Permit Support Document (6) EXPIRED
6// 7/1'7 4624/
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
111 g Request for Permit Action
TIGARD 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 0-ei ff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
aCANCEL/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).
Permit#: /Lf ac)I �)9.
Site Address or Parcel #: 423? ;f;i') 5,4)/ s
Project Name: /r)Cor..W ►- is
Subdivision Name: Lot#:
EXPLANATION: /pi
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Signature: Date: E`/>S
Print Name: �,�,, { �—f,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Sys Admin: Date 4',c-'/�ci By Route to Records: Dated, 7 t 9 ByAr
Refund Processed: Date iv7 4.. By Invoice Processed: Date By _
Permit Canceled: Date cA 7//9 By , '.rcel Tag Added: Date By
l:\Building\Forms\RegPermitAction_1205j,2S doc
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Electrical Permit ApplicatREC
EIVED FOR OFFICE USE ONLY
City of Tigard RececL.
Date/Byeiv ✓ 5Aji Permit# ,,,,`t`f�n isj;!/t/%!�j
II 4 i
13125 SW Hall Blvd.,Tigard,OR 972
Phone: 503.718.2439 Fax: 503.598. 2 4 2018 Plan Re ew
Date/By: Related Permi0r 1, /�Ue /a2
Inspection Line: 503.639.4175 Ready Date/By: Juris: r /c�® See Page 2 for
I t ARD Internet: www.tigard-or.gov CITY O Notified/Meth
4�a ����t' ® ��v Supplemental Information
TYPE ; nlvi is I PLAN REVIEW
0 New construction 0 Addition7a teration/ replacement , I Please check all that (submit 2 sets of plans w/items checked):
❑Demolition I Other: ILLUMINATED SIGNS ❑Service or feeder 400 apply amps or more ❑Building over three stories.
b where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ I-and 2-family dwelling U Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
0 Multi-family ❑Master builder ❑Other: 0 Fireum .
p p 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
Job#: I Job site address: 12388 SW SCHOLLS FERRY RD ❑Addition of new motor load of system.
100HP or more. ❑"A","E","I-2","1-3",
City/State/ZIP: TIGARD,OR,97223 0 Six or more residential units. occupancy.
0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: I Project name: MCDONALD'S REMODEL 0 Hazardous locatidns. 0 Supply voltage for more than
0 Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description . I Qty. I Each I Total I *
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
006-161-14-000 1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 33.92 I
DESCRIPTION OF WORK Limited energy,residential
(with75.00 2
above sq.ft.)
Limitedenergy,ove
INTERNALLY ILLUMINATED SIGNAGEmulti-family
residential(with above sq.ft.) 75.00 2
II PROPERTY OWNER
I 0 TENANT Renewable Energy 0 See Page 2
Services or feeders installation,alteration,and/or relocation
Name:MCDONALD'S CORPORATION 200 amps or less 100.70 2
Address:2999 OAK ROAD STE 210 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:WALNUT CREEK,CA 94597 601 amps to 1,000 amps 301.04 2
Phone:( 425 )577-0415 I Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email:DOUG.BATES@US.MCD.COM relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
U APPLICANT I 0 CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name:FREIHEIT ARCHITECTURE above service or feeder fee,
each branch circuit 7.42 2
Contact name: MATT GRINNELL B.Fee for branch circuits without
Address: 929 108TH AVE NE STE 210 service or feeder fee,first 56.18 2
branch circuit
City/State/ZIP:BELLEVUE,WA,98004 Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( 425 )827-2100 Fax: : ( ) Each manufactured or modular 67.84 2
Email: MGRINNELL@FREIHEITARCH.COM dwelling,service and/or feeder
Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name:TBD Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy
Address: panel,alteration,or extension. 0 See Page 2 2
City/State/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: Electrical Lic.: Suprv.Lic.: specifically listed(%2 hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: 1/'" TOTAL PERMIT FEE:
�� This permit application expires if a permit is not obtained within 180
Print name:MATT GRINNELL-FREIHEIT ARCHITECTURE Date:07/20/2018 days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:Building.Permits\ELCPermitAppELR ERE.doc Rev 06/17/2015 440-4615T(I 1/05/COM/WEB
a 7-' r°'�-y
Xlectrilcal Permit Application—City of Tigard „ 5
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE
Description I Qty. Each I Total I *
Fee for all residential systems combined: $75.00 Renewable electrical energy systems:
Check Type of Work Involved: 5 kva or less 100.70 2
5.01 to 15 kva 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
n Burglar Alarm 25.01 to 50 kva 301.04 2
n Garage Door Opener* 50.01 to 100 kva 552.26 2
>100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System*
Each additional kva over 25 7.42 3
❑ Vacuum Systems* >100 kva-no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
❑ Other: Each additional inspection is 66.25/hr I
charged at an hourly(1 hr min)
Inspections for which no fee is 90.00/hr
specifically listed('A hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Subtotal(Enter on Page 1):
Fee for each commercial system: $75.00 * Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
n Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
Fire Alarm Installation
HVAC
n Instrumentation
Intercom and Paging Systems
Landscape Irrigation Control*
Li Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:`,BuildingPermits\ELCPermitApp_ELRERE.doc Rev 06/17/2015