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Permit ACI,A7.95 CITY OF TIGAR® ELECTRICAL RESTRICTED ENERGY PERMIT tG` a COMMUNITY DEVELOPMENT Permit #: ELR2010 -00046 Date Issued: 03/24/2010 tTiGAAL? 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 25101 DD00101 Jurisdiction: Tigard Site address: 6975 SW SANDBURG ST 160 Subdivision: Lot: 0 Project: Serenity Tallative Hospice Project Description: Low voltage for voice /data. FEES Owner: WESTON INVESTMENT CO LLC Description Date Amount 2154 NE BROADWAY, STE 200 Restricted Energy Permit 03/24/2010 $67.84 PORTLAND, OR 97232 12% State Surcharge - Electrical 03/24/2010 $8.14 PHONE: Contractor: HASTINGS COMMUNICATIONS INC 10015 SW STEEPLECHASE CIRCLE BEAVERTON, OR 97008 PHONE: 503 - 789 -5852 FAX: 503- 524 -5678 Type of Use: COM Class of Work: ALT Total Number of Systems: 1 Audio & Stereo: N Boiler Controls: N CCTV: N Clock Systems: N Data & Telecommunications: Y Fire Alarm: N HVAC: N Instrumentation: N Total $75.98 Intercom /Paging: N Landscape /Irrigation: N Landscape Lighting: N Medical: N Required Items and Reports (Conditions) Nurse Calls: N Protective Signal: N Security Alarm: N Other: N Other Desc: 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 a - • - - 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. AT NTION: Oregon la ire s u to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 -001 1010 through OAR 952 -001 - 00. You may btain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. ( Permittee Signature: Iss ed By: , 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 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. • '9t a , ii; s}k + rw.w awl , `'` -i .< • Electrical Permit Application 'ss s , OR I lu tl t)iN�l ,st x M. . - _ ``!I tIti {a'ri+kr0:1'C.411.. `� . • 1� @ � 1 -iii 1Y#* �3Sfi i Received { /� O / �` n � `to - 4 4 City of Tigard Re eiv : d O' �� Permit No.: C I. OrCJ �( / 11 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review C Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit: TI(. i 1. u'. iss Inspection Line: 503.639.4175 Date Ready /By: Jur ri ® See Page 2 for Internet: www.tigard - or.gov Notified/Method. rte Supplemental Information ' TYPE OF WORK PLAN REVIEW ❑ New construction Addition /alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below): ❑ Service or feeder 400 amps or more ❑ Building over three stories. ❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards. CATEGORY OF. CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. Tess to ground, or exceeds 14,000 ❑ Commercial -use agricultural ❑ 1- and 2- family dwelling J'Commercial /industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ",' 1 -2 ", "I -3 ", Job no.: Job site address: `�, / 100HP or more. occupancy. 97�JW SGtl�1��(// / ❑ Six or more residential units. ❑ Recreational vehicle parks. City /State /ZIP: Qt J ❑ Health-care facilities. 0 l oca ti ons. ❑ Supply voltage for more than l 600 volts nominal. I Suite /bldg. /apt. no.: Project name: S�� / T f !� 77 v e gse ❑ Service or feeder 600 amps or more. !!! FEE SCHEDULE Cross street/directions to job site: Description 1 Qty. 1 Fee. 1 Total 1 New residential single- or multi - family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4 Ea. add'I 500 sq. ft. or portion 33.92 1 Tax map /parcel no.: Limited energy, residential 67.84 2 DESCRIPTION OF WORK • • (with above sq. ft.) Limited energy, multi - family 67.84 2 I. r7 t4J V n / ✓e j r residential (with above sq. 11.) I Services or feeders installation, alteration, and /or relocation 200 amps or less 100.70 2 .0 .PROPERTY OWNER • ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: 601 amps to 1,000 amps 301.04 2 Address: Over 1,000 amps or volts 552.26 2 City/State/ZIP: Temporary services or feeders installation, alteration, and /or n relocation Phone: ( ) Fax: ( ) 200 amps or less 59.36 1 201 amps to 400 amps 125.08 2 Owner installation: This installation is being made on property that I own which is not intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2 Branch circuits - new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with ❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee, . 7.42 2 • each branch circuit Business name: B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact name: branch circuit Each add'I branch circuit 7.42 2 Address: Miscellaneous (service or feeder not included) Ci City/State/ZIP: Each manufactured or modular ty dwelling, service and/or feeder 67.84 2 Phone: ( ) Fax:: ( ) Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 E - mail: Sign or outline lighting 67.84 2 • CONTRACTOR Signal circuit(s) or limited - energy / / 7 _t� Business name: panel, alteration, or extension. ` Page 2 L / 2 s rr .t15 (f�rNn1v.! t crr nn c �rf C • Each additional inspection over allowable in any of the above O ./Address: / 00/ ,S S W s� Dip k ,,,A,24,_ 6 >G /F Additional inspection (1 hr min) 66.25/ hr 0o /� (� pp Investigation (1 hr min) 66.25/ hr City /State /ZIP: i/4 6 /� / 70 v L Industrial plant (1 hr min) 78.18/ hr Phone: (5 73) SLci Si 76 Fax: ( ) Inspections for which no fee is 90.00 / hr specifically listed (%: hr min) CCB Lic.: /3/ 9 7 ? Electrical Lic.:3y_ 1092ce Suprv. Lic.:/ 3 osG . ELECTRICAL PERMIT ,FEES Suprv. Electrician signature, required: - Subtotal: Plan review (25% permit 6 7� g� y mit fee): --1 Print name: �� yi'GA_ A , s D e: 3 2 y... /v State surcharge (12% of permit fee): t../ 4 TOTAL PERMIT FEE: 7 5 1 9 g Authorized signature:, - 4. This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name:g L.4 / - '71r _ r t Date: 3-2Y- / 0 • Number of inspections allowed per permit. 'J' 1:\Buildingermits \ELC- PermitApp.doc 10/01/09 440- 4615T(It/05 /COM/WEB Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL.WORK'ONLY: - • Fee for all residential systems combined .. $67.84 Check Type of Work Involved: ❑ Audio and Stereo Systems* ❑ Burglar Alarm n Garage Door Opener* ❑ Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* n Other: ■..COMMERCIAL WORK ONLY: Fee for each commercial $67.84 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: n Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation n HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* n Medical n Nurse Calls n 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.doc 10/01/09