Permit City of Tigard, Oregon o 13125 SW Hall Blvd. ° Tigard, OR 97223
•
.11
November 20, 2009 .
Dickinson's Electric Inc.
8449 SW Barbur Blvd
Portland, OR 97217
Atm: Lawrence Dickinson
Re: Permit No. ELC2009 -00462
Dear Mr. Dickinson:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 7904 SW Hunziker
Project Name: Spec Space
Job No.: N/A
Refund: ® Check #101642 in the amount of $143.90.
El Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Work completed under another permit, ELC2009- 00461. 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.
I: \Building\ Refunds \Administrat ion \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 o Fax: 503.684.7297 o www.tigard - or.gov 0 TTY Relay: 503.684.2772
1 1111 v City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Pe7mitAction or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Dickinson's Electric Inc. DATE: 11/5/09
8449 SW Barbur Blvd
Portland, OR 97217 REQUESTED BY: Dianna Howse
Attn: Lawrence Dickinson
TRANSACTION INFORMATION:
Receipt #: 175126 Case #: ELC2009 -00462
Date: 9/8/09 Address /Parcel: 7904 SW Hunziker
Pay Method: Check Project Name: Spec Space
EXPLANATION: Work completed under ELC2009- 00461. Refund 80% of permit fees.
, .FeeDescription. From Receipt: ; ::Revenue Account No • : , • ,. :.. Refund .
-, E.xarriple:_[BUILD1i.P_ermit Fee. . Exa iple: 245- 0000 - 432000: . $ Amdunt.
Service or feeder - 200 amps or less 2200000 -43103 $128.48
12% State Surcharge 1003100 -24001 15.42
TOTAL REFUND: $143.90
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager n, . v
I
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
- .:..=:':ti' •: ?. FOR ACCELA SYSTEM ADMINISTRATION USE ONLY :,,: :: ;
Refund Request Reviewed: Date: i B ,,�,.� «.,.,.
Case Refund Processed: Date: �° •`�� r , ? e/ B { ' • - -
I: \Building \Refunds \RefundRequescdoc 04/13/09
CITY OF TIGARD RECEIPT
II g V 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
�i a Aro
Receipt Number: 176091 - 11/20/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2009 - 00462 $ 143.90
Total: $- 143.90
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 101642 DHOWSE 11/20/2009 $- 143.90
Payor: Dickinson's Electric Inc.
Total Payments: $ - 143.90
Balance Due: $143.90
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Page 1 of 1
CITY OF TOGARD RECEIPT
v
g . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
T IGARI)
6 &''. c- / /ti"f .
Receipt Number: 175126 - 09/08/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2009 -00462 Services or Feeders - 200 amps or less 2200000 -43103 $160.60
ELC2009 -00462 12% State Surcharge - Electrical 1003100 -24001 $19.27
Total: $179.87
• PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 1734 DHOWSE 09/08/2009 $179.87
Payor: Dickinson's Electric Inc.
Total Payments: $179.87
Balance Due: $0.00
•
Page 1 of 1
1111 ;,... '�'i T::.� e .,: g V L.„&„0'
e ° Community Development (�
Request for Permit Action ' ` `
TIGARD
• CITY OF TIGARD
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant 2 Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) \c ( AcCrS \ 1 5 F l C V lr i c . 1. r C .
Mailing Address: .1 L-( q .7,, N t; \Ot,,.Q ( ock .
City/State /Zip: 4. -\ (0,,, K I C ■ Q. G - 1 7 l-7
Phone No.: �j 2'{ (4 :
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available). •
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
. Permit #: e l C- 2e 0q CO /-1(e 2.
Site Address or Parcel #:
Project Name:
Subdivision Name: Lot #:
EXPLANATION: L, c~,,r k f-eL)‘) C Lt.f — N J kr E 1C ZOOc • CSC?“Lc \
.cc..pe ci ckcl eci '- -('*., *' $ bcL c L i n-tci c' \ C 7.00R - 00 4 tc•
/CC G: , -;.,_, •. e le` =/% i /2 :1%i 4f./ •i . T.c , :S iR- CTj`.N .
___ � �i��_ 9 zS "--
Signature: D ate:
Print Name: /(.l�t% Yea _ j)64-74.---,-21
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 fec 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 fec 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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By ��/� Rte to Bldg Admin: Date 2 .:E `'/. 5 -' By
: Refund Processed: Date / /f -eki 2 By �'?1I.j - Invoice Processed: Date' By
17 Permit Canceled: Date </„ :/t B}r - Parcel Tag Added: Date By
Receipt #/7 y /,:; 4::. Date 1>:,y /r ' Method .::://,` r= fc., Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
CITY OF TIGARD ELECTRICAL PERMIT
ip
-. c' COMMUNITY DEVELOPMENT Permit #: ELC2009 -00462
Date Issued: 09/08/2009
- I G ARD 13125 SW Hall Blvd , Tigard OR 97223 503 639 4171 parcel: 2S101 CA00200
Jurisdiction: Tigard
Site address: 7904 SW HUNZIKER RD
Subdivision: Lot: 0
Project: Spec Space
Project Description: (2) 200 amp service for TI
Owner: FEES
WALL STREET INDUSTRIAL LLC & Quantity Description Date Amount
A RICHARD VIAL EXEC CENTER LLC, 7000 SW
VARNS ST 2 ea Services or Feeders - 200 09/08/2009 $160.60
amps or less
PHONE 1 ea 12% State Surcharge - 09/08/2009 $19 27
Electrical
Contractor:
DICKINSONS ELECTRIC
8449 SW BARBUR BLVD
PORTLAND, OR 97217
PHONE: 503 - 246 -3550
FAX 503 - 213 -6049
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $179.87
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 thro /0„,,a ,,, OA' 952-041-0100 You may obtain a copy of the rules or direct questions to OUNC by calling 503.246 6699 or 1 800 332 2344
Issued = •1 2 �� 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' if__ �� /�Z---- Date •i
LICENSE NO. 7 /'f C
SS J Call 503.639.4175 by 7:00 a.m. for an Inspection that business day.
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 FoR OFFICE U ONLY
City of Tigard Date /B ` r / - '� Per 13125 SW Hall Blvd., Tigard, OR 97 fl ECEIVED Plan Review
' C Phone: 503 639.4171 Fax. 503.598 503.5981960, Date/B Other Permttg��C, CJ �/
T I G A R D Inspection Line: 503.639.4175 E P 0 2009 Date Ready/By la See Page 2 for
Internet: www tigard -or gov Notified/Method- liM Supplemental Information
OF TIGARD
TYPE OF 1 t PLAN ; REVIEW
❑ New construction ❑ Addition/alteratlo repplaclac emment ent
i r 0r Please check all that apply (submit 2 sets of plans w/items checked below)
❑ Service or feeder 400 amps or more ❑ Building over three stories
❑ Demolition El 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: ❑ 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.: I Job site address: 79 / 44,,, k /,i/ / Six or or more occupancy
�`/1Z ❑ Six or more residential units ❑ Recreational vehicle parks
City /State /ZIP: - TT -,fizej ❑ Health -care facilities ❑ Supply voltage for more than
❑ Hazardous locations 600 volts nominal
Suite /bldg. /apt. no.: I Project name: 1 5/0 ❑ Service or feeder 600 amps or more
(/� FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total 1 •
Ncw residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft or less 145.15 4
Tax map /parcel no.: Ea add'I 500 sq ft. or portion 33.40 1
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft )
� Limited energy, multi-family o 75 00 2
� residential (with th above sq. q. ft ft ) ,. , Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) I Fax: ( ) 200 amps or less 66.85 l
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100 30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 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, 6.65 2
each branch circuit
Business name: 13. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'l branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 90.90 2
dwelling, service and/or feeder
Phone: ( ) I Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
'CONTRACTOR Sign or outline lighting 53 40 2
Business name: �� / / �i /� Signal , al r i d-
���
energy panel, alteerattion, or
Address: 5� � / � _, 6 "4 ? _ 4 �� extension Describe: Page 2 2
City/State /ZIP: a„/ n L/� f%ys' U — Each additional inspection over allowable in any of the above
L V LLL Per inspection 62.50
Phone: ( 3) 2 6 -3 " $' V Fax: ($iag 2 /3 6'9 Investigation per hour (1 hr min) 62.50
CCB Lia.6s'ij Electrical Lie.
te 6'�fU v. Lie.: 3300 -s Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician si_o at e, - quire.. � i�\ Subtotal: /60 . ( a
r p— Plan review (25% of permit fee).
Print name: L ` j Date:
/}/ State surcharge (12% of permit fee). /9, .27
Authorized signatur/ TOTAL PERMIT FEE. /9
This permit application expires if a permit is not obtained within 160
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit
I\ Building \Permits\ELC- PermitApp doe 05/23/06 4404615T(I 1/05 /COM/WEB
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*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL 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
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1 \Bwldmg\Permits\ELC- PermiApp doc 03/23/06