Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
III a ' Request Permit Action V 0.. q 1 �
i i c:; A it l_) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov 7/./,r3
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor )f City Staff
(check one)
REFUND OR Name: .
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
X] CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: 6 C AO i 5- OO 3 Co 7
Site Address or Parcel #:
65 7 5 p .gCi 40 / A, PI. y / O
Project Name: .,r} (,�'t,id{ -✓L,b i /Je55 ySr t-/
Subdivision Name: 44- Lot #: 1J/�- -
EXPLANATION: IA P L, C.4 T E. P f. 2 N T — £ E. Zz-e 94)/3- dD 3 S3
Signature: Date: 7 / //
3
Print Name: 1 E4 6/ 4 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date 7 13 B , ' Rte to Bldg Admin: Date 'JZr B r
Refund Processed: Date. 7 By( L Invoice Processed: Date By
Permit Canceled: Date 7/2// -3 By '∎- - Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \ReqPermitAction.doc Rev 05/25/2012
CITY OF TIGARD V 0 I a ELECTRICAL PERMIT
g COMMUNITY DEVELOPMENT . . - . Permit #: ELC2013 -00364
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/02/2013
Parcel: 2S112DD01600
Jurisdiction: Tigard
Site address: 15575 SW SEQUOIA PKWY 180
Project: Safeguard Business Systems Subdivision: PACIFIC CORPORATE CENTER Lot: 4
Project Description: (10) branch circuits for TI
Contractor: JOHANSEN ELECTRIC INC Owner: PACIFIC REALTY ASSOCIATES
10948 SE VALLEY VIEW TERR ATTN: N PIVEN
HAPPY VALLEY, OR 97086 15350 SW SEQUOIA PKWY #300
PORTLAND, OR 97224
PHONE: 503 -698 -3417
PHONE: 503 - 624 -6300
FAX: 503 - 698 -2486
FEES
Quantity Description Date Amount
10 cR Branch Circuits wo /Purchase 07/02/2013 $122.96
Specifics: Service or Feeder
1 ea 12% State Surcharge - 07/02/2013 $14.76
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $137.72
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. 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 the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -001 -0010 through OAR 95 090. // You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
6
Issued By: Permittee Signature: f9AT ./ C 1 v
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' Date:
LICENSE NO. •
Call 603.639.4176 by 7:00 a.m. for the next available inspection date.
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.
th
\ D JUN 2 7 21' •
Electrical Permit A cati n 1..()It III 1 I Sf. (N, ■. I, \
City of Tigard 01 Y al- I 64043iivAr - Potmit No.:Lci2 /3 ---i 036
13125 SW Hall Blvd., Tigard, OR 97223 BulipmGry
Phone: 503.639.4171 Fux: 503.598.1960 Dato/n : Other Penril0 a p /3 -7 / /Y
Inspection Line: 503.639.4175 Date Ready/By: r. See Page 2 for
Internet: www.tigard-or.gov Notified/method: 11= Supplemental Information
14*Cikic,T';..?! :: ... ,. :".'' '' 7' ..• . -'... , : : :' :''' .'''.:;;;';'':.:::::.:-..... l'
Please check oil that apply (submit a acts of plans wfitems checked below):
El New construction ED Addition/alteration/rCp1W;ement
1:1Servioe or feeder 400 amps or more 0 Building over three stories,
E] Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
- . - "...! . c.krOxix t .: fit '.coilsTitumoki ,,:..,..:-.' ,.- .y .:.,..:.:.- : .'...!„:.. ,::::::;-':- .-:',..-.. e.ceeds l5,u00 amps at 150 volts or E3 Floating buildings.
' . ' less tO ground, or caixrds 14,000 in Conuncrcial-usc ag,ricultural
0 1- and 2-family dwelling IZI COMMerCial/industrial El Accessory building amps fur nil other installations. buildings.
El Multi-family El Master builder 0 Other: 0 Fire pomp. 0 Installation of 75 KVA or
larger separately derived system.
':. 4.4;BItiti00. 1 6.R . 14.1 4 1k*,*14ti . OPtitik i' t::, .';:.., "r H' ...: ..-'' : 0 Addition of new inotoi load of 0"A".
IOOHP or more. occupancy.
.10b no.: JobsiteacMm SW Sequoia, ot 180 0 Six or !nom residential units. 0 ltecroationzd vehicle parks.
City/State/ZIP: 0 Health facilities. 0 Supply voltage for more than
— 0 Hazardous locations. 600 volci nominal.
t/Stiito/bldg./apt. no.: 180 Project name: Safeguard Business Osemo or feeder 600 amps or MON.
ntk .. .: -. 1 7 :,... : j . ; :- ., ' ..i . .. '..:....,:.'.,.,.'.'..',,
Cross street/directions to job site: Destrintkot 1 Qmn. 1 Fee. I Total 1 •
New residential single- or multi-family dwelling unit.
Incladm attached garage. ...
Subdivision: Lot no.: 1,000 sq. ft. or less , 168.54 4
Ea. addl 500 sq. ft. or portion 33.92 1
Fax map/parcol no.: Limited energy. residential 75.00 2
'... .::',...., - : 4 7,...,....;'.;;:.: , ... : ‘,7',...,::'':•' . . :.".'.:pt, (with above N. ft.)
.. Limited energy, muIti•flunily 75.00 2
Tenant Improvement residential (%vith above sa. fl.)
Services or feeders Installadon sod/or relocation _
_
200 amps or less 100.70 2
1 11610 i ti:60t4iiC ...:,:.." ii. 201 iunpg to 400 amps 133.56 2
, .. . . . .. .. ,. .. ., . , . .
401 amps to 600 amps 200.34 2
Name: ,
601 amps to I.000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State/ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 _ 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
040 ;' t.'i ,....:.,.. . .T - -,- . --.., . above service or feeder fL.e, 7.42 2
• • •• •• - •• • each branch circuit
Business name: Johansen Electric U. Fee for brtutch clreidu wilhour
service or teedor fee, first /49 56.ig 2
Contact name: Charlynn Leifsen branch circuit
kach add'I branch circuit 7.42 2
Address: 10948 SE Val ley View Terr Miscellaneous (service or feeder not Included)
Each manufactured or modular
City/State/ziP: Happy Valley, OR 97086 67.84 2
dwelling, service and/or fbedor
Phone: ( 503) 698-3417 Fax: : ( 5 03 ) 698-2486 Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E-mail: ..
, Sign or outline lighting 67.84 2
,• :" ..: !i'... , .;;:.• % :',. , .... 5 : , : . ... ,? , -- ; ,. . , ':•.01 1 012.k - CtOR4..1 . ....' : ::-!,: 7 :'....V ''. ' Signal circuit(s) or limited-energy
_panel, alteration, or extension. _, Page 2 2
Business name: Johansen Electric Each additional inspection over allowable In any of the above
Address: 10948 SE Valley View Terr Additional inspection (1 hr min) 66.25/ hr
Investigation (1 hr min) 66.25/ hr
City/State/ZIP: Happy Valley, OR 97086
Industrial plant (1 hr min) 78.18/1u
Phone: (503) 698-3417 I Fax: ( 503) 698-2486 Inspections for which no Ice is 90.00/ hr
specifically listed (1 hr min)
CCB Lic.: 51539 1 Electrical f.ic.: 3-243C Supri. Lic.: 2053S •.'.':.:•.::'":4.1,-;',..•-•::::-:!Wite1lldCAV'PgRAIft:FEES,::'..,,.::-.:',::'',:
Subtotal:
Suprv. Electrician signature, required:
_ Plan review (25% of permit fee):
.
Print name; • State surcharge (12% of permit fee):
me; Carl 3, ansen . .,,. / I, _'.'-.',... .,. _
Authorized signature: IL A / TOTAL PEFtM11' FEE: /3 7 72.—
___........" 'fhb permit application expires Ifs permit Is not obtained svith la 180
Print name: Charlynn Leifsen Date: 6/27/13 days after It has been accepted as compkte.
• Number of iremeolionx allowed per pemilt.
I 0 44046151(1 vosICOMIWEB
Z /T 'apia 98VZ869C09 98VZ869C0S Ioaaa NaSNIIHOr MI ZZ:ZT ETOZ-LZ"unf