Permit •
CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
` COMMUNITY DEVELOPMENT Permit #: ELR2009 -00288
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/10/2009
Parcel: 1 S136CA01601
Jurisdiction: Tigard
Site address: 11665 SW PACIFIC HWY
Subdivision: Lot: 0
Project: Key Bank
Project Description: Install (2) low voltage systems, 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 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 t - nte . Those rules are set , rth in OAR
952- 001 -0010 t AR 9 1 -01 . F1 Yoummaay obtain a copy of the rules or direct questions to OUNC by calling 503. 46.669 or 1.800.332.2344.
Issued B : Q! '�" -4 V u Permittee Signature: ¥ — Al
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 FOR OFFICE USE ONLY
City of Tigard DateB Received • /0 0 9 • �� Permit No.: / O /'a t
;. V 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review i u P / � „C,� Db � �
II Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit: v ,9v
. 1 - 1 (..;ARID . D Inspection Line: 503.639 Date Ready See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction Addition/alteration/replacement 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
JOB SITE INFORMATION AND LOCATION
El Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "I -3 ",
Job no.: Job site address: //4 ` 1 / C� ! / I or more residential occupancy.
❑
J J kG ?W� _ ❑ Six Six or or more residential units. Recreational vehicle parks.
City/State /ZIP: 7t5 ` , ®`/ ❑ Health -care facilities. ❑ Supply voltage for more than
J ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: f� n ) < ❑ 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: Lot no.: 1,000 sq. ft. or less 145.15 4
Ea. add'I 500 sq. ft. or portion 33.40 l
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
4,\n5.1eLif ; h � � � ; �� Limited energy, (with above sq. 75.00 2
residential (with above sq. R.)
S ervices 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
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 ❑ CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'l branch circuit 6.65 _ 2
Miscellaneous (service or feeder not included)
City/Statc /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
` bp I -� i 0 /r Signal circuit(s) or limited- •
Business name: D \ € energy panel, alteration, or
Address: `3 / 0 v Ste/ 4'/ 7 4 w extension. Describe: Page 2 /S/c/..) 2
/ ` i
City/State /ZIP: 9 7 n /e Each additional inspection over allowable in an of the above
l Per inspection 62.50
Phone: (SDI) /..(4 Q- /700 I Fax: ( i/ A 9) / /OA -,/( Investigation per hour (I hr min) 62.50
CCB Lic.: 7 9 3 Electrical LieLic g ! Liu Industrial plant per hour 73.75
�`t— "—� 7 ELECTRICAL PERMIT FEES
Suprv. Ele c lan P:o si gnature, required: Subtotal: /SQ • `�
Print name: r s Date: 4746/0 Plan review (25% of permit fee): �' State surcharge (12% of permit fee): I V . 00
Authorized signature:0 TOTAL PERMIT FEE: /(0$,C90
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.
I:\ Building \Permits\ELC- PennitApp.doc 05/23/06 440- 4615T(II /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*
rr f -'
❑ 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 L 1 ',\
Total number of commercial systems:
` ! v .
*No licenses are required. Licenses are required
. for all other installations
•
f: ' Building \Permits\ELC- PermitApp.doc 03/23/06