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Permit
CITY OF TIGARD MASTER PERMIT • it COMMUNITY DEVELOPMENT Permit #: MST2012 -00037 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/16/2012 Parcel: 2S103CC07400 Jurisdiction: Tigard Site address: 13580 SW 124TH AVE Subdivision: WHISTLER'S WALK Lot: 21 Project: O'Brien Project Description: Finish basement and replace existing window with slider. Plumbing work done under PLM2009- 00217. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 1 First: 0 sf Basement: 1024 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 1 Second: 0 sf Garage: 490 sf Front: 0 Smoke Dwelling Units: 1 Third: 0 sf Right: 0 Detectors: Yes Total: 1024 sf Value: $85,354.00 Rear: 0 PLUMBING Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0 Drains: 0 Tubs /Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Drywell -Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits _ 1000 sf or less: 0 0-200 amp: 1 0 -200 amp: 0 W/ Svc or Fdr: 6 Ea add'I 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 0 Mfd Home /Feeder /Svc: 0 401 -600 amp: 0 401 -600 amp: 0 601 -1000 amp: 0 601 +amp- 1000v: 0 1000 +amp /volt: 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio 8 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: ADD SF VB R - 3 1024 Owner: Contractor: O'BRIEN, MICHAEL D OWNER Required Items and Reports (Conditions) 13580 SW 124TH AVE TIGARD, OR 97223 PHONE: PHONE: FAX: Total Fees: $2,329.30 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 a • • • ce 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. AT TION: 0 —on law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules re set forth in OAR 952 -001 -r 010 through OA • 9 .01-1090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1. 32 4 Issued By: Permittee Signature: J r� 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. Buil`aling Permit Application Residential RECEIVED loll OFFICE USE ONLY Received 9 City of Tigard CCpp g 2012 Date /B : / 7 ' Permit No.: 1 ! p/�- 37 13125 SW Hall Blvd., Tigard, OR 97223f e 2 !� Plan Review � � ' 0 Phone: 503.718.2439 Fax: 503.598.1960 Date /B : Other Permit: C. A TI RI , Inspection Line: 503.639.4175 Cfri °V TA VISION Date Ready /By: . � a la See Page 2 for Internet: www.tigard- or.gov B01.DI NODVISION . . fig Me od: r , / _ Supplemental Informs on / MV .. . /W /mil/ szl'-' ,talc!+' ' 7 /v TYPE OF WORK REQ IRED DATA: I- 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 ❑ Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the for the CATEGORY OF CONSTRUCTION work indicated on this application. , 20 ❑ I- and 2- family dwelling ❑ Commercial /industrial Valuation: $ �. ❑ Accessory building ❑ Multi- family Number of bedrooms: I ❑ Master builder ID Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: j359 5VJ 114-11H j New dwelling area: t square feet City /State /ZIP: T 0. °1 `223 Garage /carport area: square feet Suite/bldg. /apt. no.: Project name:t6Wr Covered porch area: square feet Cross street/directions to job site: Deck area: square feet Other structure area: ' square feet I REQUIRED DATA: COMMERCIAL -USE CHECKLIST - Subdivision: 1 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. attMtor imelzakmtwr j . • , i/L 1 QK �13E. Valuation: $ u PL K Aoo - ©Gat 7 N Existing building area: square feet New building area: square feet ❑ PROPERTY OWNER ❑ TENANT Number of stories: Name: o p • 06I1_16N Type of construction: Address: 135 Bo Sw 12_41%, ✓9 Occupancy groups: City /State /ZIP: 110AM) £,t- C M —2-3 Existing: Phone: ( 5(s3) 9 C M, B Fax: ( ) New: ❑ APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES* (Please refer to fee schedule) Business name: Structural plan review fee (or deposit): Contact name: FLS plan review fee (if applicable): Address: Total fees due upon application: City/State /ZIP: Amount received: v"`t q 95 °7 Phone: ( ) Fax: : ( ) E -mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* CONTRACTOR Commercial and residential prescriptive installation of roof -top mounted Photo Voltaic Solar Panel System. Business name: u.),o Submit two (2) sets of roof plan with connec .. . - ails O ; L� and fire I - .artment access, along e 2010 Oregon Address: Solar Insta • ion Special a e checklist. Permit ' udes plan review City/State /ZIP: and • : • inistrative fees): $180.00 Phone: ( ) Fax: ( ) State surcharge (12% o it fee): $21.60 CCB lic.: Total fee due upon applicatio . $201.60 Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: I Date: 2.2'3 - ) Z * Fee methodology set by Tri- County Building Industry Service Board. I:\ Building \Permits \BUP- RESPernitApp.doc 02/24/2011 440- 4613T(I I /02 /COM /WEB) Building Permit Application Checklist ' , •° One- and Two - Family Dwelling FOR OFFICE USE ONLY City ll of Tigard Received UPI Date /By: Permit No.: 1 3125 SW Hall Blvd., Tigard, OR 97223 Associated permits: C Phone: 503.718.2439 Fax: 503.598.1960 TIGARD 24- Hour Inspection Line: 503.639.4175 • ❑ Electrical ❑ Plumbing ❑ Mechanical Internet: www.tigard- or.gov ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No N/A I 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 j rmit 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 se _ tg of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑ building codes. Ldthral 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. 1 I 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 areaNutlding 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 al s licable to the . ro'ect under review. JURISDICTIONAL SPECIFICS 23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 1 1" or I I" 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 \Pennits \BUP- RESPennitApp.doc 02/24/2011 4404613T(I I /02 /COM /WEB) Electrical Permit Auplic ElVE" FOR OFFICE uSE ONLY 9 2012 Received CCU DateB : r� A,� PermitNo.: f`! -- a 13125 S W Hall Blvd. City of Tigard Tigard,Ola FA Plan Review r °� • Phone: 503.718.2439 Fax: 503.598.1 Date/By: Other Permit: F I G A R u Inspection Line: 503.639.4175CI'I� V IGARD Date Ready/By: lens: ® See Page 2 for Internet: www.tigard- or.gov gUILDING DIVISION Notified/Method: Supplemental Information TYPE OF WORK PLAN REVIEW ❑ 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. El Demolition El Other: where the available fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural 1a1 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 JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ", "1-2", "1 -3 ", Job no.: Job site address: I 3St 9w 11,116, 1 or mars. occupancy. ❑ Six o o r r more residential units. ❑ R ecreational vehicle parks. City /State /ZIP: MAW (/t "/ } ❑ ilealth -care facilities. ❑ Supply voltage for more than I ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: atitdi + AIgS ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description i Qty. I Fee. I Total I • New residential single- or multi - family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4 Ea. add'l 500 sq. ft. or portion 33.92 1 Tax map /parcel no.: Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) . Limited energy, multi- family 75.00 2 /� 04g4 • 1MP Ear residential (with above sq. ft.) , I ' Services or feeders installation, alteration, and/or relocation 200 amps or less / 100.70 2 j21ROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: bll OAK 061-4t- j', 601 amps to 1,000 amps 301.04 2 Address: nsb0 sw 11,111 At Over 1,000 amps or volts 552.26 2 City/State /ZIP: 'n( 4142 S Temporary services or feeders installation, alteration, and/or relocation Phone: ( I yap — ' b9 a Fax: ( ) 200 amps or less 59.36 1 201 amps to 400 amps 125.08 2 Owner installation: This installation is being ma on property that I own which is not intended for sale, lease, rent, or exc e, a - rd g to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2 Branch circuits — new, alteration, or extension, per panel Owner signature: Date: 2.2, • I t A. Fee for branch circuits with above service or feeder fee ❑ APPLICANT ❑ CONTACT PERSON fee, / A 7.42 2 each branch circuit �!' Business name: B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact name: branch circuit Each add'I branch circuit 7.42 2 Address: Miscellaneous (service or feeder not included) Each manufactured or modular City/Statc /ZIP: 67.84 2 dwelling, service and/or feeder Phone: ( ) Fax: : ( ) Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 E - mail: Sign or outline lighting 67.84 2 CONTRACTOR Signal circuit(s) or limited- energy Business name: panel, alteration, or extension. Page 2 2 p� Each additional inspection over allowable in any of the above Address: � — Additional inspection (I hr min) 66.25/ hr Investigation (I hr min) 66.25/ hr City/State /ZIP: Industrial plant (1 hr min) 78.18 / hr Phone: ( ) Fax: ( ) Inspections for which no fee is specifically listed (V2 hr min) 90.00 / hr CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: Plan review (25% of permit fee): Print name: Date: State surcharge (12% of permit fee): Authorized signature: 7 TOTAL PERMIT FEE: T his permit application expires if a permit is not obtained within 180 Print name: , f,-T Date: s� days after it has been accepted as complete. NIIf'N)14.. O. v�nL 2.' 2 1' I I. • Number of inspections allowed per permit. I:\ Building \Permits\ELC- PermitApp.doc 07/01/10 4404615T(I1/05/COM/WEB Electrical Permit Application - City of Tigard ` • - Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: Fee for all residential systems combined .. $75.00 Check Type of Work Involved: El Audio and Stereo Systems* El Burglar Alarm ❑ Garage Door Opener* El Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* El Other: • COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems El Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation El Intercom and Paging Systems El Landscape Irrigation Control* ❑ Medical El Nurse Calls ❑ Outdoor Landscape Lighting* El Protective Signaling El Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\ Building \Permits\ELC- PermitApp.doc 07/01/10 Mechianical Permit Application FOR o FFICI: uSI: ()NIX City of Tigard , Received ffi M V 13125 SW Hall Blvd., Tigard, OR 972 Iii CEIVED Date/By: , ♦ //� Phone: 503.718.2439 Fax: 503.598.1' 61 Date/By: an Review Other Permit: r I G A R D Inspection Line: 503.639.417 Date Ready/By: Luria: ® See Page 2 for Internet: www.tigard or.gov FEB 2 9 2012 Notified/Method: Supplemental Information TYPE OFag Or DGARD COMMERCIAL FEE* SCHEDULE — USE CHECKLIST M ING DIVISION 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. Value: $ CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES* 126- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist. ❑ Multi - family - ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total JOB SITE INFORMATION AND LOCATION Heating/cooling: _ Air conditioning Job site address: i3S9jb sty/ (V I Al (requires site plan showing placement) 46.75 ' Furnace 100,000 BTU (ducts/vents) 46.75 City/State /ZIP: NM OP_ 6 11-20 Furnace 100,000+ BTU (ducts/vents) 54.91 Suite/bldg. /apt. no.: Project name: oaQaetJ /Awl &Jr Heat pump (requires site plan showing placement) , 61.06 _ Cross street/directions to job site: Duct work _ 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: 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 n Gas fireplace 33.39 l,) T irifilmobrr Flue vent for water heater or gas fireplace 23.32 Log lighter (gas) 23.32 Wood/pellet stove 33.39 Wood fireplace /insert 23.32 121;ROPERTY OWNER I ❑ TENANT Chimney/liner /flue /vent 23.32 Other: 23.32 Name: M (a O4 Environmental exhaust and ventilation: Address: i s&o 1111 Range hood/other kitchen equipment 33.39 City /State /ZIP: 'rD 01t. "/ 9-1.1.1 Clothes dryer exhaust 33.39 Sol CFO . gm $ Fax: toilet compartments, (bathrooms, rooms) s, Phone: ( D ) ( ) toilet corn ents, utility rooms) ! 23.32 ❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32 Business name: Other: 23.32 Fuel piping: Contact name: $14.15 for first four; $4.03 for each additional Address: Furnace, etc. Gas heat pump City/State /ZIP: Wall /suspended/unit heater Phone: ( ) Fax: : ( ) Water heater E -mail: Fireplace Range CONTRACTOR Barbecue Business name: /'t)` ' j "U ti `— Clothes dryer (gas) V V� Other: Address: MECHANICAL PERMIT FEES* City /State /ZIP: Subtotal Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) Plan review (25% of permit fee) CCB lie.: State surcharge (12% of permit fee) TOTAL PERMIT FEE Authorized signature: • This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: # 0- 6414W, Date: 2. 21.1 L • Fee methodology set by Tri- County Building Industry Service Board I:\ Building \PermitsMEC- PermitApp.doc 09/09/10 4404617T(11 /02/COM/WEB) Mechanical. Permit Application - City of Tigard Page 2 - Supplemental Information Commercial & Multi- Family Fee Schedule: Total Valuation: Permit Fee: $0.00 to $500.00 Minimum fee $69.06 $500.01 to $5,000.00 $69.06 for the first $500.00 and $3.07 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and $2.81 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and $2.54 for each additional $100.00 or fraction thereof, to and including $50,000.00. $50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and $2.49 for each additional $100.00 or fraction thereof, to and including $100,000.00. $100,000.01 and up $2,608.71 for the first $100,000.00 and $2.92 for each additional $100.00 or fraction thereof. Note: All new commercial buildings require 2 sets of plans. 1:\Building\Permits\MEC- PermitApp.doc 09/09/10 2 /5 ^-- M 5 Tao l,?-00o 3 7 13580 1014 _ = oag [ Lt; � _ �g3a *05.35 I . I_PA,c(Iy_cL,60___ARAAneQ9_ Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325 (2)) This statement is required for residential building, electrical, mechanical, and plumbing per mits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that a ll subcontractors who work on the structure must be licensed with the Construction Contractors Board. or I will be performing work on property I own, a residence that I reside in, or a residence that I w ill reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. M 1C Im P. o64. Print Name of Permit Applicant 5•!6.12 Signature of Permit Applicant Date Permit #: 1 STo�O (a —CYO 37 $6-go 11 n ' ' ;ii = z, Address: I � L� � vl: �!• �; - Y� ; Issued by: Date: This Copy for Permit Offices