Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit#: ELR2009 -00156
13125 SW Ha ll Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/05/2009
T 1 Gtl RD Parcel: 2S113AA01100
Jurisdiction: Tigard
Site address: 16588 SW 72ND AVE, BLDG# B11
Subdivision: OREGON BUSINESS PARK I Lot: 0
Project: Spec Space
Project Description: HVAC
FEES
Owner:
PACIFIC REALTY ASSOCIATES Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY Restricted Energy Permit 06/05/2009 $75.00
#300 12% State Surcharge - Restricted Energy 06/05/2009 $9.00
PHONE:
Contractor:
OHAC INC
PO BOX 241
DUNDEE, OR 97115
PHONE: 503 - 538 -2953
FAX: 503 -691 -8556
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: N Fire Alarm: N
HVAC: Y Instrumentation: N Total $84.00
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. AU 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... You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: ///�7•ti L_ � r __ Permittee Signature: 4/V F/ a —i o L /e `97 - eAil
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.
City of Tigard, Oregon 0 13125 SW Hall Blvd. m Tigard, OR 97223
,•
August 27, 2009
Oregon Heating & AC
P.O. Box 241
Dundee, OR 97115
Attn: Teresa Stupor
Re: Permit No. ELR2009 -00156
Dear Ms. Stupor:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 16588 SW 72 " Ave., B11
•
Project Name: Spec Space
Job No.:
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $67.20.
❑ Trust account "deposit" receipt in the amount of $
Notes: 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,
At 2/
Wit- L_
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds\ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
CITY OF TIGARD RECEIPT
• I 4
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
i A.: A
Receipt Number: 175008 - 08/27/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2009 -00156 $ - 67.20
Total: $ -67.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 07395A DHOWSE 08/27/2009 $ -67.20
Payor: Teresa Stupor - Oregon Heating & AC
Total Payments: $ - 67.20
Balance Due: $67.20
Page 1 of 1
CITY OF TIGARD RECEIPT
•
II 13125 SW Hall Blvd., Tigard OR 97223
503.839.417
TIGARD
f — Receipt Number: 173865 - 06/05/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2009 - 00156 Restricted Energy Permit 220 - 0000 $75,00
ELR2009 - 00156 12% State Surcharge - Restricted 100 -0000- 207020 $9.00
Energy
Total: $84.00
PAYMENT MET OD CHECK ff CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 07395a OHOWSE 06/05/2009 $84.00
Payor: Teresa Stupor - Oregon Heating & AC
Total Payments: $84.00
' Balance Due: $0.00
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Page 1 of1
90/90 39tid DNI.C3H N09380 9SS8- T69 -E0S bE :Zt 6002/ET/L0
. '
I to
City of Tigard
TIGARD Accela 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 Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Oregon Heating & AC DATE: 8/20/09
P.O. Box 241
Dundee, OR 97115 REQUESTED BY: Dianna Howse
Attn: Teresa Stupor
TRANSACTION INFORMATION:
Receipt #: 173865 Case #: ELR2009 -00156
Date: 6/5/09 Address /Parcel: 16588 SW 72 ^d Ave., B11
Pay Method: CreditCard Project Name: Spec Space
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORMATION: •
Fee Description From Receipt Revenue Account No. Refund
Example: . [BUILD] Permit Fee • Example: 245- 0000 - 432000 $ Amount •
Restricted Energy Permit 220 - 0000 - 431510 $60.00
12% State Surcharge 100 - 0000 - 207020 7.20
TOTAL REFUND: $67.20
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager I PU.IIN Cc
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date: a e ` `
Case Refund Processed: Date: ''.` ` '.' • By:
I: \Building \Refunds \RefundRequesc.doc 04/13/09
•
•
• ° Community Development
RECEIVED
1.1G RD Request for Permit Action
JUL 13 2009
TO: CITY OF TIGARD OF TIGARD
Building Division Services Coordinator QJOVOSIO
13125 SW Hall Blvd_, Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner p Applicant ® Contractor ❑ City Staff
(check one)
REFUND OR Name: Oregon Heating & AC
INVOICE TO: (Business or Individual)
Mailing Address: P 0 Box 241
City /State /Zip: Dundee, OR 97115
Phone No.: 503- 538 -2953
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION.
PI REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fcc schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit.).
Permit #: ELR2009 -00156 •
Site Address or Parcel #: 45d�J 7 45," _5
es / G - ,6
• Project Name: 3 Spec Spaces
Subdivision Name: Lot #:
EXPLANATION: job cancelled
•
Signature: L...rdt Date: 07/13/09
Teresa Stupor
Print Name:
Refund Policy
1, The Director or Building Official may authorise to refund of
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application it withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended,
e) not more than s0% of the building permit fee for issued permits prior to any m pection requests.
2. Refunds will be returned to the original Paycr in the same method in which payment wns received Please allow 1-2 weeks for processing refund..
I'0R 0 1::11(:1. {i'hi O1VLI
Rte to S • s Admin: Date B • Esc to Bld • Admin: Date , ff�
Refund Processed: Date , ®o C By •12 Invoice Processed: Date By
Permit Canceled: IHMIMITAB B ' ;;A - . eel Ta: Added: Date B
- Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
90/50 3SVd SNIld3H NO9380 9558 - 169 —E09 OE:IT 600Z/ET/L0
Electrical Permit Application i tiiz (ihi I(1 litil O\I ' ,; . i sl
01 of Ti �1-a R ECEIV E R eceived �r S'
IN •J g Date/8 : Q ,C `� f,t Permit 2lo. 90 ��V .
• 13125 SW Hall Blvd. Tigard OR 97223 PlanRevie p
Phone: 503.639.4171 Fax 503598.1960 N 0 3 2009 Date/13y. Other Permitai/O. QO7ieOD `9l(
r ;,; I L t Inspection Line: 501639.4175 Date Ready /By: Jule: 0 See Page 2 for
Internet: www.tigard -or.gov n M A D h Notified/Method: 77c--- i Supplemental Information
:a 1 r u i
r iTiti i iii. "Ir' 1 f i t Y' t tF i'' 1 ry l'f l� . (. . , t 1 ; t "� tti ? L { M1 , { : ! „ Y. Pr. . t
)�,. i �` �"rt!r'� { • i i',�.{, v,. (�` r'( { y, j if is { .. h. , 1+ F ?'N! t hi` I , . _. f [ i .J . � 1 } t.� . ;•I r t }.: ' J { t : ..t� � it "u.� � 9 •: t � y tf . i 'fi •, , cM
z .7, t t ! " +�h }'.rl;i it {t �. l .i p::.. >< ,,t t� . t t. {. i 1 K. �. I 1 Lt IL dp `ye 111 it Y �C slat A -'�i ii e .'s �r t II I t11. w it . s
,.... r._ ..r c,.dkihiiaSL• iR,}b:,llnr u,. n t: , fl! �ni, ��,)i��-ar =•.. r..i ..i lt'L.i „ n' ..7 O. , is i t r, t_...:. _,�L- --° ! t .a R�,..,r_l., s ,, �' �,.. 21,., 3 e: � .:aJU._L._.1LwL .,��., . ..-- - �..,. >4 ..°c.
❑ New construction El Addition/alteration /replacement please check all that apply (submit 2 sets of plans w /items checked below):
D Service or feeder 400 amps err mum Building uvei three stories.
❑ Demolition
❑ Other: where the mailable fault current 0 Marinas and boatyards.
• , " 4 ;ii a + t , I � i i iii r rc� fi ∎ , `I 4 ; " ^"'`"''- i `"'T x j 4 W ors 470 riii G t fir exceeds 10.000 amps at 150 volts or ❑ Floati boil
..... '' r � r ^r P ng dings.
...�. �.,1«ul;La bliii..i. C �: (ifi5.� .i.htii,i 1 t.,ti •t.l,.tl .h 14 i.ii∎lai . ihlh Ili:. i•n t..1. c .1 ' Z:ri r�: L: i
1- 2-family dwelling Is to Around. or exceeds 14 ❑Commercial -use agricultural
❑ y g ® Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi-family q El Master builder ❑ Other: C3 Fire pump. ❑ Installation of 75 KVA or
..ab�i t o :;h,ati(iui, II i 1. i lil l i l i 6 @ i � u n3 i1 dnarilf ? rt Le a i t�n � { r .lr ' r ' ! i ud u . { a 111 0 A 4it oney system, larger separately derived system.
Addit of nov motor load of ❑ "A" "E ", "1-2" "1 -3"
Job no.: 09 -0208 Job site address: 16588 SW 72 Ave 1001IP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: Portland, OR 97224 ❑ Heahh -care facilities. ❑ Supply voltage for more Than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: 3 Spec Spaces 0 Service or feeder 600 amps or more
tiY iK /fi yr�" ��''t'�1't _ ��` c.l .1 . Jot,- : r
p ;c- iii
Cross street/directions to job site' Teri ``ii F ee, Total • own Q4.
New residential single- or multi - family dwelling unit
includes attached garage.
Subdivision: I Lot no.: 1 sq. R. or less I 145.15 4
Tax map /parcel no.: Ea. add'1 500 sq. ft. or portion 33.40 1
Limited energy, residential •
!1 n { ° 41 tpIY { i,1 l i 11jj �1ff:;; �i �x{r turd ` pis. a F: { i ti t , rl f , ,1 fl t f l , • �l ; t 75.00 2
u.l:Eisl,i f l:t.I: III III ?i1111114,l ,.11 iMiliiil il� = �u+y u.ii�'!.ia 4zi.§l4iill.)d:h•In •:..:
•:'ii', IIII :'4 ,'. I ft ! ti i jtt r• i ii , { yl liittli., • '. 1 (with above sq. f
Limited energy, multi - family
75.00 2
residential (with above sq. it.) _
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
a{ 3 , r p x., S ttt �1 ! II tr ry � t � t�t t r y ;Y j { fi t 11(� {a ` L r f x+t t, y y ti , l': �i t { A >w -
ivi-1r •:! nl.E.ci:N i ec `dtnr: iul'f!!. a ic'f.:,tic iLLi : t KN6 1 :r. i i 4 ,L(h11i} ,.1!}, 1" ^ } c.�tt!i j i } L 201 amps to 400 amps 106 - 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or vrllts 454.65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that 1 own which is not 201 amps to 400 crops _ 100.30 2
intended for sale, lease. rent, cr exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Branch circuits - new, alteration, or extenslon�er panel
Owner Signature: Date:
,_ i -...., "fIS""" 4{7n�itc�:i iNl i;til',riIIIFilt'� -4(•:r:ii `;,
,•. t.. .,....r,, ; 1..H; ^it•...•.;.��.;. iIF ;:
A. Fee for branch circuits with
w , t∎ria II. .lt ll �� Ci t) t it 1' ti, l ll IIIII ' rj11 l..L.J 1 , { li f 'ir •like.:,i!ial; about service or feeder fee,
.�}. 1 ...u1L.1� Ctit. uG i -. �ii.tFi 7 , Lr vt ,k..s.la.c...�.ht. n ..r...a, h branch circuit 6.65 2
Business name: B. Fee for branch circuits
•
Contact name: without service or feeder fee, 46.85 2
firstbranch circuit _
Address: • Each addl branch circuit 6.65 2
Niscellaoeous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( ) i Reconnect only _ 66.85 2
_ Y
•
E - mail: • Pump or irrigation circle 53.40 2
l4.tl ,at }.f iftitl'. [rr[�[i}t�l��ff `� �� 3� j 1' i i�1r {1111 ..`{tI1 t j t } �HIY (g{ etlt J11 t ,l if :.'91 f ft f � l , »rt }I)t. si or Outline lighting 53.40 2
} .tL_�� L .�L..iiiL":l.ti4. �r�L1lIGf.1.,t I � ,.LL'tCJ..I fla�l.Ia1LY.:ttte...tlaff..ti1 v1.ILi _ll` �i,L�E.:...ii��r'1 �l..L>�.:..�.1...,�U
Business name: Oregon Heating cSk AC Signal circuit(s) or limited -
ener panel, alteration, or
Address: P 0 Box 241 eurensinn. neecrihe: 1 Page 2 75.00 2
City /State /ZIP: Dundee, OR 97115 Each additional inspection over allowable in an of the above
Per inspection 62.50
Phone: (503) 538 -2953 Fax: (503) 691 -8556 investigation per hour (1 hr min) 62.50 -
GCB Lic.: 172126 [Electrical Lic.: L1-{R40 Supn'. Lie.: 1798LEB Industrial plant per hour 73.75
/ kv, 4 ! ` 2 d, w,.a... w.. i j...,� .` ...:... r .: ; C't7.t" :'ii.791$,F �
.. '+.rn .-i
,r �'�
Suprv. Electrician signature, required: l_'l b Subtotal: 75.00
I Alan review (25% of permit fee):
Print name: Greg Boone Date: 06-03 -09 1 v /
l I State surcharge (t 2% of permit fee): 9.00
Authorized signature: - `r 3J �/ TOTAL PERMIT FEE: 84,00
Print name: Teresa Stupor Dart: 06-03-09 This permit application expires if a permit is not obtained within 180
P days after it has been accepted as complete.
' Number of inspections allowed per permit.
r.zoileies\pere acJeLe.pennitnpp.eec 0;231JG 440- 4■13t(l 1 /05 /COM'W'Ea
LO /Z0 30dd JNI1V3H NO93ZI0 9598- I69 -E05 9t' :EI 600Z/E0/90
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
• 8 i b o , .,.. ,3:1 {A 1f r_
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ other
Fee for each commercial $75.00
system
(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
I HVAC
❑ Instrumentation
n Intercom and Paging Systems
❑ Landscape Irrigation Control*
Medical
❑ Nurse Calls
TI Outdoor Landscape Lighting*
n Protective Signaling
❑ Other
Total number of commercial systems: 1
*No licenses are required. Licenses arc rcquired
for all othcr installations
C 16uildiegkPermitsl ELC- PmmitApp.doc 03/2V06
LO /E0 3SVd ONI1d3H N003d0 9558- t69 -COS 9b :Ei 600Z/E0/90