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Permit CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: ELC2011 -00362 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/29/2011 Parcel: 1 S135BC01100 Jurisdiction: Tigard Site address: 11131 SW GREENBURG RD Project: Jump Sky High Subdivision: OAKBURG Lot: PTS 25 -. Project Description: (3) branch circuits for roof top fans and service outlet. Contractor: BEAR ELECTRIC Owner: ROBINSON FAMILY TRUST PO BOX 389 BY EVELYN L ROBINSON TR DONALD, OR 97020 PO BOX 91305 PORTLAND, OR 97291 PHONE: 503 - 678 -1355 PHONE. FAX: 503 - 678 -1108 FEES Quantity Description Date Amount 3 crt Branch Circuits wo /Purchase 06/29/2011 $71.02 Specifics: Service or Feeder 1 ea 12% State Surcharge - 06/29/2011 $8.52 Type of Use: COM Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $79.54 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952- 001 -0010 thro 952 - 001- 009 You may obtain a copy of the rules or direct questions to OUNC by calling 503.2 .1987 or 1.800.332.2344. Issued By: Pe rmittee Signature: 1Oe l (`Pill • OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION •NLY SIGNATURE OF SUPR. ELEC' �� �� 4 7 4 �!� l , Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m. for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. JUN- 27- 2011(MON) 14:51 Bear Electric (FRX)5036781108 P.001 /002 /"'. Electrical Permit Apple t; _ }: E V ED FC11t'c)Fr1f li titif, ()NIA 2 8 2011 Received tf�i gri EA-360% City of Tigard II II 1>aae:nv: L�m,it,n,: i , 13125 SW )-call Blvd, Tigard. OR 9� pion It4wivav Phone: 5(117131.2439 Fax: 51135 beam.$ T l<3ARD Insp ction Line: 503.639.4175 CI 1 1 OF TIGA D Dine lteoak:uy: AMR; prs8c2 fur .� � iLniNG DIVISION a � ,� d��aw�i �wtw., � i, l,0 1 w i ry ne y ; � i 1 � m ld, � ormattlon ''sj +"�»4 �.�,^ I Init.maK wwt� A nt -ur. Gov .. 1 �' � 1' tirMhd�'andtnal' * .. '..4tA'� ]u a �r 4 e n ntat i� ,. ❑ New construction El Addition/alteration/replacement melac chcck 41i mut ur0121suhmil'? vets of plans , a; ilemachecked below': •�� Cl tiu�viceor feeder 4)(l amps or more ❑ Building over dime dories. Q i7Klrloi }} LJ Oiher: whcreIhemaituhlc fault current ❑perinea and boatyrolls. I and . r lwtlily dwelling Commercial/industrial tlrial Q Ac wt n .r f G °�," " �; kna l o dll m g oun or s or priming 1 4,0 ts a -dings ial 41) ke r i . . rr mN�TR1��ST2C9 I u t ground. or �xcads 14 ttl }U ❑ Commercial-Li. ty:rlcutturul cemory building amps Air all other Installations. buildings. 0 Multi- lhmily Q Master builder ❑ Other: ❑ fire pump. ❑Installuhon of 73 KVAor Y v P''''".1 t ' ;H h)! r O b" S ililYi © A Q '[JU ", a eta 13mcryrncy s) /1icm. lurga separately derived T stem. a i �, ..... .r�.S r 1. �.,..�? 0 addition afnov motor load or 2 Job no.: I Job site address : % � t r vova tool11*i*morn, neaspun4y, ,e e 7 . CI SII( more residential untl. ❑ Recreutkmul vehicle perks. City /State /ZiPf' 1 p t - ❑ Health-earc lbellIties, ❑ Supply voliugc livnxom than ❑ I ls k'eattons. bon volts nominal. Suite /bldg,apt.no.: [ Project flume: ❑ say' ccorl' amps ormore. ll t' '? s w ,. r KO ., 114.0! 1 . ' „EaSCLLED,U T eit ,,,z¢i + tit :ii, , ., a.,' 0'00 street/direetiun$ to job site: newripaaxi ( ()Iv. 1 oee cutwa 1 • New residential single- or In 0M-family dwelling unit. Include attached garotte, Subdivision: Lot no.: 1.000 sq_ ft, or less 8 168.34 4 —' En. add'! 500 sq, II. or portion 33.92 1 Tax lttilp/p;ITCCI no.: Limited energy, resideritial 75.0i1 2 Ftt .... ... giiTTI.FIRP;PAirg ' . , '..,. „��.'2u (with above art. 11.1 1 Litnitcdenergy.multi family 75.00 2 1e- - "ch `>a \\ Ctt 9C:n— . - a c r ' '° �� air )di d residential (wills above ay. Il,) . �D ” Scrvicca or feeders insta nation n altcrution, i il /or rclo catinn • 2 Iun.7 r a l t -� ` Zenn u,ps or ts iiIIZS \ , C S? e 4C \A r le- et a ' 201 amlls o los amps t 3 (1.56 M a,w, + " 0.1 n al Q 11:! 1 t� P , : ... ,: r �.,: w ..:, �l E�9r l�i� d d Name: 1516 Up maps 200..34 2 - 601 41111Y4 lo 1.000 Mortis 3 0 1.04 Addn:ss• Over 1.000 wens or volts 552.26_ 2 City/State /ZIP: Temporary services or feeders instn!hatiun, alteration, and /or rrlutmtlott Phone: ( ) I Fax: ( ) 200 tunas or less 5936 1 201 amps to 400 amps 125.08 ., Owner installation: This installation is being made on property that I own which is nut 40 amps to 599 amps 1 6 8.54 2 intended for sale, lease, rent, or exchange, according to ORS 447. 449. 670. and 701. • Brunch circuit: - new. alteration. or extension, per panel Owner signature: Date: A. Fee for brunch circuits with i. . 3, r "'�" .. . - ., .. g litO . ,..�..�p �g[�' /�77.d , .:. � t l All ®•'r�,P -'.i. :i :li „l 'w .�1 iMRM'YT ,k7 dM��f14� /j �, above service � � r - ur feeder 11 7.42 2 each branch cumin Business name: B. Pee for brunch circuits s'tlbow . service or feeder Ice, first ` 56.18Q. a 2 Contact name: hratich circuit ' Each add'I branch circuit ..E 7.42 14,„ 2 Address: Miscellaneous (crvicc or feeder not included) City/State/ZIP: Each manufactured or modul 6744 2 dwcIIintl. service: end /or feeder _ Reconnect 67.84 2 Phone: (. ) I Fax: : (. ) only _ _, Pump or irrigation circle 67.334 2 E-mail: a.' Sign outline 118)a inn 67.84 2 GI.�C NTIV O tl '" �' " t .. r .. - 1 + '�� ^^ l " ' si cimfir(F) or timilcd- cncrpy Business name: 1 11' 3. eC Ct \(-( panel_ alteration. orextenskm. _ Page 2_ n 1 �'SS �* Each additional inspection over allowable in any of the above Address: K • __�� - Additional inspeedt,I (I fir Inllr) ., . _ 66.25/ le A0, C fk Investigation {Ihrnthr) U GC,„ • he l Industrial plant (i hr min) 78.14/ hr Phone: ( 1 F. Fax: l o l Inspections fur which no fee is � � " � \ ``�� `�� specifically listed (yi lirmin) 90.001 itr CCB Lie.: 46 . Electrical Lie.: ` Suprv. Lie.: * S tX . . ,li 'Ca+l "„t .1 immi3 It 1'Err. .:1, 0 1..2g; ,; Suprv. Electrician signature. require.. 4 Su Plan �� ��►� ` r Plan review (25% of permit lt fee): Print uiune; 1 — 2 - 7 — i 1 Sts,,,, aurchar•9e (12%, of permit lee): Limbo r — TOTAL PERMIT FEE: 11 n Authorized signature: This penult appliewlton esplres It u permit is not obtained within I BO Ilan after It has been uccrptcvl se rumor*. ( / Print name: I Date: • Numhirnriospotiktnz per permit, ` p J ( • (_J 1 11t nniNTI,C I , t.'.4,e U illu a 440- 101.51 '(I.11054),AI!WLTI 44 g y ' ` NY.. ` {Ay e ;$,1 y bit City of Tigard October 20, 2011 Bear Electric PO Box 389 Donald, OR 97020 Re: Permit No. ELC2011 -00362 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 11131 SW Greenburg Rd. Project Name: Jump Sky High Job No.: N/A Refund Method: ❑ Check # in the amount of $ . ® Credit card "return" receipt in the amount of $63.64. Note: Please allow 2 -5 days for this refund transaction to be . credited to your account by the company that issued your card. ❑ Trust account "deposit" receipt in the amount of $ . Comment(s): Per applicant as customer canceled job; refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, i Dianna Howse Building Division Services Supervisor Enc. 1:\ Buildin \Refunds1 ,i;t.St , ai {,can udo(Dafi gon 97223 e 503.639.4171 TTY Relay: 503.684.2772 © www.tigard- or.gov A 0 City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request. Refund requests are due to Accela System Administrator by Wednesday at 5:00 PM for processing by the following Wednesday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing. PAYABLE TO: Bear Electric DATE: 10/20/2011 PO Box 389 Donald, OR 97020 REQUESTED BY: Dianna Howse Applicant TRANSACTION INFORMATION: Receipt #: 183079 Case #: ELC2011 -00362 Date: 6/29/2011 Address /Parcel: 11131 SW Greenburg Rd. Pay Method: CreditCard Project Name: Jump Sky High EXPLANATION: Per applicant as customer canceled job. Refund 80% of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000 - 43104. $ Amount Electrical Permit Fee 220 - 0000 -43103 $56.82 12% State Surcharge 100 -0000 -24001 6.82 TOTAL REFUND: $63.64 APPROVALS: If under $5,000 Professional Staff If under $12,500 Division Manager I(, If under $25,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board . FOR TIDEMARK SYSTEM ADMINISTRATION. USE ONLY • • Case Refund Processed: I Date: I / 0 /700 I By: I 1: Building \Refunds \RefundRcqucst.doc x 09/01/2010 , CITY OF TIGARD RECEIPT I PIIII V g . 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD . A - A,iv Receipt Number: 184290 - 10/20/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2011 -00362 -S e- -----6- ( -lf , E7 ?,l/ S ,?2.0 C i $ -63.64 fr vC.Git' i C`..ch f.- Total: $-63.64 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 019294 DHOWSE 10/20/2011 $ -63.64 Payor: Bear Electric Inc. Total Payments: $ - 63.64 Balance Due: $63.64 • Page 1 of 1 i „ . CITY OF TIGARD RECEIPT i s 1 3125 SW Hall Blvd.. Tigard OR 97223 503.639.4171 • TIGARD 6 6 Receipt Number: 183079 - 06/29/2011 • CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2011 -00362 Branch Circuits wo /Purchase Service or 2200000 -43103 $71.02 Feeder ELC2011 -00362 12% State Surcharge - Electrical 1003100 -24001 $8.52 Total: $79.54 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 019294 DADAMSKI 06/29/2011 $79.54 Payor: Bear Electric Inc Total Payments: $79.54 Balance Due: $0.00 Page 1 of 1 .RUG- 16- 2011(TUE) 09:06 Bear Electric (FRX)5036781108 '.- P. 0.0.1 /002 ° Community Development - " ' r i • T I G A It D Request for Permit Action • TO: CITY OF TIGARD Building Division Services Supervisor 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov FROM: ❑ Owner JE Applicant 5E Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) 8 ,F Mailing Address: (� ,� Rr:Aci 13 City /State /Zip: C Q l(� Phone No.: (5 \39 PLEASE TAKE ACTION FOR THE. ITEM(S) CHECKED (1): 2 CANCEL PERMIT APPLICATION. S 'I M REFUND PERMIT FEES (attach receipt, if available). INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: El _C.r2NN \ (C>3\02 Site Address or Parcel #: ( \3\ W CocPP11-,\1 Rr4. Project Name: % L f /,, //° :S ' k y /W( Subdivision Name: Lot #: EXPLANATION: N,,S��e�- �r+nC` '�\4 Signature: V ► rt>r. ; Date: — \ l \ \ + _ r Print Name: M • - Refund lefundinlicr 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 ur canceled bra .re any review effort has been expended. e) not more than 80% of the land use application fee for is.ued permits d) not more than 80/o of the building plan r view 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 returned 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 Rtc to S sAdmin: Date y mn B Rte toB1 : Admin: Date B Refund Processed: Date 43/20/ / I3Z , c0 Invoice Processed: Date By Permit Canceled: Date ft( _ a/ B • arcel Ta _• Added: Date B Receipt # Date Method Amount S T:\ Building \Form > \RrgPenniuletion.doc Rev 02/23/2011