Permit III CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2021-00640
T i ;A R.LD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/8/2021
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Parcel: 2S 110BA03500
Jurisdiction: Tigard
Site address: 11575 SW CLOUD CT
Project: Herboth Subdivision: SHADOW HILLS Lot: 30
Project Description: (1)branch circuit for new bedroom.
Contractor: OWNER Owner: AGARD, KIRSTEN ERIN
HERBOTH,GLENN ALBERT
11575 SW CLOUD CT
TIGARD, OR 97224
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 11/05/2021 $56.18
Specifics:
Service or Feeder
1 ea 12%State Surcharge- 11/05/2021 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 wit 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 coov of the rules or direct auestions to OUNC by callina 503.232.1987 or 1.800.332.2344.
Issued By: 1-In-tllj \ll..n.Op,Vlv3v. Permittee Signature: Ow Apptit,a44.4-14.
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.ELEC'N 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.
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RECEIVED
Property Owner Statement
OCT 2 8 1021
Regarding Construction Responsibilities c;IFY OF TIGARL
( - - ,,, ' '' i ' '' '' "1 ' ''''''''''' "f "1 " " "'`1 %.`'Itt thltJILDING DIVISION
) 1)Pt WM An tir-
tsle!ci (ORS 701 325 (2))
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) This statement Is reguirert for resocier)ttAt titw(tifici Her trf,-,..ii /lie(tiariical and plitmtiong rietinits,
: Licensed arctirtert and engirippr applicants, exornpt from hr ritsing under ORS 701 010(7), need not
s librrnt this staterciera ItItc. Ilatt'n1Pnl will he Mori with the ix,rrilit
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oven reside in or will reside in the corntleted structure and my general contractor is
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i I 1*0"Vril inform my general contractor that all subcontractors who work on the strirritirre most be
licensed with the Construction Contractors Hoard
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I will be perlorTn.(19 work on property I own a residence that I reside in or a residence that I will
reside in If I hire subcontractors I will hire only subcontractors licensed with the Construction
i,
, I Contractors Board It I change my mind and hire a general contractor. I will select a contractor
i
Ircho is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit
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I i I have read and understand the Information Notice to Homeowners About Construction RosponsibilitiOS,
and I hereby cerItty that the information on this homeowner statement is true and accurate.
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