Permit CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2011 -00415
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/28/2011
Parcel: 2S 102AA00600
Jurisdiction: Tigard
Site address: 12045 SW HALL BLVD
Project: 7- Eleven Subdivision:
Lot:
Project Description: (2) branch circuits for sign retrofit
Contractor: BERGELECTRIC CORP Owner: ALPROP LLC
13650 NE WHITAKER WAY 6149 SW SHATTUCK RD
PORTLAND, OR 97230 PORTLAND, OR 97221
PHONE: 503 - 255 -1818 PHONE:
FAX: 503 - 255 -1919
FEES
Quantity Description Date Amount
Specifics:
2 crt Branch Circuits wo /Purchase 07/28/2011 $63.60
Service or Feeder
1 ea 12% State Surcharge - 07/28/2011 $7.63
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $71.23
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 through o • 9 s01 -00.0. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. `
Issued By: f Permittee Signature: Q� �/� �L /Cl/ ��d
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sate, 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.
07/29/2011 12:21 FAX 5032559932 PDX. PURCHASING 1 002/002
• 67/29/2911 08:16 50259131960 CITY OF TIGARD PAGE Bl /Bl
w0 * (3105. 3
CITY OF TIGARD ELECTRICAL PERMIT
• COMMUNITY DEVELOPMENT k* ELC2011.00415
;,; •. R u> 13126 SW Na0 vied., Tigard OR 97223 503118.2439 Dee. eau 07f2812011
Parrak 2$102AA00600
Jurt.dtegon: Tigard
NM Minor 12045 SW HALL BLVD
Poo* 7 Subdvtsmn: Lot
lotoloot tasotlpllen: (2) branch circuits for blgn retrofit
Contractor: BERGELECTRIC CORP Own= ALPROP 1.1.0
13850 NE WHrTAKER WAY 8148 SW SHATTUCK RD
PORTLAND, OR 87230 PORTLAND, OR 97221
PHONE: 0035 -1818 PHONE:
FAX: 803- 2551919
FEES
Cluent Dosxalption we Amount
2 ert Branch Circuits woIPu dnaao merlon 863.60
Sar4 o or Feeder
1 eo 12% S ets Surcharge - 07/28/2011 37.83
Type et Use: COM Elemtost
CM, of Workr ALT
Type of Conan
Oooupeney Grp:
_ Total 1.23
Required Mon is Ropey (gondttloni)
was pork le laced subject to the regutottena contained In the Tigard namtdper Cade. Stale of OR. S alts codes and ad Mar app' 4k law. m mot will
be done br eacereanxe ye approved plena. This pamnit 011 expire If work Is not abated wIlbIn 180 drys of hewnoe. or If wwk le wrtpandsd fir morn the 1
dem A7T'ONTIOIt: Onpon law rumbas you to PoIIow the Pelee Sdrpted by the Oregon UtBltq NoVneedon Center. Those none are Rat Its In OAR
0 through -0 You moy obtain e copy of the ndee weed ouossons to WIC by Wino 503.102.1097 or 1.000.912.234x,
Wand ar Pitman* Signature: Di+/ e 77 0 , %./
OWNER INSTALLATION ONLY
The Installation* being made on promo/ I own WW1 to not • • . ale, moo or nod.
OateEER'S SIGNATURE -■■11_ DEW
CONTRACTOR INSTAUAIION ONLY
61ONA1MRR OP bum. ELE
Dan
LICENSE NO. —
Ce l 5Of.00ew1Te by Tag ern !Oren not evadable Irhepagan dm.
Tau norm own chat! be kept In • eoeaplonma place en the lobate wrdl eernotinen of the prefect
Approved pram ere roguhW cal ale lop Ole et the thn of •oeh hhepeovem
07/25/2011 12:34 FAX 5032559932 PDX.PURCHASING al002/004
Electrical Permit Application RPCEp, I'OROI''l.l('I': I - 1l': oNL.1
City of Tigard . R 7 r> ,. �� 4 , s Permit No. G C� 2 /J
4 lair;, : 0// B
13125 SW Hall Blvd., Tigard, OR 97223
JUL 2 5 . �1kn „i, • Phone; 503.718.2439 Fox: 503.598,1960 Dmo /ay: Other Permit:
r t C;A li n Inspection Line: 503.639 CITY OF Ti �¢e3 Routl /B Juri / � ® Pa 2
Internet: www,tignrd- or.gov nt u1 ia1l� F ` o Fed/Mahod: t� SupptSee emrngc t far information
1' �'f�''R'!!r7 . - : -enT.; ..,,yT. , N nr �'. -�.�r• ^ - _•gi p^ '•rPi T' Tt �. rF�t - , ;il" t � �`y. , , ^t���
!{�'ki �� ������,, 7t�i7S7i W,�' U ��� ( i 1 1u i " t ,. : G''�+ , � :1a I 71,7 ST
!`. 'a,, i .,2.. �..»� -_ urLT •il.:i x,_e? .. 1 tir izti, ... _�.,_i' i,,._..1 .� Il uli ^�:th. 44.1 . -..a.. ... .=- 11
❑ New construction 74 Addition/altcration/replacemenl p .
hoto ;Moak all that (submit I of plans w /items ;hocked below):
['Service or feeder 400 amps or more 0 Building over throe stories,
❑ Demolition • Other: where the available Fruit nturnnt ❑ Marinas and boatyards,
i , , ' 1 .•s II ti 1 ; n ' :.t1 n. 351yt' ', n d: lS a -tali ra 4 � ` • LL_ ? } ,': exceeds 10.000 amps at 150 volts or ❑ Floating buildings,
less to ground, or exceeds 14,000 ❑ Commercial-use agricultural
Q 1- and 2- family dwelling :1 Commercial /industrial Q Accessory building amps Rrrnll otherinstsllnllons, buildings,
❑ Multi - fam ❑ Master builder ❑ Other: . CI Fire pump, ❑ lnnttIletion 0F75 KVA or • I5mer a system. ix
' ', ii %, .at ill I 3 . 1 4 ) . 1 Ill l :u, \ I!i'1 :,..:�✓.. 2 l / \ ' ■ pu i l . , : ,P',t ? % O.i : ,, f! If • ' :s l: ['Mai of raw motor of ❑
larger separately t.2 derived system,
y
/ t�n5,v G 1 ^,'� f ' I ` 1 2` { ❑ 109HP or move. occupancy. Job no.; 706 site address: A t L 1 )l t 3 Six or more residential units, ❑ occupy ionnl vehicle parka,
City /Stoic /ZIP: -. 14701 �� �� Q health• care c ai i on s, El Supply voltage for more than
\ l Cr J� Mnzgrdoue Ipaatipna, 600 vette nPminel,
Suilc/bld Vrn q
g, /apt, no.: Project na -
e: CI Service or feeder 600 amps or more,
1 P �1� 11i ,�
job site: �-• �.•'t ln1 I . s, D i; I.Sy'Iln', 414 +i ";4+r '
Cross street/directions to
J oerrdpuon I cry. pee, 1 - rats; 1
New residential single- or multi- family dwelling unit,
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
'fax map/parcel no.. gt;q y +;� Limited energy, residential
i Id i rill• ... " . ∎M A t 'lcl is :1.nl t) ` .:.. 9),!, : , Il (with above sq, R,) 75.00 2
t ,'f"1 / ^
Limited energy, multi- family 75.00 2
'to \� residential (with above all ft.)
S ervices or feeders 1natallatlonodieration, and /or relocation
200 amps or less 100,70 2
I A; 71i1;Gll ly i `u )y:7;7'� "o ^ i, p� ,: �j •- ^4 ❑ °i ai` r 'a '; - 1, "1't' 201 amps to A00 amps . ... � )" }' � , I t � �P t i ' It • 133,56 2 P P
401 amps to 600 amps 200,34 2
Name: " , - EirlieTh 601 amps to 1,000 amps 301,04 2
Address: �Q�{ � ►� Over 1,000 amps or volts
552.26 2
' 7, n 9t 'I � " # ' I — Temporary enrvleco or foodero Installation, alteration, a nd /or
City /State /ZIP: r.cl I -)' t-
relocation
Phoriu; ( ) Fax; ( ) 200 amps or lens 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 � sigriaturc: Bute: A. Fee for branch circuits with
a.J',�!!`'�� A .'I ����tl �, ar { y�,.(eu I:A LW -1 u� i, '' r : :'I�.,(� shove ioMeeor feederfee, 7,42 2
i ., ar,_: o. . I�o .� .y .„ ...„ 9lRil'it "Jkh^!��r3iii :4311u ( !J_ _ . _n i; ,� each branch circuit
Business name: Bergelectrle Corp B, Foo for branch circuits wit/iota
service or feeder fee, first 4(9• 2
Contact name: . e' f ;� l branch circuit 56.18 U
Each sdd'I branch circuit 1 7,42 7, L f L 2
Address: 13650 NE Whitaker Way Miscellaneous_ (service or feeder not included)
Each City /State/ZIP: Portland Oregon 97230 dwelling, s and/or d/ r f 67,84 2
dwelling, service and/or £ceder
Phone: (503) 255 - 1818 Fax: : (503) 255 - 1919 Reconnect only 67.84 2
E-mail: )1 R ry r , ( _ Pump or irrigation circle 67.84 2
1 ' 1 r ,! t' �` T� „iii ;•, S . i � „ ,'• i iii r i � � Sign or outline lighting 67.84 2
ill' ''L: .,td � rut 1. c.3 rr lu : ic's .aA t i r'' „ Y' a � } ' a y 101 � t � 9 � r ��'L q � y t�a�yts , r � t � y � p , y I
_ . . t �• :. Signal circuit(s)or limited-energy
Business name: Bargeleetrlc Corp panel, [Mention, or extension, Pegs 2 2
Each additional Ins .action over allow Isle In an of the abov
Address: 13659 NE Whitaker Way Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Portland Oregon 97230 Investigation (l hr min) 66 / hr
Industrial plant (1 hr min) 78,18/ hr
Phone: (503) 255 - 1818 I Fax: (503) 255 919 - Inspections lbr which no fee is 90.00/ hr
/
U
f CCD Lie.: 110521 V I Electrical Lie.: 37 -662C Suptv, Tyie, V s • eci5 cell listed '/a hr min
5485S - 7 1:711,nlc , ,' • T'a o7v"t'l aai; ' '. - 7 '�''I';
// Subtotal: pj . �Q
Suprv. Electrician signature, required: /G+6M., � 1 Plan review (25% of Perri[ fee):
Print name: Vicn r lip Date: X125/ 0 - State surcharge (12°/0 of permit fee): —7 , (_o iv
Tt7T PERMIT FCC; /
Authorized signature: v • ' f / , This permit application expires If a permit Is not obrained withi
M days ahoy It hi. boon accoprod as com
Print name: ` , ` , Date: -7 u • Number of Inspections allowed par permit.
g■l tulldlegll 'amLUlal,C•PannliApp,dae 07/01/10 coo -iei IT( i I%oO /CDM,W110
07/25/2011 12:34 FAX 5032559932 PDX.PURCHASING Ii 003/004
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for a li 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
n Boiler Controls
n C lock Systems
❑ Data Telecommunication Installation
❑ F • ire Alarm Installation
❑ HVAC
❑ Instrumentation
El Intercom and Paging Systems
El Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems'
*No licenses are required. Licenses are required
for all other installations
u wullJlns■rwmilmt.c•rormhnpr.aoe 07(01 /10
07/29/2011 12:20 FAX 5032559932 PDX. PURCHASING 1 J001 /002
;IN 1 •
Community Development H
Request for Permit Action E t L
TIGARD
li �
JUL G
TO: CITY OF TICARD CITY OF TIGARD
Building Division Services Supervisor BUILDING DIVISION
13125 SW I all Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 w'ww.tigard- or.gov
FROM: ❑ Owner ® Applicant ® Contractor ❑ City Staff
(check one)
REFUND OR Name: Bergelectric Corp
INVOICE TO: (BusincxR or Individual)
Mailing Address: 13650 NE Whitaker Way
City/State /Zip: Portland, OR 97230
Phone No.: 503.255.1818
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
❑ CANCEL PERMIT APPLICATION.
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 #: ELC2011 -00415
Site Address or Parcel #: 12045 SW Hall Blvd.
Project Name: 7- Eleven
Subdivision Name: Lot #:
EXPLANATION: job cancelled
Signature: i v Date: 7/29/11 _
a er Weidman
Print Name:
prfund Policy
1. The Director or Building Official may authorize the refund of
a) any fee which wax erroneously paid or collected,
b) not more than 8o% of the land we application foe when an application is withdrawn or canceled before any review effort hua been expended.
c) not more chap 80 °/. of thy land we application fee For issued permit&
d) not more than 80 °/i of the building plan review far When an application ia canceled before any plan review effort haw been expended.
e) not more than 80% of the building permit fee For iaaued permit.: prior to any inspection requests•
2. Refunds will be returned to the original Payer in the Name method in which payment wall received. Plcaac allow 1 -2 weeks for processing retunJi.
FOR 0111(1 1.IS1 ONLY
f-.r r.N
Rte to S s Admire: Date B Rte to $ld• �,dmin: Date / / /lJ f fAILI ����
Refund Processed: Date COQ' B 411 Invoice Processed: Date B
Permit Canceled: Date i���� B. OM Parcel Ta Added: Date B
Receipt # One Method Amount $
]: \Buil ding \ Forms \RegPermitAction.doe Rev 02/23/2011
:. r..g..t,%I.L77.7)!.:5
r ,_, .
,.. mo � �
City of Tigard
August 11, 2011
Bergelectric
Corp. g
Attn: I- Ieather Weidman
13650 NE Whitaker Way
• Portland, OR 97230
Re: Permit No. ELC2011 -00415
Dear Ms. Weidman:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12045 SW Hall Blvd.
Project Name: 7- Eleven
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ - .
® Credit card "return" receipt in the amount of $56.98.
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's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430. •
Sincerely,
J L T ,0. (.7(- 1 ?----- --
Dianna Howse .
Building Division Services Supervisor
Enc.
•
l:\ Building \Ref a5na r Y1Ltait c�n�eigam�; ;;�1 97223 • 503.639.4171
. TTY Relay: 503.684.2772 , 0 www.tigard - or.gov
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
9 P � g g PP
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: Bergelectric Corp DATE: 8/1/2011
Attn: Heather Weidman
13650 NE Whitaker Way REQUESTED BY: Dianna Howse
Portland, OR 97230
• TRANSACTION INFORMATION:
Receipt #: 183453 Case #: ELC2011 -00415
Date: 7/28/2011 Address /Parcel: 12045 SW Hall Blvd.
Pay Method: CreditCard Project Name: 7- Eleven
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: Building Permit Fee . Example: 2300000 -43104 , $ Amount
Electrical Permit Fee 220 - 0000 -43103 $50.88
12% State Surcharge 100- 0000 -24001 6.10
• TOTAL REFUND: $56.98
APPROVALS:
-6 If under $5,000 Professional Staff , •
If under $12,500 Division Manager
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 -ON .
Case Refund Processed: I Date: I J.44,0/4/ By: I
I
I:\ Building \Refunds \RefiindRegucst.doc x 09 /01/2010
•
a..
CITY OF TIGARD RECEIPT
1
• t a . • • 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
/ ' �/ em u A.. / . �
Receipt Number: 183643 - 08/11/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2011 -00415 ..tr(? iz, cwt. /4 •12 i'!i i 4: ere() -d/ / C 3 S ` $-56.98
/ ''i - e Tl 7E - �'Gt. /LC //�/i -/ze- cam /CZ' '_ t''''t ^- : •, - C O / Total: /� S -56.98
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 927326 DROWSE 08/11/2011 $-56.98
Payor: Sean Cox, Bergelectric Corp.
•
Total Payments: $ - 56.98
Balance Due: $56.98
•
•
• Accela
System Administration
• Finance De artment Re uest
Date: , // /(
To: Liz Lutz
Kathy Gende
From: Dianna Howse/
Re: Receipt #: /F _ �s3 ./e3
�/
Please process this request as follows:
.....
Journal Entry (route copy of JE to
Dianna Howse).
Reversal (fees have been reversed on
Revenue Account Report).
•
_ Credit Card Return (fees have been
•
reversed on Revenue Account Report).
Otth��er /Explan
1�6 Ll h/ /� Arc -'z _____ � -
.
Thank you! - IN
r: \Boil din \Forms \RteSlip- FinanceR
•
Page 1 of 1
•
•
CITY OF TIGARD RECEIPT
I,
2 . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
t' I C - e_
Receipt Number: 183453 - 07/28/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2011 -00415 Branch Circuits wo /Purchase Service or 220 - 0000 -43103 $63.60
Feeder
ELC2011 -00415 12% State Surcharge - Electrical 100- 0000 -24001 $7.63 •
Total: $71.23
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 927326 DROWSE 07/28/2011 $71.23
Payor: Sean Cox, Bergelectric Corp.
Total Payments: $71.23
• • Balance Due: $0.00
•
•
•
•
•
•
•
Page 1 of 1