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Permit CITY OF TIGARD ELECTRICAL PERMIT •'' -- COMMUNITY DEVELOPMENT Permit #: ELC2011 -00656 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/23/2011 • Parcel: 2S 110DD09300 Jurisdiction: Tigard Site address: 15845 SW HIGHLAND CT Project: Baldwin Subdivision: SUMMERFIELD NO.6 Lot: 309 Project Description: (2) branch circuits for kitchen remodel Contractor: A & J ELECTRIC Owner: BALDWIN, GERALD L & CHERYL L PO BOX 330 15437 SW 114TH CT #95 FOREST GROVE, OR 97116 TIGARD, OR 97224 PHONE: 503 - 359 -5891 PHONE. FAX: 503 - 359 -1981 FEES Quantity Description Date Amount 2 crt Branch Circuits wo /Purchase 11/23/2011 $63.60 Specifics: Service or Feeder 1 ea 12% State Surcharge - 11/23/2011 $7.63 Type of Use: SF • 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 R - 1 -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. i Issued By: Permittee Signature: /7A" /7 "› X17 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. Nov 23 11 10:02a Leeann Greason 503 -359 -1981 p.2 Electrical Permit Applica . CE " FOR 01'1(1: l fi£ ws-I 5' ., City of Ti NOV 2011 D 3 Received 0 ate/B : ���� +'o — Permit No a / D 6 1 3125 SW F1a11 Blvd., Tigard, OR 97223 Plan Review Phone: 503.639.4171 Fax: 5930 �,ri tip TIGA p : Other Permit TIC P O Inspection Line: 503.639.4175 1 a a RD DatcReady/By: Ilierl 0 See Page 2 for Internet: www.tigard or. govB UILDING DIVISION Notified/Method: IA Supplemental Information _..: a. ^^c..4.,:p t 4"." r'`"rroFr- _ 4�,zY'�a ,:' aMrs..n Z . IIt sl � ..y -.,... r a..Z^.m _ .. xLL mt t`� ° ` fi 'K 1 Please check all that apply (submit 2 sets of plans wfitems checked below): ill New construction . Addition .' alteration /replacemetlt 0 Service or feeder 400 amps or more ❑ Building over three stones. IL) Demolition El Other: where the available fault current ❑ Marinas and boatyards. t. rR e. r • a e a q F '*°`":' � :: exceeds round, amps at 150 oohs or Fluai Mg mme buildings, ',u 1- and 2 - family rp >rk,, er;rLrcMe.,. ,:L;;s.�,z. �. ,+;.. a.R.�,.:Y.�:s I leas to ground, or exceeds 14,000 ' dwellin ❑ Accessory building ❑ Commercial agricultural } g ❑ Commercial/industrial t3' g amps for at other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Other: ©Fire pump, ❑ Insratlatian of 75 KVA or �. '" r s ❑ Emergency system z P a + ; - .; �g c! sY larger separately derived system e '' te ATM ' - . or 2._ �, si,7,1 =^i tiY x ❑ Addilion of new motor loa o ❑ .. „ „ Z ,, .. l ,: Job no.: Mb site address: ����.� — I 00HP or more. occupancy. ❑Six or more residential units. ❑ Recreational vehicle parks Ct1>JState/z1 P: � l ) 5 Q L i ` �J /� l7 5 . 1 1-16 ET V r y " ` ❑ Health - care facilities. ❑ Supply ',olta for more than U ❑ Haaardoas locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: ❑ service or feeder 600 amps or mere. ,! ,0 r. 17 ', ra. 4 --'-'-',4'..2, Cross street directions to job site: . � � °*t a+ .� : . .,. 'n ' ! y ' s� .;: S� ''e e *.; .Drieription Qtr. Pee. Total • . New residential single- or multi - family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less _ 168.54 4 Tux map/parcel no Ea. add 500 sq. it or portion 33.92 ] l t � n ` rt r'- ,,,,,,� ,,, Limited energy, residential 67.84 2 8' ii '.iza 'ye " .I.r �,, `'^ me ; (with above sq. f t. ) ,.�t.:r?+rr it i'�x�.a:rii d 4-.v, :�" -s€ .,"? Limited energy. multi - family 67.84 2 a.r residential (with above sq. ft.) . Services or feeders installation, alteration, andlor relocation 200 amps o r less ._,.,,..: ; .' ` ` r, , ; t sew `l' 133. 2 .,_.., a t..o r e c ,. .: a.. __:_ , . _ v '-s -. 201 amps to 400 amps 133.56. 2 1Vame:� -�� ` � N.., , -. ' - i',. 401 amps to 600 snips 200.34 2 601 s to 1,000 am i Address: � � J B n- ( a"'0 amps 55126 2 r1 Over 1,000 amps or volts 552.26 2 i City/State/ZIP: Temporary services or feeders installation, alteration, and /or I relocation Phone: ( ) Fax: ( ) 200 amps orlcs 1 59.36 i Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2 intended for sale, lease, rent. or exchange, according to ORS 447, 449, 670. and 701. 401 amps to 599 amps 168.54 2 Owner signature: Date Branch circuits— new, alteration, or extension, er panel A. Fee for branch circuits with " $" ' ' ar .: • p 4'.€ volt above service or feeder f ee, ,. err ..cxt!..',:.5 s _,srv?s.s mice ...rte .,a,_ - " "' . 7.42 Business name: each circuit 2 B. Fee for branch circuits Contact name: without service or feeder fee, first branch circuit >G.18 ���� -- Address: Each add'I branch circuit Miscellaneous 7.42 ) City/Slate/71P: or feeder not included t Each manufactured or modular Phone: { ) dwelling, service and /or feeder 67.$4 2 Fax :: ( ) E-mail: Reconnect only 67.84 2 Pump or irrigation circle ;.x;° _.Iki=r. <,;i ",,' - e : 5, 3 a i '41 - ` t 0'3 c 6`t Sign orout! outline fighting 67.84 2 -3 � , _...,:u . e x.s s. _i ..,qa :t-,>n +0 ax«cc ::3 glt 8 67. S4 Business name: A &J Electric, inc Signal circuit(s) or limited - energy panel, alteration, or • Address : PO Box 330 extension. Describe: Page 2 2 d (lily / Stace1Z! P: Forest Grove, OR 97116 Each additional inspection over allowable in any of the above ' Phone: (503) 359 - 5891 Fax: (503) 359 - 1981 Per inspection 66.25 / Investigation per hour (l hr min) 66.25 ' LC Li Etc.: 959 t/ Electrical Lie.: 34 - Suprv. Lie.: 9,1< industrial plant per hour 78,18 Su prv. Electrician signature, required: _ • ->� .> L`� �' ? .,,y r< q � �` /� Subtotal: \ .N Print ua Anthory Wilson Dater : - N A.,_ ..,,,_ Platt review (25% of permit fee): Authorized si State surcharge (12% of permit fee): / gnaturc: TOTAL PERMIT FEE;: --- ` '�� l Print name: Date: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 111 l�ihhngTermns'•t_C -Perm itApp doe 10!01109 s Number of inspections allowed pet permit. 440.4615" (t 1l05JCOM/ W FA 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: A & J Electric DATE: 1/4/2012 Attn: Leeann Greason PO Box 330 REQUESTED BY: Dianna Howse Forest Grove, OR 97116 TRANSACTION INFORMATION: Receipt #: 184684 Case #: ELC2011 -00656 Date: 11/23/2011 Address /Parcel: 15845 SW Highland Ct Pay Method: CreditCard Project Name: Baldwin EXPLANATION: Per applicant's request as minor label was used; refund 80% of permit fees. ` <REEiJND` - �= '�: -'- '�� =;� ��� _ ,�.� -. �.�..���- 'fir -�<. �� �,n..a�� �� *�;.�.�:�, ��.�_�,.k ,�I1vFORMATION w x see '� , W 7 �rFee`Descri non =Fi a�: �`"' �� � � > � � � � .+�.� �.�.;� � �.�� � �� � Revenue"Accoui t.7�� *- ` ':. ` '. �lin : '•;;, ;' ` '? ,, , -.•=� 5 -f ,.. -1Vo "- �e->.. ',j:, y4 Refund kEAa Bull eerm tTFge s ; . E ;ri ,i !Example. 264 m , 4 f$ m_ o tt Electrical permit fee 220- 0000 -43103 $50.88 12% State Surcharge 100 - 0000 -24001 6.10 TOTAL REFUND: $56.98 APPROVALS: - I f 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 t.; iraf r.. ;;`.:FOR TIDE SYST_ E - O - : , _ : -. ; . ; .� ...... a . �, � M ADMINIS.�T�RAT.IQIV�i7S�E0' ,NLYe�. ��,�, ���, , Case Refund Processed: Date: /� B I:A Building \Refunds \RefundRe x 09 /01/2010 • CITY OF TIGARD RECEIPT 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD /?E ,v Receipt Number: 185099 - 01/06/2012 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2011 -00656 6 EC 7711 e9 PEA 'T 0 -- 0000 — Y 3r47 3 I' f. $ -56.98 %? �� s���E ,ycc�t.e' 6 1 r c) cl2CJ - 02 9'c o/ � , io Total: $ -56.98 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 546957 DHOWSE 01/06/2012 $ -56.98 Payor: Leeann Greason, A & J Electric, Inc. Total Payments: $ -56.98 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD RECEIPT _ 13125 SW Hall Blvd., Tigard OR 97223 • 503.639.4171 TIGAR 02 / Fr i47r/4-- Receipt Number: 184684 - 11/23/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2011 -00656 Branch Circuits wo /Purchase Service or 220 - 0000 -43103 $63.60 Feeder ELC2011 -00656 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 546957 DHOWSE 11/23/2011 $71.23 Payor: Leeann Greason, A & J Electric, Inc. Total Payments: $71.23 Balance Due: $0.00 Page 1 of 1 • Dec 14 11 03:06p Leeann Greason 503 - 359 -1981 p.1 I 1 TIL III Community Development // 41/9 'x-W ( ' RECEIVED TIGARD Request for Permit Action DEC 14 2011 TO: CITY OF TIGARD CITY OF TIGARD Building Division Services Supervisor BUILDING DIVISI 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov FROM: n Owner Applicant ® Contractor n City Staff (check one) REFUND OR Name: A &J Electric INVOICE TO: (Business or Individual) Tailing Address: PO Box 330 City/State/Zip: Forest Grove, OR 9711_6 Phone No.: 503 - 359 -5891 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): n CANCEL PERMIT APPLICATION. ® REFUND PERMIT FEES (attach receipt, if available). n INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ELC2011 -0066 Site Address or Parcel #: 15845 SW Highland Ct Project Name: , Subdivision Name: Lot #: EXPLANATION: Small scope of work, use minor label instead Signature: 11111%._ '''.:N-- \� ._ Date: 12/ \�1 \� -4 Print Name: \ N-... ,`�•`'`. •-,..-•, , �.La -- -cam 1Lrw„d Poi - 1. '11te Director or 1lui:d_ng Official may autl - once the refund of: a) any fee which was erroneously paid or collected. b) nor 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 titan 8it of the land use application fee for i,;slcd permits. c) not mime than 80 ".'ii of the ht:ilding 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 permit: prior to any Inspection requests. 2. Refunds will be returned to the original Payer in the sane method in which pserne -et eras received. Pleai e allow 1-2 weeks for processing rt. fonds. FOR, O FILE' USE ONLY Rte to Sys Admire: Date is /y // B - . 1 Rte to BldgAdmin: Date / 6i l o Z. By i . , g- ( F.- Refund Processed: Date /� / By - 4 g�r Invoice Processed: Date / By / 0 Permit Canceled: Date 7/ /, By .J arcel Tag Added: Date By. — Receipt # Date Method Amount $ I: \ Roil ding \forms\ lfce11errnitAction.doc Roc 02/23/2()1 'I { a1 ti � itiGAIM City of Tigard January 6, 2012 A & J Electric Attn: Leeann Greason PO Box 330 Forest Grove, OR 97116 Re: Permit No. ELC2011 -00656 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 15845 SW Highland Ct. Project Name: Baldwin Job No.: 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 minor label was used; refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, 0 1111 ' 1 4 - Dianna Howse Building Division Services Supervisor Enc. I:\ Budding\ Re funds PESVon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard- or.gov