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Permit p ,� CITY OF TIG�4 7 ELECTRICAL RESTRICTED ENERGY PERMIT ` ' - 14 COMMUNITY DEVELOPMENT Permit #: ELR2010 -00258 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/17/2010 Parcel: 2S 101 DA00104 Jurisdiction: Tigard Site address: 13333 SW 68TH PKWY, STE# 220 Project: ACS Subdivision: FARMERS INSURANCE Lot: 0 Project Description: HVAC Contractor: HVAC INC Owner: TRIANGLE POINTE LLC 5188 SE INTERNATIONAL WAY 901 NE GLISAN ST #100 MILWAUKIE, OR 97222 PORTLAND, OR 97232 PHONE: 503 - 462 -4822 PHONE: FAX: 503 - 462 -6555 FEES Description Date Amount Specifics: Restricted Energy Permit 11/17/201D $75.00 12% State Surcharge - Electrical 11/17/2010 $9.00 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 Intercom /Paging: N Landscape /Irrigation: N Landscape Lighting: N Medical: N Nurse Calls: N Protective Signal: N Security Alarm: N Other: N Total $84.00 Other Desc: 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 issua . : or if w is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification c e - Toe rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of tl e�rules or . ; t questions to OUNC by calling 503.232 i ^ .r 1 8 2.2344. ........../\" , ■ Issued By:.. _....i00. Permittee Signature: i i /J 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 Application - _ ' FOR OF.EICE %sE;10tN(Y. , y,. C ity of Tigard Received Permit No:' `J g , Date/B : 1 I 11 ' {� . e . • � 1,-,- 1 , , o ° 13125 SW Hall Blvd., Tigard, 'IL ti �a Plan Review i Phone: 503.639.4171 Fax: ' ' o °�9 DateB : Other Permit: 1� TIG Inspection ww or gov7 1 Q Date ed/M y S See Page 2 for 1>\0\1 10\! 1 2 a� Notified/Method: Supplements! information - Mill TYPE OF WORK 1/ 040 PLAN REVIEW ❑ New construction A Addition, 18if/ Please check all that apply (submit 2 sets of plans w /items caked below): ❑ Demolition ❑ Other: 12,01. l � t 011ie ❑ Service or feeder 400 amps or more ❑ Building over three stories. where the available fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural © I- and 2- family dwelling ..Commercial /industrial ❑ Accessory building amps for all other installations. buildings. Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or ❑ Emergency system. larger separately derived system. JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A " "E ", "I -2 ", "1 -3 ", Job no.: Job site address: IooHP or more. occupancy. VM� 3 1 � 3 �� � W \Q � 2 ❑Six or more residential units. ❑ Recreational vehicle parks. 1 City/State /ZIP: � c1 a/�- / \ c ^ I�)-'' ❑ Health -care facilities. ❑ Supply voltage for more than t `(�, ❑ Hazardous locations. 600 volts nominal. Suite/bldg.lapt. no.: '?-11.0 `N Project name: Lh 1(.:\Dill,/ ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Deser4dion 1 Q5y. 1 Fee. 1 Tel 1 * New residential single- or multi- family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4 Ea. add'l 500 sq. ft. or portion 33.40 1 Tax map /parcel no.: Limited energy, residential DESCRIPTION OF WORK (with above sq. ft.) 75.00 2 Limited energy, multi- fm,tily 75.00 2 }A/0 ��� l V ( residential (with above sq. ft.) Services or feeders installation, alteration, and/or relocation • 200 amps or less ' 80.30 2 ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 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 volts 454.65 2 ' City/State/ZIP: Temporary services or feeders installation, alteration, and/or relocation Phone: ( ) Fax: ( ) 200 amps or less 66.85 1 i Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2 Branch circuits new, alteration, or extension, per panel ' Owner signature: Date: A. Fee for branch circuits with j, APPLICANT a CONTACT PERSON above service or feeder fee, 6.65 2 each branch circuit Business name: 4v B . Fee for branch circuits without service or feeder fee, 46.85 2 Contact name: & OA' first branch circuit +11, f D Each add'l branch circuit 6.65 2 Address: 1 4 %., ,��� Cl �� uvl 14 �� Miscellaneous (service or feeder not included) Cit /State /ZIP: Each manufactured or modular • 90.90 2 ' 7 '^ dwelling, service and/or feeder Phone: ( S O 2 Phone: b � - t O Fax : : (�3) '( (U)' U`SS Reconnect only 66.85 2 E -mail: ' \) ( \. Q , () V ' \ J\ ; (j IN Pump or irrigation circle 53.40 2 f tv /p1 vl �f CONTRACTOR Sign or outline lighting 53.40 2 Signal circuit(s) or limited- Business name: 1-.0 >ft energy panel, alteration, or k\)--( Address: extension. Describe: I City/State/ZIP: Page 2 �d /`� 2 Each additional inspection over allowable in any oftbe above ��l ;}' 01 v" Per inspection 62.50 Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50 CCB Lic.: (O Oil Electrical Lic.:( `j, I C(,( Suprv. Lic.: 3 -7 R (La Industrial plant per hour 73.75 /n /0i C $ .3 ELECTRICAL PERSu FEES Suprv. Electrician signature, required: //�/ v (/ V Subtbt ?sue , otal: �p Date: •I Plan review (25% of permit fee): Print name: M I V 1nt p A ' �/I State surcharge (12% of permit fee): Authorized signature: ,+ r 1 I l TOTAL PERMIT FEE: ,e�- , r This permit application expires if a permit is not obtained within 180 Print name: . A ` i n Date: 1 t m D days after it has been accepted as complete. e * Number of inspections allowed per permit. 1:\ Building \ Permit s\ELC- PennitApp.doc 05/23/06 440- 4615T(1 l /05 /COM/W[B Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: ' RESIDENTI 00 ORK _ rt, k ; , ,,., w n , , 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* 111 Other: COMMERCIAL WORK. ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ F 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 1:\ Building \Permits\ELC -PermitApp.doc 07/01/10