Permit Support Document 04/12/2019 02:07PM 5036189985 XTREME PAGE 02/03
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT AK; 1 2 is q
711Request for Permit Action ���`� ; ��:,
i ;,, ;;p 13125 SW Hall Blvd. •Tigard,Oregon 97223. 503-718-2439•www.rigard-or.gov ,
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
• Phone: 503-718-2439 Pax: 503-598-1960 TigatdBuildingPenxtits®tigard-or.gov
FROM: ❑ Owner El ApplicantContractor ❑ City Staff
Check(V)one , `
REFUND OR Name: ,
,�
INVOICE TO: (s ere or Individu•I) A ° C - N I/ • ;a it
Mailing Address: 0 et0A3 Ilit3 Shea LAy ..,1,S
City/State/Zip: L4Z, I it, d
Phone No.: CO3 — "
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
Permit#: __,C ° ' v Bill ..14.
Site Address or Parcel#: C7V 6 t.4..3,—hGG fiA, ,
Project Name: te N-Tiler l C/r:
Subdivision Nauru: Lot#:
E. "` • ATION: � /�a;A - Li tv n
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Sigllatuxe: / ra' t - I. . Co --"!- Date: ! ~-
Print Name: ;, • r .eel
Aefiwd 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 of permit fee for issued permits prior to any inspection requests.
2.•Ail refunds will be returned to the original payer in the fotm of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
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Route to Sys Admin' Date By . Route to Records: Date/ /7 /9 B
Refund Processed: Date clityt By „ , voice Processed: Date By
Permit Canceled: Dato•✓/'r9 B.d v r arcel Tag Added' Date —By
I:\guiding\Forms\RegPeca itA,ction.J 20518.doc
04/12/2019 02:07PM 5036189985 XTREME PAGE 03/03
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CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
111111 "--
' ' COMMUNITY DEVELOPMENT Permit#: ELR2019-00068
T h-1 13125 SW Hall Blvd..Tigard OR 97223 503.7182439 Date Issued: 04/11/2019
• - 1: 2S113B000300
Jurlsd ;• Tigard
Site address: 8040 SW DURHAM RD
Project DURHAM EDUCATION CTR ivision: N. e Lot: None
Project Description: #9760-VOICE&DATA ONL
•
Contractor: XTREME COMMUNICATIONS I C Owner. TIGARk UALATIN SCHOOL DISTRICT
24023 NE SHEA LN#21c 6960 ' SANDBURG ST
WOOD VILLAGE,OR 97 0 Ti • 'D,OR 97223
•
PHONE 503-618-8616 PHONE:
•
FAX: 503-618-9985
FEES
Description Date Amount
Restricted Energy Permit 04/11/2019 $75.00
12%State Surcharge-El-r, = 04/11/2019 59.00
Type of Use: COM
Class of Work: ALT
Total Number of Systems: 1 •
Audio&Stereo: 0 Boiler Controls: 0
CCTV: 0 Clock Systems: 0
Data&Telecommunications: 1 Fire Alarm: 0
HVAC: 0 Instrumentation: 0
Intercom/Paging: 0 Landscape/Irrigation: 0
Landscape Lighting: 0 Medical: 0
Nurse Calls: 0 Protective Signal: I
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 aft other applicable law. All work will
be done in accordance with approved plena. This permit will expire if work is not started within 180 days of issuance, or IT work Is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregoh Utility Notification Center. Those rules ere set forth in OAR
952-001-0010 through OAR 952.001-0090. You may obtain a copy of the rules or direct Questions to OUNC by calling 503232.1987 or 1.900.332.2344.
laaued By: 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.El-EC' Date:
LICENSE NO.
Call 503.039A175 by 7:00 a.m.for the next available inspection date.
Thia permit card shall he 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.
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
8040 SW DURHAM RD, TIGARD, OR, 97224
Record Type: Record ID:
Commercial - Electrical Limited Energy ELR2019-00068
Inspection Type: Inspector:
198 Low voltage final Jeff Grove
Result:
PASS - NoCofO
Comments:
Violation Summary:
Inspector Contractor