Permit CITY OF TIGARD MASTER PERMIT
` . s COMMUNITY DEVELOPMENT Permit #: MST2012 -00109
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/07/2012
Parcel: 2S103DCO3200
Jurisdiction: Tigard
Site address: 11250 SW VIEWMOUNT CT
Subdivision: VIEWMOUNT Lot: 20
Project: Wilkinson
Project Description: Move master bath on 2nd floor.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0
Detectors: Yes
Total: 0 sf Value: $6,000.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 2 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Tubs /Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 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
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 add9 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 3
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:
ALT SF VB R - 3 0
Owner: Contractor:
WILKISON, J ERIC /SARA OWNER Required Items and Reports (Conditions)
11250 SW VIEWMOUNT CT
TIGARD, OR 97223
PHONE: 503- 367 -0579 PHONE:
FAX:
Total Fees: $486.33
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. ork 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 suspende more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility NoYrfica n Center. Those rul re set forth in OAR
952- 001 -0010 through O' - 952 You may obtain a copy of the rules or direct questions to OUNC by calling 3.232.19 .800. . 344.
Issued By: t � /l ja Permittee Signature:
• Call 503.639.4175 by 7:00 a.m. for the next available inspection ate.
This permit card shall be kept in a conspicuous place on the Job site until com lotion of the project.
Approved plans are required on the Job site at the Ume of each Inspection.
Building Permit Application RECEIVED
Residential FOR OFFICE USE ONLY
City of Tigard MAY 2 3 2012 Received Permit No.: _, , p
I Date : 6L- r/d Q
q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie ►!41��
CTI'Y OF TIGARD ,` Other Permit:
Phone: 503.718.2439 Fax: 503.598.1960 S d H t►R Date / •
Inspection Line: 503.639.4175 Date Ready /By: Jam: HI See Page 2 for
TIGARD BUILDI1�GDIVISI N otified/Method:p0 7 `'�� Supplemental Information
Internet: www.tigard- or.gov
TYPE OF WORK Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
❑ New construction ❑ Demolition equipment, materials, labor, overhead, and the profit for the
ddition/alteration /replacement ❑ Other: work indicated on this application.
CATEGORY OF CONSTRUCTION Valuation: $ 000
R and 2- family dwelling ❑ Commercial/industrial Number of bedrooms: Q
❑ Accessory building ❑ Multi - family Number of bathrooms: 0
❑ Master builder ❑ Other: Total number of floors:
JOB SITE INFORMATION AND LOCATION New dwelling area: 0 square feet
lob site address: 1 i 2 5 D 3 L/ V: e talp',u K a , Garage /carport area: square feet
City/State /ZIP: T'i3tL( 4( r D Q. 47223 Covered porch area: square feet
Suite/bldg. /apt. no.: I Project name: {.,_ --p fir- f i Deck area: square feet
Cross street/directions to job site: 1 (t(.th I i 1—i.l IJ 4 0 0) '— ) Other structure area: square feet
REQUIRED DATA; COMMERCIAL -USE CHECKLIST
Permit fees* are based on the value of the work performed.
Subdivision: I Lot no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
Tax map /parcel no.: work indicatcd on this application.
DESCRIPTION OF WORK Valuation: $
MovL PA R4 101 11 Existing building area: square feet
New building area: square feet
Number of aisri0PlERTY OWNER J 0 TENANT Type of construction:
Name: F' A, c, kf 1 rt: s p
Occupancy groups:
Address: 1 12 5 5W V •r¢ pi o v , y f L'4• Existing: •
City/State/ZIP: 1 ;, tt_✓4 l 0 R. GI 7,03 New:
Phone: ( 5cgy ) 34, 7- D 5 r') T Fax: ( ) BUILDING PERMIT FEES*
❑ APPLICANT ❑ CONTACT PERSON (Please refer to Pe 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: /Q gA
Phone: ( ) I Fax: : ( ) PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
E -mail: s mercial and residential prescriptive installation of
roof - t . I ounted PhotoVoltaic Solar Panel System.
CONTRACTOR Submit two sets of roof plan with connectio _. - Is
Business name: OW 0e- and fire departme ccess, along with th> : i 0 Oregon
Solar Installation Spe , Code c - ist.
Address: Permit Fee (includes . -. -view
$180.00
City/State/ZIP:
and adm''' rative
Phone: ( ) I Fax: ( ) State surchar z 2% of permit fee): $21.60
CCB lie.:
al fee due upon application: $201.60
This permit application expires if a permit is not obtained
Authorized sign. ure: within 180 days after it has been accepted as complete.
* Fee methodology set by Tri -County Building Industry
Print name: Date: *S 2...3 12 Service Board.
_
REQUIR' I DATA; 1- AND 2- FAMILY DWELLING .
1:\ Building \Permits \BUP- RESPermitApp.doc 02/24/2011 440 4613T(I 1 /02 /COM /WEB)
Jun 07 2012 1:56PM The maw 5034694540 p. 1
06/07/2012 13:48 5035981960 JUN 07 2012 CITY OF TIGARD PAGE 01/01
,PIumlbinu Permit Apnliiestioap r I , . 1 .
Building Fixtures A 13tittatt4d O , >H. si i , ..:. , , , 1 , , _ , , , .,
City of Tigard MAY 2s 2. j( • t Fermis No.: ..1 ('
I ,
13129 SW Hall BM. Tip rd.OR 97225 T... Parma -,.. I moue; 503.7182439 F. 503.59JPFY OF TI(i�1RD p o + neBr: ' e e Set :t bn>ocaiosLbnr 503639.4)75 if.. iN 4 t
blteeeu wwrw Di �Stt)1 W I
0 New construction 0 Demolition >;�eaedsl hlaeA sere Means
Description 1 Otv, 1 En. f Total
Eradidonialteridoxireplectrnalt 0 Other Newk2.fami1r &retimen (includes 100 5. for each uhlittamneaien)
: . GII'il1EGOltrOF ONNI21111CTION SFR (1) beds , 9 12.70 -
Q,�amd Mustily dwelling a Commerd8IMduseriel • SFR (2) bat 437.7!
0 Accessory boihrtnp ❑ Multl.thrnliy SPR (3) bath 5110.32
Each additinlul batMcitchen 25.02
0 Mader builder ❑ Other: Fire sprinkler ._ sq. A.) Page 2 ,
- JD$ SITE virmuutter4 AND LOCATION ' Site tilin g".
Catch basin or area divan 1176
rob silo addroter 14,2.,5 0 5 W V ; t: Waldo k t LC
Dryw41. teach One. or acids drain 11176
CityISliterxiP: 7; • nt 0 Q 4 7 .Z)
5 q ( Posting; drmbn (no. linear R : _) page 2
Sukelbldgfept. no.: PI*"na ": szvuazdalt Mmufae arcd home utilities 50.03
Cross Meet/directions to Job site I 1 - t - _ __so Manholes 11.16
Rain drain cormectm 18.76
Sanitary sewer (no. linear R.: ,•,.,_) Page 2
SI!xm sewn (no. linear 1: ___) Page 2
Watcv service (no. Bomar A: _.) Page 2 _
Subdivision: I Lot no.: Fixture or item:
Tax no.: Beddow t revsnter 31.27
71PON OP WORN Backwater vdvc 12.51
f y Clothes washer 25.02
Moe.. vet •t 4 F t Dishwasher 25.02
Drinking fountain ' 7502
• £jeeblalmmp 25.02
°wan ' 0 1ZNA TI' Explosion tank _ 12.51
Name: Er• : it ti:( Ki So..
Finnan/sow cap 2302 '
Floor drahMlom stalc/hub 25.02
Address: 1 115 o 5 w (f 7C wo, 0 u At Ci. Garbage disposal _ 25.02 •
City/State/ZIP: T-y it/<. , Oft g, 3 2 c3 Nose bib 21.02
Phone: ( 543) 367 - D S Fax: c ) - lee roaster 12.51
0 AMuCAIIfr 0 cc r7ACr PERSON Intercepter /gre■re trap 25.02
Business name! Medical pis (value: i ) Page 2
Contact node: �" 12.51
Roof debt (Gommeroiel) 12.51
Address: SieldbesinI1 v rj' 25.02
CitytStatclZlP: Solar unite (pota valet 62.54
Phone: ( ) Fuel:: ( ) Tub/dlowor or 12.51 ,
E-mail: • Urinal 25.02
t
Water dose / 25.
water hatter 37.52
Business nor= Tri P(uim . e,r,.5 TNL. Weterpl*10nV 5129
Address: ' O I✓ I .50 ' v , Omer: 25.02 p
City/StetelZIP: R7.wr1, ✓e r 4 . 0 r, . 0 e 41 Dig Subtotal eR ti 7
o.e: ( 563, S i 9 - 6 4 f Foot: (S21 6 /2 v Minimum panmit ttc: $7.50
Plan review (25% of permit �)
CC8 Lie,: I _ I if /! I Plorrdfstg Lk. no.: • „ q Steve =rebut?. (1216 of permit fox) .
Authorised ii& nerur0 !n al J -1 7 / TOTAL PERMIT FEE
Print name: Arm. Dole: - --(7___ This taPpu w, apt. ra its onrushb not obi ■ion!*AM 190aa}r
are blabs eapar
a baea see/peed d u areo.
A EAs e" S r i X 7v 03_ S es._19 , ' '' 1° by Tr.conely anticline' %Ivory srraot 9eard.
imodurePamo■NAAtamo*M,dea wow ie40Icr se tve,wam) 41Y
J
Mechanical Permit APPI1CatIO FOIZ OFFICE USE ONLY
"City of Tigard patsy �� ✓l Permit No.:
n 13125 SW Hall Blvd., Tigard, OR 97223 ��� / /O
i , MAY 2 3 Plan Review Other Permit:
Phone: 503.718.2439 Fax: 503.598.1960 2 Date/By:
TI G A It p Inspection Line: 503.639 CITY Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov OF TIGARD Notified/Method: Supplemental Information
BUILDING DIVISION
TYPE OF WORK COMMERCIAL FEE" SCHEDULE — USE CHECKLIST
Mechanical permit fees* are based on the value of the work
❑ New construction 9 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"
rand 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:
1 f Air conditioning
4
Job site address: (Z S 0 ,S Lt/ V; G W J'1 v v H I G - • (requires site plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46.75
City /State /ZIP: T `ya / d 0 ft. q ?.2-23
Furnace 100,000+ BTU ( ducts/vents) 54.91
Suite/bldg. /apt. no.: Project name: 4.J.3 i 6,013 Heat pump
(requires site plan showing placement) 61.06
Cross street/diredions to job site: I I t i T 1, 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
Gas fireplace/insert 33.39
M 0 t/t, tM eth ' - r bn, CI 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
U4I OPERTY OWNER I ❑ TENANT Chimney/liner /flue /vent 23.32
Other: 23.32
Name: E r 14/i I {'t' /So Environmental exhaust and ventilation:
Address: ( (1. 0 6 i 1/74 W vmor, t,E Range hood/otherkitchen
equipment 33.39
City/State /ZIP: ;, a i I / 0 1 2._ O( ? 2,23 _ Clothes dryer exhaust 33.39
Single-duct exhaust (bathrooms,
Phone: ( 5,5) 36,--)— o 5 7 I Fax: ( ) toilet compartments, `
partrtments, utility rooms) I 23.32 2..✓,
❑ 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
C it y / S tat e / ZIP: Wall/suspended/unit heater •
Phone: ( ) Fax: : ( ) Water heater
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: (r) (AD f3 f 12,0 Clothes dryer (gas)
` / Other:
Address: MECHANICAL PERMIT FEES"
City/State /ZIP: Subtotal &2_# . `3'f�
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) 69
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee)
TOTAL PERMIT FEE
Authorized S�re: This permit application expires if a permit is not obtained within 180
n days after it has been accepted as complete.
Print name: I Date: � 2
C / /02_ • Fee methodology set by Tri -County Building Industry Service Board
3
I:\Building\Permits C- PermitApp.doc 03/07/12 4404617T(I1/02/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 03/07/12 2
Electrical Permit Application RECEIVE] I:OR t)FFICE USE O\'I.V
Ph 2 012 Received �3 �,� j`15rav�� — GIUIa q
City of Tigard MAY OF 2 Re e/Be: 5 1 Permit No.:
n 13125 SW Hall Blvd., Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 DateBy: Other Permit:
1
Inspection Line: 503.639.4175 CITr TIGA Date Ready/By: Juris: ® See Page 2 for
�' IZ D
BUILDING D IVISIO ot ified/Method: Supplemental Information
Internet: Line: g B UILD
503.639.4175
pP
r � TYPE OF WORK PLAN REVIEW
12 New construction [3 wddition/alteration/replacement Please check all that apply (submit a sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ 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
r 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
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: 1(.,2 5 0 .. &A r, e . t 1 tooHP or more. occupancy.
✓ W L D U « ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: i ( , L 0 (L J, 2 ❑ Health -care facilities. ❑ Supply voltage for more than
7 ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: N„4Lr- - 1- 0 Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: I (if 711 -Kt 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' 1 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, '
gy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
�./ ( Limited energy, multi-family 75.00 2
I v' - I ta- 4 - e.r bcd it residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
®P OPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
' • ! 401 amps to 600 amps 200.34 2
Name:
E f i G �t/� ( �� i 5 o vt 601 amps to 1,000 amps 301.04 2
Address: ( a 5" o 5 W V/1 e wu.o v 0c1 U. Over 1,000 amps or volts 552.26 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
:5 U,� 0 Q c `) 2 2 relocation
Phone: ( S',23) 3 6 7 _ 6 g -- el Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being eoperty that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, le e, rent, or exchan , ccording to ORS 447, 449, 670, and 701.
+SR 3 /IL B circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ AP PLICANT I ❑ CONTACT PERSON above service or feeder fee, 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
tg Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 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: OkDO f r2, panel, alteration, or extension. Paget 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City/State /ZIP: Investigation (I hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18 / hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed (%: hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: o Subtotal:
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE:
Authorized signature:
This permit application expires if a permit is not obtained within ISO
Print name: Date: days after it has been accepted as complete.
Num of inspections allowed per permit.
I:\ Building \Pemiils\ELC- PerinitApp.doc 07/01 /10 440- 4615T(11 /05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
j RESIDENTIAL WORK ONLY:
Fee for all residential systems combined .. $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
El Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ 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
❑ Boiler Controls
El 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:\ Building \Permits\ELC- PertnitApp.doc 07/01/10
CITY OF TIGARD
BUILDING DIVISION PERMIT #:
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639-417.1
Inspection Requests (24 Hrs.): (503) 639 -4175 °'I � ..
INSPECTION WORKSHEET FOR DATE: ; /S/_ ( 7� TIME: PAGE:
SITE ADDRESS: (l 0 ? 5-0 I � ( AV V I bilitjW° L( Li / ' 4'L— CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: 015 % 01 Q() 00 (0
DESCRIPTION: /
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: Pour Time:
Code # Inspection Descrip ion Confirm # Contact # Message
I /c404 0
Corrections/Comments/Instructions:
P I /1 1), i 1 S
�J
•
M ASS ❑ PARTIAL APPROVAL El CANCEL ❑ NO ACCESS
❑ _ FAIL ❑ CALL FO INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: �,Yvvl Date: (, - I 1 - Ia. Phone #: (503) 718-