Permit . a S CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT PERMIT #: ELR2008 - 00035
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/13/2008
PARCEL: 1S12600-00300
SITE ADDRESS: 09619 SW WASHINGTON SQUARE RD L04 ZONING: C -G
SUBDIVISION: WASHINGTON SQUARE LOT: JURISDICTION: TIG
PROJECT: POTTERY BARN
Project Description: Low voltage for HVAC.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: HVAC: X PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS: 1
Owner: Contractor:
WASHINGTON SQUARE LLC HVAC INC
BY THE MACERICH COMPANY 5188 SE INTERNATIONAL WAY
9585 SW WASHINGTON SQUARE RD MILWAUKIE, OR 97222
TIGARD, OR 97223
Phone: Contact #: PRI 503- 462 -4822
FAX 503- 462 -6555
FEES Reg #: ELE 26 -571 CLE
LIC 50897
Description Date Amount SUP 605LEA
[ELPRMT] ELR Permit 2/13/2008 $75.00
[TAX] 12% State Surch 2/13/2008 $9.00 REQUIRED ITEMS AND REPORTS
Total $84.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these
rules or dir t ques ns UNC at 503.246.6699 or 1.800.332.2344.
Issued Permittee Signature: ,
A :Iii
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'N: DATE:
LICENSE NO:
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 termit Application 1 O12 014-1( tit: ()NIA
Ci of Tigard t Received '� 17 .enn iliMUM-M
13125 SW Hall Blvd., Tigard, OR 97223 Plan e R N 0 4 P AC/
Phone: 503.639.4171 Fax: 503.598.1960 Ji Daze/B
Other Permit:
Inspection Line: 503.639.4175 J � '! �: Date Ready/By. WI ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method Supplemental Information
TYPE OF WORK , - • - PLAN REVIEW , •-.-;''.; b , -• -.
❑ New construction Addition/ ratior1 placement Please check all that apply: •
❑ Demolition Other: OService over 225 amps, cornm'I 0 Hazardous location
OService over 320 amps -rating 0 Buildng over 10,000 sq. ft.,
= CAT NSTRUCTION • of I- and 2- family dwellings 4 or more new residential
❑ 1- and 2- family dwelling ( Co �merctaVin ustrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi - family ❑ Master builder ❑Other: 0 Building over three stories OFeeders, 400 amps or more
❑Occupant load over 99 persons ❑Manufactured structures or
• • JOB SITE INFORMATION AND LOCATION ❑Egress/lighting plan RV park
Job no.: 3 qi3 Job site address: c7 1 q! csw w sg kj ❑Health-care facility ❑der:
Submit 2 sets of plans with any of the above.
City/ State/ZIP: Tj atamd 0 f-� r The above are not applicable to temporary construction service.
J r i h Q_ . FEE*. SCHEDULE , -- -,
Suite/bISuite/bldg. /apt. no.: Project n e: 0 gia„, 0 s e l SQ Description I Qty. i Fee. I Tad i ••
Cross street/directions to job site: New residential single- or multi-family dwelling unit.
Includes attached garage.
1,000 sq. R or less 145.15 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
Limited energy, non - residential 75.00 2
- DESCRIPTION OF WORK • • - Each manufactured or modular
/ dwelling, service and/or feeder 90.90 2
n nA 1 tuts n 1 k Q S-t \'-e-wi Services or feeders installation, alteration, and/or relocation
` 200 amps or less 80.30 2
. ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: Over 1.000 amps or volts 454.65 2
Reconnect only 66.85 2
City /State/ZIP: Temporary services or feeders installation, alteration, and/or
Phone: ( ) Fax: ( ) relocation
200 amps or less 66.85 I
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 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
- ❑ APPLICANT I ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
-
B. Fee for branch circuits
Contact name:
without service or feeder fee,
Address: each branch circuit 46.85 2
Each add'l branch circuit 6.65 2
City/State/ZIP: Miscellaneous (service or feeder not included)
Phone: ( ) F ( ) Pump or irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E -mail: Signal circuit(s) or limited-
- • CONTRACTOR .. - .... . . energy panel, alteration, or
I' 1 extension. Describe: / Page 2 2
Business name: i -1- Vf-c: _
Address: Si 8c S E / ..]. -4t V - Each Each additional inspection over allowable in any of the above
Per inspection 62.50
City/ State/ZIP: M, au cuAit u2 / Qy C7 Investigation per hour (I hr min) 62.50
Phone: (b3 ) 402_- & Fax :3) a _(055 S Industrial plant per hour 73.75
ELECTRICAL PERMIT-FEES'.: ._ .. _. ,.,:-
CCB Lic.: 502.47 Electrical Lie. 0 -5 7 /t"[,& l Suprv. Lic.:605 LEA Subtotal
Suprv. Electrician signature, required: &� F % Plan review (25% of permit fee)
Print name: -( E SCola a2 "/ Date: 12/ 0 8' let 61) State surcharge �of permit fee)
_ �J TOTAL PERMIT FEE
Authorized signature: . J !/_ 6 A T permit application aspires if • permit Is not obtained within 180
/� days after it has been accepted as complete
Print name: &(,1 r 1 RO rr t W
0 1S Cey% Date: 2/i 3/0 e • Fee methodology set by Tri-County Building Industry Service Board
• • Number of inspections per permit allowed
is\Building\Pennita E C- PermitApp.doc 12/03 4404615T(1O02/COM/WFB
•
City of Tigard
T I G A R D Tidemark Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: HVAC, Inc. DATE: 4/14/08
5188 SE International Way
Milwaukie, OR 97222 REQUESTED BY: Dianna Howse
Attn: Sherrie Robinson
TRANSACTION INFORMATION:
Receipt #: 2008 -456 Case #: ELR2008 -00035
Date: 2/13/08 Address /Parcel: 9619 SW Washington Sq Rd
Pay Method: Check Project Name: Pottery Barn
EXPLANATION: Per appliant's request as pneumatic controls were used, which does not require low
voltage permit. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 . $ Amount
[ELPRMT] ELR Permit 220 - 0000 - 431510 $60.00
[TAX] 12% State Surcharge 100- 0000 - 207020 $7.20
TOTAL REFUND: $67.20
APPROVALS:
If under $500 Professional Staff / �� J
If under $7,500 Division Manager Gf / 4 1
If under $22,500 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: I y/ / Q,� I BY: 147'
I:\ Building \Refunds \RefundRequescdoc 05/23/07
ph
;Y� CITY OF TIGARD 4/9/_0r
13125S''* Hall13h•d. 9:I5:59AM
r , :, Tigard, OR 97223 5113.639.4171
ii
Receipt #: 27200800000000000456
Date: 02/13/2008
Line Items:
,
Case No Tran Code Description Revenue Account No Amount Paid
MEC2008 -00075 [MECH] Permit Fee 245- 0000 - 431010 1,079.00
MEC2008 -00075 [MECPLN] Plan Rev 245- 0000 - 433050 269.75
MEC2008 -00075 [TAX] 12% State Surcharge 100- 0000 - 207020 129.48
ELR2008 -00035 [ELPRMT] ELR Permit 220- 0000 - 431510 75.00
ELR2008 -00035 [TAX] 12% State Surcharge 100- 0000 - 207020 9.00
Line Item Total: $1,562.23
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Check HVAC INC DEB 5408 In Person 1,562.23
Payment Total: $1,562.23
•
CRCCCiv.rpt Page 1 o1 1
•
04/09/2008 08:38 FAX 503 462 6555 HVAC INC gi 00.1
RECEIVED
• Community Development APR 9
Request for Permit Action 2 008
• ;� ��:�� CITY OF TIGA
8111 Dar 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 [ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) /4( D �y
D Mailing Address: SE Jt,1 el( h q mr, a.9 [J g
V City/State /Zip: -
i/ y 1 uz O V '5art g 7 �1
/// of " Phone No.: 53- LkoD -
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
r" 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 #: £U CO— .PS 6
Site Address or Parcel #: LD I q Scu 1L- s‘l S Rd Log
Project Name: P o � u- O ea l�
Subdivision Name: u inSitt l517:vl ini E__ Lot #:
c�
EXPLANATION: i nu .vvw`�ce. C�vl`�'r b (S (u �e�v �e. Se Pi " I1 o'f � z u Vo
I a o
00
I
Signature: � - // � f �,r.g• Date: 4 -f 19 /p 3
Print Name: SVIe,vv ei o1o tinSe -,l
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 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 80%o of the building plan review fee when an application is canceled before any plan review effort has been expended
e) not mote 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.
•
I l fl■ (11'I'li:l l :�l
Rte to S • Admin: Date 4 jag B 474 Rte to Bl.. Admin: Date O,- lartir •
Refund Processed: Date �, B � �� ��
' � ✓�� �r�� Invoice Processed: Date B
Permit Canceled: Date y /jy pd By o Parcel Tag Added: Date By
Receipt #0, -5'J y Date 4h TAy Method C4 dc___ Amount $
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
•
I1
TIGARD
April 21, 2008
HVAC, Inc.
5188 SE International Way
Milwaukee, OR 97222
Attn: Sherrie Robinson
Re: Permit No. ELR2008 -00035
Dear Ms. Robinson:
The City of Tigard has canceled the above referenced permits) and enclose a refund for the
following:
Site Address: 9619 SW Washington Square Rd.
Project Name: Pottery Barn
Job No.: N/A
Refund: ® Check #56997 in the amount of $67.20.
❑ Credit card "return" receipt in the amount of $ .
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as pneumatic controls were used which does not require a low
voltage permit. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
•
I: \ Building \ Refunds \ Administration \LtrRefund- CancelPermiLdoc '01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772