Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit #: ELR2011 -00030
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/08/2011
Parcel: 1 S134BC00401
Jurisdiction: Tigard
Site address: 12442 SW SCHOLLS FERRY RD 202
Project: Scholls Ferry Rehab Subdivision: Lot: 0
Project Description: Low voltage for voice and data cabling.
Contractor: XTREME COMMUNICATIONS, INC. Owner: PROVIDENCE HEALTH SYSTEM
24023 NE SHEA LANE, #215 4400 NE HALSEY BLDG 1 SUITE 160
WOOD VILLAGE, OR 97060 PORTLAND, OR 97213
PHONE: 503 - 618 -8816 PHONE: 503 - 215 -6282
FAX: 503 - 618 -9985
FEES
Description Date Amount
Specifics: Restricted Energy Permit 02/08/2011 $75.00
12% State Surcharge - Electrical 02/08/2011 $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: Y Fire Alarm: N
HVAC: N 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 •- issued su t to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done ' accordance with proved 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. ' TENTION: Oregon la req • - you to follow the rules adopted by the Oregon Utility Not' -nter. Those rules are set forth in OAR
952 -00 -0010 through OAR 95 I r -00• •. You may obtain a copy of the rules or direct questions to O I -w1407 or 1.800.332.2344.
c
Issu By: Permittee —.roe? '�� ��� '
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.
02/08/2011 11:34 5036199985 PAGE 01/03
Electrical Permit Application RE , :_,... FOB OFFICE USE ONIV
!I 125 V
City SW Hall gar Blvd„ Tigard, 97223 V L. i. of Tid Received
pDinnt:/RElcvtiew „2 Alm! Permit No : 2 _ 4.,,,...
it - Phone; 503.639.4171 Fax: 503.598.1960 TIGARD
:
13 OR CIMMINIMMOMIN
1 1 -
71 1 Datell3 :
inspection Line; 501,639.4175 Cr B 8 2011
.... Dole Rondy/13y: OM fr.! See Pate 2 for
Internet; www.tigard-or,goV CITY OF TiGkAii Not•ified/Mothod; • Supplemental Information
. '. ',' ; :::!, " - •:':.: • Fit,Ot AY•tt:-!WO VI . ' •'-'' '• .' • • .i...'i: ...' '• . ,;''.:'. -," .. Prk4Or:totviEW:.....
Please check all that ripply (aithmit 2 seta of P 1 ' 41,1 WhitrAS checked below); 0 New construction El Addition/alteration/replacement
a Service or Itcdcr 400 amps or more 0 Buil diha over three stories,
12 Demolition 171 Other: where I he available Null current 0 Merinos and boatyards.
A000*V ... ''''".,:. ',:,':' ' ' ' ' ' meals 10.000 amps at 150 volts or 0 Floating buildinr,
leas to ground, or exceeds 14,060 in Commercial -use ataiettitttral
0 1 - and 2-family dwelling El Commercial/industrial CI Accessory building amps for all other iastallationa. buildings.
El moiti.tatnity 0 Master builder 0 Other: 0 Fire pump. El Installation of 75 KVA or
.,,_._ , . .._ ,....:, , . , , CI Ktnergcncy system. iarecr seperetely derived system,
.: ,:,•' i... .:.. *titiT • • ' • • :: ":. :: 0 Addition at new motor load of 0
Job no.: 14 ( E Job site address; i ALM. 7,„.. $W ,iett F D 10HP or more
Si or more resident tel units. ()eminency
0 Recreational vehicle parks.
City/State/ZIP; 7 q7?-7.-3 r3 Health-care facilities.
0 II o zn I.doon locations. 17 Supply voltage for more then
eon volts nominal.
Suite/bldg/apt. no.: %, 0.2.--) Project name: 6 /4,46_164,2„w_ . service or loader 600 amps or more,
• :' :: • ' t' ...' ' ' . nr sClittbutt :. - i
Cross StreCt/d ircctions to jot) site: flcsCriptinn ,,,,,_,__I 1 , re_suj__
— New residential single- or multi dwelling unit.
n.tacac.. garage.
Includes t I a
— . —
Subdivision; 1 Lot no.: 1,000 sq. ft. or less 168,54 4
- _,..... - EU. add 500 sq, IL or portion 33.92 1
Tax map/parcel no.: _
Limited energy, residential
75,00 2
Or(StRitTiO" i.;: :;, - :. ,;., : : . ,: , (with above sq. ft)
Limited energy, multi-family
r / .. 75 00 2
V4.4._)" ., 0 toff_ residential (with above sq, ft) ,
— Services or feeders installation, alteration. and/or relneation
200 amps or less 100.70 2
lititittleft .0*0 , `'.:fl. .!:i. ,:'5:; ,::;;: ,: '•;'••.• . , • ... . 201 orops to 400 amps 133.56 2
.....
. ...., . „ ,
401 amps to 600 amps 200,34 2
Nome: . 601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
-- — - — Temporary services or feeders instaliadon, alteration, and/or
City/State/ZIP : relocation
Phone: ( ) Fax: ( ) 200 amps or los s 59.36
— 1
,08
Owner installation: This installation is being made on property that I own which is n 201 imps to 400 amps 125 2 ot : • .
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 extel„, isini2
Owner signature; Date: A, Pee for branch circuits with
. .....,, . . .
- • : ' " '• 0' Xtt.lit/Of.:;? * 7 I : ' ' ,1 ' ., CI: Cti i - - : Z. :: abOtta Service or feeder fee, 742 2
each branch circuit ,
EltisincS8 name: B. Fee for branch circuits wi/hout —
service or feeder fee, first 56.18 2
Contact name: branch circuit ,
- - Each otkl'I branch circuit 7,42 2
Address; Miscellilacons (service or feeder not included)
Bach menu flictured or mndular
C ity/State/ZIP ; 67.84 2
, dwell i npr cc and/or feeder .—
Phone: ( ) Fax: ; ( ) Reconnect only 07.84 2
.. .. - Pump or Irrigation circle 67.84 2
8-mail: _
Sign or outline lighting 67.84 2
. • , • i - , i' • :.: :i•:! • .,- v.• • •• ., ONT.I•tACTO,R. '.' .`,,;•''!.: ':..' .. : :. ;I ;. 1 ':: '■' . 1 1 i: ,'' ,.. ' ' Signal circuit(s) or limited-ctiergy ,
• pnnol, alteration, Or CxtMisi on, i Page 2 76 2
Rosiness name: Xictsg carltekesic .
Each additional Inspection over allowable ia an of the tL______
Address: 2 1 0_24_fri_e____1(kut Lilo e ___,It S" Additional inspection (1 hr inin) 66 25/hr
,
' Investigation (1 hr min) 66.25/ hr
City/State/ZIP : pfAttkof eta" 10„./e q7
V- / industrial plant (1 hr nlil 78,18/ hr
Phone: (Oa) V I , j u Li 0 U Li 5 . 0 . N 4 , 8 . 9? 9 c— Inspections for which no to is
• "^•—• specifically listed ( min) —
e0,00/ lir "-
cc B II ic •
J...4/ Electrical Lie.: , _515- .7. Suprv. Lie.: ,3 31 L :,:-,;.- j .: :.•:: .:.pLEcpucAt.ltitl : • :: :••-- ----•
----2
Suprv. Electrician signature, required: . ireinly — Subtotal: -.-
e _ Al:4:a Plan review (25% of permit fee)!
..
Print name; 041 A.4' ( _ej Dale: 2,, „ fr, y state sur )5, (12% of permit fec); 7
I 4 "
‘..
TOTAL FEE:
Authorized signature: ..._ay..,__
This PERMIT
s num' it applicetio expires If n permit is not obtained wit in 180
days offer it h pm. es been accepted
on complete.
Print name: Date: * Number of inspections allowed per permit,
',mole* \ rermitsNP.I.C-PermhAeprinc D7/01/10 VO4515711 t/05/COM/W6T3
02/08/2011 11:34 5036189985 PAGE 02/03
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
i�ES XII1I;' 1 CS
Pee for all residential systems combined $75.00
Cheek Type of Work Involved:
❑ Audio and Stereo Systems*
n Burglar, Alarm
•
n Garage Door Opener,*
n Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
Other.:
comMtkOraNtIbitt
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
n F ire Alarm Installation
n IIVAC
n Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
M edical
n Nurse Calls
n O utdoor Landscape 1,..ighting*
Ti Protective Signaling
n Other.
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
\ P■dding \r rermlorp.doc 0