Permit TIGARD
City of Tigard
March 28, 2013
Willamette Electric
Attn: Kerma Goss
PO Box 230547
Tigard, OR 97281
Re: Permit No. ELC2013 -00165
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13018 SW Laurmont Dr.
Project Name: Banks
Job No.: N/A
Refund Method: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $60.78.
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 was canceled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Di. nna 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
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Willamette Electric Inc. DATE: 3/28/2013
PO Box 230547
Tigard, OR 97281 REQUESTED BY: Dianna Howse
Attn: Kerma Goss
TRANSACTION INFORMATION:
Receipt #: 190593 Case #: ELC2013 -00165
Date: 3/13/2013 Address /Parcel: 13018 SW Laurmon Dr.
Pay Method: CreditCard Project Name: Banks
EXPLANATION: Per applicant's request as work was cancelled. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Electrical permit fee 220- 0000 -43103 $54.27
12% State Surcharge 100- 0000 -24001 6.51
TOTAL REFUND: $60.78
APPROVALS: SIGNATURES /DATE:
If under $5,000 Professional Staff /
If under $12,500 Division Manager
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: 3/Z.//_3 I By: I
I: \Building \Refunds \RefundRequest.doc x 09/01 /2010
03/14/2013 THU 16:24 FAX 5036242938 Willamette Electric 11001 /001
03/14/2013 16:50 5035961960 CITY OF TIGARD PAGE 01/01
C
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
I 14 Request Permit Action
1 , c , A k 1, 13125 SW Hall Blvd. • Tigard, Oregon 97223. 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor V 0 1 13
1312.5 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigatd- or.gov 3fr /3
FROM: ❑ Owner N; Applicant Contractor 1=1 City Staff
(crock ono) /
REFUND OR Name: - � i — - ^'
INVOICE TO: 03usinass to individual) ( / i /7 V17e - if _ e�' 0. .---/ --1%
Mailing Address: , 0 .; -.) ■_. 2—:3 r
Cit /zip: 4 7 7,
Phone No.: 5 " / a - — 3 3
ALE - . E TAKE ACTION FOR THE ITEM(S) CHECKED (
0 CANCEL /VOID PERMIT APPLICATION.
• REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
0 REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: L L.. 13 —a0 /6 ----- �v t
Site Address or Parcel #: 3 + a 4 ) . 4 , .Ch %ten • kV d 1
Project Name: � ---'" /�
Subdivision Name: ��� �1��,nfM & 4 n �7(,vt�� Lot #: / .'
EXPLANATiON: j d , � dhC� . /� /
.-
r
Signature: i/l2' / Date:
Print Name: *9 4 1 74
Rama roues
1. The Director or Building Official may autho iac the ecfiind of.
e) any fcc which was crmncously paid or collected.
b) not more then 80% of the land Use application fcc when an application is wilhdratvn or canceled be ire any review effort has been expended.
c) trot more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when on application is canceled before any plan review effort hat been expended
c) not more than 80% of the building pctmit fee for issued permits prior to any inspection tegucant
2. Refunds will he returned to the original Payer in the same method in which payment. wee received. Pleat allow 2.4 wcelta for processing refunds.
FOR. OFFICE USE ONLY
•
Rte to S. A.dmin: Date B Rte to Bid_ Admin: Date 2743 B , ;,
Refund Processed: Datc.3A7.7/ B r. Invoice Processed: Date
Permit Canceled; Date _, AVM!" B. 4 Parcel Ta: Added: Date By
Receipt # Date Method Amount $
is \Building \Boners \RegPeemitnctio,t.doc Rev 05/25/2012
/3.5 7 O fi� 7e o- to 7. PL, ,-=- Sy n a /
4 . 6 _ 3 ?•,, i - r,/ii = G.5/
/5,a 'i9io i ti6 6 7P
CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2013 -00165
T I G ARE) 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/13/2013
Parcel: 1 S133DC16100
Jurisdiction: Tigard
Site address: 13018 SW LAURMONT DR
Project: Banks Subdivision: VILLAGE AT SUMMER LAKE PARK Lot: 16
Project Description: Reconnect electrical service
Contractor: WILLAMETTE ELECTRIC INC Owner: BANKS, LEROY Y & CYNDY F
PO BOX 230547 13018 SW LAURMONT DR
TIGARD, OR 97281 TIGARD, OR 97223
PHONE: 503 - 624 -3631 PHONE:
FAX: 503 - 624 -2938
FEES
Quantity Description Date Amount
1 ea Reconnect Only 03/13/2013 $67.84
Specifics:
1 ea 12% State Surcharge - 03/13/2013 $8.14
Electrical
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $75.98
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 OA 52 -001 090. You ay obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature: 0 A PU4T U
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.
03/13/2013 WED 12:12 FAX 503624293 { ctric RI002 /002
Electrical Permit Application ..-.. ..: . : • . - ,:. •••:. FOR OFFICE USG e l l , !
City of Tigard MAR 1 3 2013 D ;egg 3 3 $r , • PennitNo.: �(�
IN 'I
13125 SW Hell Blvd., Tigard, OR 97223 Plan Review
I I 1 / 3' DO So S
n ' Phone: 503.639.4171 Fax: 503.598.19ferry (* TIGARD _ Date/By: Other Permit:
Inspection Line: 503.639.4175 ` � ate Ready/By: tall ' /, Ed See Page 2 for
IGnRD Internet: www.tigard- or.gov BUILDING DIVISIO `Plotificd/Mcihod: Ll7° I Supplemental Information
_ 9!1��:D* �tir..bf3yt: ' ■�.li' N'� = Ea• : " ' e...:, -
❑ New construction Addition/slteration/replacement Please check all that apply (submit 1 sets of plans w /items checked betray
elmv).
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current
t , _;. _ . Marinas and boatyards
.: • .. _ _ ! exceeds 10,000 amps at 150 volts or
' :. ;. -.. _ .-''�`�I'k'(''; �?�" t� ��..::.: � •
.. �: .:::::: �;�- _ ... _ I d ❑ F7aatiag braidings.
1- and 2-family dwelling Commercial /industrial as s amps for , e exceeds 1 ns. ❑ Commercial -u agricult
�. y g ❑ 0 building amps for all other installations.
buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Pity p ❑ Installation of 75 KVA or
u ❑ Emergency system. larger separately derived system.
r iti.5 :' J; i,.;# Tti, „i0
t 4,00: ': ... 1
" ., 0 Addition ofnew motor load of ❑ " A „ .B.. 2 ,. , .. 1 . 3
Job no.: el ei s - EJ ( Job site address: / 1 C f j & 5 t00IIP or more, occupancy.
�„ � r h rim d r� �✓' % ❑Six or more residential units. ❑Recreational vehicle parka.
City/State/ZIP: r/ ' (3 r G e� ❑ Health-care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
Cross street/directions to job site: nescripii n � LLn ; 1 . I +, I -- root ' 1 -
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: ( Lot no.: 1,000 sq. ft. or less 168.54 4
Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1
Limited energy, residential
• DE$CRT TION (with above sq. ft.) 75.00 2
1 Limited energy, multi- family 75.00 • 2
iQ 'e 6-1.6 i- 1- 1 . ,..- vi t Y residential (with above sq. R.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
0 P.Iffiklft iO NEIt . i ' .tr i4, Aiei : • 201 amps to 400 amps 133,56 2
•
Name: 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
Temporary services or feeders installation, alteration, and /or
City /State/Z1P: relocation
Phone: ( ) ( Fax: ( ) 200 amps or less 59.36 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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
above service or feeder fee,
}:.�YPT'>tl!A7! j '1!1 t j±< ` FAR .. + ... 7.42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) ( Fax: : ( ) Reconnect only i 67.84 G ) u`�, 2 _
E -mail: • Pump or irrigation circle 67.84 2
Signor outline lighting 67.84 2
= '':.:' .. Signal circuit(s) or limited energy
Business name: Willamette Electric Inc, panel, alteration, or extension. Paget 2
Each additional inspection over allowable in any of the above
Address: P.O. Box 230547 Additional inspection (1 hr min) 66.25/ hr
_ Investigation (1 hr min) 66.25/ hr
City /State /ZIP: Tigard, OR 97281 Industrial plant (1 hr min) 78.18 / hr
Phone: (503) 624 -3631 [ Fax: (503) 624 - 2938 Inspections for which no fee is 90.00/ hr
specifically listed '4 hr min)
CCB Lic.: 75059 ( Electrical L ---,.. ie.• 34 -283C ( Suprv. L ic.• 4 226 -S ... ..: ? l _ a ;; :. '. + •; ° it,; ' • 7 "�": ;.. f :; ; " :, '; i
c'"+' Subtotal: fP y . .
Suprv. Electrician signature, requi .
7 / � review (25% of permit fee):
Print name: David Fife Date: State surcharge (12% of permit tee): e '
Authorized signature: TOTAL PERMIT FEE: . 7 5 j
This permit application expires if a permit is not obtained within 180
Print name: Date: • days after it has been accepted as complete.
Number of inspections allowed per permit.
1:lBuildI5 'erndntELC-PenntIApp.doc 07/01 /10 440- 46t5T(1UO3/COM/w8B