Permit l �
CITY OF TIGARD
ELECTRICAL RESTRICTED ENERGY PERMIT
, DEVELOPMENT SERVICES PERMIT #: ELR2006 -00062
'= I� 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 2/21/2006
PARCEL: 2S102CB -03101
SITE ADDRESS: 12950 SW PACIFIC HWY 265 ZONING: C -G
SUBDIVISION: HUDSON PLAZA LOT: 021 JURISDICTION: TIG
Project Description: Protective Signal.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: HVAC: PROTECTIVE SIGNAL: X
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
HENDERSON, MARILYN DOROTHEA PHILLIPS ELECTRONICS
JENSEN HUDSON TRUSTEE 1110 NW FLANDERS
11795 SW KATHERINE ST PORTLAND, OR 97209
TIGARD, OR 97224
Phone: Contact #: FAX 503- 227 -4992
PRI 503- 222 -5083
Reg #: LIC 125364
FEES ELE 26- 213CLE
Description Date Amount
[ELPRMT] ELR Permit 2/21/2006 $75.00
[TAX] 8% State Surcha 2/21/2006 $6.00 REQUIRED ITEMS AND REPORTS
Total $81.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law re• uires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR • .2- 001 -0100. You may obtain copies of these
rules or direct questions'to OUNC at 503 - 246 -6699.
Issued By: 277,41 - , ) Permittee Signature: j . A. 41kr=..r`
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'N: 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 Applic`E'V r ,� FOR OFFICE USE ONLY
Y
City of Tigard F • Received
` ��l Permit No: ,
1312 Hall Blvd., Tigard, OR 97223 Plan Review , , /I �.
Phone: 503.639.4171 Fax: 503.598.1960 f ZU /I t -, j Date/By: Other Permit:
Inspection Line: 503.639.4175 C) F Dat ReadyBy: kris: el See Page 2 for
Internet: www.ci.tigard.or.us CITY of ri �gR p Notifiea/Met --r I (�' Supplemental Information
BU1lDfN -DNI,ION PLAN REVIEW
TYPE OF WO
❑ New construction Er Addition/alteration /replacement Please check all that apply:
❑ Demolition ❑Other: ❑Service over 225 amps, comm'l ❑Hazardous location
❑Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
CATEGORY OF CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential
❑ 1- and 2- family dwelling g Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi - family ❑Master builder ❑Other: ❑Building over three stories ❑Feeders, 400 amps or more
❑Occupant load over 99 persons OManufactured structures or
JOB SITE INFORMATION AND LOCATION ❑Egress/lighting plan RV park
n ❑Health -care facility ❑Other:
Job no.: Job site address: /2 sap, l - il 2cs —
i Submit 2 sets of plans with any of the above.
City/State/ZIP: ' 7 g d), .'72 .3 � / �/ / The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: I Project name! l e cu3 ato Descr l p t loo FEE* SCHEDULE
I Qty. I Fee. I Total I **
Cross street/directions to job site: New residential single- or multi - family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
Limited energy, non - residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
/ dwelling, service and/or feeder 90.90 2
-�E° ��O Q/00_,I ` Services or feeders installation, alteration, and /or relocation
� �/ 200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State /ZIP: Temporary services or feeders installation, alteration, and /or
relocation
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 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: • branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee,
each branch circuit 46.85 2
Address: Each add'l branch circuit 6.65 2
City/State /ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle 53.40 2
Phone: ( ) Fax:: ( )
Sign or outline lighting 53.40 2
S E -mail: Signal circuit(s) or limited -
CONTRACTOR energy panel, alteration, or
Business name: Z G / extension. Describe: ? Page 2 - 2
(/ t owvC C
1 / `' W Ci Each additional inspection over allowable in any of the above
Address: /
�` �� ( J ° as .X -1 Per inspection 62.50
City/State /ZIP: /v) l tO`i , 72-S 9 Investigation per hour (1 hr min) 62.50
¢ Phone: ) Fax: ) Industrial plant per hour 73.75
z�z-s �z -
ELECTRICAL PERMIT FEES*
CCB Lic.:t - 4 Electrical Lic.:26 2t. -C' Suprv. Lic. �- j.. 9 Subtota +d� 7c-- r�� � K.. " "� _ � �_ �r �
i.
Suprv. Electrician signature, required: iy (. ` ,/ Plan review (25% of permit fee) .
Date:�1 r State surcharge (8% of permit fee) A
Print name: LI °x J l
lL I -C� {,°211 �, TOTAL PERMIT FEE
Authorized Signature: This permit application expires if a permit is not obtaine within 180
days after it has been accepted as complete
Print name: Date: • Fee methodology set by Tri -County Building Industry Service Board
•• Number of inspections per permit allowed.
i:' Building \ Permits \ELC- PermitApp.doc 12/03 440.4615T(10/02/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 system $75.00
•
(SEE OAR 918- 260 -260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
•
❑ Fire Alarm Installation
❑ HVAC .
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
Ef Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
i:\ Building \Pennits\ELC- PertnitApp.doc 04/03
CITY OF TIGARD .4
BUILDING DIVISION PERMIT #: ELR200E;.O00G2
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 2/21/2006
Phone: (503) 639-4171 44, 401,0,i i l�
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 2/22/2006 TIME: 7:07AM PAGE: 40
SITE ADDRESS: 12950 SW PACIFIC HWY 265 CLASS OF WORK:
SUBDIVISION: HUDSON PLAZA LOT #: 021 TYPE OF USE:
PROJECT NAME: STATE FARM INSURANCE
DESCRIPTION: protective Signal.
OWNER: HENDERSON, MARILYN DOROTHEA, PHONE #:
CONTRACTOR: PHILLIPS ELECTRONICS PHONE #: 503..22
Inspec . • • . - • - uled For: Date: 2172p006 Pour Time:
' ode # Inspection Description Confirm # Contact # Message
135 35 L o w t 0
voltage V' No LIG 0273183.01 503 -2 22.5083 Y
• - 'ons /Comments /Instructions:
6 tkqtmetOr NLam. um 6'O PtoNAJ be Wt io
Zxt..i Atte& ACV S DSO
fl Nil& 1 ( A I NVG.Ui imq 9 ()$ .Lk
0 (3-‘,.. 5 c i s QW
o 10 cove& CaziU0 €)C.'..1
`C i L-e c o ∎ll N ? IA or .. `i 1 N.L
s i cu e N e" To 1/4)r k R. G-61-1-4
s kC\
c
..` ' . RTIAL APPROVAL ❑ CANCEL El NO ACCESS
► _�
❑ Am PASS - ` Ok FOR INSPECTION , 111 ADDITIONAL FEES ASSESSED
Inspector: I\6 Date: vZ• Phone #: (503) 718- lAtilt