Permit CITY OF TIGARD Z ° ELECTRICAL PERMIT
° I O PERMIT #: ELC2007 -00863
° COMMUNITY-DEVELOPMENT
DATE ISSUED: 12/26/2007
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171
PARCEL: 2S103DC -06400
SITE ADDRESS: 11220 SW FAIRHAVEN ST ZONING: R -3.5
SUBDIVISION: EXODUS LOT : 005 JURISDICTION: TIG
PROJECT: WOLF
Project Description: (1) service, (2) feeders, (16) branch circuits.
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAUPANEL:
MANF HM/ SVC/ FDR: 601 +amps - 1000 volts: MINOR LABEL (10):
SERVICE/FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: 3 W /SERVICE OR FEEDER: 16 PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
DEAN WOLF OWNER
11220 SW FAIRHAVEN
TIGARD, OR 97223
Phone: 503 - 267 - 8840 Contact #:
FEES
Description Date Amount Reg #:
IELPRMT) E1.0 Permit 12/26/200' $347.30
'TAX] 8% State Surcharge 12/26/200' $27.78
Total $375.08 REQUIRED ITEMS AND REPORTS
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 direct questions to C at 503.246.6699 or 1.800 32.2344.
Issued By: jauz ,pl d Permittee Signature: (Z)
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 Permit ApplicatlEC FOR OFFICE USE ONLY
Received
of Tigard
CI 2 ] Permit No.
•J L, 11C1. ! 200 Date/By: I il�o/D7 �� 2.007�404 if 46 3
111 • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
': C Phone: 503.639.4171 Fax: 503.59taV OF fIGARD Date/By: Other Permit:
r i C. n It D Inspection Line: 503.639 Date Ready /By: /uric: Si See Page 2 for
Internet: www.tigard- or.gov 6u►�iN� a�tvrsroN Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction kAdditio Iteration/re lacement 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 ❑ 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
6-1- and 2 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 ", "l -2 "l -3 ",
IOOHP or more. occupancy.
Job no.: Job site address:
1 2 2 o Si,.' t:41 rkc yeti SI ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: ' µ rttX 1 7 2 2 3 ❑ Health -care facilities. ❑ 600v nome for more than
❑ Hazardous locations.
Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
job site: Description FEE SCHEDULE
Cross street/directions to
J 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 145.15 4
Ea. add'I 500 sq. ft. or portion 33.40 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
S e r VI C e Gil a„_ t_ / - e - V2 - (•,! .e. G4_,/ 7°5 residential (with above sq. ft.)
Services or feeders installation, alt ati n, and/or relocation
200 amps or less l Sv L - 3l 80.30 , V 0. // ZI 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps '' 106.85 / 2
Name: °e p‘ G 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: I 12 2 Q Si.) c I .1a V e h S..f. . Over 1,000 amps or volts 454.65 2
City/State /ZIP: / Temporary services or feeders installation, alteration, and/or
T � a ref q 7 2 - 2 - 3 relocation
Phone: (So3) 267 g g i D Fax: ( ) 200 amps or less 66.85 1
Owner installation: T ' installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lea r nt, or exchange, accor ' g 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: lit/ Date: (2 — 26 - D 7 A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, /o 6.65 Mk. ic 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR • Sign or outline lighting 53.40 2
Signal circuit(s) or limited -
Business name: n--h.ryLitl-t _ energy panel, alteration, or
Address: extension. Describe: Page 2 2
City/State /ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( )
Investigation per hour (I hr min) 62.50
CCB Lie.: Electrical Lie.: Suprv. Lie.: 23 35- S Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required:.. Subtotal: -3 t/
Plan review (25% of permit fee):
Print name: Date: State surcharge (8% of permit fee): Q -7.7 y
Authorized signature: - 64 WG TOTAL PERMIT FEE: ' S D ¶
Print name: Date: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
• Number of inspections allowed per permit.
1:\ Building 'Permits\ELC- PermitApp.doc 05/23/06 440- 46t5T(II /05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
•
LIMITED ENERGY PERMIT FEES: •
RESIDENTIAL WORK ONLY: – — j
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- 260 -260)
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*
El Medical
❑ Nurse Calls •
El Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*N� licenses are required. Licenses are required
for allfother installations
I:\ Building \Permits\ELC- PermitApp.doc 03/23/06
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 •
•
T I GARD
April 21, 2008
Dean Wolf
11220 SW Fairhaven St.
Tigard, OR 97223
Re: Permit No. ELC2007 -00863
Dear Mr. Wolf:
The City of Tigard has canceled the above referenced permits) and enclose a refund for the
following:
Site Address: 11220 SW Fairhaven St.
Project Name: Wolf
Job No.: N/A
Refund: ® Check #56998 in the amount of $300.07.
❑ Credit card "return" receipt in the amount of $ .
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as work is not being done. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4 1 1 2 7 - 07e7—
Dianna Howse
Building Division Services Coordinator
Enc.
•
I:\ Building\ Refunds\ Administration \LtrRefund- CancelPermitdoc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
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: Dean Wolf DATE: 4/14/08
11220 SW Fairhaven St.
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 2007 -5559 Case #: ELC2007 -00863
Date: 12/26/07 Address /Parcel: 11220 SW Fairhaven St.
Pay Method: Check Project Name: Wolf
EXPLANATION: Per applicant's request as work is not being done. 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] ELC Permit 220- 0000 - 431510 $277.84
[TAX] 8% State Surcharge 100- 0000 - 207020 22.23
TOTAL REFUND: $300.07
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager � � ^ l Og
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 / /5yeie I By: I 40
l: \Building \Refunds \RefundRequest.doc 05/23/07
pr i CITY OF TIGA.RD 3/25/2008
13125 SW Hall Blvd. 8:52:18AM
• Tigard, OR 97223 503.639.4171
TIGARD
Receipt #: 27200700000000005559
Date: 12/26/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELC2007 -00863 [ELPRMT] ELC Permit 220- 0000 - 431510 347.30
ELC2007 -00863 [TAX] 8% State Surcharge 100- 0000 - 207020 27.78
Line Item Total: $375.08
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Check DEAN WOLF BB 3981 In Person 375.08
Payment Total: $375.08
•
CReceipi.rya Page I or I
•
•
RECEIVED
Community Development
T 1 c n It Request for Permit Action MARS 5 2008
CITY CD )11°1► ,°
TO: CITY OF TIGARD l3JIumG or1vGsiC)m
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 S Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) pea n WO If
V 0 1 0 Mailing Address: 1 \ 220 5'w a r ha Ve City/State/Zip: fi a rd q 7 2-2 3
g
v//
Phone No.: So 3 26 7 g g
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL PERMIT APPLICATION.
3 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 #: Eke_ oZ0O7 - 60 8( -5
Site Address or Parcel #: // aa-D /%1-i21141f( •
Project Name: /,JO -f
EXPLANATION: lc f V t to WI d V er E f e c. 11 e 1-.e r
c ehcloslnl It In choir\ \tnV - re hee.- ?G E s c,,c( h«?`
v ecc- -fie,(ee+n s- l( reoc If. So q i cIl.i - fo ►vl five el-0.1
Signature: (� w �/ Date: 3 - 2 .5-0 $'
Print Name: Q -e O t V\ w o \ f
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% of the building plan review fee 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 S s Admin: Date gictimumna Rte to Bld. Admin: Date yQO1 B .r 9
Refund Processed: Date / � y p f3 By 0 '•I Invoice Processed: Date By
Permit Canceled: Date 4/ //c By 4,-;;. Parcel Tag Added: Date By
Receipt # t)$5 Date / 07 Method ( e Amount $
I:\ Building \forms \RegPermitAction.doc Re 07/26/07