Permit •
e ° Community Development RECEIVED
TIGARD Request for Permit Action AUG 0 7 2009
CITY OF TIGARD
TO: CITY OF TIGARD BUILDING DIVISION
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
(check one)
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® 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 #: ELC2009 -00011
Site Address or Parcel #: 12744 SW North Dakota St
Project Name: Key Bank
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Work done under ELC2009 -00034 by different contractor. Not sure what
happened to the aperwork.
Signature: Date: 8/7/09
ebbie R Adamski
Print Name:
Refund Policy
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 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
Rte to S s Admin: Date , flJ L •' Rte to Bld• Admin: Date - E � �,�� N/17
Refund Processed: Date By - Invoice Processed: Date By
Permit Canceled: Date yfryV y r B �: - r - arcel Tag Added: Date By
Receipt # Date / Method Amount $
1:\ Building \ Forms \RegPermitAction.doc Rev 07/26/07
Workflow Task Task Status Status Dat( Action By Record Dat Comments
ELC signature on application DONE 1/9/2009 Debbie Adh 1/9/2009
Case update (see note) DONE 1/9/2009 Debbie Adi 1/9/2009 Check received with application was for incorrect amount. Charlene with Ramsay Signs is m
Permit created DONE 1/9/2009 Debbie Adz 1/9/2009
Check for parcel tags DONE 1/9/2009 Debbie Adz 1/9/2009
Application received RECD 1/9/2009 MAIL 1/9/2009
ELC2009- 00011, Key Bank, 12744 SW North Dakota J
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wiling a new check. Return 1st check with issued permit. Paperwork is in green folder awaiting correct check.
•
Community Development
TIGARD Request for Permit Action
4(45)
fi v a il k
TO: CITY OF TIGARD ti g A`
Building Division Services Coordinator -F 0 � O \v
13125 SW Hall Blvd., Tigard, OR 97223 J _te
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov C>
FROM: ❑ Owner ❑ Applicant n Contractor ® Cittaff
(check one)
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
N 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 #: ELC2009 -00011
Site Address or Parcel #: 12744 SW North Dakota
Project Name: Key Bank
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Should not have created permit! Check submitted with application was
for incorrect amount. Applicant said they would send new check. The next day they called and said
the job has s een cancelle. Original check # 2028 was returned by mail on 1/14/09.
Signature: �;� 1 , c , Date: 1 /14/09
D ebbie R. Adamski
Print Name:
Refund Policy
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 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
Rte to S s Admin: Date /IN i 9 MIRA Rte to Bld: Admin: Date yAJO B � 4
` Refund Processed: Date B Invoice Processed: Date By
✓ Permit Canceled: Date / ,2/ 9 By a »-11 Parcel Tag Added: Date By
Receipt # Date Me •d Amount $
1:\ Building \ Forms \RegPermitAction.doc Rev 07/26/07
' t trical Permit Application rol< 01- 1( G l• o I.V
Received 11„, . City of Tigard 13125 SW Hall Blvd., EC EIVED Date/By: / 7 D 9
Plan ' /ti Permit No.: �Q� O�l /
d Tigard, OR 97 Plan gee,
• Phone: 503.639.4171 Fax 503 960 DatdBy: Other Permit:
I ,
Internet: Inspection line: gov7s S AN 0 g 2009 ��� ?Kea I ® for
TYPE OF Why op TIGARD PLAN REVIEW
❑ New construction ® Addition/al i-`, tlSIOP 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 dwelling ® Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi-family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: Job site address: 12744 SW North Dakota 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State/ZIP: Tigard OR 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt no.: I Project name: Key Bank ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Sw Scholls Ferry Rd Deseripmn I Qty. I Pea I Tact I •
New residential single- or multi- family dwelling milt.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft or less 145.15 4
Tax map/parcel no.: Ea. add'1 500 sq. R or portion 33.40 1
Limited energy, residential
75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Replace existing damaged Key Bank sign with exact replacement. Le s d energy, tmilti dential (with above s sq. q . ft ft.) r Lim 75.00 2
-
Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER I ❑ 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
relorallon
Phone: ( ) 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:: Branch circuits — new, alteration, or extension, per panel
A Fee for branch circuits with
® APPLICANT I ® CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit
Business name: Ramsay Signs Inc B. Fee for branch circuits
Contact name: Charlene Parker without service or feeder fee 46.85 2
first branch circuit
Address: 204 Jefferson St Each add'l branch circuit 6.65 2
Mlsoellsmeons (service or feeder not included)
City/State/ZIP: Eugene OR 97402 Each mamrfaaured or modular
dwelling, service and/or feeder 90.90 2
Phone: (541) 342 -1769 I Fax: : (541)342-3291 Reconnect only 66.85 2
E -mail: charlene®ramsaysigns.com Pump or irrigation circle 53.40 Ain 2
CONTRACTOR Sign or outline lighting { 53.40 613 `lv 2
Signal circuit s or limited -
Business name: Ramsay Signs Inc
energy panel, alteration,
Address: 204 Jefferson St extension Desai • Page 2 2
City/State/ZIP: Eugene OR 97402 Each additional htapection over allowable in of the above
Phone: (541) 342 - 1769 I Fax Investigation ation (541) 683 -3291 Per inspection ation 62.50
per hour (1 hr min) 62.50
CCB Lic.: 63422 I Electii Lic.: 26 ge LS I Suprv. Lic.: 493SIG 1 Industrial plant per hour 73.75 -
S `. I t 1 i' ELECTRICAL PERMTT FEES t7
Suprv. El ectrici an signature, required: \\ '� Subtotal: yl. k1 53.
Print name: Phill Date: Steiger Plan review (25% of permit fee): 18.75•
• JJ LL
State surcharge (12% of permit fee): 1L8� f. T
Authorized signature: NI/ / - e , TOTAL PERMIT FEE: �g1
Print name: Charlene Parkker — I Date: 117/09 This permit days after has been ac s c acc e rte d b as ct complete. wit6ia l80
ftr n has cpte m complete.
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 Alann
❑ 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
O er
Total number of commercial systems: 1
*No licenses are required. Licenses are required
for all other installations