Permit A lp ' ' ELECTRICAL PERMIT -
CITY OF TIGARD RESTRICTED ENERGY
L �I�" DEVELOPMENT H BMENq Tigard, 639 -4171 DATEESSU 8/7/03 03 -00244
SITE ADDRESS: 15230 SW SEQUOIA PKWY 190 PARCEL: 2S112DA -00300
SUBDIVISION: ZONING: I -P
BLOCK: LOT: JURISDICTION: TIG
Project Description: Installation of limited energy for HVAC wiring.
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: X PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER: :
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
PACIFIC REALTY ASSOCIATES PROTEMP ASSOCIATES INC
15350 SW SEQUOIA PKWY #300-WM I 807 NE COUCH
PORTLAND, OR 97224 PORTLAND, OR 97232
Phone: Phone: 233 - 6911
Reg #: ELE 26- 1063CRE
LIC 38868
SUP 2613LEP
FEES Required Inspections
Description Date Amount Low Voltage Inspection
[ELPRMT] ELR Permit 8/7/03 $75.00 Elea! Final
[TAX] 8% State Tax 8/7/03 $6.00
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 requires
you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 -001 -0010 throuc
Issue y 1 _ _ •. 4j , 7 � �.,',L' Permittee Signature ' _
I
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 639 -4175 by 7:00 P.M. for an inspection needed the next business day
• FOR OFFICE USE ONLY
Electrical Permit Application Received Electrical `/
' ` ' Date/By: Permit No. �. d) _ c/}p;'f
City of Ti and Planning Approval Sign
g Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use
�/��di d tt� Date/By: Case No.:
.or.us i
Internet: www.ci.tigard.or.us g ■ e_ ®
Contact Juris.: See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 -" Name/Method: Supplemental Information.
TYPE OF WORK PLAN REVIEW (Plea se check all that apply) .
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
❑ Addition/alteration/replacement ❑ Other: ❑ Service over 320 amps - rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
❑ 1 & 2- Family dwelling ❑ Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address:/ s"2 3 O Sw � "."(371/0,1A "" / .
PI' FEE* SCHEDULE
Suite #: / /® I Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: IA/65r ne rt >>vL Description Qty Fee (ea.) Total 1
Cross street/Directions to job site: New residential-single giIncude or multi-family per
dwelling unit. Includes attached garage.
Service included:
1000 sq. ft or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Lot #: Limited energy, residential 75.00 2
Subdivision: Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
— Services or feeders - installation,
P4-4— $1 0574 alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTY OWNER I ❑ TENANT 601 amps to 1000 amps 240.60 2
Over 1000 amps or volts 454.65 2
Name: Reconnect only 66.85 2
Address: Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: 200 amps or less 66.85 1
Phone: Fax: 201 amps to 400 amps 100.30 2
❑ APPLICANT ❑ CONTACT PERSON Branch n to h circuits amps 133.75 2
Branch circuits -new, alteration, or
Name: extension per panel:
A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 6.65 2
City /State /Zip: B. Fee for branch circuits without purchase of
service or feeder fee, first branch circuit 46.85 2
Phone: Fax: Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: Signal circuit(s) or a limited energy panel, /
Business Name: �o ASSOO X2/ .. Descr p ion rextension / Page 2 2
Description:
Address: g7 sE /7 '-`` Avt'
Each additional inspection over the allowable in any of the above:
City /State /Zip: f z,,d;(/n ( 97( , Z^ Per inspection per hour (min. 1 hour) _ 62.50
Phone: ,23 3 69// Fax:. ,3 g - 9 7' 7 Investigation fee:
CCB Lic. #: 3-g-&---- Lic. #: ,92&/.06, CG C Electrical Permit Fees*
Supervising electrician Subtotal $ 1S. at)
signature required: Plan Review (25% of Permit Fee) $
Print, Name: Lic. #: State Surcharge (8% of Permit Fee) $ � cc D
, TOTAL PERMIT FEE $ bU
Authorized / Notice: This permit application expires if a permit is not obtained within
Signature: Date: $ / 7/O3 180 days after it has been accepted as complete.
// *Fee methodology set.by Tri -County Building Industry Service Board.
- (Pease print name)
i:\Dsts\Petmit Forms \ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
'RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
Audio and Stereo Systems
0 Burglar Alarm
• Garage Door Opener
• Heating, Ventilation and Air Conditioning System
Vacuum Systems
n Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
n Audio and Stereo Systems
Boiler Controls
• 0 Clock•Systems
n Data Telecommunication Installation
0 Fire Alarm Installation
HVAC
n Instrumentation
Intercom and Paging Systems
• Landscape Irrigation Control
0 Medical
0 Nurse Calls
Outdoor Landscape Lighting
Protective Signaling
n Other
• Number of Systems
* No licenses are required. Licenses are required for all
other installations
i:\Dsts\Permit Forms\ElcPermitAppPg2.doc 01/03