Permit Apr. 23. 2014 3:00PM No. 0756 P. 3 C �/
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 I D
A244--
Request Permit Action RECE/vT I GA RD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 •www,tigard-or.gov
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1 0: CITY OF TIGARD , APR 2 3 2014
Building Division Services Supervisor C[TYOF
13125 SW Hall Blvd.,Tigard,OR 97223 13UJLD JNC SIG RD
Phone; 503.718,2430 Fax 503.5981960 www.tigard-or.gov JS10N
FROM; ❑ Owner ❑ Applicant ® Contractor ❑ Ciry Staff
(check one)
REFUND OR Name; ADT LLC
INVOICE TO: (Business or tndivid<mal)
Mailing Address: 7989 SW Cirrus Dr
City/State/Zip: Beaverton, OR. 97008
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1);
❑ CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELR2013-00265
Sire Address or Parcel#: 11652 SW Pacific Hwy
Project Name: Habebi Hookah Bar LLC
Subdivision Name: Lot#:
EXPLANATION; Customer cancelled install
Signature: cs.l� rt`C-0
Date: 4/23/14
Lou MM h y S 1 9,
Print Name: 7 :Te9in/
7So� n'.07i
� Y�l a- _ — ea/9 'rte
Refund Policy /.Pt)
1. The Director or Building Official may authorize the refund of: 670 r 7.8•7() s
a) any fee which was erroneously paid or collected. 47,A-O '�6 PO
b) not more than 80e10 of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) nor more than 80%of the land use application fec for issued permits.
d) not more than BO%of the building plan review fcc when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the build nrperretit 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 l:SH: ONLY
Rrc ro Sys Admin: Dare 1/ ,2 c/ By 'WY Rte to Bldg Admin: Date y ley /4/
Refund Processed: Date 2.- / B. ,y4 Invoice Processed: Date B
Permit Canceled: Dare y 2.7 'y By .ter Parcel Tag Added: Date By
Receipt# Date Method Amount$
1:\Building\Forms\RegPemmicAction.doc Rev 05/25/2012
V MI
TIGARD
City of Tigard
May 8, 2014
ADT LLC
Attn: Lori Murphy
7989 SW Cirrus Dr.
Beaverton, OR 97008
Re: Permit No. ELR2013-00265
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11652 SW Pacific Hwy
Project Name: Habebi Hookah Bar
Job No.: N/A
Refund Method: ❑ Check# in the amount of$ .
® Credit card"return" receipt in the amount of$67.20.
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$ .
Comment(s): Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
,4 2.. :
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
N City of Tigard
i .TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: ADT LLC DATE: 4/29/2014
Attn: Lori Murphy
7989 SW Cirrus Dr. REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 193658 Case #: ELR2013-00265
Date: 10/24/2013 Address/Parcel: 11652 SW Pacific Hwy
Pay Method: CreditCard Project Name: Habebi Hookah Bar
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Restricted Energy Permit 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff --- tt'7C-rle.:__
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYST,F44DMINISTRATION USE ONLY
Case Refund Processed: Date: y I By: i<r)
1:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
• • COMMUNITY DEVELOPMENT Permit#: ELR2013-00263
Date Issued: 10/24/2013
TIGARD 13125 SW Hall Blvd,Tigard OR 97223 503 718 2439 parcel: 2S113AC00103
Jurisdiction: Tigard
Site address: 7236 SW DURHAM RD 600
Project: 1-5 Trucking Subdivision:COUNCIL VIEW ACRES(LOTS 21-44) Lot: 25-27,2:
Project Description: Low voltage for CCTV
Contractor: PROTECTION ONE ALARM MONITORING Owner: PACIFIC REALTY ASSOCIATES
7312 SW DURHAM RD ATTN: N PIVEN
PORTLAND,OR 97224 15350 SE SEQUOIA PKWY#300
PORTLAND,OR 97224
•
PHONE. 503-443-2922 PHONE
FAX. 866-223-9925
FEES
Description Date Amount
Specifics:, Restricted Energy Permit 10/24/2013 $75.00
12%State Surcharge-Electrical 10/24/2013 $9 00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1
Audio&Stereo 0 Boiler Controls: 0
CCTV. 1 Clock Systems 0
Data&Telecommunications' 0 Fire Alarm: 0
HVAC' 0 Instrumentation: 0
Intercom/Paging: 0 Landscape/Irrigation: 0
Landscape Lighting. 0 Medical 0
Nurse Calls: 0 Protective Signal. 0
Security Alarm 0 Other 0 Total $84.00
Other Desc: 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 i = .r.anc- . 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. • TENTION. Oregon -, re. -s you to follow the rules adopted by the Oregon Utility Notification Center Those rules are set forth in OAR
952-1,1-0010 through OAR 952-00 1690 o ay obtain a copy of the rules or direct questions to OUNC by calling 503 232 1987 or 32 2344 -�
Is ued By: �/< —' . 1 ' Permittee Signature: `1� ?Eel �•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 503.639.4175 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.
Electrical Permit Applicatk of FOR OFFICE USE ONLY
City of Tigard — Date/B Received /O �./ i Permit No eL= ./ -41,24,3
III . ° 13125 SW Hall Blvd,Tigard,OR 97223 Plan Review
Phone' 503 718 2439 Fax 503 598 f Gl S 2'v DateB Other Permit
TIGARD Inspection Line. 503.639 4175 Date Ready/By lens ® See Page 2 for
Internet www tigard-or.gov /i, p., ‘ , , Notified/Method Supplemental Information
Vi to ' , ,
TYPE O) O „ ' ' - PLAN REVIEW
Please check all that apply(submit 2 sets of plans w/stems checked below)
®New construction ❑Addition/alteration/replacement
❑Service or feeder 400 amps or more ❑Building over three stories
❑ Demolition ❑ Other: where the available fault current El 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
❑ 1-and 2-family dwelling ® Commercial/industrial ❑Accessory building amps for all other installations buildings
❑ Multi-family ❑ Master builder ❑ Other: ❑Fire pump ❑Installation of 150 KVA or
JOB SITE LNFORMATION AND LOCATION ❑Emergency system larger separately denved system
❑Addition of new motor load of ❑"A","E","l-2",'l-3",
Job no.: 131014390 Job site address:7236 SW DURHAM RD 100HP or more occupancy
❑Six or more residential units. El Recreational vehicle parks
City/State/ZIP:TIGARD,OR 97223 El Health-care facilities ❑Supply voltage for more than
❑Hazardous locations 600 volts nominal
Suite/bldg./apt. no.:600 Project name: —5 / l Ckt tJ ❑Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site:SW LOWER BOONES FERRY RD Descnption 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 168 54 4
Ea add'1 500 sq ft or portion 33 92 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
INSTALL OF CCTV SYSTEM _residential(with above sq ft)
Renewable Energy ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
❑ PROPERTY OWNER ® TENANT 200 amps or less 100 70 2
201 amps to 400 amps 133 56 2
Name: MARQUEZ BROTHERS INTERNATIONAL INC. 401 amps to 600 amps 200 34 2
Address:7236 SW DURHAM RD STE.600 601 amps to 1,000 amps 301 04 2
Over 1,000 amps or volts 552 26 2
City/State/ZIP• TIGARD,OR 97224 Temporary services or feeders installation,alteration,and/or
Phone: (916)929-2800 Fax:( ) relocation
200 amps or less 59 36 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125 08 2
intended for sale, lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168 54 2
Owner signature: Date: Branch circuits—new,alteration,or extension,per panel
® APPLICANT ❑ CONTACT PERSON A Fee for branch circuits with
above service or feeder fee, 7 42 2
Business name: PROTECTION ONE each branch circuit
B Fee for branch circuits without
Contact name:JOHN O'BRIEN service or feeder fee,first
branch circuit 56 18 2
Address: 7312 SW DURHAM RD Each add'I branch circuit 7 42 2
City/State/ZIP: PORTLAND,OR 97224 Miscellaneous(service or feeder not included)
Each manufactured or modular 67 84 2
Phone (503)443-2922 Fax: :(866)223-9925 dwelling,service and/or feeder
Reconnect only 67 84 2
E-mail:johno'brien @protectionone.com Pump or irrigation circle 67 84 2
CONTRACTOR Sign or outline lighting 67 84 2
Business name: PROTECTION ONE Signal circuit(s)or limited-energy / See 75�)
panel,alteration,or extension ( Page 2 2
Address: 7312 SW DURHAM RD Each additional inspection over allowable in any of the above
Additional inspection(1 hr mm) 6625/hr
City/State/ZIP: PORTLAND,OR 97224 Investigation(1 hr min) 66 25/hr
Phone:(503)443-2922 Fax:(866)223-9925 Industrial plant(1 hr min) 78 18/hr
Mis!t, Inspections for which no fee is
90 00/hr
CCB Lic.: 116325 Electrical Lic.: 34-/2. ec c_ Suprv. Lic.:Z/06 LEA specifically listed CA hr min)
ELECTRICAL PERMIT FEES
Suprv. Electrician signature,required: e.2 . - Subtotal: 75".60
Print name: JOHN O'BRIEN Date:/p/Z,,//�j Plan review(25%of permit fee)
State surcharge(12%of permit fee) Q,°6'
Authorized signature: TOTAL PERMIT FEE. 't_/.t0
Print name: ERIC JACOBSEN 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
I\Binldmg\Perm as\ELC_PermsApp_ELR_ERE doc Rev 05/21/2013 440-4615T(I I/05/COWWEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE
Fee for all residential systems combined $75.00 Description I Qty. I Fee I Total I *
Renewable electrical energy systems:
Check Type of Work Involved: 5 kva or less 100 70 2
5.01 to 15 kva 133.56 2
❑ Audio and Stereo Systems*
15.01 to 25 kva 200 34 2
nBurglar Alarm Wind generation systems in excess of 25 kva:
25 01 to 50 kva 301.04 2
n Garage Door Opener* 50 01 to 100 kva 552 26 2
>100 kva(fee in accordance with 552 26 2
n Heating, Ventilation and Air Conditioning OAR918-309-0040)
System* Solar generation systems in excess of 25 kva:
Each additional kva over 25 7 42 3
n Vacuum Systems* >100 kva—no additional charge 0 0 3
❑ Each additional inspection over allowable in any of the above:
Other: Each additional inspection is 66 25/hr 1
charged at an hourly(1 hr min)
Inspections for which no fee is 90 00/hr
specifically listed(%1 hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system $75.00 Subtotal:
(SEE OAR 918-309-0000) Plan review,if required(25%of permit fee).
State surcharge(12%of permit fee):
Check Type of Work Involved: TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
❑ Audio and Stereo Systems days after it has been accepted as complete.
Number of inspections allowed per permit.
n Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I\Budding\Permus\ELC_PermnApp_ELR_ERE doc Rev 05/21/2013