Permit 111 n CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit#: ELR2012 -00146
T [ G A R O 13125 SW Hall Blvd.. Tigard OR 97223 503.718.2439 Date Issued: 07/17/2012
Parcel: 2S112DC01500
Jurisdiction: Tigard
Site address: 15757 SW 74TH AVE 590
Project: A & J Distribution Subdivision: FANNO CREEK ACRE TRACTS Lot: 6
Project Description: Low voltage burglar alarm and cctv
Contractor: ADT LLC Owner: A & J DISTRIBUTION
2815 SW 153RD DR 15757 SW 74TH AVE
BEAVERTON, OR 97006 TIGARD, OR 97224
PHONE: 503 -469 -7219 PHONE: 208- 329 -0757
FAX: 503 -469 -7128
FEES
Description Date Amount
Specifics: Restricted Energy Permit 07/17/2012 $75.00
12% State Surcharge - Electrical 07/17/2012 $9.00
Type of Use: COM
Class of Work: NEW
Total Number of Systems: 1
Audio & Stereo: N Boiler Controls: N
CCTV: N Clock Systems: N
Data & Telecommunications: N Fire Alarm: N
HVAC: N Instrumentation: N
Intercom /Paging: N Landscape /Irrigation: N
Landscape Lighting: N Medical: N
Nurse Calls: N Protective Signal: N
Security Alarm: Y Other: N Total $84.00
Other Desc: 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 OAR 952-001-0090. You may obtain copy of the rules or direct questions to OUNC by calling 50
3 � 2 ` P1� 32 or 1.800.332.2344,
Aititti
Issued By: J-1— Permittee Signature: V - 4
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.
07/16/2012 08:37 FAX 5034697110 ADT SECURITY lj002
Electrical Permit ApplicatiREC IVED rolz OFFICE USE. ONLY
City of Tigard Received ,—
Date/By: 1 I ! ( O (12_ Sr Per N 'r 'rlo
LQ a— i� /r'/1A
III n 13125 SW Hall Blvd., Tigard, OR 97224 16 20 ' Phone: 503.718.2439 Fax: 503.598.I Plan Review
C
Date/By: Other Permit:
r I c n R D Inspection Line: 5(B.639.4175 �'� OF � %I DF
Internet: w Date ReaReady/By: huts: ® See Page 2 for
ww.tigard - or.gov rtfl Notified/Method:
.:i. •,. :. . ,. � i Supplemental Information -
,.. ,...,, ' 11311;!. °QiVIS1t7IV:. .. ... ,
® New construction ❑ Addition /alteration/replacement Please check all that apply (submit g sets of plans w /items checked below):
❑ Demolition ❑ Service or feeder 400 amps or more ❑ Building over three stories.
. �
..:;., . : ' .:::::: : ..: ...:. .. .. :1.1'1. ,., able fault current Marinas and -
. .. .. ATE : , ,
... . •.:,...... • • -.. � � RY • •• ❑ a ids
-.. .. , � ... exceeds 10, e.0 amps t
• • � ;.. . ,•; , , � I�: C+OIY�?�ii/CT'(tSN' ,�� °' ' ,. ps at 150 v olts or Floating buildings.
CI 1 - and 2 family dwelling ®Commercial /industrial 0 Accessory building lei ground, or exceeds 14,000 ❑ Commercial -use agricultural
El Multi ❑ Master builder for all other installations. I buildings. tatio
Other: ❑ Fire pump. ❑ on of 75 KVA or
.: .. � ?; - :, JO , 'S f� IINE? t4T Ar'!b;'1.. TIOI El Addxuo ofne em. g rely derived system.
• ..:.. � ,::.... •..; .. �':. IQN'' p
.. .::,. ,� ..:: .:...... :.. q..... .., ' � :..,:.; ❑Additi00 0fnewmotorloadcf 0 ., A „,. ", "13°.
Job no.: 083- 26562- Job site address: 15757 SW 74 Ave 100HP or more. occupancy.
['Six or more residential units. ❑ Recreational vehicle parks.
City /State/ZIP: Portland, OR 97224 ['Health-care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt no.: 590 Project name: A&J Distribution ❑ Service or feeder 600 amps or more.
Cross street/directions to job site: ' ",';;.
...Description Qty. I • ..Fee. I Total I '_-
New residential single- or mold-family dwelling will
Includes attached garage.
Subdivision: • Lot no.: 1,000 sq. ft. or less • 168.54 4
Tax map /parcel no.: Ea add'I 500 sq. ft, or portion 33.92 1
:' Y.+., r ... ,.�:I .....r�1: ..v. ._ . residential
75 2
, .. ,,.,. • -� Limited energy,
: : :::.:.. V: . ....... r.., : a, ,: :. .: ; .
• , •::. - .� ::: "':' .:: �!; �; :�:�.; (with above sq. ft.) • • " "'' Limited energy, multi- family 75.00
Low voltage burglar alarm and ccty residential (with above sq. ft.) 2
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70
.. l* :. :; s : • ! , • . , . .. . .. . . .:. :. 0:1' ••:..• . 201 amps to 400 amps ,
13356 2
Name: A&J Distribution 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: 15757 SW 74 Ave Over 1,000 amps or volts 552.26 2 _
City/ State/ZIP: Portland, OR 97224 Temporary services or feeders Installation, alteration, and/or
relocation
Phone: (208)329 -0757 Fax: ( ) 200 amps or less 59.36 1
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
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with '
_.. c; ::a l AEI!, ' above serv c rc f r fee,
.�........ .. ...... .......:..•:,_.:_HT,.. :: ;:..: `•.::. ::. "� °CJO'N�'AC'C,'Q> &RsoN'. 742 2
cede
_ b tan c wit
Business name: B. Fee for branch circuits without
service or feeder fee, first
Contact name: _ branch circuit 56.18 2
Address:
_ Each add'I branch circuit 7.42 2
-
Miscellaneous (service or feeder not included) .
City/ State/ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) _
Reconnect only 67 2
E -mail: — Pump or irrigation circle 67.84 2
•, . ,., , ... :
. �. .,....,,......:•:,: ,r;;.,. - ...r.:• �.... Sign or 2
:: i_ il;; ;!;.i ' i . In'. ' :• ,0. ,.'.' .._ (10R".: : a :; lighting 67.84
Signal circuit(s) or limited -energy
Business name: ADT LLC panel, alteration or extension. ► Page 2 75.00 2
re. _ Each additional inspection over allowable in any of the above
Address: 2815 SW 153 Dr Additional inspection (1 hr min) 66.25/ hr
City/ State/ZIP: Beaverton, OR 97006 investigation (1 hr min) 66.25/hr
Industrial plant (1 hr min) 78.18/ hr
Phone: (503) 469 -7219 I Fax: (503) 469 -7128 Inspections for which no fee is
specifrcall listed (t4 hr min) 90.00 / hr
- '6 "- B ,*? Lic.: 196560 t F cal Lie.: CLE3)17 j Su ic.: 42521 ",. � , "_""' •.-. E .. •
1,��
\ l l Subtotal: 75.00
P signature, Suprv. Electrician si ature IUI
Plan review (25 %of permit fee):
Print name: Eric Willard Date: la • 012 State surcharge (12% of permit fee): 9.00 /
TOTAL PERMIT FEE: 85.00 J
Authorized signature: ' //
This permit application expires if a permit is not obtained within 180
vi
.d name: Date: days after it has been accepted as complete. va l
• Number of inspections allowed per permit, 7f'
I: 1Building \PermitslFr.C- PermitApp.doc 07/01 /10 440- 4615T(II/0S/COM/WEB
07/16/2012 08:37 FAX 5034697110 ADT SECURITY (j003
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for al ... r .. : _ id
1 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:
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
El HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
O Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
® Protective Signaling
El Other
Total number of commercial systems: 1
*No licenses are required. Licenses are required
for all other installations
lAllulwing\v«miis\eLc- rQmiapp.ax 07/01/10
TIGARD.
City of Tigard
December 6, 2012
ADT LLC
Attn: Lori McMurphy
2815 SW 153r Dr.
Beaverton, OR 97006
Re: Permit No. ELR2012 -00146
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15757 SW 74 Ave. #590
Project Name: A & J Distribution
Job No.:
Refund Method: n Check # in the amount of $
® Credit card "return" receipt in the amount of $67.20.
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 work was not accessible to be completed.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request Jar Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: ADT LLC DATE: 12/3/2012
Attn: Lori McMurphy
2815 SW 153' Dr. REQUESTED BY: Dianna Howse
Beaverton, OR 97006
TRANSACTION INFORMATION:
Receipt #: 187570 Case #: ELR2012 -00146
Date: 7/17/2012 Address /Parcel: 15757 SW 74th Ave. #590
Pay Method: CreditCard Project Name: A & J Distribution
EXPLANATION: Per applicant's request as work was not completed. Refund 80% of permit fee.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Electrical permit fee 220- 0000 -43103 $60.00
12% State Surcharge 100 - 0000 -24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATURES /DATE:
If under $5,000 Professional Staff
If under $12,500 Division Manager N i J�
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: AZ /(d //.2-- By: 1/4 exy
I: \Building \Refunds \RefundRequest.doc x 09/01/2010
11/01/12 10:17AM HP LASERJET FAX p.01
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
74 ...1,...-; " Request Permit Action atO
'r 1(i l t 37 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www' 01
Novo 1
TO: CITY OF TIGARD ���ARO .
Building Division Services Supervisor 'N S,
13125 SW Hall Blvd., Tigard, OR. 97223 B i`G
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner ❑ Applicant ® Contractor, ❑ City Staff
(chcok ti,nC) , f
REFUND OR Name: ADT LLC
IIWOIcE TO• (Business or fndividu:l) y � 444.—
Mailing Address: 2815 SW 153 ' t Dr _. ^ !X
City/State/Zip: Beaverton, OR. 97006 W.•, __ ..
Phone No.: 503 -469 -7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
i CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE. CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ELR201 -001 46
Site Address or Parcel #: 15757 sw 74'" ave #590
Project Name: A z DDistribution
Subdivision Name: Fanno Creek Acre. Tracts Lot #: 6
EXPLANATION: Work not complete - Occupants arrested on drt warrant - no access to
finish installation.
Signature: `" __- `' , Y'sc _ , .. Date: 10/31/12 .... ..�..._
Lori McMurphy a
Print Name:
lisulingsx
I, The Director or Building Official may authorift the refund of:
a) any fee which wax ermneuualy paid Or cunt:ctea
I)) not rm,rt- than RIYy6 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 Pie 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 2.4 weeks for processing refunds.
FOR OFF1CF USE ONLY 'S cr
Rte t o Sys ?,drool: Date !l ..,1. I L 7 ' , Rte to Bid: Admin: IM �`.1, / J° "0 '70 ~ Refund Processed: Date /2. Co By 4' , 4); invoice Processed: Date B..Y.__ _ �' -
Pertntt C .arc le Date B 1 di7` . 3 Ta. Added; Date I3 — ��' (/
_ Rec_c >i t t# ____ _ Date Method Amount $
L•\ Huilediing \liortne \Rof'ctmitAcnon.doc Rev05 /25/201L Q _....
r i ?3