Permit City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
•
•
T I GARD:
December 31, 2007
Azimuth Communications
P.O. Box 508
Wilsonville, OR 97070 •
Attn: Robert Ulberg
Re: Permit No. ELR2007 -00444
Dear Mr. Ulberg:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 10095 SW Century Oak Dr.
Project Name: Kolina
Job No.: N/A
Refund: ❑ Check # in the am ount of $ .
® Credit card "return" receipt in the amount of $64.80.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: 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,
•
•
Dianna Howse
Building Division Services Coordinator
Enc.
•
•
•
I: \Building\ Refunds \Administ ration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • 777 Relay: 503.684.2772
t.
Community Development
TIGARD Request for Permit Action
•
TO: CITY OF TIGARD G r : f�
Building Division Services Coordinator Cy �� �� •
13125 SW Hall Blvd., Tigard, OR 97223 � � .l 10
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- oh 1 O,
FROM: ❑ Owner ❑ Applicant [ ] Contractor ❑ City4 t 4.
(check one) 4 0
REFUND OR Name:
INVOICE TO: (Business or Individual) P2.) oat-M. Cpl M t�1 14.40 64 1S°
Mailing Address: 1 x Sok, 5'(,)g
VO i D City/State /Zip: WI IS i)10 l)► LL.i. ; iY7 0
/a /a /c 7 , 4 7---- --Phone No.: 503 6. 3 9 "- c l t
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
V! CANCEL PERMIT APPLICATION.
E 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 #: 2.6 C7 " OC444
Site Address or Parcel #: L Oq 5 1 „) C s LA,tL 11-
Project Name: I<o L, {J A-
Subdivision Name: Lot #:
EXPLANATION: i,J(; LK lAA C A.►JZ t- t C)
Signature: u Lt( - Date: ) Z - f 2. -6
Print Name: RCA RiZT (,11.3e -
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 B 5, Rte to Bld: Admin: Date /. % D 7 B ,v7
Refund Processed: Date /a a� O 7 By • Invoice Processed: Date By
Permit Canceled: Date / o 2 By 4» Parcel Tag Added: Date By
Receipt # Q 7 -53j/ Date 45/// O / Method CG Amount $ ,(
I:\ Building \ Forms \Regl'emmitAction.doc ev 07/26/07
City of Tigard
TIGARD 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: Azimuth Communications DATE: 12/26/07
P.O. Box 508
Wilsonville, OR 97070 REQUESTED BY: Dianna Howse
Attn: Robert Ulberg
TRANSACTION INFORMATION:
Receipt #: 2007 -5381 Case #: ELR2007 -00444
Date: 12/11/07 Address /Parcel: 10095 SW Century Oak Dr.
Pay Method: CreditCard Project Name: Kolina
EXPLANATION: Per applicant's request as job was canceled. 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] 8% State Surcharge 100 - 0000 - 207020 4.80
•
TOTAL REFUND: $64.80
APPROVALS:
If under $500 Professional Staff
I f under $7,500 Division Manager
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 / ", /' /' '7 1 By: I
I \Bu,ldin \ Refunds \RefundRc 05 /23/07
Eri CITY OF TIGARD 12/12/2007 •
13125 SW Flail B lvd. 10:20:58AM
Tigard, OR 97223 503.639.4171
TIGARD
Receipt #: 27200700000000005381 . /c -/ i4- _
Date: 12/11/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELR2007 -00444 [ELPRMT] ELR Permit 220- 0000 - 431510 75.00 .
ELR2007 -00444 [TALC] 8% State Surcharge 100- 0000 - 207020 6.00
•
Line Item Total: $81.00
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
CreditCard ROBERT ULBERG BB 01551B In Person 81.00
Payment Total: $81.00
cReccipt.rpt Page 1 of 1
Er CITY OF TIGARD 12/31/2007
13125 SW Flail Blvd. I I :39:17AM • '
Tigard, OR 97223 503.639.4171
TIGARD •
Refund Receipt #: 27200700000000005621 0 4.Cf/. -- g-s 4—L
Date: 12/31/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
ELR2007 -00444 Reversal - [ELPRMT] ELR Permit 220-0000-431510 (60.00) _
ELR2007 -00444 Reversal - [TAX] 8% State Surc 100- 0000 - 207020 (4.80)
Line Item Total: ($64.80) .
Refund:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Credit Reversal ROBERT ULBERG 01551B In Person (64.80)
Refund Total: ($64.80)
•
a
N `y5 0 0 0
0 . ti W -4) v v"
co • � . 0 a:
vs • °' B 0 0 ^ w cu ° \
"O .4 Z 0 I-I Q r
E V h . X v v a
a+ 0 a �,., 45 3 g u a.
P,�
( `� o U a 14 ,...., v�j 'O .., O(� cis /1 L W ►� N CC ca E, Z «' a. � ,
V cd a+ SE a" v v 2 v b.
i .,\ 0 . p'' (A ca y V w y 6 V
..0 C 8 °Q �0
• Q rx o €
y e
Itil ,,
r " A p 0 v _y m F w a: a --
eReccipi.ipi l'age I of I
•
op 4
CITY OF -T I G A R D ELECTRICAL RESTRICTED ENERGY PERMIT
COMMUNITY DEVELOPMENT PERMIT #: ELR2007 - 00444
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 12/11/2007
PARCEL: 2S 111 CC - 00700
SITE ADDRESS: 10095 SW CENTURY OAK DR ZONING: R -7
SUBDIVISION: SUMMERFIELD LOT: 004 JURISDICTION: TIG
PROJECT: KOLINA
Project Description: Low voltage: Audio.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: X 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: ALL ENCOMP : X HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS:
Owner: Contractor:
RON KOLINA AZIMUTH COMMUNICATIONS INC
10095 SW CENTURY OAK DR P.O. BOX 508
TIGARD, OR 97224 WILSONVILLE, OR 97070
Phone: 503 -880 -5145 Contact #: PRI 503-639-0110
FAX 503 -639 -0115
FEES Reg #: ELE 36 -94CLE
LIC 145828
Description Date Amount SUP 2312LEA
[ELPRMT] ELR Permit 12/11/2007 $75.00
[TAX] 8% State Surcha 12/11/2007 $6.00 REQUIRED ITEMS AND REPORTS
Total $81.00
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 direct questions to OUNC at 503.246.6699 or 1.800.332.2344. II
I
tr__,
ssued By: — Permittee Signature: VU
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 Perm's eeElvF l� FOIL OFFICE USE ONL
City Received
of Tigard 8 Permit No. ' ','L 0.0 13125 SW Hall Blvd., Tigard, OR 9722� `` Plan Review
Phone: 503.639.4171 Fax: 503.598.146CLU 1 1 2 _ il' ` Other Per
� � I
Inspection Line: 503.639.4175 �.' - ='jI' DatrJB .
� Date Ready/By: tuns: ® See Page 2 for
Internet: www.ci.tigard.or.us C[i Y ur I.IA. 'i Notified/Method Supplemental Information
• B n FTV 1 S1ON PLAN REVIEW
❑ New construction I� IJ Addi tion/alteration/replacement Please check all that apply:
❑ Demolition ❑ Other: ❑ m
Service over 225 amps, com'I ❑Hazardous location
❑Service over 320 amps – rating ❑ Buildn over 10,000 sq. ft.,
CATEGORY OF CONSTRUCTION of I- and 2- family dwellings 4 or more new residential
ESI 1- and 2 family dwelling ❑ Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi family ❑Master builder ❑Other: ❑Building over three stories 0 Feeders, 400 amps or more
DOccupant load over 99 persons ❑Manufactured structures or
JOB SITE INFORMATION AND LOCATION ❑Egress/lighting plan RV park
Job no.: Job site address: /Q0q5 5-1.4) CL' IV 1 4 be, ❑Health care facility ❑ Other.
Submit 2 sets of plans with any of the above.
City /State/ZIP: "n 614 0 The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name: FEE* SCHEDULE
Description I Qty. I Fee. I Total 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'I 500 sq. ft. or portion 33.40 I
Tax map /parcel no.: Limited energy, residential 75.00 2
Limited energy, non - residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
^ I Q dwelling, service and/or feeder 90.90 2
I { Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: K L t -1 601 amps to 1,000 amps 240.60 2
Address: S ail& G 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: (5Z - 'b - 25-`3C) • `— / S Fax: ( ) relocation 2000 0 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 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT I C3 CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name:
2, 04.1.,., Co,,l,t,lutlit,a,-,0,vs branch circuit
B. Fee for branch circuits
Contact name: 7
��O U L a L �C without service or feeder fee, 46.85 2
// �/ each branch circuit
Address:
11 ° 3). v. Zl)V J (� 0 Each add'I branch circuit 6.65 2
City / State/ZIP: �'( 1 S Gt J J L t 1)2- q 7v7 Miscellaneous (service or feeder not included)
���� Pump or irrigation circle 53.40 2
Phone: lili3 )'7C - L ! % Fax: : (503) (a S `/ -O i/ S Sign or outline lighting 53.40 2
E - mail: Signal circuit(s) or limited -
CONTRACTOR energy panel, alteration, or 7S;UC
• extension. Describe: 1 Page 2 1 s Ue 2
Business name: t1 2 mu T>a c 0vvi trl u nJ i c 4 U 1
Address:. P L \ . Z 1! 3( .Gl X Each additional inspection over allowable in any of the above
Per inspection 62.50
City/ State/ZIP: 4 .i (, Sci, )i LL 6- 04- i ( Investigation per hour (I hr min) 62.50
Phone: ( S ► ) 3 ) 6 ?I' -Q ii G F a x : ( ) ? q . C i , - Industrial plant per hour 73.75.
ELECTRICAL PERMIT FEES*
CCB Lic.: ly 5 I 21 Electrical Lic.:3t - r lice Suprv. Lic.: 1312 Lee Subtotal
Suprv. Electrician signature, required: , ta Plan review (25% of permit fee)
Print name: 2&•71- UG g6g6 Date: /2 /1 / I) State surcharge (8% of permit fee)
7 TOTAL PERMIT FEE I —
Authorized signature: This permit application expires if a permit is not obtained within 180
• . days after It has been accepted as complete
Print name: Date: • Fee methodology set by Tri-Cotmty Building Industry Service Board
•• Number of inspections per permit allowed. •
i :\ Building \Permits\ELC- PennitApp.doc 12/03 440.46 I5T(INO2/COM/WlB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
. .-
LIMITED ENERGY PERMIT FEES:
` RESIDENTIAL WORK ONLY: — — 1
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:
1. COMMERCIAL WORK ONLY:
Fee for each commercial system. $75.00
(SEE OAR 918- 260 -260)
Check Type of Work Involved:
udio and Stereo Systems
❑ Boiler Controls •
❑ Clock Systems
❑ Data Telecommunication Installation
❑ 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
is\ Building \Permits\ELC- PmnitApp.doc 04/03