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Permit CITY OF TIGARD ELECTRICAL PERMIT PERMIT #: ELC2008 -00179 ° COMMUNITY DEVELOPMENT DATE ISSUED: 3/31/2008 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 1 S136DA -00100 SITE ADDRESS: 11308 SW 68TH PKWY 2ND FL ZONING: MUE SUBDIVISION: LOT : JURISDICTION: TIG PROJECT: TIGARD BUSINESS CENTER Project Description: TI. Installing (6) feeders, (30) branch circuits, and (1) fire alarm low voltage system. 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: SIGNAL/PANEL: 1 MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10): SERVICE/FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS 0 - 200 amp: W /SERVICE OR FEEDER: 30 PER INSPECTION: 201 - 400 amp: 6 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: BENENSON 68TH PARKWAY BROADWAY ELECTRIC - COCHRAN INC KEY LLC, THE 626 SE MAIN BY FIRST AMERICAN TAX VALUATIO PORTLAND, OR 97214 WORCESTER, MA 01615 Phone: Contact #: PRI 503 - 234 - 6564 FAX 503 - 238 -2098 FEES Description Date Amount Reg #: ELE 37 -546C [ELPRMT] ELC Permit 3/31/2008 $915.60 LIC 72942 [TAX] 12% State Surchar 3/31/2008 $109.87 SUP 3447S Total $1,025.47 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 OUNC at 503.246.6699 or 1.800.332.2344. Issued By: _ Permittee Signature: ,g 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 Application FOR OFFICE USE ONLY � - Received c CI of Tigard (�� Pe rmit No.: +� 131 Hall lvd., Tigard, OR 9 Date/By: 3 3 ( O � ��v �/C/t 71 C g INI Plan Review Phone: 503.639.4171 Fax: 5 OK *o p Date/By: Other Permit: TI I A It D Inspection Line: 503.639.4175 IrM% Da a �83f17 Juris: ia See Page 2 for Internet: www.tigard- or.gov M a� t c4,} ? w if Supplemental Information TYPE OF O� l - , \ N PLAN REVIEW v �. ❑ New construction ] "Addition /alts Please check all that apply (submit 2 sets of plans w /items checked below): ��� em= 3 t " Q Q MP -'6 s \C�� I Service or feeder 400 amps or more ❑ Building over three stories. 12 Demolition ❑ Other: „` ®F 1 % 5 S C where the avai fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION 0\ � exceeds 10,000 amps at 150 volts or ❑ Floating buildings. 1 less to ground, or exceeds 14,000 ❑ Commercial -use agricultural ❑ 1- and 2- family dwelling ['Commercial /industrial ❑ Acce 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 site address: 2 Q II '' // j� �j� IOOHP or more. occupancy. Job no.: If O (� I JV U S (U - ( r� CFetJ 47 ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State /ZIP: / / Q� ❑ Health -care facilities. ❑ Supply voltage for more than �.� T e eve( aSi�trf"C' ( l ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: 2 1 ) I Project name: p , 1 3 V . ® 1 ' 4 ❑ Service or feeder 600 amps or more. f FEE SCHEDULE Cross street/directions to job site: .. p- f - Description I Qty. I Fee. I Total I • f/ . New residential single- or multi- family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4 Tax map /parcel no.: Ea. add'l 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 75.00 2 %) 7.4c► s' 70 a-, /-rO residential (with above sq. ft.) Services or feeders installation, alteration, and/or relocation F R (G, rr-, 5 U Sfr 200 amps or less 80.30 2 ❑ PROPERTY OWNER / TENANT 291 amps to 400 amps 4, 106.85 ( ( 0 2 Name: p,S,s 401 amps to 600 amps 160.60 2 601 amps to 1,000 amps 240.60 2 Address: /076 C d if t ._— ol S 9N Over 1,000 amps or volts • 454.65 2 / / Temporary services or feeders installation, alteration, and/or City/State /ZIP: ArT4Aw 97ZZ, relocation Phone: O Fax: 200 amps or less 66.85 1 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, 3D I 6.65 513 2 Business name: each branch circuit , B. Fee for branch circuits Contact name: without service or feeder fee, 46.85 2 first branch circuit Address: Each add'I branch circuit I 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 � ,,cc. Signal circuit(s) or limited- Business name: / /..Ir /g✓.f G'��°(_AGlr_ energy panel, alteration, or Address: S�- "77,9 p„, extension. Describe: Page 2 2 City/State /ZIP: 0,...'114,1_„ I _ 922-751 Each additional inspection over allowable in any of the above Per inspection 62.50 Phone: (2,3 ) Z 3y _ S6 d/ I Fax: (32Q3 ) 24 -201a Investigation per hour (1 hr min) 62.50 CCB Lic.: 729 yZ I Electrical Lic.S7.--S-V a Suprv. Lic. :3V S/7J- Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: ` ` "" K Subtotal: qi ( qi C 40 l Date: Plan review (25% of permit fee): Print name: I t ` State surcharge (12% of permit fee): / Qct. g 7 Authorized signature: �� TOTAL PERMIT FEE: loa5 q 7 / This permit application expires if a permit is not obtained within 180 Print name: 1. ' u e ( C� t Date: - — - / - 0 g days after it has been accepted as complete. • Number of inspections allowed per permit. I:IBuilding\Permits\ELC- PermitApp.doc 05/23/06 440-4615T(11/05/COM/WEB IN I: ° Community Development 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: INVOICE TO: (Business or Individual) Q oHn w A y 2 l Q ,Mailin Address: LQ 2 ( - e_-. Heil N y ry o � i ;.. City /State /Zip: % 2 - r L A. A.,) (1)( 9 7 a I q / / Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL PERMIT APPLICATION. g 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 kC Appg -co / 7 Site Address or Parcel #: 113 p ,I.. (p $' J(iy Project Name: \ ?(430 ,- r)�►JC.,`_ 4 -L774 y5r Subdivision Name: y'I/t Lot #: ji-VIl; EXPLANATION: Lt.)oV-- p2ti tvu_S 1 .€.2--(H t ( E f-R-- ad.- c. go $ - 00087. QLt_F gv -f To c1 Wc-E L --- k4 -0" a4 2. y Ne)1 % _ - , eL ao_ st //AtcV ELfcTl2r • Signature: _ • / ,_ � . .t_t Date: 94 / 5 Print Name: _ _ P L , J I I! 1 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 Sys Admin: • Date /• a $' By V *' Rte to Bldg Admin: Date ' By Refund' Processed: Date 1/1/4 By Ili, Invoice Processed: Date By Permit Canceled: Date y hy f By t /' Parcel Tag Added: Date By Receipt #©t /8.37 Date .. / ce Method ei� Amount $ Forms R v 07/26/07 r; City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 • • • TIGARD` April 21, 2008 Broadway Electric 626 SE Main St. Portland, OR 97214 Re: Permit No. ELC2008 -00179 Dear Sir /Ms.: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 11308 SW 68 Pkwy Project Name: Providence Health Systems Job No.: N/A Refund: ® Check #57000 in the amount of $820.38. ❑ Credit card "return" receipt in the amount of $ . ❑ Trust account "deposit" receipt in the amount of $ . Notes: Per applicant's request and as approved by electrical inspector as work was completed under ELC2008- 00087. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, /6 5 2 ; ( 4WX-e-__. Dianna Howse Building Division Services Coordinator Enc. I: \ Building \ Refunds \ Administration \LtrRefund- CancelPerrnitdoc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov . TTY Relay: 503.684.2772 City of Tigard T 1 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: Broadway Electric DATE: 4/14/08 626 SE Main St. Portland, OR 97214 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 2008 -1037 Case #: ELC2008 -00179 Date: 3/31/08 Address /Parcel: 11308 SW 68th Pkwy Pay Method: Check Project Name: Providence Health Systems EXPLANATION: Per applicant's request and as approved by electrical inspector (GN) as work was completed under ELC2008- 00087. 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 $732.48 • [TAX] 12% State Surcharge 100- 0000 - 207020 87.90 TOTAL REFUND: $820.38 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager 7 —/ 9- — C)8 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: 0," I B I 4:PV I: \Building \Refunds \RefundRequest.doc 05/23/07 Electrical Permit Application - City of Tigard Page 2 - Supplemental Information ' . LIMITED ENERGY PERMIT FEES: ' riftsitiENITALVOiik — — 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 p Boiler Controls TI Clock Systems ❑ Data Telecommunication Installation 3 ,4 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 I:\ Building \Pmnits\ELC- PamitApp.doc 03/23/06 CITY OF TIGARD 4/1/2008 • 13125 SW Hall Blvd. 1:42:13PM 1'igard. 97223 503.639.4171 TIGARD. Receipt #: 27200800000000001037 Date: 03/31/2008 Line Items: Case No Tran Code Description Revenue Account No Amount Paid ELC2008 -00179 [ELPRMT] ELC Permit 220- 0000 - 431510 915.60 ELC2008 -00I 79 [TAX] 12% State Surcharge 100- 0000 - 207020 109.87 Line Item Total: $1,025.47 Payments: Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid Check BROADWAY ELECTRIC BTT 9261 In Person 1,025.47 Payment Total: $1,025.47 • cRevcipl.rpt Page I oI I