ` days after it has been accepted as complete.
''\\ Number of inspections allowed per permit
I:\Building'Permits\ELC_PermitApp_EIR ERE.doc Rev 10/16%2017 440.4615T(11/05/COM/WEB
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 nese Qry. Each Total1
Renee wa wa ble electrical energy systems:
Check Type of Work Involved: 5 kva or less 100.70 2
5.01 to 15 kva 133.56 2
n 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
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 an 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(/hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES •
Subtotal(Enter on Page I):
$75.00 Fee for each commercial system: * Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
n 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:03uilding\Pnmils\ELC_PermitApp_ELR_ERE.doc Rev 10/26/2017