Permit CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2012 -00018
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/13/2012
Parcel: 2S 115 BA00100
Jurisdiction: Tigard
Site address: 16200 SW PACIFIC HWY Z
Project: Albertsons Subdivision: DOVER LANDING Lot: 58
Project Description: Electrical for power monitoring system.
Contractor: STONER ELECTRIC Owner: ALBERTSON'S INC EXECUTIVE PENSIO
1904 SE OCHOCO BY ALBERTSONS INC #565
MILWAUKIE, OR 97222 ATTN: TAX DEPT
PO BOX 20
BOISE, ID 83726
PHONE: 503 - 462 -6500 PHONE:
FAX: 503 - 659 -4968
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 01/13/2012 $56.18
Specifics: Service or Feeder
1 ea Signal circuit or Limited 01/13/2012 $75.00
Type of Use: COM Energy Panel
Class of Work: ALT 1 ea 12% State Surcharge - 01/13/2012 $15.74
Electrical
Type of Const:
Occupancy Grp:
Total $146.92
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 952 - 001 -0090. You may obtain a co• of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: tel.: Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNERS 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.
Jan.12. 2012 1:13PM Stoner Electric Group No. 1002 P. 1
Electrical Per App lication k ? FOR OrFICr ITS : ONIX
� p 4 k e .. Received �y
v
C1�' Of Tigard *' u \� Date/f3 : 1 NAW, /r 1
r" 13125 SW Hall Blvd., Tigard, OR ' it, 0 �O Platt Review
Phone: 503.639.4171 Fax: 503.5'.19% ' 1 Pale/0 ; Other Permit;
I . WARD
Inspection Line: 503.639.4175 \1�� C; Ready/I3 Date • RI See Faze 2 for
Internet; www,tigard- or,gov J e ' �N � oH NN ied/Mrlhod: WM Supplemental Information
.,tc
❑ New construction Ri Addition/altcrationteiZteWent Please check all diet apply (submit 2 sets of plans wlitems checked below):
❑ Service or feeder 400 amps or more ['Building over throe stories.
❑ Demolition ❑ Other: where the available fault current Li Marinas and boatyards.
,iii t ,�■- ,, -_ -
CATEGORY -,O , 4,eLygi.iiO , I,y =. ;:.,,] exceeds 10.000 ❑ Floating buildings.
^"� "`' least, ground, or exceeds 14,000 ❑ Commercial -use agricultural
El and 2- family dwelling m Commercial/industrial ❑ Accessory building amps for all other installations, buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire ptunp. ❑ lnatellation of VA Or
� '
- : . : JOB SITE::INRO _: „- . ..
� +' - ,�,,��,:....... ,. , • Emergency system. larger separately dented system,
�+ �'" 1' � . :'1' �%�7u< . ".,.. .., .;a ::,.,�,,,, Q � y �����'�`�'. � i. .. .� �;�� ❑ Addition of new motor load of ❑.. ,.
rob no.: 92 7g I Job site address: / , zo Q F Six or or more. occupancy.
L a S!J /.�] L i c ❑ Six on nom residential units. ❑ Recreational vehicle parks.
,� QBealth-care facilities. ID Supply voltage forma a than
City/State/ZIP: //i - ,q„72, , OA" 9 7g-z 9 ❑l�n:acdottsrotations. 600 volts nominal.
4 ' r�oN S Q5y.- ❑ Service or feeder 604 amps or rn,re.
Suite/bldg./apt. no.: Project name: ! ., .T.'4%"12".::. gEE`SCHI U,U + _ ., `'
CIoss street/directions to job site: nmcrietien I Orr. I Pea I Tend I . .
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. 11. or loss 168.54 4
_
Be. ndd'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no:
ab residential
l.: •�! - i. Ir :, :: , r ".:;. . DEISC]. 1 I ,J[t '�` �t; . , ":; 4N (wil
Lt ls vv sq. R) 75.Q0 2
2
Limited energy, multi- family 75.00 2
1 4/5 - 779' -( /" /Zs-it rviel,t./ /, Z- residential (with above sq. ft.)
Services or feeders Installation, alteration and /or relocation
200 amps or Lass 100.70 2
lAV , WN`irli . r & €d ' j —0,7r.;::. l' amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: -
- 601 amps to 1,000 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: ( ) I Fa ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 4 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. Pee for branch circuits with
x s : :mt service or feeder fee,
, i ��0 l ter PEIt ,:. ;`0,1 each above service
circuit 7.42 2
ICANT
Business name: B. Pee for branch circuits wi /ho ur
service or feeder fee, first I $ ' 2
Contact name: branch circuit
Each add'l branch circuit 7,42 2
Address: Miscellaneous (service or feeder not included)
Each manufactured or modular 67,84 2
City/State/ZIP: dwelling. service and/or feeder
Phone: ( ) 1 Fax: • ( ) Reconnect only 67,54 2
Pump or irrigation circle 67.84 2
Email
_,_� �✓''_:°; Sign or outline lighting 67.84 2
y;',r'„ ,, (7,�E'' CONT'C I! : :, r Si g nalc ir cu il (s)orl imi led- energy
Business name: STONER ELECTRIC �
INC. . panel, aileration , pr wctension, , / Fagez 75 : tQA
2
ELECTRIC, INC Each additional Inspection over allowable in any of the above
Address: 1904 SE OCHOCO Addilloni inspection (1 hr mm) . 66.25/hr '
investigation hr min) 66,25/hr
City/State/ZIP: MILWAUKIE, OR 97222 - Industrial plant (1 hr min) 78.18/ hr
Phone; ( 503) Fax: ( 503) 659 -4968 Inspections for which no roc is 90.00/ hr
s eciticali listed i4 hr min) •
cat Lie.: 44823 I Electrical Lie -: 26 -122C Suprv. Lie.: 3496S 1 ' ° ..,. i$0011CAL::PERMIT , .EE - `� "?
Suprv. Electrician signature, required: / e Subtotal: l 3(, / 8
h1 ie�+s rC Plan review (25% of permit f ee): , 49-- T
Print name: MICHAEL FALCONER Date: 1 /, / , Z - State surcharge (12%ofpermitfee): j‘",747-
TOTAL PERMIT FBS; Ja% r 4,
Authorized signature: This permit application expires Ira permit Is not o a ncd w lthln 180
days after It has been accepted as complete.
Print name: Date: • Number or inspections allowed per permit,
l: lBsnd■ng \Peno;ioHt,C- P<mlilAppdon as /oi /lo 440- 4613T(I1/o3 /COM/1/Eg
Jan. 12. 2012 1:14PM Stoner Electric Group No. 1002 P. 2
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved;
❑ Audio and Stereo Systems*
❑ Burglar Alarm
n Garage Door Opener*
❑ Ideating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
r. V : V • C t/: (V/6 LY : I
Fee for each commercial $75.00
system
(SEE OAR 918 - 309 - 0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
E Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
g Other \te ∎W3 \�S
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
r; lBvpainotrrnh te- p«miwpp,aoc 07 /Ol(1O
Er
TIGARD
City of Tigard
August 22, 2012
Stoner Electric Inc.
Attn: Dennis Whitcomb
1904 SE Ochoco
Milwaukie, OR 97222
Re: Permit No. ELC2012 -00018
Dear Mr. Whitcomb:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 16200 SW Pacific Hwy
Project Name: Albertson's
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $117.53.
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, refund 80% as job was canceled.
If you have any questions please contact me at 503.718.2430.
Sincerely,
XV -■ //
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Buildin \acfundall i&Wnli lie d q g t t i, tcGif /o 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Stoner Electric Inc. DATE: 07/26/2012
Attn: Dennis Whitcomb
1904 SE Ochoco REQUESTED BY: Dianna Howse
Mihvaukie, OR 97222
TRANSACTION INFORMATION:
Receipt #: 185153 Case #: ELC2012 -00018
Date: 01/13/2012 Address /Parcel: 16200 SW Pacific Hwy
Pay Method: CreditCard Project Name: Albertsons
EXPLANATION: Refund 80% of permit fee per applicant's request as job was canceled.
REFUND INFORMATION: -
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee . Example: 2300000 -43104 $ Amount
Permit Fee 220- 0000 -43103 $104.94
12% State Surcharge 100 - 0000 - 24001 12.59
TOTAL REFUND: $117.53
APPROVALS:
If under $5,000 Professional Staff
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 TIDEMARKSYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: ?Jy / //L By: „,.
1: \Building \ Refunds \RefundRequest.doc x 09/01/2010
Jul. 12. 2012 8:39AM Stoner Electric Group No. 3336 P. 3 C
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JUL 12 2012
7
Request Permit Action
cm(oFTIGARD
l I ( .; A R l.) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • wwvvEgI d ODIVISION
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 501718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: El Owner ❑ Applicant x Contractor ❑ City Staff
(check onc)
REFUND OR Name:
INVOICE TO: (Business or Individual) 2-1-0 U el.-c_Tre r G . fiU c -
Mailing Address: /90 4- s,E oGhp c-0
City /State /Zip: VA t 1_w A-rak rr, oR. 972 2- Z
Phone No.: e03 — it ,.iii/
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).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ELC 20! z —oop /B
Site Address or Parcel #: &zoo .Scs) ac,,,, (p„{IV,¢
Project Name: 4 r,5c9nnn 6,5
Subdivision Name: Lot #:
EXPLANATION: —Jo 6 Ci4 Cex.L. ,e- m,6, p( -r ' 0,5'i' 5
Signature: ( Date: 7 /lt /, z,
Print Name: art n,S /.tir< -mines
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,
e) 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 fcc 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 S s Admin: Date ifimmegiam Rte to Bid: Admin: Date , L - B' !
Refund Processed: Date J2 By 5/iT Invoice Processed: Date By
Permit Canceled: Date ,', B , 24g arcel Ta Added: Date B.
Receipt # /Ger /53 Date J / // Method s!' LL Amount $
I: \lluilding \Forms \RegPcrmitAction. oc Rev 05 /25/2012