Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit#: ELR2009 -00289
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/10/2009
Parcel: 1 S 133AD16000
Jurisdiction: Tigard
Site address: 12744 SW NORTH DAKOTA ST
Subdivision: Lot: 0
Project: Key Bank
Project Description: Install (2) low voltage systems for alarm and video.
Owner: FEES
HALL, DONALD W & GRACE L & Description Date Amount
HALL, JOHN G ET AL, BY FIRST AMERICAN Restricted Energy Permit 09/10/2009 $150.00
REAL ESTATE TA, 8435 N STEMMONS 12% State Surcharge - Electrical 09/10/2009 $18.00
PHONE:
Contractor:
DIEBOLD INC
15100 SW KOLL PKWY
BEAVERTON, OR 97006
PHONE: 503 - 469 -1700
FAX:
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 2
Audio & Stereo: N Boiler Controls: N
CCTV: Y Clock Systems: N
Data & Telecommunications: N Fire Alarm: N
HVAC: N Instrumentation: N Total $168.00
Intercom/Paging: N Landscape /Irrigation: N Required Items and Reports (Conditions)
Landscape Lighting: , N Medical: N.
Nurse Calls: N Protective Signal: N
Security Alarm: Y Other: N
Other Desc:
This permit i • sue. •'ect to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done i accordance wiI approved plans. This permit will expire if work is not started within 180 days of issuance, • ' work is suspended for mere the 180
days. A ENTION: Oregon =w -• ■ires you to follow the rules adopted by the Oregon Utility Notification .rater. hose rules are . -t .rth in OAR
952-001-9.810 through OAR 952-'.1-0100. • may obtain a copy of the rules or direct questions to OUNC by calling 503. 6.6699 0 .800.332.23
•
Issued = • Permittee Signature: F •VallP•
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 an Inspection that business day.
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.
Electrical Permit Application Folz of iict: USE ONLY
City of Tigard Received " 9 �� 2) Permit
III ° 13125 SW Hall Blvd., Tigard, OR 97223 D Plan Review V� -�YJ �� 9��
0 Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit: PAZ 9-60
T I c; A 1t D Inspection Line: 503.639.4175 Date Ready/By: Juris: H1 See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction 0 Addition/alteration/replacement Please check all that apply (submit a sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
ID Demolition 0 Other:
where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
El 1 - and 2 - Earn!! dwelling less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
2-family g 23 Commercial/industrial ❑ Accessory b uilding 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 ", "l - ", "l - ",
�/ r I00HP or more. occupancy.
Job no.: Job site address:
1a,7 y ,✓ ►, t9 ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /L1P:
11 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: 6 l< ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft. or less 145.15 4
Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Ailttijeliii �/ Limited energy, multi - famil 75.00 2
/i y G(,r� a 1,// residential (with above sq. ft.)
�f Services or feeders installation,alteration, and/or relocation
I 200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) I Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Owner signature: Date: Branch circuits — new, alteration, or extension, per panel
A. Fee for branch circuits with
❑ APPLICANT I 0 CONTACT PERSON above service or feeder fee,
each branch circuit 6.65 2
Business name: B. Fee for branch circuits
without service or feeder fee,
Contact name: first branch circuit 46.85 2
Address: Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) I Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Signal circuit(s) or limited - 0 Business name: I el) O l energy panel, alteration, or
Address: ingest/4i �. ` �� / I A( Il w 6 extension. Describe: Page 2 2
City/State /ZIP: �� "" ,�, / 0 r i`_ o o (, Each additional inspection over allowable in any of the above
5021 ' // Fax: ( ) Per inspection 62.50
Phone: (
J `./69 - l7vd I Investigation per hour (I hr min) 62.50
CCB Lic.: 51y93 Electrical Lic.: Wd . Lic.: gf 7L 4 Industrial plant per hour 73.75
/ f/ ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: / Subtotal: 151) •
Print name: / Date: l Plan review (25 % of permit fee):
•�� 4 'n � j � 0/ 0 State surcharge (12% of permit fee): i e .0 0
Authorized signature: V TOTAL PERMIT FEE: / (GR .00
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440-4615T(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 •
I:\ Bui lding\Permits\ELC- PermitApp.doc 03/23/06