Permit •
CITY OF TIGARD ELECTRICAL PERMIT
Per
° COMMUNITY DEVELOPMENT
Permit #: ELR2012 -00156
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/24/2012
Parcel: 1 S 136DB00201
Jurisdiction: Tigard
Site address: 11565 SW PACIFIC HWY
Project: Fred Meyer Subdivision: 2000 -025 PARTITION PLAT Lot: 2
Project Description: Low Voltage for TI
Contractor: MERLIN POINTE TECH LLC Owner: FRED MEYER INC
12606 NE 95TH ST SUITE C -130 3800 SE 22ND AVE
VANCOUVER, WA 98682 PORTLAND, OR 97202
PHONE: 360 - 892 -0065
PHONE: 503 - 232 -8844
FAX:
FEES
Quantity Description . Date Amount
1 ea Restricted Energy Permit 07/24/2012 $75.00
Specifics:
1 ea 12% State Surcharge - 07/24/2012 $9.00
•
Electrical
•
Type of Use: COM
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $84.00
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 952 -001 0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
•
Issued By: % K ,�r Permittee Signature: 1
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 601639.4175 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.
Electrical Permit Application RECEIVE 1 F(aR OFFICE, USE ONLY
City of Tigard Received
JUL 2 4 2 012
Date/BV: 1 1 .. y' 1 I �/ 91 �/
Permit No.:6��( 1— 001 -51
° 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:bkP 42 - C6
r I G n R D Inspection Line: 503.639.4175 CITY OFT1G r ' t Date Ready/By: Juno ® See Page 2 for
Internet: www.tigard - or.gov BU�INGDN1S1i 1i°tifted/Method: �, f O Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction 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.
['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 f 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 ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: Job site address: 1 1565 6t,j `r I.t W W or more. occupancy.
❑ Six x or or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: '1 j(pe,D Of.. 91 2.23 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: fReD MthG1` ❑ 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 168.54 4
Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1
Limited energy, residential
75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi- family 75.00 2
,1 � �_� N _ - , .k. C - residential (with above sq. ft.)
`�`^'rr Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
Name: f Riar3 Hata_ 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Ci /State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
• Phone: ( ) Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not •
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
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: iu . \VJ btu i ' �GIE�j B. Fee for branch circuits without
t �^-• service or feeder fee, first 56.18 2
Contact name: branch circuit
�'�"`U ' ` Each add'I branch circuit 7.42 2
-.Address: )2(4nr 1,,..G ' Z 1 Miscellaneous (service or feeder not included)
City/State/ZIP: 1 f ) (\ 9. _ Each manufactured or modular 67.84 2
ty r` " 2
, 1 v dwelling, service and/or feeder
Phone: rr� ,,�� « Fax: : Reconnect only 67.84 2
�c7lot J) gib 2 'r15 ( ) Pump or irrigation circle 67.84 2
E -mail: me kelp E t 1 A Q� tri , (.. A Signor outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited - energy
( � 'j'` �1w,n panel, alteration, or extension. Page 2 2
Business name:
AA Y E� N '�ru�+L �, Each additional inspection over allowable in any of the above
Address: & 0. IS T JT. C.. -'yam Additional inspection (1 hr min) 66.25/ hr
` q p� Investigation (I hr min) 66.25/ hr
City /State /ZIP:
\)A0 A *% 1 010$ 2 Industrial plant (1 hr min) 78.18/ hr
Phone: (10 ) Q97 (0c Fax: ( ) Inspections for which no fee is 90.00 / hr
(� specifically listed (%2 hr min)
CCB Lic.: (53 251 Electrical Lic.: 31-100ov G Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: / . ' �� Subtotal:
•%
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
,/ • TOTAL PERMIT FEE: �hi (I) Authorized signature: j This permit application expires if a permit is not obtained within 180
Date: days after it has been accepted as complete.
Print name:
T� o(,f l 7 42_ • N um b er of inspections allowed per permit.
1:\Building\Permits\ELC- PermitApp.doc 07/01/10 4404615T(11/05/COM/WFB
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*
❑ H eating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ O ther:
[ 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, r r
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls •
❑ Outdoor Landscape Lighting* •
❑ Protective Signaling •
g Other
/ Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\Building\Permib\ELC- PermitApp.doc 07/01/10
•
n
TIGARD:
City of Tigard
September 11, 2012
Merlin Pointe Technologies
Attn: Teep Oliver
12606 NE 95t St., #C -130
Vancouver, WA 98682
Re: Permit No. ELR2012 -00156
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11565 SW Pacific Hwy
Project Name: Fred Meyer
Job No.: N/A
Refund Method: ® Check #207588 in the amount of $6720.
❑ Credit card "return" receipt in the amount of
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 job contract no longer valid. 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
rp !, City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Regauest for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Merlin Pointe Technologies DATE: 08/23/2012
12606 NE 95 St., #C -130
Vancouver, WA 98682 REQUESTED BY: Dianna Howse
Attn: Teep Oliver
TRANSACTION INFORMATION:
Receipt #: 187668 Case #: ELR2012- 00156
Date: 07/24/2012 Address /Parcel: 11365 SW Pacific Hwy
Pay Method: Check Project Name: Fred Meyer
EXPLANATION: Per applicant's request job contract no longer valid; refund 80% of permit fees.
•
REFUND INFORMATION:.
Fee Description From Receipt • 7 Revenue A ccount No. • Refund
Example: Building Permit Fee Example: - 2300000 -43104 • $ Amount
Restricted Energy Permit 22 0- 0000 -43103 $60.00
12% State Surcharge 100- 0000 - 24001 7.20
TOTAL REFUND: $67.20
APPROVALS:
If under $5,000 Professional Staff
If under $12,300 Division Manager
A
If under $23,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
• . - ' : FOR TIDEMARK SYSTEM MINISTRATION USE ONLY:: - -
Case Refund Processed: Date: I 9 /1 id-- By
1 \Building\ Refunds \RefundRcyucst.doc s 09 /01/2010
City of Tigard ° COMMUNITY DEVELOPMENT DEPARTMENT
Request Permit Action y , // , -
T t to p 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www., 1 4._... G..
w s` .1 ° .D
TO: CITY OF TIGARD �` '' 1 5 2012
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223 CITYOFTIGARD
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov BUILDING DIVISION
FROM: n Owner n Applicant Contractor n City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) 1\1 1` � \Ni \ `- mAgo LO ()\V S
Mailing Address: /260(0 NL Q)s S I 4 0 , 1307
City /State /Zip: U` 1\1000 J 94MoQ,2_
Phone No.: 30 $12 d0 (o5
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
2I CANCEL /VOID PERMIT APPLICATION.
El REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ELOO\Z - COla,
Site Address or Parcel #: 11565 5c1) ?k.. 1 L- 1
Project Name: Rut MV-
Subdivision Name: I Lot #:
EXPLANATION: (,t 0., cX Q Qg c a tL c
n� r
Signature: /4)2 oL Date: -S-�
Print Name: D C
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 2 -4 weeks for processing refunds.
Rte to S s Admin: Date fifffiallfflin Rte to B1d• Admin: Date j 7 B - 6
Refund Processed: Date '/AMMIl� Invoice Processed: Date B /S DT)
Permit Canceled: Date A ! B Parcel Ta• Added: Date B g • ��
' - = � ; ��d�JQm Method • �� ' Amount $
I: \Building \Forms \RegPermitAction. oc ev 05/25/2012
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 188320 - 09/11/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2012 -00156 $ -67.20
Total: $ -67.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 207588 DHOWSE 09/11/2012 $ -67.20
Payor: Merlin Pointe Technologies
Total Payments: $ -67.20
Balance Due: $67.20
Page 1 of 1
1 1111 CITY OF TIGARD RECEIPT
$ : 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 187668 - 07/24/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2012 -00156 Restricted Energy Permit 220 - 0000 -43103 $75.00
ELR2012 -00156 12% State Surcharge - Electrical 100- 0000 -24001 $9.00
Total: $84.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 016141 STREAT 07/24/2012 $84.00
Payor: Merlin Pointe Technologies LLC
Total Payments: $84.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
7 E : 13 125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 187668 - 07/24/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2012 -00156 12% State Surcharge - Electrical 100 - 0000 -24001 $9.00
ELR2012 -00156 Restricted Energy Permit 220- 0000 -43103 $75.00
Total: $84.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 016141 STREAT 07/24/2012 $84.00
Payor: Merlin Pointe Technologies LLC
Total Payments: $84.00
Balance Due: $0.00
Page 1 of 1