Loading...
Permit ; Nc,C scat (fi'mot ( biAAck c,' r', r fi CITY OF TIGARD ELECTRICAL PERMIT { COMMUNITY DEVELOPMENT Permit #: ELC2011 -00173 TIC ARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/06/2011 g fp Parcel: 2S109BA00900 Jurisdiction: Tigard Site address: 13655 SW MOUNTAIN RIDGE CT Project: Purkey Subdivision: THREE MOUNTAINS ESTATES Lot: 17 Project Description: (2) branch circuits for relocation of a/c unit. 6/30/11, repinted permit to include (2) additional branch circuits. Contractor: BRANDON KING ELECTRIC LLC Owner: PURKEY, DENNY J & DIANE E 18400 NE HILLSIDE DRIVE 13655 SW MOUNTAIN RIDGE CT NEWBERG, OR 97132 TIGARD, OR 97224 PHONE: 503 - 538 -2727 PHONE: 503 - 590 -6115 FAX: FEES Quantity Description Date Amount 2 crt Branch Circuits wo /Purchase 04/06/2011 $63.60 Specifics: Service or Feeder 1 ea 12% State Surcharge - 04/06/2011 $7.63 Type of Use: SF Electrical Class of Work: ALT 2 12% State Surcharge - 07/01/2011 $1.78 Electrical Type of Const: 15 Electrical Permit 07/01/2011 $14.84 Occupancy Grp: Total $87.85 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 OA' 952- 001 -0090. You may obtain_a copy of the rules or direct questions to OUNC by calling 503.2 1987 or 1.800.332.244. Issued By: "0 • 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. ELEC' 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. CITY OF TIGARD ELECTRICAL PERMIT `r'7 COMMUNITY DEVELOPMENT Permit #: ELC2011 -00173 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/06/2011 Parcel: 2S109BA00900 Jurisdiction: Tigard Site address: 13655 SW MOUNTAIN RIDGE CT Project: Purkey Subdivision: THREE MOUNTAINS ESTATES Lot: 17 Project Description: (2) branch circuits for relocation of a/c unit. Contractor: BRANDON KING ELECTRIC LLC Owner: PURKEY, DENNY J & DIANE E 18400 NE HILLSIDE DRIVE 13655 SW MOUNTAIN RIDGE CT NEWBERG, OR 97132 TIGARD, OR 97224 PHONE: 503 - 590 -6115 HONE: 503 - 538 -2727 FAX: FEES Quantity Description Date Amount 2 crt Branch Circuits wo /Purchase 04/06/2011 $63.60 Specifics: Service or Feeder 1 ea 12% State Surcharge - 04/06/2011 $7.63 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $71.23 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENT . •. • - • - • law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952- 001 -00 • throu•h OAR 952-88 •s• '. • ay obtain a copy of the rules or direct questions to OUNC by calling 503.2 . 87 or 1.800.332.23 4. Issued :y: Permittee Signatur OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR. ELEC' I Date: f/v, LICENSE NO. 5 34 5 Call 503.639.4175 by 7:00 a.m. for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. FROM : 40 ,,n' FAX NO. : Aug. 31 2010 09:03PM P 1. t ee fro- O €. by ch G r ✓.-c- i-'t . X; 5A- ' V "‘ C Ro t�S Elect rea P A li EIVED 1.0k QF F' I( 1 r sl i) I 'I + • City o f T l ark R e ceived / No.: L ' O t ••) t r Dot : /ny: 6 i I," Permit 114 r a .. 13125 SW Ball Blvd., 'l "igtud, OR 97223 Plan kcview Other PcrmiC _ Phone: 503. 718.2439 Fax: 503.598,196(�U N 3 0"2011 Date/Ely: . Inspection Line; 503.639.4175 - ' 1)ate.Rcady /13yt P ® e P,gv 2 for TSi. .. ;III apD !� Sc S$:menial inforlrntan i Internee www,tigard- or.gov , III O F TIGARD .. f ., v r i' i'1 i, { - rr , ti,�,r,ie ?i 4 h.1-,, • • ma� aaisr • Nt, n .,y,nl - � .ye t!te, d 1 vlh' ^ri i ,,!. Vl Y r I r ^, r „ e , ' ? r , I „ .7<. : , _ 1 .l V' + , ;t:t a,4lil,' : * i r... l l „aV i rK " •N t Ati . ' ) •1 .'l 1 a :: '4: 7 :r: -' L l r Zl r r l:i kill ilr Ili ,t!i14.,t I a l' , ,,Y , '°a'' �rrn, � aiurlrir - -r ,-� , r. J SV •I, Ir , 6 �'.,.... r Please check all that apply (submit Sots of plans w /hunts checked I below) ❑ New constriction P2 • dditinn /altcration/replaccmerll ❑ Service or feeder 400 amps or more ❑ naildina over lhrce stones. ❑ 0 Other: where, the avniluble fault current El Marinas and boatyards. Dcmplil.in n r :: ^..,, ��,•.,... ..:� ...,,•, �,......._ r.�r.�a::v ,,,�... � ,n.:v::a'�.dy�. „�u •�P:J: e;.;rr.iegxr,.;:" am S 0 volts or Floatms buildings. !:r,-,. • r r.r, r:; = : l y t ! I t Y ; I F r` .,, .19 10,00 mow. at 1- , :rl �;;;,;,'i,; »;;L;r, i , Ifli �a j • , � Q �,i,.r,• .r . ?Il, "� (' C,.. : l -tl..e agricultural ,�,,„, r „,,,, "..•,• ' ,r> , ,�, r Icss to round, or exceeds ] 4,000 ❑ C'ommecciu c a tic ra 1 O.1 and 2- family dwelling ❑ C:ommcrcial/industria( ❑ Accessory building mops COI' all other inaudlations. tr buildings. y ❑ Master builder ❑ Other: pump. r--1 Installation of K or ten ❑ Multi-family der; system. )th ❑Fite p. on an Ifmtlr CI1Cy system. lamer w1 v G,.... i r ,• ; :.., ; ,......,: c.:' "M1l::� i,, ,.:::..- ......tllik .. y N. ;:: , 1 i f 2 .:I c: +,. �. ll: t "ii '`l i ,. R y ',:: t t t : t i I t 1 i r) it I t a t . , • ,: t m , : v ,r, l M1 ,. , li?f ; ?, tylf ,17.,,. t ,'�i' ❑ Addilio o f n ew motor lead of ❑ "A ". 1_-t.. {-y 6„515 5 5U Pyl C� dJ �'•� f00HP ormore. occupancy. Job no.: Job site address: t ] J�.J I r t rP1 p R ecrea tional vehi ,arks. © or more residential units. t ❑ Health -care Iazilitics. ❑ d00 volts nominal. for morn than City /StateIZTP: s \ -- , ()CU( qh�� � _ El Hazardous locations. V ❑ Se or feeder 600 amps m more Suite/bldg./apt. no.: Prulcct name: ,..,...,,',,::, •. ""'^��,,°".. n whose Cross street/directions to job site: Ocsedpt:on M 1 Qty. 1 . Fee, ( 'I'md 1 ,._ New residential single- or multi - family dwelling unit. includes attached garage. Subdivision: _ 1,000 sq. ft. or less 168.54 4 Lot no.: - „ . •^ y Pa. add't 500 sq. R. or portion 33.92 I o, • Limited energy, residential ) `. ,. /parcel n 2 .. map /parcel �:,.���,�,... • • �, ,:. rn •�.�.,•.r.� � • ,, y ,..r��•. y .�..,.,� ��, n," �:.'w °� �.:: e, .: drra: rp7! P !l.irl.;;ilx.c.:'.:.,v.;r. ' �, rY.; r r24 1 : . , i1 ,I , . r 1!r I " tI .hli , '�TL' ir {r���}.,O;; , r,.E�„ r l n „�yl; { . il l t Sii},rr,, (With lbUVe4t ,t. ft.) 7 (1{ w .,� _ a",u; , p r.,: Il) ,i ,. , I.',.,,,, � "�. r .,,hTl : " 2 I Limited energy, multi•t?tmily 75.00 , r . 2 yl vest ca ,� e i,�(t,� l e c h, y + � � residential (with above sq. tt. - /• - ^_ J f ��-/a�_ Services or feeders installation, alteration. and/or relocation . 2 yhOtJ• �(,/C tt/ 4 . 200 amps or ICES 100.70 2 ..,rr , rP ,.,....:.., ii .r.".^,.!" ••,r.,..r.::.. i•,,.....�,. ',';: .� y ... ale : ,,IT'i: :: A=:::. -.,. ."""•".�. . a� EI:{,: ":: , 4 , 4m!ii1.:.:. -.., �' f{ :.,.. w .r, :;,1 ;,1., "° 2 ;�r,.:: a1;:.::.�, ,:,:, , •„ ... , ,.::' ., .... �,...,.,:.... rdr:::: ;11;1... .air: ? :,.... 1;r «:.: 201 amps to 400 am 1'33.56 ............c,::::...... . .. »..m1U1,,7. �,r .,.,,,e,. , Phil` rn ; . v . :: , . ,,, .ii , h ?I1,i :,v .. pl ',n r "' rr. • l ":" f�...., . : P. none: t 1 � y PL/ tr as,. 401 amps Lu 600 amps 200.34 2 601 amps 10 t 000 amps 301.04 2 Address: 1 [ 4, W r 0 N - f Over 1 000 amps or Volts J ______5522f 2 O Temporary services or feeders instanation, alteration, and /or City /State /ZIP: I. "1 () relocation Phone: (SO 3 ) tA S tilCIO Fax: ( ) ~ 200 amps or loss 59.36 I - 400 201 amps to 4 amps 1265.08 2 Owner installation: This installation is being made on property that I own which is not 201 amps to 4 amps 18.5 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 470, and 701. Branch circuits -new, alter or extension, per panel Owner signature: _ . Date: A, Fee for branch cifcuit•4 with circuits without „ „ ° ,•:,• ; t s hove s ervice or feeder fen : r: - r ,,..,.,.,, r.r n, e. ::,.. ', 1,:I:, !, 1 ,, . '�1 :I rl 1.:: . 2 2 ,, „M1L,.... F .. l I, ., �.�•::,:;,.:: ' ?:a Y • ,Li: ii" ;tii: yii4. 7 , ,,, ,,,, ,;'..., . ......:, r r' ha "r,. l., rd.. ., : • ...... . .......11 .'. , :. � 4 . . a „r. ;Gt'r �r :: , ,,,. � : :�..•I� , �r � � ,, , ,� „� t,,, i ; ,. ���;�it�` ,r,��:, .: P�su1. each branc c ircuit 56. t , 1 r � L C R. Fee for blanch h Business name: �, o service or feeder fee, float 18 2 branch circuit. Contact name: 6�� �,� _ -- -• Each add'l branch circuit �• 7.42 ---.E. Address: q 0() PE l& l( ,'�.l ✓. .1 t_ _ Miscellaneous _ or feeder not included) • - p � � Fsch manufactured or modular 2 City /Slu.te /ZTP: J�/ bUL 011 I - dwell i% service and /or feeder 67.x4 Fax: Reconnect only 67.84 2 Phone: ( ) c3 - 2,1 : ( ) 2 . �, i ilea circle 67.84 E -mail: 3 V ` V e-0lYl'% 1 M or u outline lighting 67.84 m � 2 , ,. , . ,. rr / l rrl r qn,., �,,++ , I - J,u - ,•, +... i Irl+ r iJal, /r Sign l ircu Business / ,Pi ', ":•'l '-Pr' 1 1',0 � i + � : e t „ , ..,, , r Signal cireuit(s) or lilnit:el -mum s name U ;: ,C 2E191, alteration, or extension. Pagc 2 2 Each additional inspection over allowable in any of the ahoye_ Address; E) 1,100 € - l . i W'VL Additional inspection (1 hr min) 66.25/ hr D' 1 'n tnvcytigttli0p (1 hr min) 66.25/ hr City /State/ZIP: N K C 1 ,i� • 78.18/11r _ lndustr'ial plant (1 hr min) Phone: (! ) s `�vv - Fax: ( ) Inspections the which no tee u 90.00 / hr s pe e citi - call I l + isted (' / n) r,..,.'', hr tai CC$ Lie.: (ri agj ( I Elec.tnc al 1 ic.. ' � Suprv. LIC.. G o !.::; ,tl C,. lJ t�;fr,r 'i ,l ' " subtotal: y Suprv. Electrician Signature, required: _ _ Plan review (25% of permit fee); Kett Print name: L/jp I till' y�,� D ate: *{p( ' c1 i ` State surcharge (12% of permit fee): ; , �l �] - 1 . OTAL PERMIT FEE: I C.- Authorized signature: Thi permit upptication cxpir , Ira wink .e not obtained within ISO "--" "' days after it has been accepted as complete. Print. name: Date: - J ' Number of inspect h tns allowed per permit. I:1 8uildingiPennils \ELC- PermitApp.a0e 07/1/1/10 440.46157(11 /t15 /COM/WEB FROM : FAX NO. : Jun" 05 2010 02:59PM P 1 Electrical Permit Application FOR OFFICE 1. ONI.% City of Tigard g Received t/ O Date/13 : 7 S if p�l • / Pcnnit Ni). n.: �11—�173 i- _ 13125 SW Hall Blvd., Tigard, OR 57223 A K .a J L 0 j 1 Plan Review Phone: 503.718,2439 Fax: 503.598,1960 • Date/J3 Other Permit: hint: 503.639.4175 T : i , � ti r, Inspection r' i T\, rate Ready/Hy J H See rage 2 for Internet www,tigard- or.gov - Notified/Method: Supplemental information .... Ire "� d :�• ,.. �x...........e.... , iss'. !' ... ' ;x ,. '_'' r -... _ . .., ...; ,,,o,,,� • . rr:cr,, ..;, C�! :,u rmrr - ^nrrr: • r..... . r . 1. a :•::•i.l.... l._ . 4 CGa :fir. :...x. l ?.. ur. +.,, rx ,ti,...._...A,J...e. ,,:, .,.,.,,. x{ , . i1 ... ,r s , .. n ,. >..r .-....,r. ,a die" Sf i�`i:iiir 1 - im t,. r;; : :re, ,,, :v , :1d, a t. "R'1• .'te.... , d,*.. r r.,Ya ++ - �� :r'- n xi:n ... as ,ry.rxf.'�� � c . ..:"i' �{�'. _..., �= iiGEE)fS'fi' :f ......._., ,...r.. ...3, :RH1h,,, - ... alh ,..... ,{ , - ....fir � .. "- � .. x , y � ra { . ,a „ - :� in r 7• __ �?,�,.l� ���c: :... - �' . .. � q - (.. :. :. ..._I�Y lsr � +•+ t!�' h r�'t ;'r :a :..�r .au (rP+ fl : ° .. ... ; . �rrb.lald�'v";.Mn :,�i�- „ _...lu. : : :. m., : , . ....... ❑ New construction Addition /alteration/replacement Please check all that apply (submit 2 sets of plans w /itomss checked below): 0 Service or Seeder 100 0 Demolition (] Other: ur r es. i , i,ilirtl+4''iiIliif'i'r.. "6.fnl� '- �T.'" _ boatyards, y „„,.•r..1r 1. „- , - e}l�, .. _r y, • 1 • .- ,.,... {ql,, .. 1. > M:. nihur fl 1 d l ?ii : !';liii�': i ;l L , !f„ �iAiitt� iq` nrlt44 xccei 1 U,Ix)0 amps at 0 volts 0 ❑ Building and 1; racy, • ..1 SteHl _ rl „ •„ r �: Aar , 4 .� er , ' g kings less to ground, or eacaxl.. 14,000 ❑ Commercial -use agricultural tia, I. and 2- family dwelling ❑ CommerciaVindustrial ❑ Accessory building amps for all other iavlallminns, buildings. Mu ❑ Master builder . Multi ,,,,,, , , , ,,,, , , - „ ,.. r slallalion of 7 : t1 -..-:&..".,"':",'_•, :.:_ a• pump. L g KVA or iitt?:u_:.. •e:.i y. :.,IKII .... .T x7 ,:r :� ` t::n�:r•.:.;;: ❑ A deraencySystem• ❑ la separately derived em- Other: sanir, :i:_ II�;M :� : � :� : :,. , .. � (, i "�. ' ` ., .1- : :, : :.., .., 1ljt Y � - , ,• A� � rt •r.f :..!l :_ , rna :au,v. a. „� 1 ,_. .w "r..,..,. ,.i� ,a•ar..r. 5 ,. d' „i. tA7� , st ar l - r'•r tt ''''� , � ,, rltdi[4lt..l 4a {I>ti t . .,- ....... .,,,,,- •- •r...r�„_,1 'Nai;.... ❑ Additioaof acwato4,rkr xi n f "P”. r, r, lob no,: Job site address: — 36 3 t • I 100HP or mom. eaergemcy, ► ❑ Six or more residential assts. 0 Recreational ...aide parks. City/State/ZIP; • `A 1 2Z'J / Gq.1. ❑ Health-care facilities, ❑ Supply voltage for mom dun 011avn rdons locations. . 60(1 volts nominal. Suite/bldg, /apt, no.: Project name: ❑ Service or feeder 600 amps ur mere, • u • ,. 1vae : : : :f : ^k ;.�.,....,: y ,. y ,. g;l ¢I�h. •:•• ,. '•n:s.•:: :::•p.: a..,r... ^ .. Cr site: �� � SI i : : :'- :!l }INr. ?r!j;;Prain -1 -. `+ F : : : : :.:: __ :a; Cross street/directions to site `A � r. y dwelling � New residential single- or multi-family r; :�.: ;:C.::: •:S, _ nail. includes attached garage. Subdivision: LLot no.: 1,000 s . R, or less -�� 168.54 4 Tax m Ea. kill 5011 sq. ft. or portion 33,92 1 ap/purccl no. f1a ::: - 1 ,.:_ , };• .. _. 1,bliited energy, residential ...p_ ,.a, ,•:,l - ,'.g.•,!fl;:r:x,;,:s:kar : a. eix ii ;ria ia$•P ; t'r; iiiAiliir:u: 75.00 2 , e;F:.:rvdt,aa Ir _.• : :. :_.......,.......: t....:.. +:11 ., : :..� . . . ........... ............. :.,�;, :........ ' .. ,, . :.....,?,'�� „! :. � !! �;. �Fl,f tNiA n�i•,,,y; , •.�.,,,4?.rh,r- •;;�;�,t;,?al�Jl Cwith (tbtive sq. [L) _ ,/` Limi enerbry, multi - tinnily. 75.00 2 P4 Ckl 015414- ` C- r�C LAC' l residential (with above sal. tt.) '� , - Scrvices or feeders Installation, alteration, rind /or relocation 1 e' iO ...4 © e, � l,LA t', � 1 200 amps or lees 1 00, 70 2 • 2 t , fi � r..:..::_rr., ,.,_.,:,,:nc -:::kh o-. ,, iced l 1 rinr,''?�..tr` : :p7r�'� .: .: •.: , • -,_ i ,... S �tH,:,.... : ^I,4, ,.. ; �; G , ,; :';5 :> ���� r .rl`�''•� � ° �-1� :�dr.� 201 amps to 400 am 133.56 .... , , ��, , : : a :n 5 . ... , .•,- 1iz4t' Y H1. 5f5ip, e: r...Nd111,.,- ar.N!xlrrN7}r : " :' C'. amps 133.S r - � le m••',:1 •• :r- :• :.sr.l.e"L'i1t1� Name: I�� 401 amps to taxi amps 200.34 2 . 601 amps to 1,000 amps 301.04 2 Address: 1 ,¶-5 S.i • w, "IA aQ ' Over 1,000 amps or volts 552.26 2 City /State/' %IP: j 4 q - � f Temporary services or feeders ill t2llaliOd, alteration, and /or relocation Phone: ( 503) A d — 6 tk. 5 Fax: ( ) 200 amps or less 59:36 _ I Owner installation: This installation is being made on property that I on which is not 201 amps w 400 amps 125,08 z intended for sale, least, rent, or exchange, according to ORS 447,449, 670, and 701. a01 amps lit 599 craps 168.54 Bunch circuits — new, alteration, ur ex tension, per panel Owner signature: Dune: A. tee A. 1for branch circuits with :. ,- : ; ....'.,,, °N :n :: , '7 '•!!1 :14tr; °;r. , , l ., r,• .. A.,t, ��,1; ^,err,,, m..;... ^re.: a ,...... ?al,T,•∎:ii p;;';:t!!1�! , „ - ,t 4111: : :. :.!r;.pp� , ; i rat ,µi: :.::: I ,.d, �d fllra'i� .. ,I x- a; , : : : above branch or fi 7 fix, ........... ,,, r . �,w ��` ; :; ". ; + ,ti- t :;'r= �tc��; 7A2 2 .. a" :i .,:::,:•::, ' ' t � "' :: , . r rr.! each brv cite:uit Business name: A~ti Q(„ „ i t t _ ((./ B Fe for branch circuits without I - 641 l f �~ �. // t.. I�c..N' service or fcc er fee, rust l 56.18 2 Contact atone: •�, branch . branch nc 1 /l/ r 4 Fis a branch ci ` I 7. 42 2 Address; `b 1, W �� J L Miscellaneous (service Or feeder not includct City/SLOW/DPI `� �l fn Each manufactured ar modular 2 0 a - 1 l ; dwanin service and/or feeder Phone: (5) c-34g _ Z .Fax: : ( ) Reconnect only ,-- 47.84 67.84 2 Frinail: , 1 P�� ti t om . i� Pump or imgation circle 67 2 .: _ :::::.::. ,.,, ,. .. ..,. .,.,., _.,... 67.84 1'llISIIFI:I. IlE.;,; ,.,.,,,..., . • § , r- ...,. ..... , I illg; , e : • Si C li rrii'": ^:.ii..rrlav :-,{ a - s , e ''fi V , ,r,.: J .1 ,�w ; � r . . x,r.,.,.... y,.. .. .N:!tte,t . ,, ...u ,' 1 . I ...,_. , , " _ , � ' �r:. Pi.. ,....,. : . FrY'....,,. ISh :x:.dr : :, :Y :7 :;1{;: : -r:: r;r " ' l�r <a{iur*Ij- •'r;l.;;P�r :; :;'r•' • Si or ) . 2 0 U ...,...� , .. � / 9te : I * :. , , max.. r ; .�., r yna ctr wil {s or h mttr;d- energy Business name: f ��,,,, 0 ,,, ‘ , � £ r 1 Pond, ablation, or extension. Paget 2 .. Each .._ Each additional hlspection over allowable in illy ache above Address: 0 p 0 i Additio inspection , L. inspection 0 hr min) 66.25 / hr City/State/ZIP: �f 0 / ���� • lnvrst� 66.25/ hi JJ.� industrial plant (1 hr area) 78.18/ hr Phone: ( c-31. Fait' 1 � r 1 ) / D / / //3 inspections for which no fee is 90.0(1 / hr CCBLic,: -5q2. Suprv. ! - $.,.x, ca1 listed hr min , , r P 1'?' .,•, T.., t� 1 taeclriutl Lie.: ('r Z �a '° 1�� ..{``// p 5 Niel :r....�_a��' ?�) :u "r ' ..�},n ,,; s ".�.' :, Suprv. Gectriciatt ug twte, required: V�� Subtotal: �, .. � w ` __ __ l'tan review (25% of permit see): name: 13,1F++ 6 `` Date: ^ C ( Q� p�, ti State surcharge ('12% of permit fee): r1 • £ `� Print name: Authorized si there, r -. T - .10.1'AL PERMFI' FEE: R ` Z"34, This permit application expires if a permit is not obtained within ISO ['Hitt name: 1 �o a 1.'- . r J Dare: © V /c a 7 u day% after it has been accepted as eompkte. �1 JJ N u,nLur or eosins rinns allowed per permit. 1:Iauiltling\Penpjta .PermitApp.le; 07/11/10 44(MmISr(1l/05ICOM/Wf -II