Permit 1111 CITY OF TIGARD ELECTRICAL PERMIT
' COMMUNITY DEVELOPMENT Permit#: ELC2014-00685
Date Issued: 12/16/2014
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S101AA08700
Jurisdiction: Tigard
Site address: 12511 SW 68TH AVE
Project: Kassay Clinic Subdivision: WEST PORTLAND HEIGHTS Lot: 34
Project Description: Service upgrade and TI build-out: (3)200 amp or less services,(1)601-1000 amp service and(24)branch circuits.
Contractor: TIMBERLINE ELECTRICAL CONTRACTORS Owner: BEVELAND BUILDING LLC
9414 SW BARBUR BLVD,#100 12511 SW 68TH AVE
PORTLAND, OR 97219 PORTLAND, OR 97223
PHONE: 503-459-4089 PHONE:
FAX: 503-254-4227
FEES
Quantity Description Date Amount
3 ea Services or Feeders-200 12/16/2014 $302.10
Specifics: amps or less
1 ea Services or Feeders-601 to 12/16/2014 $301.04
Type of Use: COM 1000 amps
Class of Work: ALT 24 crt Branch Circuits w/Purchase 12/16/2014 $178.08
Service or Feeder
Type of Const: 1 ea Plan Review Electricial 12/16/2014 $195.31
Occupancy Grp: 2 ea Info Process/Archiving-Lg 12/16/2014 $4.00
$2.00(over 11x17)
1 ea Info Process/Archiving-Sm 12/16/2014 $0.50
$0.50(up to 11x17)
1 ea 12%State Surcharge- 12/16/2014 $93.75
Electrical
Total $1,074.78
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 ccordance • 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. TTENTION: Oregon : requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 01-0010 through OAR 952-01 :••0'Y•r ay obtain a copy of the rules or direct questions to OUNC by calling 503.2 . 98 • .••• 32.2344.
Is ued By: _ �L�i' � Permittee Signature: .
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' a��;' Date: l�/��j/
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 AaalicaiCEiVE1) FOR OFFICE I SE ONLY
City of Tigard Received DateBy: /� /4/ (
• Permit No.: f[j / i2O(e 8S'
Ph . --
13125 SW Hall Blvd.,Tigard,OR 9 2 Zia% Plan Review •
Phone: 503.7182439 Fax: 503.59 8.1960 Date/By: / it /' .1 4/ Other Permit:,et,�j„,/�.,�
T 1 G A R n Inspection Line: 503.639.4175 , LUn`�" Date Ready/By: w' tuns: Fa See Page 2 for
Internet: www.tigard-or.gov ILA UE Notified/Method: w? �7 /' \4/41 Supplemental Information
TYPE l tJ ayer4iNL14N REVIEW
❑New construction ®Addition/alteration/replacement
Please check all that apply(submit 2 sets of plans vv/items checked below):
❑Service or feeder 400 amps or more ❑Building over three stories.
❑ Demolition ❑Other: where the available fault current ❑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 ®Commerciallindustrial ❑Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 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 no.:538 Job site address: 12511 SW 68th Ave second floor t OOHP or more. occupancy.
DJ Six or more residential units. ❑Recreational vehicle parks.
City/State/ZIP:Tigard,Ore 97051 Health-care facilities. ❑Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name:Dr Kassay ❑Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. 1 Fee. I Total
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'I 500 sq.ft.or portion 33.92 1•
Tax map/parcel no.: Limited energy,residential
DESCRIPTION OF WORK (with above sq.ft.) 75.00 2
Limited energy,multi-family
75.00 2
Service up grade and TI build out on second floor residential(with above sq.ft.)
Renewable Energy ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
❑ PROPERTY OWNER I ❑ TENANT 200 amps or less 3 100.70 302.10 2
201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
Address: 601 amps to 1,000 amps 1 301.04 301.04 2
Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
Phone:( ) Fax:( ) relocation
200 amps or less 59.36 I
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 I ❑ CONTACT PERSON A.Fee for branch circuits with
above service or feeder fee, 24 7 42 178.08 2
Business name: each branch circuit
B.Fee for branch circuits without
Contact name: service or feeder fee,first 56.18 2
branch circuit _
Address: Each add'I branch circuit 7.42 2
Miscellaneous(service or feeder not included)
City/State/ZIP: Each manufactured or modular
67.84 2
Phone:( ) Fax: :( ) dwelling,service and/or feeder
Reconnect only 67.84 2
E-mail:
Pump or irrigation circle 67.84 2
I` CONTRACTOR Sign or outline lighting 67.84 2
Business name:Timberline Electrical Contractors Signal circuit(s)or limited energy See
panel,alteration,or extension. Page 2 2
Address:9414 SW Barbur Blvd,Suite 100 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 6625/hr
City/State/ZIP:Portland,Ore 97219 Investigation(1 hr min) 66.25/hr
Phone:(503)459-4089 Fax:(503)254-4227 Industrial plant(I hr min) 78.18/hr ,
Inspections for which no fee is 9000/hr
CCB Lic.: 160037 Electrical Lic.: 26-1211C Suprv.Lie.: 4518S specifically listed('A hr min) _
/ ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: 781.22
Print name: Craig Gossett Date' 12.2.2014 Plan review(25%of permit fee): 195.31
State surcharge(12%of permit fee): 93.75
Authorized signature: TOTAL PERMIT FEE: 1070.2
Print name: 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.
t:\BuildingTermits\ELC_PeemitApp_F1.R_EREcloc Rev 05/2112013 440.46I5T(I1/05/COM/WEB
03/09/2015 02:15 FAX lj002/002
,f:1 A Request to Energize an Electrical Installation
Jurisdiction address:
,rte,
C.1,17
REQUESTING SUPERVISING ELECTRICIAN INFORMATION
Name of supervising electrician: Craig Gossett Date of request: 03 /09/2015
Supervising electrician's license number: 4518S Date installation was completed: 03 /09/2015
Electrical permit no.: ELC2014-00685 If a temporary permit is posted at the job site,please include a copy of it with this form.
EMPLOYING ELECTRICAL CONTRACTOR INFORMATION
Name of electrical contractor: Timberline Electrical Contractors License no.: 26-1211C
Business address: 9414 SW Barbur Blvd,Suite 100
City: Portland State:Ore ZIP: 97219
Phone: 503-459-4089 Fax:503 -254-4227 E-mail: paulatimbedineelectric.com
CUSTOMER INFORMATION
Customer's name: Kassay Clinic
Customer's address: 12511 SW 68th Ave
City: Tigard State: Ore ZIP: 97051
Address of installation if different than customer's address:
City: State: ZIP:
INSPECTING AUTHORITY INFORMATION
Authority having jurisdiction to inspect: City of Tigard Phone: 503 -718-2439
Address: 13125 SW Hall Blvd
City: Tigard State: Ore ZIP: 97223
RECEIVING ELECTRIC UTILITY INFORMATION
Name of electric utility receiving request: POE Phone: 503 -736-5450
Address: 3700 SE 17th
City: Portland State: Ore ZIP:
REASON FOR REQUEST
A. Restoring electrical service that was interrupted or disconnected because of either a:
® Service change or ❑ Uncontrollable event,such as fire,flood,or severe weather;
or
B. Electrical service at a remote location needs to be:
❑ Initialized ❑Restored
COMPLETION INSTRUCTIONS AND SIGNATURE
Supervising electrician Electrical contractor
Please note--After sending this form to the electric Please note—By close of business on the first business
utility named above,you must send a copy of this form to: day, following energizing of a completed installation in
(1)the electrical contractor,(2)the customer,and(3)the response to the above request,you must: (1)notify the
ins I- ,'ng j:thority. authority having jurisdiction that the installation has been
y:. energized,and(2)request that the authority inspect the
3.9.2015 completed installation.
Su • electrician's signature Date
J, DEPARtMSSENTEEOFF
�VNC�S
440-0948-COM(9/08/COM
03/09/2015 02:15 FAX Z001/002
Timberline Electrical Contractors, Inc.
P.O Box 918 CCB#160037
Lake Oswego, OR 97034
Ph. 503-459-4089 Fax 503-254-4227
Fax
To, City of Tigard Electrical Inspecbors From Paul Hutson
Fa=c 503-598-1960 Pages: 2
Phone; 503-718-2439 Date: 3/9/2015
Re: Request to Energize and Electrical
Installation form
X Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
Good afternoon,
The attached form states we are required to send a copy to the"inspecting authority".
Please reference permit#ELC2014-00685, 12511 SW 68th Ave, Dr. Kassay
Paul Hutson
503-849-9453
Fax 503-254-4227
PRIVILEGE AND CONFIDENTIALITY NOTICE
The information in this electronic mail or facsimile(and any associated attachments)is intended for the named recipient(s)only and
may contain privileged and confidential information_If you have received this message in error,you are hereby notified that any use,
disclosure,copying or alteration of this message is strictly prohibited. If you are not the intended recipient(s),please contact the
sender by repty email and destroy all copies of the original message. Thank you
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
12511 SW 68TH AVE, TIGARD, OR, 97223
Commercial - Electrical
199 Electrical final
PASS - No C of O
ELC2014-00685
Jeff Grove
Violation Summary:
Inspector Contractor