Permit •
„ CITY OF TIGARD ELECTRICAL PERMIT
�' - s . • • COMMUNITY DEVELOPMENT Permit #: ELC2009 -00582
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/30/2009
Parcel: 2S102CB06801
Jurisdiction: Tigard
Site address: 10475 SW PARK ST
Subdivision: Lot: 0
Project: Solis
Project Description: Reconnect only.
Owner: FEES
SOLIS, EDGAR Quantity Description Date Amount
C/O 2645 SW 153RD DR.
BEAVERTON, OR 97006 1 ea Reconnect Only 10/30/2009 $67.84
PHONE: 503 -641 -3309 1 ea 12% State Surcharge - 10/30/2009 $8.14
Electrical
Contractor: •
OWNER
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $75.98
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 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By:
442gre„2:k_______
Permittee Signature: 4/11 /97°, L 7 C 1 C A
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' Date:
LICENSE NO.
Call 603.639.4176 by 7:00 a.m. for an Inspection that business day.
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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Electrical Permit Aroplicatic' \\ 9 FOR OFFICE LSE ONL
. Y
.
' - L.u City of Tigard c) C i C \ , '' Received D : ie 3e 0 9 cil Permit No.:EW ..--
R, # 0
ii ft . ° , 13125 SW HaliBlvd, Tigard, OR 97223
•
• - Phone: 503.639.4171 Fax: 503.598.1960 t ., Oc ' -lk( D - \ ,..,, , Plan Review i
''' it t k0 ' Date/B •
TIGAR1.) Other Penn
l t:
Inspection Line: 503.639.4175 G ■ , N3 0 ‘ Date Ready/By: RI See Page 2 for
Internet: www.tigard-or.gov \ l n\'''`i'
31\'''' Notified/Method: EirM Supplemental Information
n,r -_-,:mosoutripqr,,,,,,,,riterAsipougpiiiiiglrep4irolivioolic:il;;;;;iNg;t14 .iNYJoiw.R:lig9EigFOgqitgitcy140 ./.1
O ! 3'..11::42W'Ji41:!4::M:1:!:1!:*11;1 ';]!4:R!V;;Zgl!"Ael
0 New construction 0 Addition/alteration/replacement Please check all that apply (submit 2 sets of plans w/items checked below):
0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition IS Other: 6* C. A ,..1 - r — •Ver a. S £ where the available fault current 0 Marinas and boatyards.
OBVII11,4.1 r aligaNiggrak000#40.4.,, Wit:OiligiiipiANF1993.01'kN rci
N l exceed to s 10,0000ampsceaedst 4 000 or H c Floating bru ..
[3 1 - and 2-family dwelling 0 Commercial/industrial CD Accessory building snips for all other installations, buildings. agn
0 Multi 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 75 KVA or
the llWagg.050/#106100,05iWibaffigiel!Mii,INNFTi01;1:11:M] V D Eme sYslem. larger separately derived system.
11. . , ... ,,,1 ,1141174rs: ..' ,,, :.,,,,. ".„,, .,,,ii; ■,:m.,61, A .., .. I :..,.....,:di. A;..4.....,,,,,Ahd.J....V.tg_•?.!;!;:ifV.trDI:i:'•ii!jj:!IIItil.:; 1:1 Addition of new motor load of 0
Job no.: Job site address: 100HP or more. /, .e 4,..) A d e_ K
0 Six or more residential tmits. occupacy.
0 Recreational vehicle parks.
City/State/ZIP: - ,- 4 , 0 4 . 97Rag 0 Health-care facilities.
. 0 Hazardous locations. 0 Supply voltage for more than
600 volts nominal.
Suite/bldg./apt. no.: Project name: 0 Service or feeder 600 amps or more.
' fili7,6;000,1.5,6112AVMW,_. ,PRIMPIRKWARIZ
Cross street/directions to job site: Description 1 Q ty. I Fee. i r rail i • -
New residential single- or multi-family dwelling unit.
q f 43 -rr) S.4.4) p6,4,2_,K. Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. addi 500 sq. ft. or portion 33.92 1
Tax map/parcel no.: Limited energy, residential 67.84 2
' lornititIMANgaliket2:-..1401600#0.0gstgrgi;iNailiginglakiniratil ( with Ilb° N ft.) .
Limited energy, multi-family 67.84 2
c-4- Z. / A/ Si 0 E e--r co A/ 0 -ii A residential (with above sq. ft.)
A /..' fr / 0 t.
V A G 1 < i. Services or feeders installation, alteration, and/or relocatio
200 amps or less _1 100.70 2
40N.tarlW00§itaiiii*,143i.raAlik..! gi".10:111.V-q1'0474Kit''.;.!ii•ji'aVili. 201 amps to 400 amps 133.56 2
\,r) 4.• SI ,. .. • • 1.. , ,... - • ,01,, ,•• • r ,-,, i 4i! .e,:::.ivi ,-.-',:......::..,:. ,,,i.,......: , .1: , ,.]:tio.,::;t;i::
401 amps to 600 amps 200.34 2
\..- Name: p 6 A 4 &) 4; ,S 601 amps to 1,000 amps 301.04 2
Address:e6 a z& II 'r ,s., (s 3 ,,,t ) 4 . Over 1,000 amps or volts 552.26 _ 2
.‘& City/State/ZIP: i # 1 y tx..-r A/ 0 i. 9 7 0 ° ‘ Temporary services or feeders installation, alteration, and/or
relocation
\.. Phone: (41)Z) (:),/, /- - 0 F Fax: (z3 6 7 6 -,. 9 Rr-- 200 amps or less 59.36 1
. 201 amps to 400 amps 125.08 2 .:
Owner installation: This installation is being made on property that I own which is not
p intended for sale, lese rent, or ex9ae, according to ORS 447, 449, 670, 3,nd 701. 401 amps to 599 amps 168.54 2
Owner signature: /W. ' t
Branch circui - new, alteration, or extension, r panel _
c:11, f Auk, Date: ' A 0 i ts A. Fee for branch circuits with
FncilingtillItt 1
i Weel'illi§(5k above service or feeder fee,
illilitnalid41046il.....; . A;!;‘;.
k\ • . t.ignli:...1: E each branch circuit 7.42 2
_ .
Business name: ') c ic 1 , E #__ r r i At f -- _. A/c 7rei;li, - B. Fee for branch circuits
, without service or feeder fee, 56.18 2
\f‘
Contact name: -r-( E.,,e, E . 5 A 4 L e. ,,,) To first branch circuit
•I\ Each add'i branch circuit 7.42 _ 2
Address: G. '/5 - 6 is AA- - DA Miscellaneous (service or feeder not included) _
>. City/State/ZIP: /5 £. A. y t- Ai 0 K 9 7 0 t' Each manufactured or modular 67.84 2
dwelling, service and/or feeder ._ .
\ .s.. Phone: (s-Va ) 4, V /..- 3 3 o 1 Fax : (s-a3) 6 . ? ..6 ..... I i s- Reconnect only i 67.84 /pill( 2
(.....? E-mail: c A- ,s, 7 . 7 - e- A-0 7 es....q4 L. • cau..• Pump or irrigation circle 67.84 2
' .
wort. ' ,,,mmur,ftwygtommegorpforzotgigilggy,5,1ff,10,1i0,,p1rmoniipnoiLig Sign or outline lighting 67.84 2
Signal circuit(s) or limited-
Business name: AI/ 4 energy panel, alteration, or
, extension. Describe: Page 2 2
Address:
City/State/ZIP: Each additional inspection over allowable in any of the above
Per inspection 66
Phone: ( ) Fax: ( )
Investigation per hour (t hr min) 66.25
- ".
CCB Lic.: 1 Electrical Lic.: 1 Suprv. Lic.: Industrial plant per hour 78.18
-.•-smer
gIVragggiiigigaig0XL.W,C.i.WiNafttg _ Uill51,0.tl,•Aa
Suprv. Electrician signature, required: Subtotal: Lo . $69
_
Print name:
Plan review (25% of permit fee):
Date:
- State surcharge on, of permit fee): . I
Authorized signature: TOTAL PERMIT FEE: 1
- This permit application expires if a permit is not obtained within 180
Print name: 1 Date: days after It has been accepted as complete.
• Number of inspections allowed per permit.
1:1BuildingWernsies\ELC-PermitApp.doc 10/01/09 4404615T(11/05/COM/WED
Electrical Permit Application - City of Tigard
Page 2 Supplemental Information
LIMITED ENERGY PERMIT FEES:
.o-�?- !in ?jA�'"�v�ms�5•,nf�•- `v' „u L
Fee for all residential systems combined .. $67.84
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other. t/
5
a�...�..'�...... -.�i .,�'.1 - a..`'�� `4Su� 7 a Arya. �� .; ir ilk{ l� ?�i•`i� ` 111111 . i
Fee for each commercial $67.84
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
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ 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 :\BuildingTamits \ELC•PmahApp.aa 1WOI/09
DCR PROPERTY MANAGEMENT, INC.
2645 SW 153` Drive • Beaverton, OR 97006
Business 503 - 641 -3309 • Fax 503 - 626 -2915
Email: dcrmgmt @hotmail.com
City of Tigard
Building Division
Via fax: 503 -598 -1960
Enclosed is the application for a permit to inspect the rental house
located at 10475 SW Park, Tigard, Oregon. DCR Property Management,
Inc. is the agent for the owner, Edgar Solis, who resides in Utah.
I have also enclosed a copy of our management agreement with Mr. Solis
. which went into effect June 20, 2001. If you require verification from the
owner, he has a local cell number which is 503- 351 -2118.
I understand the fee for this permit/inspection is $75.98 which I authorize
the City of Tigard to charge Discover ( information enclosed) .
Thank you for your assistance.
Theresa Valento
Property Manager
•
DCR PROPERTY MANAGEMENT, INC: 560
2645 SW 153 Dr.
Beaverton, OR 97006
503 -641 -3309
503 - 626 -2915 (FAX)
MANAGEMENT AGREEMENT
t consideration of the covenants herein contained, .5 G (hereinafter called "Owner"),
zd DCR Property Management, Inc. (hereinafter called "Agent "), agree as follows:
) The Owner hereby empl ys the Agent exclusively to rent, lease, operate, and manage the property known as
�o " „$ ' Sr T/. f)' Q 9 7"'Z?upon the terms hereinafter set forth for the
period of t9 &) , CAl beginning on the cJ day of. .g- , -/ and ending on the
3 o day of J w , v 20.: 1 0 1 - - , and thereafter for annual periods. Either party may terminate this agree-
ment upon thirty (30) days written notice after the expiration of months of the original term.
) The Agent accepts the employment and agrees:
a) To use diligence in the mane ement of the premises for the period and upon the terms herein provided, and agrees
to furnish the services of the organization for the renting, leasing, operating and managing of the herein described
premises.
b) To. render monthly statements of receipts, expenses, and charges and to remit to Owner receipts less disburse -
- meats. In the event the disbursements shall be in excess of the rents collected by the Agent, the Owner hereby
agrees to pay . such excess promptly upon demand of the Agent
c) To deposit all receipts collected for Owner (less any sum properly deducted or otherwise provided herein) in a
Client's Trust Account (C.T.A.) in a national or state institution qualified to engage in the banking or
business, separate from Agent's personal account. However, Agent will not beheld liable in the event of
bankruptcy or failure of the depository. .
l) The Owner hereby gives to the Agent the following authority and powers and agrees to assume the expenses in
connection herewith:
a) To advertise the availability for rental of the herein described premises or any part thereof, and to display "For
Rent" signs thereon; to sign, renew and/or cancel leases for the premises or any part thereof; to collect rents due
or to become due and give receipts therefore; to terminate tenancies and to sign and serve in the name of the
Owner such notices as are appropriate;. to institute and prosecute actions; to evict tenants and to recover
possession of said premises; td s ie for in the tiame ol' fife Owner and r2covei rents other sutras due; and when
expedient, to settle, compromise and release such actions or suits or reinstate such tenancies. Any lease executed
for the Owner by the Agent shall not exceed / year(s).
b) To make or cause to be made and supervise repairs and alterations, and to do decorating on said premises; to
purchase supplies and• pay all bills therefore. The agent agrees to secure the prior approval of the Owner on all
expenditures in excess of $ for any one item, except monthly or recurring operating charges and/or
emergency repairs in excess of the maximum if, in the opinion of the Agent, such repairs are necessary to protect
the property from ciAmage or to maintain services to the tenants as called for in their leases.
c) To hire, discharge, and supervise all labor and employees required for the operation and maintenance of the .
premises; it being agreed that all employees shall be deemed employees of the Owner and not the Agent, and that
the Agent may perform any of its duties through Owner's attorneys, agents or employees and shall not be respon-
sible for their acts, default or negligence or reasonable care has been_ exercised in their appointment and retention.
d) To make contracts for electricity, gas fuel, water, telephone, window cleaning, ash or rubbish hauling, and other
services or suchof:them as the Agency shall deem advisable; the Owner to assume the obligation of any contract
so entered into at the termination of this agreement.
e) To recognize Agent as the broker in any pending negotiations on saidpremises, or part thereof, and in the
event of the consummation thereof Owner shall pay to Agent a commission therefore at the rate prescribed in
Paragraph 4 (e) hereof.
•
The Owner further agrees:
a) To save the Agent harmless from all damage suits in connection with the management of the herein described
property and from liability from injury suffered by any employee or other person whomever, and to carry, at
his/her own expense, necessary public liability insurance adequate to protect the interests of the parties hereto.
The Agent also shall not be liable for any error of judgment or for any mistake of fact of law, or for anything
which it may do or refrain from doing hereinafter, except in cases of willful misconduct or gross negligence.
b) All refundable deposits will be retained in the C.T.A. until properly allocated at termination of tenancy to
which they apply.
c) The Agent is hereby instructed and authorized to accrue and, pay from the Owner's funds:
Item Company /Address Amount
() Mortgage
() Insurance
() HOA Dues
( ) Property Taxes
() Other
( ) Funds to Owner
e
d) To retain in C.T.A. to use for emergency purposes, a minimum of $ /4 -
e) To pay Agent: eJ;
1. A management fee ofof the scheduled monthly income_
2. A rental (tenant placement) fee of V2 of the scheduled monthly rent. .
f) Other:
1_ Rent to be $ per month.
2. Security deposit is to be $ , Pet deposit $
3. Rental terms
4. Owner restrictions !1O 1P s /Up 311 -d :0•144:
5. Tenants to pay monthly rent in full. A refund from Owner's C.T.A. will be given to tenant for authorized
repairs or services performed by the tenant.
g) If this agreement pertains to more than one (1) unit/property, Agent is authorized and instructed to transfer funds
from one unit/property to another for purposes of prompt payment of bilis.
his agreement shall be binding upon the successors and assigns of the Agent, and the heirs, administrators, executors,
id assigns of the Owner.
1 WITNESS WHEREOF the parties hereto have affixed or caused to affixed their respective signatures this
%S; day of /
Y BY � " s
Agent Owner
roker Initials BY
Owner
DCR PROPERTY MANAGEMENT Property
2645 SW 153RD DRIVE
BEAVERTON, OR 97006 V „' Management, Inc”
Phone: 503-641 -3309 • Fax 50326 -2915
o-, os ®s
Fax ...,
Tx 716 ice - /Lida • EO % Fmnx De' - Af$ T'
Fax ro 3 - S f 8 - / 9 60 Date: (a - 2P- e S
Phone: Pages 7
Re: CC:
0 Urgent Erfor Review ❑ Please Comment 0 Please Reply ❑ Please Recycle
•Comments:
/ , Q - L% e-f A
d am`
PLEASE CALL IF YOU HAVE NOT RECEIVED ALL PAGES.
THANK YOU,
al
Theresa Valento
Ca Lawson
. a,Ae""-d : s?'it•eil'a"4......."
CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2009-00582
• 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/30/2009
Parcel: 2S102CB06801
Jurisdiction: Tigard
Site address: 10475 SW PARK ST
Subdivision: Lot: 0
Project: Solis
Project Description: Reconnect only.
Owner: FEES
SOLIS, EDGAR Quantity Description Date Amount
C/O 2645 SW 153RD DR.
BEAVERTON, OR 97006 1 ea Reconnect Only 10/30/2009 $67.84
1 ea 12% State Surcharge - 10/30/2009 $8.14
PHONE: 503-641-3309 Electrical
Contractor:
OWNER
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $75.98
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. /
Issued By: Permittee Signature: 4Al' /$~/00 L eel--77 U ~V
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' Date:
LICENSE NO.
Call 603.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Electrical Permit A licati FOR .
p9
City of Tigard ~p Receiv
ed /0
OC bateB ~d OJT Permit No.:16-LO''.~Za •-QO,.XJ
_ 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
12, : Other Permit:
Phone: 503.639.4171 Fax: 503.598.1960-~`~ DateB :
a Inspection Line: 503.639.4175 Cj` Date RcadyBy'. Juris: H See Page 2 for
Internet: www.tigard-or.gov v\`OA v Notified/Method: Supplemental Information
i(t+08"1 i 9 o~ ss ~l, xr~, v•u~y,y i"a~1 yt~+,xr~.+r,7'1+=il<vc.tII)tl +,±,~l ttY ~i! 1+.. "f f ~r 1,,: 7 !''1~.'m5 ~`£`re ~1 7r - .~+a,'i~,+:' Ji'l i(`1
~u31,"...1' ~t ~ ?f 1:;4 + t , I +Il . l+.tl+. !4,~1, .4:SSF.:e,'li~t~~'3;~:,4,'tzf,St ll +iY.x••r++~r,~,+~.A'+~,+(~i.lll `i~.phgl~, ~J$~H~..ii'~~~ei.'..
~s,, U Ell
❑ New construction ❑ Addition/alteration/replacement Please check all that apply (submit 2 sets of plans w/items checked below):
/ ❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ® Other: V/} GA to -r A- lo et where the available fault current Q Marinas and boatyards.
1~y x rtyy~t 7, f r ~j~, Floating ; exceeds 10,000 amps at 150 volts or buildings.
rlaa "T, t I?l., xQ`~I''i,~O,ll!`i)~{~`il,.
less to ground, or exceeds 14,000 El Commercial-use agricultural
1- and 2-family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi-family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
u'ru S" trif•~ Pt is ~r jj, h n r , ~r ,t ,~r+• r n , fi;t 1 r,r. x /y ❑ Emergency system. larger separately derived system.
b Addition of new motor load of ❑ "A" "E, "1.2 1-3"
❑
Job no.: I Job site address: 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: 7-+l t~ a 0 Health-care facilities. Q Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt, no.: Project name: ❑ Service or feeder 600 amps or more
N ,n'~p~l' a'~~rlri ,+2° t rr_
t~~tT..Rtrl .rbv'+:;~1±.'Fh9"~m'4..,r,~
Cross street/directions to job site: Description 1_ Qty. I Fee Total
,t New residential single- or multi-family dwelling unit.
7 te) -7-0 nn s. co Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1
Limited energy, residential
t 67.84 2
/ t ;Iz f 72+„~ rirl~`i
t{~ 'Qr it !b' + , 7' B
fl T,
±,`f,. 1i?!4•-.w.~. !!i rr?"frff~%t+. S'!; 'x.rl ,x ,nsY;l i:'1."'U „'.'`~i' Wit118bOVe sq. ft.)
y Limited energy, multi-family 67.84 2
C L E G T~~ r `Gi¢ / a s ~7^7`11 n/ O /Q residential (with above sq.
Services or feeders installation, alteration, and/or relocation
1ri4 GA r ~O u 200 amps or less 100.70 2 V IM
201 amps to 400 amps 133.56 2
Name: (p S 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address:0 7 3 ,e Over 1,000 amps or volts 552.26 2
City/State/ZIP: 6[-R y f-A rn Al o 9 7 d D Temporary services or feeders installation, alteration, and/or
relocation
Phone: (S 03) (pc f -33o 5' Fax: (Sj,-_~ 6 Z ~ - _-a y' 200 amps or less 59.36 t
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale, lea e, rent, or exc}agge, according to ORS 447, 449, 670, qpd 701. 401 amps to 599 amps 168.54 2
Branch circuits - new, alteration, or extension, per anel
Owner signature: ff~~ Date: A. Fee for branch circuits with
t
+{_Yi t i`1'{1 , iC CT F ] Sl7N _ above service or feeder fee, 7.42 2
Business name: each branch circuit
C ~~p F_ B. nt .rvi _T Al C- B. Fee for branch circuits
Contact name: without service or feeder fee, 56.18 2
Vl -r'W E_ ESA 24 L /J T"O first branch circuit
\ Address: o2& y5 - 6 3 ~ ` D,e Each add'I branch circuit 7.42 2
Miscellaneous (service or feeder not included)
City/State/ZIP: R ✓ AJ /e T C' c) 6 Each manufactured or modular 67.84 2
Phone: Fax:: a dwelling, service and/or feeder
> ` 3 3 0 9 (S 3) G Reconnect only 67.84 2
E-mail: G R /yt ~yt i Q r- ps ,4 L C.B.c._ Pump or irrigation circle 67.84 2
J~ {j 1• ~q + Si or outline lighting 67.84
i~ u~ P rr~ 7y ~ t Rt nl+t+ ~..t i~l! +t - 11 I ri..,, l+ ~'#!i:`l ~4''
Business name: Signal circuit(s) or limited-
z" 1A energy panel, alteration, or
Address: extension. Describe: Page 2 2
City/State/ZIP: Each additional inspection over allowable in any of the above
Per inspection 66.25
Phone: ( ) Fax: { ) Investigation per hour (I hr min) 66.25
CCB Lie.: Electrical Lie.: Suprv. Lie.: Industrial plant per hour 78.18
ti= + + .{t} i i a EG+Tr 'iy ~ P x;til~` ra,lliaL
Suprv, Electrician signature, required: Subtotal:
Print name: Date: Plan review (25% of permit fee): ea=
State surcharge (12%ofpermit fee): ,
Authorized signature: TOTAL PERMIT FEE: 1 g
This permit application expires if a permit is not obtained within 180
PI Irlt name: Date: days after it has been accepted as complete.
" Number of inspections allowed per permit.
1:\I uHdingWermitslELC-PermhApp.doc 10101/09 440-4615T(11/05/C0M(WEb