Permit CITY OF TIGARD
ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT Permit #: ELR2012 -00227
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 10/01/2012
Parcel: 2S113AB00500
Jurisdiction: Tigard
Site address: 16083 SW UPPER BOONES FERRY RD 300
Project: Therapeutic Associates Subdivision: FANNO CREEK ACRE TRACTS Lot: PT 37
Project Description: (1) HVAC
Contractor: AMERICAN HEATING INC Owner: G &S FC LLC
1339 SE GIDEON ST 16083 SW UPPER BOONES FERRY RD,
PORTLAND, OR 97202 STE
TIGARD, OR 97224
PHONE: 503 - 239 -4600 PHONE:
FAX: 503 - 239 -7038
FEES
Description Date Amount
Specifics: Restricted Energy Permit 10/01/2012 $75.00
12% State Surcharge - Electrical 10/01/2012 $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: N Fire Alarm: N
HVAC: Y 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 through OAR 952 -00 - 090. 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: ./r_ Permittee Signature: •Z/ O 1 A'7 Q,S7ler '
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.
r w
Electrical Permit Application 11 ` : r , , 1 f f, y . FOR OFFICE USE ONLY
Tigard
of Ti
City g OCT 2 Received /2. � �-, PermitNo.:67A /a -a R 7
71 OC 0 .- 21? Received � Q �Z A
q 13125 SW Hall Blvd., Tigard, OR 97223 Pl Review
= Other Permit
Phone: 503.718.2439 Fax: 503.598.14Q- . Date /B : 0 , 049 / L
1 r i s + i!'� • ' ® See Pa e 2 for
Inspection Line: 503.639.4175 r ' - ' I' '' Date Read /By: g
TIGARD
Internet: www.tigard- or.gov + , ;� i �s,.:•? f +.?t:! r'
'�•, Notified /Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
Please check all that apply (submit 2 sets of plans w /items checked below):
❑ New construction ® Addition /alteration /replacement
❑ 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 ® Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ F pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "I 2 ","I - ",
I00HP or more. occupancy.
Job no.: Job site address: 16083 SW Upper Boones Ferry Ro ❑ Six or more residential units. ❑ Recreational vehicle parks.
❑ Health -care facilities. ❑ Supply voltage for more than
City/State /ZIP: Tigard OR 97224 ❑ Hazardous locations. 600 volts nominal.
y 7 Suite/bldg. /apt. no.: 3 Fl 300 Project name: Therapeutic Associates ❑ 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
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
75.00 2
DESCRIPTION OF WORK
(with above sq. ft.)
Limited energy, multi - family 75.00 2
jta,low voltage wiring t - stat residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee, 7.42 2
each branch circuit
Business name: American Heating B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: Brad Manchester branch circuit
Each add'l branch circuit 7.42 2
Address: 1339 SE Gideon St Miscellaneous (service or feeder not included)
Each manufactured or modular 67.84 2
City/State /ZIP: Portland OR 97202 dwelling, service and/or feeder
Phone: (503) 239 -4600 Fax: : (503) 239 -7038 Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: American Heating panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: 1339 SE Gideon St Additional inspection (I hr min) 66.25/ hr
Investigation (I hr min) 66.25/ hr
City/State /ZIP: Portland OR 97202 Industrial plant (1 hr min) 78.18/ hr
Phone: (503) 239 -4600 Fax: (503) 239 - 7038 Inspections for which no fee is 90.00/ hr
specifically listed (1/2 hr min)
CCB Lie.: 33135 Electrical Lie.: 26993CRE Suprv. Lie.: 2640LEB ELECTRICAL PERMIT FEES
Subtotal: r
Suprv. Electrician signature, required Plan review (25% of permit fee):
Print name: T Steve Young Date: 10/1/2012 State surcharge (12% of permit fee): 9 t O v
TOTAL PERMIT FEE: 8'
Authorized signature: ;- 2 . , °. ,,,00. This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Brad Manchester Date: 10/1/2012 * Number of inspections allowed per permit.
I: \Building \Permits \ELC- PennitApp.doc 07/01/10 440- 4615T( I I /05 /COM/WEB