Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
• COMMUNITY DEVELOPMENT Permit #: ELR2012 00184
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/13/2012
Parcel: 2S113AD01800
Jurisdiction: Tigard
Site address: 16798 SW 72ND AVE B14
Project: Pacific Realty Subdivision: ROSEWOOD ACRE TRACTS Lot: PTS 5 -1.
Project Description: Low voltage for Comcast coax cable.
Contractor: CAPITOL DATA & COMMUNICATIONS Owner: PACIFIC REALTY ASSOCIATES
11401 NE MARX ST ATTN: N PIVEN
PORTLAND, OR 97220 15350 SE SEQUOIA PKWY #300
PORTLAND, OR 97224
PHONE: 503 - 255 -9488 PHONE: 503 -624 -6300
FAX: 503 - 257 -7121
FEES
Description Date Amount
Specifics: Restricted Energy Permit 08/13/2012 $75.00
12% State Surcharge - Electrical 08/13/2012 $9.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio & Stereo: N Boiler Controls: N
CCTV: N Clock Systems: N
Data & Telecommunications: Y 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: N 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 • g :: R 952 -1.1 -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. l \ i • �� Permittee Signature (
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 503.839.4175 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 Applic I, + • FOR OFFICE USE ONLY Re ceived /�,� n ■ it dD Date /By: ∎ffi il7✓] Permit no.: EL/LoL ;z 18
11111 , II City of Tigard Plan Review
13125 SW Hall Blvd., Tigard, OR ? 9, y . Other Permit:
n/ 9 2012 Date/By: 503.639.4171 Fax: 503.598'. 9 &0 Date Ready /By: Juris: U e Page 2 for
T l A R D Inspection Line: 503.639 R ,
�.� AID Notified /Method: Supplemental Information www.tigard- or.gov �/ , r.
f a ' n ""y",3 :3N
TYPE OF WOR Il''''-t' "' PLAN REVIEW
U New construction 0 Addition /alteration /replacement Please check all that apply:
❑ Demolition ❑ Other: ❑ Service over 225 amps, comm'I ❑ Hazardous location
CATEGORY OF CONSTRUCTION ❑ Service over 320 amps - rating ❑ Building over 10,000 sq.ft.
Li 1- and 2- family dwelling 0 Commercial /industrial ❑ Accessory building of 1- and 2- family dwellings 4 or more new residential
❑ Multi- family ❑ Master Builder ❑ Other ❑ System over 600 volts nominal units in one structure
JOB SITE INFORMATION AND LOCATION ❑ Building over three stories ❑ Feeders, 400 amps or more
Job no.: C12298 Job site address: 16798 SW 72nd Ave ❑ Occupant load over 99 persons ❑ Manufactured structures or
❑ Egress /lighting plan RV park
City/State/ZIP: Tigard, OR ❑ Health -care facility ❑ Other:
�,� Submit 2 sets of plans with any of the above.
IR6ta+
f r � �'_ _ The above are not applicable to temporary construction service.
Suitc/bldg. /apt. no.: Project name: Blida@
FEE SCHEDULE
Cross Street /Directions to job site: Description I Qty. I Fee. I Total I ••
New residential - single or multi- family dwelling unit.
Subdivision: Lot no.: Includes attached garage.
1000 sq. ft. or less $ 168.54 4
Tax map /parcel no.: Ea. Add? 500 sq. ft or portion $ 33.92 1
DESCRIPTION OF WORK Limited energy residential $ 75.00 2
Install Comcast Coax Cable Limited energy, non - residential $ 75.00 2
Each manufactured home or modular
U PROPERTY OWNER I U TENANT dwelling, Service and /or feeder $ 67.84 _ 2
Name: Service or feeders installation, alteration, and /or relocation
200 amps or less $ 100.70 2
Address: 201 amps to 400 amps $ 133.56 2
401 amps to 600 amps $ 200.34 2
City /State /ZIP: 601 amps to 1000 amps $ 301.04 2
Over 1000 amps or volts $ 552.26 2
Phone: Fax: Reconnect only $ 67.84 2
503 -295 -5555 Temporary services or feeders installation, alteration, and /or
Owner installation: This installation is being made on property that I own which is not relocation
intended for sale, lease, rent or exchange, according to ORS 447, 449, 670, and 701 200 amps or less $ 59.36 1
Owner signature: Date: 201 amps to 400 amps $ 125.08 2
401 amps to 599 amps $ 168.54 2
U APPLICANT I U CONTACT PERSON Branch circuits - new, alteration, or extension, per panel .
Business Name: A. Fee for branch circuits with
service or feeder fee, each
Contact name: branch circuit $ 7.42 2
B. Fee for branch circuits
Address:
without service or feeder fee,
each branch circuit $ 56.18 2
City /State /ZIP: Each additional branch circuit: $ 7.42 2
Miscellaneous (service or feeder not included)
Phone: Fax: Pump or irrigation circle $ 67. 2
Sign or outline lighting $ 67.84 2
E -mail: Signal circuits(s) or limited -
CONTRACTOR energy panel, alteration, or
Business Name: Capitol' Data & Communications, Inc.
extension. Describe: Tele /Data 1 75 75.00 2
Page 2 _
Contact name: Terry Brasch Each additional inspection over allowable in any of the above
Per inspection $ 66.25
Address: 11401 NE Marx Street Investigation per hour (1 hr min) $ 66.25
Industrial plant per hour $ 78.18 _
City /State /ZIP: Portland, Oregon 97220 ELECTRICAL PERMIT FEES°
Subtotal 75.00
Phone: 503 - 255 -9488 Fax: 503 - 257 -7121 Plan review (25% of permit fee)
State surcharge ( 12% of permit fee) 9.00
CCB Lic.: 142457 'Electrical Lie.: 26.1054CLE I Suprv. Lic.: 2757LEA TOTAL PERMIT FEE 84.00
Suprv. Electrician signature, required: T , _ _ This permit application expires if a permit is not obtained within 180
IIJJ days after it has been accepted as complete
Print Name: Terry Braseh C.----4----.-- Date: 08/08/12 • Fee methodology set by Tri -County Building Industry Service Board
Authorized signature: 6`ej? "Number of inspections per permit allowed.
Print Name: Terry Brasch
503- 718 -2439
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
'RESIDENTIAL WORK ONLY:
Fee for all residential systesm combined $ 75.00
Check Type of work Involved:
❑ Audio and Stereo Systems*
El Burglar Alarm
El Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
•
❑ Vacuum Systems*
El Other:
COMMERCIAL WORK ONLY:
Fee for each commercial sytem $ 75.00 •
(SEE OAR 918-260-260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
0 Data Telecommunication installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
El Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
Cl Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems: 1
*No licenses are required. Licenses are required
for all other installations