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Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT COMMUNITY DEVELOPMEN Permit #: ELR2011-00071 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/23/2011 Parcel: 2S110AA00300 Jurisdiction: Tigard Site address: 14145 SW 105TH AVE Project: Pacific Health & Rehabilitation Center Subdivision: Lot: 0 Project Description: Fire alarm. Contractor: HI TECH SYSTEMS INC A CORPORATION OF WASH Owner: TIGARD INVESTMENT GROUP LLC 512 NW CARTY RD BY EYRING REALTY INC RIDGEFIELD, WA 98642 1777 N CALIFORNIA BLVD #300 WALNUT CREEK, CA 94596 PHONE: 360- 887 -7062 PHONE: FAX: 360- 887 -7065 FEES Description Date Amount Specifics: Restricted Energy Permit 03/23/2011 $75.00 12% State Surcharge - Electrical 03/23/2011 $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: N Fire Alarm: Y 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 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 issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the -.ad. • ed by the Oregon Utility Notification Center. Those rules are set forth in OAR 952- 001 -0010 through OAR 952- 001 -0090. You meyvtStBRf rules or di -ct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued B � /� -�_ t Permittee Signature: 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. CC__ C ommunit Development 1114 Y p -04 („p Request for Permit Action TIGARD ✓e.// O TO: CITY OF TIGARD 80,l i �o,/ Building Division Services Coordinator ©j `c' �3 0 13125 SW Hall Blvd., Tigard, OR 97223 9/1/ Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner n Applicant Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) F d \ e •G ;f 0 t 't— Mailing Address: 6—I 7_ /t»41 �u(1-y ( City /State /Zip: It , ` € l X \ , , , k ; ; f 15 ; L 2— Phone No.: ; c 9 0 - -. gs17 7C) - PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( •): CANCEL PERMIT APPLICATION. 0. r REFUND PERMIT FEES (attach receipt, if available). trn Sr ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ri d 6 REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). fiX , , CPU mit #: gi-/L O'er'/ l - eoc I f " S , , p. Site Address or Parcel #: /4/ S t(S '� Project Name: P, l /I C. l4-i 19-071 °I- �gm-gm /i r6 N e / iZ- Subdivision Name: q Lot #: EXPLANATION: =r 6 �/L(� )�/ � c , , 0 /6 Signature: 6-19t4 _-- - --`' Date: li (/ I Print Name: 5 CO' - -(-e Gi ' Refund Policy vtf 1, The Director or Building Official may authorize the 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 is 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 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be retumed to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY . Rte to S s Admin: Date 7 ©a' : IKONI Rte to Bld. Admin: Date r igem :, Refund Processed: Date : ii W Invoice Processed: Date By Permit Canceled: Date f', M' B %r.2, Parcel Ta. Added: Date B Receipt # a/ , £' Date a 2 / / Method Gr Amount $ FY, 1: \Building\ Forms \ Req e miiiAction.d c Re 07 /26/07 Electrical Permit Application l oR oI I I( F. l SI: ()NIA City of Tigard Received Dateiv i�I Permit No.: L �. / IN 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review ' I Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit: r-Psdri (/ -,- XJ(J : TI G A K D Inspection Line: 503.639.4175 Date Ready/By: Juris: El See Page 2 for Internet: www.tigard - or.gov Notified/Ivlethod: '1(' Supplemental Information TYPE OF WORK PLAN REVIEW ❑ New construction . - KCddition /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. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural ❑ 1- and 2- family dwellingmmercial /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 ", "1 -3 ", Job no.: I Job site address: i LA 1 4 5 S LA/ 106 s'} 1 r 100HP or more. occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State/ZIP: T t- ❑ Health -care facilities. ❑ Supply voltage for more than ty / I� I ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: I Project name: r I1. A (r ti lli kjei jiVIO .'k ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total I " J� /� j /`� ` New residential single- or multi - family dwelling unit. / — L G) 611'`(,,,, , a, c* I V V 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 DESCRIPTION OF WORK (with above sq. ft.) 75.00 2 Limited energy, multi- family 75.00 2 A && O n- \ ft./ „smo - u -\-- le-4 � residential (with above sq. ft.) 1 Services or feeders installation, alteration, and/or relocation r. f cf. \4 rr 1!V'1 ypct VA el A l0 w I re- t 11 be_ raA 1l 200 amps or less 100.70 2 ❑ PROPERT OWNER F w .0' TENANT t n al }k. i (4e 201 amps to 400 amps 133.56 2 Name: P ,1 } e � e ,k � t ck '* 1'O� 401 amps to 600 amps 200.34 2 l� r�V � 601 amps to 1,000 amps 301.04 2 Address: 1 L A I Lis_ c ; i V 05 ( 54 (''- Over 1,000 amps or volts 552.26 2 f- ` - 'L� 'i Temporary services or feeders installation, alteration, and /or Ci ty /State /ZIP: 1- \ 1 �i , 0 c� ` ( relocation Phone: (5 ) (p3 1 ) ( (4 L l Fax: Kb 3 ) 4a4 -71.0 ` 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 401 amps to 599 amps 168.54 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. Branch circuits - new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with . CONTACT PERSON above service or feeder fee, 7 42 2 each branch circuit Business name: H t � 5/ 1r-Ins B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact name: 0 e__. branch circuit Each add'l branch circuit 7.42 2 Address: 5 k (1,1 Miscellaneous (service or feeder not included) — City/State /ZIP: ii, r w { l 9 �/ Ls` Z dwelling, service and/or feeder Each manufactured or modular 67.84 2 �' t t e t v; Phone: Fax: : Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 E - mail: 011 1 ( J3 t t-)�1 r he. Sign or outline lighting 67.84 2 CONTRACTOR Signal circuit(s) or limited - energy j Business name: j ' r C \, 5 ` �wL pan el, alteration, or extension. I Page 2 � 5 . 2 J Each additional inspection over allowable in any of the above Address: 511_ fv L/L1 4- L it Additional inspection (1 hr min) 66.25/ hr f ,. ( c\ q 6 f r l Investigation (1 hr min) 66.25/ hr � City /State /ZIP: , I , e l ` L' {,, � ' I Industrial plant (1 hr min) 78.18 / hr Phone: ('jLO ) 14"C 7 - 7 Cc Fax: (3‘ 0 ) 5S - / 7 L � ) !3 11 Inspections for which no fee is 90.00 / hr specifically listed (%z hr min) CCB Lic.: 12. 9 36 0 Electrical Lic.: Li : ..A. Suprv. Lic.: ti5 (_E14- ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: t — Subtotal: 7S '414 '��� Plan review (25% of permit fee): Print name: 5 CZ A -1- 1•+ Date:3/ V l State surcharge (12 % of permit fee): /. Authorized signature: TOTAL PERMIT FEE: VI , This permit application expires if a permit is not obtained within 180 Print name: .. CO fi 1495 -.(__ Date: 3 /�) (' * days after it has been accepted as complete. / Number of inspections allowed per permit. y 9 I:\ Building \Permits'ELC- PermitApp.doc 07/01/10 440- 4615T(11 /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 ... $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: 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 ❑ Fire 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