Permit • CITY OF r�, GARD
ELEC' `.AL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT PERMIT #: ELR2008 -00246
1 i c; n ii D 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 8/20/2008
PARCEL: 2S 102C B -00100
SITE ADDRESS: 12850 SW GRANT AVE ZONING: R -12
SUBDIVISION: CF TIGARD ELEMENTARY LOT: 041 JURISDICTION: TIG
PROJECT: BROADWAY ROSE THEATRE CO
Project Description: Installing (1) fire alarm system.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE/IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATAJTELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: X OUTDOOR I-ANDSC LITE:
OTHER: HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
TIGARD TUALATIN SCHOOL DIST. #23 ACS ELECTRIC LLC
6960 SW SANDBURG ST 19325 EDY RD
TIGARD, OR 97223 SHERWOOD, OR 97140
Phone: Contact #: PRI 503- 442 -3938
FAX 503- 625 -1862
Reg #: ELE CLE102
FEES
,_ LIC 175877
Description Date Amount SUP 2564LEA
[ELPRMT] ELR Permit 8/20/2008 $75.00
[TAX] 12% State Surch 8/20/2008 $9.00 REQUIRED ITEMS AND REPORTS
Total $64.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through • • - - : • I10o = obtain copies of these
rules or direct questio. - o OUNC at 50 • ; • •.- - .2344. / l
Issued By, Permittee Signature:t 41:■ q1
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'N: DATE:
LICENSE NO:
Call 603.639.4176 by 7:00 a.m. for an Inspection that business day.
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.
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Date
Permit Caticekd:
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Date
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Method 411,117
Amount
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(check one)
REFUND OR
INVOIC TO:
CITY OP TIGARD
Permit System Administrator
13125 SW Hall Blvd, Tigard, OR 97223
Phone: 503.716 -2430 Fars: 503.598.1960 www.tigard- or.gov
❑ Ottmer Applicant ,j Contactor ❑ City Staff
ad • /- c.- LL
Mailing Address: /13 5 5c £IL y 24.6
City/State/zip: 'j ' ',�v, l q o
Phone No.:
ale./ FAL
Name:
(Business or Individual)
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
4 , CANCEL PERMIT .APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
INVOICE FOR FEES DUE (attach case fee schedule and explain below. � _.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). , �°
li
Permit #: 44/ 6 ' r
Sire Address or Parcel #: /28$o i(&)
'1I
Project Name:
Subdivision Narrate:
EXPLANATION:
Signature:
Print Name:
TA BuildineForms \ Reg PermirAmon.doe
096Te6SSOS:01
Building Division
Request for Permit Action
.
SEP 1 G2T
CITY OFTI !'G
G DIVISION
,^a , d - AM. 7750 off.
7 co
Lot #:
grfnnd Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was errorieously pad or centered.
b) not mote than 80% of the land use nppbnsion fee when an application is withdrawn of canceled before any tevtew effort has been expended
c) not mote than 8O% of the land use application fee for issued permits.
c) nom mare than SO% of the building plan .review fee when an application is canceled before any plot review effort hat beers expended.
d) not more than ROW of d+e building permit [cc for issued permits prior to any inspection requests.
2 Rounds will be returned to the osigionl Payer in the same method in which ppymms wars received. Please allow 1.2 weeks for processing refunds.
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• City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
111
•
T I GARD
October 7, 2008
ACS Electric LLC
19325 SW Edy Rd.
Sherwood, OR 97140
Attn: Robert West
Re: Permit No. ELR2008 -00246 and BUP2008 -00282
Dear Mr. West:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12850 SW Grant Ave.
Project Name: Broadway Rose Theatre Co.
Job No.: N/A
Refund: ® Check #59672 in the amount of $240.86.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as general contractor hired two electrical contractors and one
set of plans was approved prior to plan review of this permit. Refund 80% of permit fees
and 100% of plan review.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds\ Administration \UrRefund- CancelPermitdoc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard or.gov • TTY Relay: 503.684.2772
City of Tigard
TI CARD Tidemark Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: ACS Electric LLC DATE: 9/17/08
19325 SW Edy Rd.
Sherwood, OR 97140 REQUESTED BY: Dianna Howse
Attn: Robert West
TRANSACTION INFORMATION:
Receipt #: 2008 -2957 Case #: ELR2008 -00246 and
BUP2008 -00282
Date: 8/20/08 Address /Parcel: 12850 SW Grant Ave.
Pay Method: Check Project Name: Broadway Rose Theatre Co.
EXPLANATION: Two contractors hired by general contractor; one set of plans already approved prior to
plan review of these plans. Refund 80% of all permit fees & 100% of plan review.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. • Refund •
Example: [BUILD] Permit Fee • Example:. 245- 0000 - 432000 $ Amount
[ELPRMT] ELR Permit 220 - 0000 - 431510 $60.00
[TAX] 12% State Surcharge 100- 0000 - 207020 7.20
[BUILD] Permit Fee 245- 0000 - 432000 107.20
[TAX] 12% State Surcharge 100- 0000 - 207020 12.86
[FLS] FLS Pln Rv 245- 0000 - 433020 53.60
TOTAL REFUND: $240.86
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager ' ��
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
V • FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: I 9` / /7 /Cf V I By: I 457r
I:\ Building\ Refunds \RefundRequest.doc 05/23/07
* `.
CITY OF TIGARD
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'' . 'Iipard, OR 97223 SO3.639.4171
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Receipt #: 27200800000000002957
E
Date: 08/20/2008 9:
Line Items: E
M
Case No Tran Code Description Re% enue Account No Amount Paid -r
ELR2008 -00246 [ELPRMT] ELR Permit 220- 0000 - 431510 73.00 3
EL R2008-00246 [TAX] 12? 6 State Surcharge 100- 0000 - 207020 9.00 D
to
BUP2008-00282 [BUILD] Permit Fee 245- 0000 - 432000 134.00 m
BUP2008 -00282 [TAX] 1 24'o State Surcharge 100- 0000 - 207020 16.08 m
n
BUP2008 -00282 [FLS] FLS Pln Rv 245-0000-433020 53.60 H
H
Line Item Total: S287.68 I-
r
Payments: n
Method Paser User ID Acct. /Check No. Appros al No. Hose Received Amount Paid
yi
Check ACS ELECTRIC, LLC. BTT 2225 In Person 287.68 C. m
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Payment Total: 5287.68 �, N
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ACS ELECTRIC, LLC
19325 Edy Road
Sherwood, Oregon
97140
503- 625 -1862
Protecting Tomorrows Futures Today
FAX : ,
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To n 1 Robert
VV`f ctiero West
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