Permit • City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 1 0
-a Request for Permit Action 9/s/g.69--
, , 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(V)one
REFUND OR Name: n
TO: (Business or Individual) OAP,Tv t_ L�e-Tl2 C (1.
Mailing Address: //L/01 A E_ 1 H12y( 6 r
City/State/Zip: 4)27 LA N`i] U2 el 7 oil
Phone No.: tO3 -a S S—C tig q
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).
E FOR FEES DUE (attach case fee schedule and provide explanation below).
o( REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
pr6 p Permit#: Ei"--12-d9-0/6-" &Gl g&
I S Site Address or Parcel #: 09'60 3+-a a2f C x),) _ 'e
Project Name: M 12.1 P i S�
Subdivision Name: Lot#:
EXPLANATION: (-pp c,��� �\YT ( Arc PLC P QHry d 06 Of
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Ant' - 60 Loci !.
Signature: N..„ Q ) Date: '1 a 7 /1C
Print Name: l f /1.,(ij 1 q A b vt AA'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to S s Admin: Date t num mom! Route to Records: Date 94J/a2111 :MVILM
Refund Processed: Date 7J
/l/ it B <�.� Invoice Processed: Date By
Permit Canceled: Date �j/11js By : (•• Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_Oryf31 .doc
Electrical Permit Application
Received JQ
Date/By: / /S 00 Permit no.:Ei,k /r�
�1,5CEIVE A'��$�p
City of Tigard
13125 SW Hall Blvd.,Tigard,OR 972 Plan Review
2 Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Q
Ott Per
T I G A t D Inspection Line: 503.639.4175 n Date Ready/B d Ju
U See Page 2 for
Internet: www.tigd-or.gov 4 U 6 1 �5 Notified/Method:
9 � r � Supplementallnfonnation
01 New construction 0 Addition/alteratio I. 11! 1!!a? Please check all that apply(submit 2 sets of plans wfitems checked below):
❑ Demolition ❑ Other " ?'"1 1CV
❑ Service or feeder 400 amps or more ❑ Building over three stories
CATEGORY OF CONSTRUCTION where the available fault current ❑ Marinas and boatyards
U I-and 2-family dwelling U Commercial/industrial U Accessory building exceeds 10,000 amps at 150 volts or Floating buildings
❑ Multi-family ❑ Master Builder ❑Other less to ground,or exceeds 14,000 Commercial-use agricultural
JOB SITE INFORMATION AND LOCATION amps for all other installations. ❑ buildings
Job no.: 151535 I Job site address: 10260 SW Greenburg Rd. ❑ Fire Pump ❑ Installation of 75 tWA or 'O .
❑ Emergency system larger separately derived system. 'On
City/State/ZIP: Tigard,OR 97223 ❑ Addition of new motor load of ❑"A","E","1-2","1-3", .,,Q
100HP or more. ❑ occupancy
Suitelbldg./apl.no.: 950 (Project name: Ameriprise ❑ Six or more residential units ❑ Recreational vehicle parks.
❑ Health-care facilities ❑ Supply voltage for more than
Cross Street/Directions to job site. ❑ Hazardous locations
❑ 600 volts nominal.
❑ Service or feeder 600 amps or more
Subdivision: I Lot no.. „ 44X"';}. .. I g B " 1.= �
Description I Qty. I Fee. I Total I
Tax ma./..reel no.: New residential-single or multi-family dwelling unit.
° . i , vt° o 1'a .,1/,a°a ' {a$ x _ Includes attached garage.
INSTALL FIRE ALARM CIRCUIT 1000 sq.ft.or less $ 168.54 4
Ea.Add'l 500 sq.ft or portion $ 33.92 1
'''`' 'L° rPR 7PERT ,f ax' "i ''ts' ' "` 'm ,°may Limited energy residential
Name: (with above sq.ft.) S 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 5 100.70 2
201 amps to 400 amps $ 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 1 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
.e `+ '',.• - . '',¢.#'I=z :,, „ Li ' CONTACT PERSON" 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
'''-' h • °, "' 4.-;-4 iit '4, ,s g.?.4 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 DAN WILSON 503.262.0411 DIRECT Sign or outline lighting $ 67.84 2
Signal circuit(s)or limited-
energy panel,alterations,or
Address: 11401 NE MARX ST. extension. Describe: Fire Alarm 1 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(1 hr min) $ 66.25
CCB Lie.: 48748 Electrical Lic.: 26-496C ISuprv.Lic.: 3132-5 Industrial .lant*-r hour S 78.18
Suprv.Electrician signature,required - "r75.1371-17:f'"`' ` '"#` £` "' ''' "a `
�� Subtotal $ 75.00
Print Name: DARREL CNEEL ��08/11/15/- / Plan review(25%of permit fee)
Authorized signature: / State surcharge( 12% of permit fee) $ 9.00
/ ��4.AA.�/�L TOTAL PERMIT FEE $ 84.00
Print Name: DARRELL EE This permit application expires ira permit is not obtained within 180
days after it has been accepted as complete.
•Number of inspections per permit allowed.