Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1 0
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Re
Request for Permit Action 970S/e)(41-
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, 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ,® City Staff
Check(✓)one
REF D OR Name:
INVOIC ;TO: (Business or Individual) ,R A rot__ C. L€CTya i e Co. I QC.
Mailing Address: 1 LI 0( I-162x '-t
City/State/Zip: PO 011—Lw>JT O 2 q7 2-2-0— log
Phone No.: p'ZSS 94gg
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).
DUE (attach case fee schedule and provide explanation below).it J I REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
0,r 'I) Permit#: �12 p O f c— o0/ 8-7
155 Site Address or Parcel#: /D 500 ( f Acueg kb. t 370
Project Name: EQ, d LA-AY7) .60Z.u T70 S
Subdivision Name: Lot #:
EXPLANATION: A P P L 1 CA' �r Ci2i/4 r b TLC. PR-M Cr- o ry 0 t3 F
l.vo 0_ k• gU i S—b O (s S O
Signature: ( 0-e-0 Date: 5 ),9-71,5--
Print Name: ME-f2,43
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
l OR OFFICE USE ONl.1
Route to S•s Admire: Date aimair m Route to Records: Date 9��� B 0274W1
Refund Processed: Date ,9 By 11 ' Invoice Processed: Date By
Permit Canceled: Date T F//6 By o'!" Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.doc
Electrical Permit Application RECEIVED IY)ROI I I I: I SI:O\I.l
Receive•
City of Tigard Date/By: 1 I 'ermit no.: 1O°I�7 41
13125 SW Hall Blvd.,Tigard,OR 97223 AUG 1 3 2015 Plan Review
11 Phone: 503.639.4171 Fax: 503.598.1960 Data : . I Permit: /4(k2467.-..-,eek 56
T I G A R D Inspection Line: 503.639.4175 CITY OF TI GAR D Date T°.dy/B Mir 416747‘. ■ See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method r!�,• Supplemental Infomation
• New construction • Addition/alteration/replacement Please check aN that apply(submit 2 sets of plans w/items checked below):
❑ Demolition ❑ Other. ❑ Service or feeder 400 amps or more tom_
p El over three stories \ \`
µ where the available fault current ❑ Marinas and boatyards
• 1-and 2-family dwelling El Commercial/industrial •Accessory building exceeds 10,000 amps at 150 volts or Floating buildings t,
❑ Multi-family ❑ Master Builder ❑Other less to ground,or exceeds 14,000 Commercial-use agricultural
JOB SITE INFORMATION AND LOCATION amps for all other installations. ❑ buildings
❑ Fire Pump ❑ Installation of 75 tWA or
Job no.. 151540 I Job site address. 10300 SW Greenburg Rd.
1
❑ Emergency system larger separately derived system.
City/State/ZIP: Tigard,OR 97223 El Addition of new motor load of ❑"A","E","1-2","1-3",
Q 100HP or more. ❑ occupancy
Suite/bldg./apt.no. 370 (Project name: Epic Land Solutions ❑ Six or more residential units 111 Recreational vehicle parks. o
❑ Health-care facilities ❑ Supply voltage for more than
Cross Street/Directions to job site: ❑ Hazardous locations
❑ 600 volts nominal.
❑ Service or feeder 600 am.s or more
0nh �ad,..i . ,w4re l�'� ,, i+.Yk �i+ :;
Subdivision: Lot no.: w. ,
Description Qty. Fee. Total "
Tax ma•/.arcel no.. New residential-single or multi-family dwelling unit.
i
/2 . ..:, :s -.1.1° s q ii i=. ,a_.,: rr.,.art* Includes attached garage.
INSTALL FIRE ALARM CIRCUIT 1000 sq ft.or less $ 168.54 4
Ea.Add'I 500 sq.ft or portion $ 33.92 I
L O 't s.x; a • 74°Ia ,- a . i . a + ' ; - .? , , Limited energy residential
Name: (with above sq.ft.) $ 67.84 2
SHORENSTEIN REALTY SERVICES Limited energy,multi-family
Address:
residential(with above sq.ft.) $ 67.84 2
Service or feeders installation,alteration,and/or relocation
City/State/ZIP: 200 amps or less $ 100.70 2
201 amps to 400 amps 5 133.56 2
401 amps to 600 amps $ 200.34 2
Phone: Fax. 601 amps to 1000 amps $ 301.04 2
Owner installation: This installation is being made on property that I own which is not Over 1000 amps or volts $ 552.26 2
intended for sale,lease,rent or exchange,according to ORS 447,449,670,and 701 Temporary services or feeders installation,alteration,and/or
Owner signature: Date: relocation
200 amps or less $ 59.36 1
,• sAPPLIC ' ` ;i#:4-4 W EliEitilEMEIRTINiateENT7a. OR- 201 amps to 400 amps $ 125.08 2
Business Name:
401 amps to 599 amps $ 168.54 2
Branch circuits-new,alteration,or extension,per panel
Contact name:
A. Fee for branch circuits with
service or feeder fee,each
Address: branch circuit $ 7.42 2
B. Fee for branch circuits
City/State/ZIP: without service or feeder fee,
first branch circuit $ 56.18 2
Each additional branch circuit: $ 7.42 2
Phone: Fax: Miscellaneous(service or feeder not included)
E-mail: Each manufactured or modular
x ae
,.�'-.� ^ t ,! ; r( 4" CONtkit: TOIL '` 1 i-,:rr e, dwelling,service and or feeder $ 67.84 2
Business Name: CAPITOL ELECTRIC CO.,INC. Reconnect only $ 67.84 2
Pump or irrigation circle $ 67.84 2
Contact name: SHANE TERCEK 503.262.0405 DIRECT Sign or outline lighting $ 67.84 2
Signal circuit(s)or limited-
Address: 11401 NE MARX ST.
energy panel,alterations,or
extension. Describe: Fire Alamo I Page 2 $ 75.00 2
City/State/ZIP: PORTLAND,OR 97220-1041 -
Each additional inspection over allowable in any of the above
Phone: 503-255-9488 Fax: 503-257-7121 Per inspection $ 66.25
Investigation per hour(I hr min) $ 66.25
CCB Lic.: 48748 IElectric 26-496C ISuprv.Lic.: 3132-S Industrial lant per hour $ 78.18
Suprv.Electrician signature,require / / '3 I JI VEES'! ^'f ; ,r`'° Yt^ #° 0 00
f VY� Subtotal $ 75.00
Print Name: DARRELL MCNEEL Date: 08/12/15 Plan review(25%of permit fee)
State surcharge( 9.00
Authorized signature: t i l TOTAL PERMIT FEE 12% of permit fee) S 84.00
—
Print Name, RRELL MCNEEL Thu permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
•Number of inspections per permit allowed.