Permit CITY OF TIcARD O ELECTRICAL PERMIT
�f+ PERMIT #: ELC2007 -00604
COMMUNITY DEVELOPMENT DATE ISSUED: 8/29/2007
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171
PARCEL: 1 S 134BC -00401
SITE ADDRESS: 12442 SW SCHOLLS FERRY RD 101 ZONING: C - N
SUBDIVISION: LOT : JURISDICTION: TIG
PROJECT: PROVIDENCE
Project Description: TI - (4) branch circuits for x -ray and tech areas.
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:
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: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: 3 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:
PROVIDENCE HEALTH SYSTEM BROADWAY ELECTRIC - COCHRAN INC
4607 NE GLISAN 626 SE MAIN
PORTLAND, OR 97213 PORTLAND, OR 97214
Phone: 503 - 215 -6282 Contact #: PRI 503- 234 -6564
FAX 503 - 238 -2098
FEES
Description Date Amount Reg #: ELE 37 -546C
[ELPRMTI ELC Permit 8/29/2007 $66.80 LIC 72942
[TAXI 8% State Surcharge 8/29/2007 $5.34 SUP 3447S
Total $72.14 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.
Permittee Signature: fi
Issued By: � /// /� / /I : / P
g � pp � 6 ( j
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.
•
08/27/2007 13:02 COCHRAN BROADWAY 4 5035981960 NO.842 D01
Electrical Permit ApplicatiSft FOR or•I'ICI Lis E, ONLY
City Tigard RecReceived '� Permit
131 Hall Blvd., Tigard, OR 972 EC E ` �� ;"'' Pla R eview OP ^ 9 • U 7 , •
Phone; 503.639.4171 Fax: 503.598.1960
AUG o R *' n • i': l 'It' DatelI3 Other Permit
2007
Inspection Line; 503.639.4175 . � - I.�. -� { jj • � pace Ready/By: � ®Sae Page t for
Internet: www.ci.dgard.or.us CITY OF r s . : Nocilied/Method: Supplemental information
Ie!T�t�y�,,� {+.y��,f�7 , I•. } ��.��'L�i�:f `l� "!1 '�t7,,y1�t�f��t[,{ry'I1 Y�hr�l�,it ,ti' }`i�!yi�e .'�4 "' :•ems' 7.91}ypr�7•k.i rr nr i•r .1 &11 �p �ttpl'./
.•
�taliYa[JSCfiCi 1' , f aili�t,,�.71f+�NiR f �'.:Iiya 1,5, +,�.ti5 ';: , �i . '1o ne 1 r 9.t I I i4,.. ' . .::" :''77Sq'�1rik
h ,(:4!lz�knur]r1�r��..An.1.,�.,, a•.' , as.
,,I .lin:. A.
❑ New construction Addition/alteration/replacement Please check all that apply:
❑ Demolition ❑Other: ['Service over 225 amps, cornrrel ❑Hazardous location
3' r :x +t :' n ' ± ; ;'Ir u , r 7J_ [ fI' J, , ❑Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
rittz A. , ri l l; JL :ti',t l ; : i ; t'a , � L, l s-y r a �'e u - Eck- - itu ; �� 'h l: ' I ° , a :
:; >: of I • and 2-farruly dwellings 4 or more new residential
❑ 1 - and 2- family dwelling ($'Commerciai/industrial ❑ Accessory building ['System over 600 volts nominal units in one structure
CI Multi - family ❑ Master builder ❑ Other: ❑Building over three stories ❑Feeders, 400 amps or more
5dt LR:I:i iBl: : {:j Cif ',j S i ;: l ' ':4:w j g4 °1r;.' '•n• f ' "! ; i ❑Occupa.t load over 99 persons ❑Ma ufacrurcd structures or
1 ! y �� , I i ; 111 *A -.. . �ir_? c 9 . 1 1 ,Y4 2 . ,il •., I I'& It/41 � �. ...t tt . i Ili ; , Lt.� :' k RV park
rJ. h y' ilc ` 1 ,5 , . . k r : ❑Egress/lighti p lan PeT
Job no.: l 0 L,, Job site address: • ❑Health-care facility ❑ Other:
0 - - Submit. sets of plans with any of the above.
The above are not applicable to temporary construction service.
�" S Suite/b1; .. /apt no.: ..`� • i Project name: - _ ;i ::1 ; It : ;_i' : rt; s e. 1 ' ; it , • . :: ; •: ' • - '
►__ 1� . b J nesreripHan gry. F ea Total
Cross street/directi ' 8 to job si . l New residential single- or multi- family dwelling unit.
Includes attached garage.
1,000 sq, ft. or less 145.15 r 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 l
Tax map/parcel no.: Limted energy, residential 75.00 2
_
d' , 114:=4,1!'... d" I• j a , t �� uu +n f f , , t ;i % ,:'. t7 „ rj I -. I Limited energy, non- residential 75.00 2
.I f )1 F ..., I , .. ° ! , ` I r r, i . F I r +1 i iJLfl,t ,ci n, l'A,Iii\ ' ' { I "1 le !.1
Lv__l < , . t ..kcJ' .I ;�_ : );8 manu fa ctur ed or m odul ar
dwelling, service and/or feeder 90.90 2
■ . .. ' c : kr • Services or feeders lnstallatioo, alteration, and/or relocation
CAM a i ma" I . ;coo_ 200 amps or less 80.30 2
�- , �t t �TM�l l ' ,I , j / r 201 401 amps amps to 400 amps 106.115 2
�_lirl.�ilt. �i��i�, �, _>��.a, t_,
.t__.tlt „ i.r, , i �. �� w•600 s , 60.60 z
1112 r _ it _ • 601 amps to 1,000 amps 240.60 2
Address; C , •- Over 1,000 amps or volts 454.65 2
R econnect only 66.85 2
Temporary services or feeders Installation, alteration, and /or
reioratiob
Phone:
) z/ - i t f F ax: (S3 )2i- . / 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 1
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 403 amps to 600 amps 133.75 12
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
€ , nt•` 7 ' . , , G� gi ii, 3 i':; /iii (,I•1f1, . : ' ` gi,: i ,T •' t l �` , { A. Fee for branch circuits with
�I r
I _ �_: t I ![� I 7k Q`��'_ i., . },., I it * •l +k. , ,� service or feeder fee, each 6.65 2
Business name: branch circuit , -
Contact llama: B. Fee for branch circuits
without service or feeder fee, / 46.115 94 8:r 2
Address: each branch circuit
Each aril branch circuit 3 6.65 1 9 95 2 ,
City/State/ZIP; Miscellaneous (service or feeder not Included)
phone: ( ) p ( ) Pump or irrigation circle 53.40 2
Sign or outline lighting 52.40 2
E Signal circuit(a) or limited•
� l:
1j�'I { ' q + +tits r ,:t,'_ `Ill ifIll i 7, �,' ; ;, l yi * , I E , c ;;� ent:rgy Panel,alteration,or
.i� ZiL..li� ,'.iJ1:L �lt�r._.7�.�� t.,.� 4 .�.i_ ikr,r�, ex t rns ; on. Describe: Page 2
Address: Each additional inspection over allowable In any of the above
�P 5 °+ Per inspection 62.50
EMZMIIrjenat I
OR- - j 21 Investigation per hour (1 to min) 62.50
Phone: (5b3) 2.3 -(5 Fax' (9363 ) 2351s -Z `$ Industrial plant per hour 73.75
+t >'''W3ihilii;kaagrag L f i e- a ',n'r .°si;, ;r ..: u : . ..:'': ;.: I v ' . r
ESEEEMII
to
Electrical Lic.: 31-5 , Suprv. Lie.: 344 S Subtotal &bpi
Suprv. }?lectticitui signature, required .—� Plan review (25% of permit fee)
State surcharge (8% of permit fee) s..?y
Print name: eANh 6. o Date: '
TOTAL PERMIT FEE ?Lie
Authorized signature: ' This permit application expires If a permit Is not obtained wit lfin tart
days after It has been accepted as complete
Print name: Date: • Fee methodology set by Tri-County Building Industry Service board
•• Number of inspection per permit allowed.
Annimkowdmile;t -tiennitAnuAGa was 440.46 T(tolovCOMIWsa
City of Tigard, Oregon • 13125 S W Hall Blvd. • Tigard, f g , g n B vd. Tiga d, OR 97223 •
•
•
T I,GARD
October 10, 2007
Broadway Electric
626 SE Main St.
Portland, OR 97214 •
Re: Permit No. ELC2007 -00604
Dear Sir /Ms.:
The City of Tigard has canceled the above referenced permits) and enclose a refund for the
following:
Site Address: 12442 SW Scholls Ferry Rd., #101
Project Name: Providence
Job No.:
Refund: ❑ Check # in the am ount of $ .
® Credit card "return" receipt in the amount of $57.72.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Work was previously permitted and inspected under ELC2007- 00508. 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: \Bull ding\ Refunds\ Administ ra tion \LtrRefund- CancelPermitdoc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
1,
•
G 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 pbCity Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) JRpAl t o t (J Et y / I 7 2
v 0 1 ® Mailing Address: LOW, �� H A ► l )
/0 7 City/State /Zip: ‘ D QTL J ) OR c t 79./ q
Phone No.: 3q 6) 6 ci
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
®- 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 #: L kC 2)007 - co 400
Site Address or Parcel #: g ( -1 5_11 L S t" ce I , O l 0 /
Project Name: - r 172
Subdivision Name: /3rf)- Lot #: )J/i
EXPLANATION: 6.0 l ID LQH 1'r — LQj L S kELYI O c e_S L4/
ti O4 1 i f.`r ELC..a0o7- Do 50 %, khW t
�tt+\J • r • , •(l`� ►.� C ELCCi(tC. -.
Date:
1 919\ � � 7
Signature: ,� 1J�:
Print Name: -Af t 7 N-Ij
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 bcforc 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.
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 S s Admin: Date B Rte to Bld: Admin: Date i A gra 7 B 1 &7
Refund Processed: Date /Om0 7 B /� nvoice Processed: Date B
Permit Canceled: Date /,, / 0 7 B v Parcel Tag Added: Date B
Receipt # -3i5 Date 8"/,29/07 Method CC_ Amount $
1: \Building \ Forms \Regl emvtAction. oc I cv 07/26/07
, 1 •
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: Broadway Electric DATE: 10/9/07
626 SE Main St.
Portland, OR 97214 REQUESTED BY: Dianna Howse
DEB
TRANSACTION INFORMATION:
Receipt #: 2007 -3955 Case #: ELC2007 -00604
Date: 8/29/07 Address /Parcel: 12442 SW Scholls Ferry, #101
Pay Method: CreditCard Project Name: Providence
EXPLANATION: Work was previously permitted under ELC2007- 00508. 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 $53.44
[TAX] 8% State Surcharge 100- 0000 - 207020 4.28
TOTAL REFUND: $57.72
APPROVALS:
If under $500 Professional Staff v
If under $7,500 Division Manager D. V "
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: Date: rAT� B : ETir -
I: \Building \Refunds \RefundRequest.doc 05/23/07