Permit CITY OF TIGARD MASTER PERMIT
1111
11 COMMUNITY DEVELOPMENT Permit #: MST2010 -00166
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/29/2010
Parcel: 2S109AB09900
Jurisdiction: Tigard
Site address: 13160 SW HOOD VISTA LN
Subdivision: Lot: 0
Project: Harvey
Project Description: Convert 170 square feet of garage to habitable space.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 170 sf Basement 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Yes
Total: sf Value: $16,651.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0
Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0
Tubs/Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0
Drains: 0
Bckflw Prevntr: 0
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 1
Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Fum > =100K: 0 .
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/ Svc or Fdr: 0
Ea add' 500 sf: 0 20 1-400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr:
Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add'I Br Cir:
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +amp /volt: 0
ELECTRICAL - RESTRICTED ENERGY
SF Residential
Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
Owner: Contractor: Required Items and Reports (Conditions)
HARVEY, KATHLEEN FIRST CHOICE CUSTOM HOMES INC
13160 SW HOOD VISTA LN 13115 SW ST JAMES LN
TIGARD, OR 97224 TIGARD, OR 97224
PHONE: 503 -432 -5970 PHONE: 503- 579 -3538
FAX:
Total Fees: $1,028.16
This perrni ' • : • subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be d• • - in accordance • . 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
da . ATTENTION: Oregon law . you to follow the rules adopted by the otrfi on Center. Those rules are set forth in OAR
• • 2- 001 -0010 through OAR 95 s r - r. You may obtain a copy of the rules or direct qu tions to OUNC by ca ? • . • • 6.6699 or 1.80. 332.2344.
sued By: / 6 e 44.,L,L, Permittee &oil �!��--- . =as__
- - --- e — Building Permit Application w
Residential ® I (►R UrrICl: 1,s1.: ()NIA
City of Tigard Received LJ o d Permit /�
lig `J g Date/B : / J � p it No.: 0 � e e „..4 0 /'Y'
C
q 13125 SW Hall Blvd., Tigard, OR 972�3� - g 2.0 Plan Review
Phone: 503.639.4171 Fax: 503.598.1868 Date/B : e. _ vh.... Other Permit:
I I . ,� It r> Inspection Line: 503.639.4175 ARD Date Ready/By: Juris: El See Page 2 for ■
Internet: www.tigard -or.gov ,� D oF G - r Notified/Method: Supplemental Information
TYPE OF WORK V REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees' are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
A ddition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and theprOtthe
CATEGORY OF CONSTRUCTION
work indicated on this application. /6 0
[[l- and 2- family dwelling ❑ Commercial/industrial
Valuation: $
El Accessory building ❑ Multi - family Number of bedrooms:
1
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors: 2 - PKLST7 I\LC-1
Job site address: ' 3 , (..e.0 .S W i-to Ob U 1STA L-0 New dwelling area: ' - 7 0 square feet
City /State /ZIP: en C, , O C>I„. q X22 4.. Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
AD' 13 ATM 2 "bv-D I2.�Uwl To '�.�i_4r'iNC� Valuation: $
67 A 0-Aar— £p c..E- Existing building area: square feet
New building area: square feet
'PROPERTY OWNER I ❑ TENANT Number of stories:
Name: fr-- A-rK 1 1-i A ttutrf Type of construction:
Address: . A �` ►� _ t Occupancy groups:
City /State /ZIP: � Existing:
Phone: (S f3 2. 5? ?O Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed. If the
City /State /ZIP: applicant is exempt from licensing, the following reasons
apply:
Phone: ( ) I Fax:: ( )
E -mail:
CONTRACTOR
Business name: F112-S r C4 C-r c 0Sitino! It 0 e '9AS /dam BUILDING PERMIT FEES*
Address: 7 /! S S c ST' QOM 8,S 4-46/ (Please refer to fee schedule)
Structural plan review fee (or deposit):
City /State /ZIP:
ri o AK_0 0 ✓Z Q}22 f-
Phone: (5 eela - 7-13 Z Fax: (St:a3) l . Ca. 4GIZ2 FLS plan review fee (if applicable):
CCB lic. �3 ea Z' Total fees due upon application:
Amount received: ll t z f(. 10
Authorized signatura! This permit application expires if a permit is not obtained
/ within 180 days after it has been accepted as complete.
Print name: 7' /fl'l f All (L (c_ I Date: Cl/2_4 is * Fee methodology set by Tri -County Building Industry
Service Board.
I:\Building\Permits\BUP -RES PermitApp.doc 10/01/09 440 -4613T(I I /02/COM/WEB)
Building Permit Application Checklist
One- and Two - Family Dwelling FUR OrFiCI list: ONLY
J
City of Tigard R eceived Permit No.:
14 13125 SW Hall Blvd., Tigard, OR 97223 Date/By:
• Phone: 503.639.4171 Fax: 503.598.1960 Associated permits:
- 24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
r 16 A ii I Internet: www.tigard- or.gov ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR I'LAN REVIEW y N(1 N /:\
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑
3 Verification of approved plat/lot. ❑ ❑ ❑
4 Fire district approval required. Name of district: . ❑ ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity ❑ ❑ ❑
6 Sewer permit. ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.
11 Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ ❑
there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements
and driveway; footprint of structure (including decks); location of wells/septic systems; utility locations; direction
indicator; lot area; building coverage area; percentage of coverage; impervious area; existing structures on site; and
surface drainage.
12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑
and location.
13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑
furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc.
14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑
floor, wall construction, roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings
and foundation, stairs, fireplace construction, thermal insulation, etc.
15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. ❑ ❑ ❑
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full -size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing (prescriptive path) and/or lateral analysis plans. Must indicate details and locations; for non ❑ ❑ ❑
prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor /roof framing. Provide plans for all floors/roof assemblies, indicating member sizing, spacing, and bearing ❑ ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ' ❑ ❑
systems, see item 22, "Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑
over 10 feet long and/or any beam/joist carrying a non - uniform load.
20 Manufactured floor /roof truss design details. ❑ ❑ ❑
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑
for four or more appliances.
22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or ❑ ❑ ❑
architect licensed in Ore. on and shall be shown to be at •licable to the 'ro'ect under review.
-IURI' I)IC T ION,\I. ' I'I (II ICS
23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. ❑ ❑ ❑
26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document. ❑ ❑ ❑
27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑
28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
I:\ Building \Permits\BUP- RES- PermitApp.doc 03/21/06 440- 4613T(11 /02/COM/WEB)
Mechanical Permit Application . FOR OFFICE USE ONLY
City of Tigard Received I n
Date/By: 5T l0� i p Permit No.: / .0 ,
NI
° 13125 SW Hall Blvd., Tigard, OR 97223
C ' Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Other Permit:
Date /By:
T I G A R ID Inspection Line: 503.639 Date Ready /By: Juris: la See Page 2 for
Internet. www.tigard-or.gov Notified /Method: Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
Mechanical permit fees* are based on the value of the work
❑ New construction ® Addition /alteration /replacement
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
®I and 2- family dwelling ❑ Commercial /industrial RESIDENTIAL EQUIPMENT/ SYSTEMS FEES*
❑ Accessory building
For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other:
Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Job site address: 13160 sw hoodvista lane Air conditioning
(requires site plan showing placement) 46.75
City /State /ZIP: 97224 Furnace 100,000 BTU (ducts/vents) 46.75
Furnace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: Project name: Heat pump 61.06
Cross street/directions to job site: Duct work 1 23.32
Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Ravens Ridge Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 23.32
Gas fireplace 33.39
Add one ADA bathroom & bedroom in existing garage space Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
Wood /pellet stove 33.39
Wood fireplace /insert 23.32
❑ PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32
Other 23.32
Name: Kathi Harvey Environmental exhaust and ventilation
Address: same
Range hood /other kitchen
equipment 33.39
City /State /ZIP: same Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: (503)432.5970 Fax: ( ) toilet compartments, utility rooms) 1 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name: First Choice Custom Homes Inc Other: 23.32
Fuel piping
Contact name: Tim Walker $14.15 for first four; $4.03 for each additional
Address: 13115 SW St James Ln Furnace, etc.
Gas heat pump
City /State /ZIP: Tigard, OR 97224 Wall /suspended/unit heater
Phone: (503) 880.7132 Fax: : (503) 821.6462 Water heater
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: Firstc Choice Custom Homes Inc Clothes dryer (gas)
Other:
Address: 13115 SW St James Ln MECHANICAL PERMIT FEES*
City /State /ZIP: Tigard, OR 97224 Subtotal 90 , 00
Phone: (503) 880.7132 Fax: (503) 821.6462 Minimum permit fee ($90.00) _49--
Plan review (25% of permit fee)
CCB lic.: 138321 State surcharge (12% of permit fee)
TOTAL PERMIT FEE
Authorized signature: ai��`"�� - This permit application expires if a permit is not obtained within 180
l days after it has been accepted as complete.
Print name: Tim Walker Date: 9/26/10 • Fee methodology set by Tri- County Building Industry Service Board /
I:\ Building \Permits \MEC- PermitApp.doc 10/01/09 440 -4617T (1 I /02/COM/WEB) ,
Plumbing Permit Application
Building Fixtures
ty al' Tigard R, ta ! /A io PettDa h� 5r�rrv_c0 /66.
13125 SW Hall Blvd., Tigard, OR 97223 pion Review
• Mom 503.639.4171 Fax: 503 598.1960 may, Ode rPermitNo.:
Inspection Line: 503.639.4175 D aleReady/By: ms Se
° c; F; n 4175 Page 2for
Internet www.tigard- or.gov NntifieWerhod: Irdoem>rt1ou
TYPL OF WORK IIP SC1llE.U0...:
D New construction ❑ Demolition For spedal information are ehecidist
Description I Qty_ I Ea. f Total
El Aalditionhdlendionlrepla 0 Other New 1- 2 -ihmiy dw (includes 100 ft_ for each utility connection)
. • • • CATEGORY .OF CONSTRUCTION
S(l) bulb 312.70
rig 1- and 2- family dwelling ❑ CommtaoialAndustrial SFR (2) bath 437.78
SFR (3) bath 50032
['Accessory building ❑ Multi - family
Bach additional bath/kitchen 25.02
❑ Master builder ❑ Oder Faro sprinkler( , s411) Page 2
. JOB SITE 1�ORM Free AND LOCATION e :
Job site address: 13160 Boodvista Lane Catch basin or ama drain 18.76
City/State/72P: P. Tigard, Or 9727.4 Day e4 loch ling or treads dr. 18.76
Footing drain (no. linear ft_: ) Page 2
Suite/bldg./apt no.: I P ujcct name: Manufactured home utilities 50.03
Crass meeddimxtions to job site: Manholes 18.76
u_ Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _,) Page 2
Storm sewer (nu. linear 11.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item: _
Tax map/patcei no.: Backtlow preventer - 31.27
DESCRII' A ION OF WORK . Backwater valve 12_51
Clothes washer 25.02
ADD one bathroom and bedroom in cxv6znp garage space
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
. 0 PROPERTY. OWNER I .0 TENANT Expansion tank 1251
Name: Kathi Harvey Fixtwc /sewer p 25.02
Floor drain/floor sink/hub 25.02
Address: 13160 SW Auodvista Lane Garbage disposal 25.02
City/StatrlZIP: Tigard, OR 97224 Hose bib 25.02
Phone: (503)432.5970 Fax: ( ) i Ice maker 12.51
0 'APPLICANT . . ❑ CONTACT PERSON • Interceptor/grcas.c trap _ 25.02
Medical gas (value: s ) Page 2
Business nacre: •
- Primer 12.51
Contact name: Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 1 25.02
City/StateiZIP: Solar units (potable water) 62.54
Phone: ( ) I Fax : ( ) Tub/showedsbower pan t 12.51
[Urinal 25.02
E-maIl Water closet 1 25.02
CONTRACTOR Water beater 37
Inc; /
Delta Plulabmg 02
water piping/DWV
Business s " 56. _
Address:
0 ! W o _ Subtotal M
err / J V K NGn'unum permit fcc: $72.40
CitylState a: aarje ( )
Phone: ( ) Fax_
'�Z_ - 1 pimmn. em3
�" Y.1C - -' s /, / u a w % rm )t b no t p6g1ae0 within 1R0 data
` �9 O�1 V - l'hir lxrm ap AHOn t DI "cel . . eoa dwar .
n 7.ed signature: �J . at�r °t DIM a {:oaa� aai t „dwt*r Heard,
AUtho Date: J . mel ntosy set by T
Print. Dune' 0 '
u,ew.mn. ti.,ka.w..v"- Aaa►MO.doe 11°149 92; 8 _( e 4/ 2
Td Wtli. T : T T OTOE Si? 'd 9S2E869205 : '0N Xdd ON I EWtild dwl8Q : WONJ
27 09 10 07:56 Fibia and Pavel 503 760 1787 p.1
Sep 26 2010 9:2SPM LIRERMBUILDER HOMES 503 -921 6462 p.1
Electrical Permit Applicaliriln i 01: Orr Fig 1. i , ,l: 1 I.\
City of Tigard Received
Dal ;: f AP io ,an Pa Na: s o
• 13125 SW Hall Blvd, T igard, Olt 97223 / . b
Phone: 503.639.4171 Fax: 50::.`_!18.1460 tithe lianas:
- 1 . 1 i.. Inspection Line: 503.639.4175 Date aresdylBy: kris: El See Panel fors
btfernet: www.hgard- or.gov Nairied/Method: 8uppkamal fuformadon
� � . . ._ .. .-71,:'-1:1: Fc t - .'r r� = : �-n: _� �':� -- _ iii''
a-- .'n c 1 _1 1 -.9: ...'i u ..,, =, --1, it,21:- i..•.-n C .r. l:i _�' _7 at r . - _� 01113 at
y J . c. .
0 New construction K.' Addition. alteration/replalteration/replacement _ Neese cheek an m apply ;Iceboat shs�af lirn s ebeckcdboor
❑ Sev ee or under 400 asps or more CI over duce stories.
0 DCrrtolltien ❑ < �
, z , .tare the available find: current ❑ Marirvv and boatyards.
I I ) ' A I : 1 ji -" a;:11-:-......:7-4-:)1 amens 10,000 amps at 150 volts or ❑ Floating bmldinga.
rja 1 -and 2 -farad ty dwelling ❑ (:otsunec..aeliindttsaial Ac cessory building m wont or mimeds 14.000 ❑ Coruna Addax agzicuhmad
g amps ter all other iraallrtions. bmidings.
❑ Multi-family 0 Master b•.iildler
❑ Other: O Fire pump. ❑ lestalletion of 75 KVA cur
r r ! � IH� 1` larger sepennely derived system.
t E - '' i . K . i � i � ❑ Emergeary systmr.
l
_. . uii!� ..� ,1 :!� !.1 -`� is � =', ifY, ' 1 ., i ?.LI_ 1 .� ntiro.; ❑Addition of new motor load of ❑ A .'.. E .''' 1- 2 „ I -3
Job no.: Job Site address ', al t.Q,o {��y� 1 00H or elate Recreational ` U V � Si r m more residential wits. Recreational vehicle pans
City/Starr/MP: TL G CI C1122-4- ❑ Health -care facilities. ❑ St pply voltage for more than
1:114ocerdons (oostirms. 600 volts nominal.
Suite/bldg.:apt no.: Project name: O Saoiee cur feeder 600 amps or more.
Cross street/directions to job ciao: L . '1
. 0eoiprma Qh. la. Toll •
i New residential single- or mufti - fatally dwetllag unit.
includes attached garage.
Subdivision: - 1 Lot no.•_ 1,000 sq. ft orient 163.54 4
Tax map/parcel no.: Fa add'I 300 sq. 11. or portion 33.92
Limited energy, residential
: �uX 1 '1- � l! rl.:i; i c:. - 77..:! r k ( with above a ft_) 75.00 2 ,
A,Vb 0/3 i -- Al wk Mr 1cr4tra xs/vt 4 VEDUX3Ill Limited
residential (with above r sq. R)
75.00 2
Services or rearm infant) don,atteration, and /or relocation
tJ lr-k UT! FA C At W. ACS 200 amps or dens 102.70 2
j:21.-01",-.: e ir=
. y_ : ct- i.: - _:,:ter. r1. 1".111 . - 1 ..=. j_ ,..N -L.11:''' r j." 1.: 201 amps to4o0amps 133.56 2
Name: A i 11 f1(1. -la.�l 40I amps to son amps 2003 4 2
1 601 oars to 1,020 arnps 301.04 2
Address: S31( Q H,CO:IV { SSA L ) Over 1,0011 amps or volts 552.26 2
City.BtateiZIP: "'i'lC�p o 1._ �* -22_4` Teroporvyservit�or feeders installetirw . alteration. and/or
relocation
Phone: a Ci 4 3 Z -5°( :.o . I Fax ( ) 200 amps or less 5936 r
Owner instailatioa This Installation is bein,;:nade on property that I own which is not 201 amps to 40041006 125.08 2
intended for sale, !r , rent, or exchange, ac.xrding to ORS 447, 449, 670, and 701. 401
Branch ci O4 1 599 amps 168.54 2
rcuits -new, alteration, or eareasloo, ter nand
Owner signature: Date: A. Fee for branch circuits with
1 - I I Ili i _i ,rl - above service or fader fa.
_ , 1 � 4 , - ..:_. . ,. Y:i' each branch circuit 7.42 2
Business name: H. Fee Car branch circuits sit9Fonr
-- sari m c or feeder fee. first 1 56.18 2
Contact name: branch circuit
Each add'I branch circuit , 7.42 2
Address: Miuellaneois (service or feeder not included)
Each manufactured or modular !
CitytStaLe/ZIP: - dwelling, service and/or feeder 61.34 2
Ph ( ) [Fax: ( ) Reconnect only 67.54 2
E Pomp Of irrigationcirdc 6784 2
il. -; -� ;�. r:7� I i r � Sign or outline lighting 67.64 2
11 ,,7r - -- :) : ..., iF,r G_ _ Signal arwit(s)orlimited
Business name: C..R.Ajo li C_ - Li_�CL'S"t2..1+` GO penal, alteration, or omare;r n pager _ 2
Each additional inspection over allowable in any of the above
Awn: IS IA -2 - ,s1-. 'L': C. L'-( 5-52- I - Additional inspection (1 hr man) 6625/ hr
City /State/ZIP' su'( X 0 « d ' i3
Investigation i l (I hr min) 66.25: hr
.. -_ lj Industrial plan' (I hr min) 71.18,'hr
Phone: (C�0 ci 13 - 2)41.1.5 .: •ax: (.503) . 9-6e,C7 - 11 g? Inspectors for which no foe is 90 CO/ ht
h s caddy listed is mind
CCB Lie.: �Z Electrical Lie.: �• 6 i i Suprv, Lic.: 3 /. g Y I , v ' ' - , rT_ ._._ .., °`
Suprv. El 4 11 7 i 'rt or e, hro �� �l1 V 'i /d /1 / �3 v a 5u btofa l:
� .__ � Plan review (2S% of permit fee):
Print name: GJ `C !T ' !7 r_ / - , Z� As Date: O/ �
g 0 State surcharge (t2%ofpemitfa):
rYl t 1 TOTAL PERNITT FEE: I I
Authorized signature: This permit applkatian aspires If a pliint it not obtained within 180
slap after it has been scooted a 4bmplef .
Print naula • -- ' "maxi. of inapwiorns allowed pa pniuii.
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