Permit Er! VOtO
Community Develo s P7e 2 1/ 3 4{ K
TIGARD Request for Permit Action
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 ❑ Contractor ® City Staff
(check one)
REFUND OR Name: Salem Sign Co Inc Corey Spady
INVOICE TO: (Business or Individual)
Mailing Address: 1825 Front St NE
City /State /Zip: Salem, OR 97301
Phone No.: 503- 371 -6362
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 _— _7)
Permit #: BUP n- x!! SG ,!►` ELC2013 -00087
Site Address or Parcel #: 13815 SW Pacific Hwy
Project Name: H & R Block
Subdivision Name: Lot #:
EXPLANATION:
These appear to be duplicates of :. ' " : ::: - - -- • • ! ! ! ! ! �Le ,2oi3- e()00P
: : :_ • .�. r . • • . Receipt attached.
Signature: jkt4he/ J6 t Date: 2/11 /13
Shirley Treat
Print Name:
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b) not more than 80 °'0 of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 81)° o of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) 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 By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt # Date Method Amount $
L Building \Forms \ReciPerrrutAction.doc Rev 07/26/07
nC ENED
Electrical Permit Applicatio FOR OI FIC1 liSPONIN
City of Tigard FEB 5 2013 Recei4� ...
/ CI ( q � / Permit No.: 6Lt ? ✓ 060 S
Date/By:
7il
III
a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Re iew
.. Other Permit: " a9/3..-0065 6.
C
P 503.718. Fax: 503.598 (*TIGARD Date /B A_ . ;
l I G A R O Inspection Line: 503.639.4175 • Date Rea'i •: y: 7` iW) jurist ® See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/ shod: i iii `n 6 (.0. Supplemental Information
E 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.
. CATEGO$.Y OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
C less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
El l- and 2- family dwelling ,I "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 ", "l -2 ", "I -3 ",
Job no.: Job site address: /� / 100HP or more. occupancy.
�3 Vs .zee,/ thlde /L /l77 /_ ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Ll 4, _10 o e 9 7 + L Z�
0 Health-care facilities. 0 Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: /7/2: Z 8/b 0 Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: + N
J 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. R. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 I
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
/ 4/5 02 _ ‘./ L,/ 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
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
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
� PPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: 54 S +•/ / 1, /N C • B.. Fee for branch circuits without
7 service or feeder fee, first 56.18 2
Contact name: A / S y branch circuit •
, Each add'I branch circuit . 7.42 2
Address: a 5 `F 4 j r SI- W4 Miscellaneous (service or feeder not included)
Each manufactured or modular 67.84 2
City/State /ZIP: ter,./1 (le 9 6 / dwelling, service and/or feeder
Phone: (93) 371 . 63 6 Z Fax: : ( 3) 37/. a p a / Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail:
5 /,, h 5 e - 5 " ie:-vi S / ` � ,H , LB1'a'+ Sign or outline lighting 67.84 7 7 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: Sf„ 7x4 .. N et) 4. panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: 4 ./,,,A.! T 57 ti/E Additional inspection (I hr min) 66.25/ hr
Investigation (I hr min) 66.25/ hr
. City/State /ZIP: S LE7 oe 9 - 73 t9 / Industrial plant (1 hr min) 78.18/ hr
O
Phone: 3) 37/ • 6 3 ' Fax: ( .0 inspections for which no fee is 90.00/ hr
specifically listed (V2 hr min)
CCB Lic.: 65-25 7 Electrical Lic.241— / Suprv. Lic.:39 / 5 /6 ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: GC'y 5 .......... I o Subtotal: 67,kLi
- Plan review (25 /o of permit fee):
5 e4,:, Dat e: Print name: a 5 a /� ` State surcharge (12% of permit fee): /; ri
l 6 TOTAL PERMIT FEE: 75 9,6
Authorized signature: 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:\ Building \Permits \ELC- PennitApp.doc 07/01/10 440- 4615T(I1 /05 /COM/WEB