Permit A CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2000 -00492 .
p�,...?iiA DEVELOPMENT SERVICES DATE ISSUED: 11/2/00
-� 4 . — 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE EXPIRED 36CB -00500
SUBDIVISION: METZGER ACRE RACTS • ZONING: R -5
BLOCK: LOT: L JURISDICTION: WAC
REMARKS: Placement of new manufactured dwelling.
Note: fees determined and approved by Jim Hendryx as hardship case.
• BUILDING
REISSUE: STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: NEW HEIGHT: FIRST: sf BASEMENT: sf LEFT: SMOKE DETECTORS:
TYPE OF USE: SFM FLOOR LOAD: SECOND: sf GARAGE: sf FRONT: PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: FINBSMENT: sf RIGHT:
VALUE:
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 0.00 sf REAR:
PLUMBING
SINKS: WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: 100 TRAPS:
LAVATORIES: DISHWASHERS: FLOOR DRAINS: SEWER LINES: 100 SF RAIN DRAINS: 1 CATCH BASINS:
TUB /SHOWERS: GARBAGE DISP: WATER HEATERS: WATER LINES: 100 BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS:
ELECTRICAL .
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 - 200 amp: 0 - 200 amp: W /SVC OR FDR: 1 PUMP/IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 • 400 amp: 201 • 400 amp: 1st W/O SVC /FDR: 00 SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 • 600 amp: 401 • 600 amp: EA ADDL BR CIR: SIGNAL/PANEL: IN PLANT:
MANU HM/SVC /FDR: 1 601 • 1000 amp: 601 +amps•1000v: MINOR LABEL:
1000+ amp/volt :
PLAN REVIEW SECTION
Reconnect only:
>=4 RES UNITS: SVC /FDR > =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
• ELECTRICAL - RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor TOTAL FEES: $ 679.21
This permit is subject to the regulations contained in the
DOUGLAS DAVENPORT BENT LEVEL CONSTRUCTION, INC. Tigard Municipal Code, State of OR. Specialty Codes and
8418 SW SPRUCE ST 19379 S. MEYERS ROAD all other applicable la ws. All work will be done in
TIGARD, OR 97223 OREGON CITY, OR 97045 -8921 accordance with approved plans. This permit will expire if
work is not started within 180 days of issuance, or if the
work is suspended for more than 180 days. ATTENTION:
Phone: Phone: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set
Reg #: LIC 80851 forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Erosion Control lnsp at ,6o3 - 2462 - $0414
MFG Home Footing SeL,,e
MFG Home Plumbing Sm LA. e
MFG Home Electrical 6a.
MFG Home Set -Up Final
Issued By . C -AY---44A-A-1 ) --1 Permittee Signatur -f�� / -i_ (I G ALA
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the next business day
s cola oav -063 a
TRI- CaQJNTY Manufactured Dwelling OFFICE USE ONLY
'SERVICE CENTER g
-�4.. Permit Application •' ~'Q=' t PP Date received:/04fra Permit no : /75/ ZQdU" DD y9a,
L • City of Tigard Prnject/appl. no.: Expire date:
Clackamas 13125 SW Hall Blvd., Tigard, OR 97223 Date issued: IBy: Receipt no.:
Multnomah Phone: (503) 639-4171, Fax: (503) 598 -1960 Case file no.: Payment type:
Washington Internet address: www.ci.tigard.or.us
Health dept.: DEQ:
O " " T ' E S Land use approval: - 7 - 4/ /02a00 — DOOc2.O
TYPE OF PERMIT
0 Owner installed 0 Contractor installed 0 Repair
0 New 0 Addition/alteration 0 Replacement: Same location 0 Yes 0 No
JOB SITE INFORMATION
Job address: gj / $ JD W Zo)2.� LP 0, klitAvs 1- Space no.:
Manufactured dwelling park: Address:
City: 7 a r d State: or y Y1 '
7 ZIP: 473a 3
1
Tax map/tax lot noJaccount no.: Lot � I Block: Subdivision:
Base flood elevation: Elevation certificate:
Description of work on premises:
OWNER MANUFACTURED HOME INFORMATION
Name: 1 Q. 1 X1 p)� 2 6 -Lfl -S
,�a �
Address: �s, a ) c f F e 1 d / 0,,C, Concrete stringers/slab under home: 0 Yes *lo
City: 7, '9 and f tate: e j ZIP: 9 7 adt,S 0 Single Double 0 Triple
Phone:S53 ( 39-f Fax: ,) /,4 I E -mail: ivJ/r4
Owner representative: Valuation $ Square feet
Phone: Fax: E -mail: (dwelling and set up only, does not include other permits)
SET UP/INSTALLATION CONTRACTOR ADDITIONAL PERMITS (if required)
Name: •_. 4 - C_ g irl _ b i 0 Mechanical Permit no.:
Address: /9' c79 X . %-rNJe y 7
Cit • J S &I; tateu 4 Plumbing Permit no.: �1ST2afi0 OBI �/9�
y:() p eIL
Phone I Fax: 36 7J -mail: Electrical Permit no.: I V -091/9
CCB license no.: g)g5/ 'City/Metro license no.:0C00aE9A 0 Foundation Permit no.:
MDI license no.: 350- ftjO ❑Garage Permit no.:
SKIRTING CONTRACTOR
0 Carport Permit no.:
Name: 1 , / i . 4 , .r.
Address: g- 4 ( l•, S.A) • I; 0 Cabana Permit no.:
City: L. State:( I ZIP: T 77....2 3 0 Ramada Permit no.:
Contact persok I Phone: d,4 ( . - 31 (Al 0 Awning Permit no.:
CCB license no.: City/Metro license no.:
0 Alterations Permit no.:
• Skirting license no.: MDI/LSI license no.:
APPLICANT 0 Other Permit no.: - gwVoiw - Or,.3U O
Name: 'Dl I( rC.5 $ t Fort
Address: L�3�rj (v / a Notice: Manufactured dwelling installers must have an Oregon
Q I'C� I State a, I MDI and Construction Contractors Board license under provi-
Cit y T y ZIP: 1 sions of ORS 701 and may be required to be licensed in the
Phone: f 3I Fax: A) /4 I E- mail: A) /4 jurisdiction where work is being performed, or the appliant is
I hereby certify I have read and examined this application and know the same exempt from licensing for the following reason:
to be true and correct. All provisions of laws and ordinances governing this
type of work will be complied with whether specified herein or not.
' Applicant's signature Date Set up fee $ 30 S • 5 0
State surcharge $ 2q. (' U
Notice: This permit application expires if a permit is not obtained within State fee $ 30. DU
180 days after it has been accepted as complete. TOTAL $ 5 ti 5 1 ! 4
4404624 (Ki00/COM)
■
4 '
Electrical Permit Application
f Date received: A)/2 Permit no.:/-5-T24-67) 00q9v__'
„A
mil. �.� I _ City of Tigard Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 Date issued: By: Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval:
•
TYPE OF PERMIT •
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family 0 Tenant improvement
❑ New construction ❑ Addition/alteration/replacement 0 Other: ❑ Partial
. JOB SITE INFORMATION • . . .
Job address: eq./ , 5, u/, - ' 0 Bldg. no.: Suite no.: Tax map /tax lot/account no.:
Lot: I Block: Su.• ivision:
Project name: I Description and location of work on premises:
Estimated date of completion/inspection:
CONTRACTOR APPLICATION • .: FEE • SCHEDULE •
Job no: Fee Max
Business name: , ! Description Qty. (ea.) Total no. insp
/�( `� .r/rt C/
Q �,^ 77
New residential - single or multi-family per
Address: 74L St) AA/Lk-v.4_, dwelling unitIncludes attached garage.
t City: Pi LL I State: I ZIP: 1 7 Z/ 9 Serviceincluded:
Phone: 9 / , — 355o I a 3 - 6 0 41 E-mail: 1000 sq. ft. or less 4
Fax Each additional 500 sq. ft. or portion thereof
k CCB•no.: 45539 by /y /o/ I Elec. bus. lic. no: (( —No C Limited energy, residential 2
City /metro lic. no.: .5 2- Z / q a V ° / Limited energy, non- residential 2
Each manufactured home or modular dwelling �/
� Signature of supervising electrician (required) Date /6 h, D/
Service and/or feeder [ I� , 90 2
Sup. elect (print): License no: 3/00 Services °r feeders — installation,
alteration or relocation:
-- = PROPERTY OWNER ------- - - - - -- - 200 amps or less 2
Name (print): . ii! . ' , 201 amps to 400 amps 2
Mailing address: � t/ 6lJ % 401 amps to 600 amps 2
601 amps to 1000 amps 2
City: e .c� I State: (9 ZIP: q 7.
f - Z .3 - Over 1000 amps or volts 2
Phone ' �y ct r7 I Fax: I E -mail: Reconnect only 1
Owner installation: The installation is being made on property I own Temporary services or feeders - -.
which is not intended for sale, lease, rent, or exchange according to installation, alteration, orrelocation:
200 amps or less 2
20
ORS 447, 455, 479, 670, 701. 201 1 amps to 400 amps 2
Owner's signature: Date: 401 to 600 amps 2
- ENGINEER Branch circuits - new, alteration,
or extension per panel:
Name: A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 2
City: I State: I ZIP: B. Fee for branch circuits without purchase
of service or feeder fee, first branch circuit: 2
Phone: Fax: E-mail: Each additional branch circuit:
PLAN REVIEW (Please check all that apply) Misc. (Service or feeder not included):
O Service over 225 amps - commercial • 0 Health -care facility Each pump or irrigation circle 2
O Service over 320 amps - rating of 1 &2 0 Hazardous location Each signor outline lighting 2
family dwellings 0 Building over 10,000 square feet four or Signal circuit(s) or a limited energy panel,
O System over 600 volts nominal more residential units in one structure alteration, or extension* 2
O Building over three stories 0 Feeders. 400 amps or more *Description:
O Occupant load over 99 persons O Manufactured structures or RV park Each additional inspection over the allowable in any of the above:
O Egress/lighting plan 0 Other. Per inspection I I I I
•
Submit sets of plans with any of the above. . Investigation fee
The above are not applicable to temporary construction service. Other
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Pe[Mtt fee $ q O. Q U
i] Visa O MasterCard expires if a permit is not obtained Plan review (at _ %) $ —
Credit card number: / / within 180 days after it has been State surcharge (8 %) $ - 1. 2 7
Expires accepted as complete. . TOTAL $ 7 6 . 11.
Name of cardholder as shown on credit card
$
Cardholder signature Amount 440 -4615 (600 /COM)
Electrical Permit Fees: .. Limited Energy Fees: r
TYPE OF WORK INVOLVED - RESIDENTIAL ONLY
Complete Fee Schedule Below: Restricted Energy Fee $75.00
• Number of Inspections per permit allowed (FOR ALL SYSTEMS) .
Service included: Items Cost Total sl, Check Type of Work Involved:
Residential - per unit
1000 sq. ft. or less $145.15 4 ❑ Audio and Stereo Systems
Each additional 500 sq. ft. or .
portion thereof $33.40 1 ❑ Burglar Alarm .
Limited Energy $75.00
Each Manuf'd Home or Modular n Garage Door Opener
Dwelling Service or Feeder I' $90.90 2
Services or Feeders ❑ Heating, Ventilation and Air Conditioning System"
Installation, alteration, or relocation
200 amps or less $80.30 2 Vacuum Systems
201 amps to 400 amps $106.85 2 El
401 amps to 600 amps $160.60 2
601 amps to 1000 amps $240.60 2 Other
Over 1000 amps or volts $454.65 2
Reconnect only $66.85 2
Temporary Services or Feeders TYPE OF WORK INVOLVED - COMMERCIAL ONLY
Installation, alteration, or relocation
200 amps or less $66.85 2 Fee for each system $75.00
201 amps to 400 amps $100.30 2 (SEE OAR 918 - 260 -260)
401 amps to 600 amps $133.75 2
Over 600 amps to 1000 volts, Check Type of Work Involved:
see "b" above. ❑
Audio and Stereo Systems
Branch Circuits
New, alteration or extension per panel Controls
a) The fee for branch circuits
with purchase of service or ❑
feeder fee. Clock Systems
Each branch circuit $6.65 2
b) The fee for branch circuits I 1 Data Telecommunication Installation
without purchase of service
or feeder fee. ❑ Fire Alarm Installation
First branch circuit $46.85
Each additional branch circuit $6.65 ❑
HVAC •
Miscellaneous
(Service or feeder not included) ❑ Instrumentation
Each pump or irrigation circle $53.40
Each sign or outline lighting $53:40 n Intercom and Paging Systems
Signal circuit(s) or a limited energy
panel, alteration or extension $75.00
Minor Labels (10) $125.00 ❑ _ Landscape Irrigation Control
Each additional inspection over l i Medical
the allowable in any of the above
Per inspection $62.50
Per hour $62.50 Nurse Calls
In Plant $73.75
Outdoor Landscape Lighting`
Fees:
❑ Protective Signaling
Enter total of above fees $
8% State Surcharge $
n Other
Number of Systems
25% Plan Review Fee
See "Plan Review" section on $
front of application. * No licenses are required. Licenses are required for all other installations
Total Balance Due $ Fees:
Enter total of above fees $
❑ Trust Account # ,
8% State Surcharge $
Total Balance Due $
i:\dsts \forms \elc- fees.doc 10/09/00
4 Su,2 000 — 00 3YO
i
Ahiob Plumbing Permit Application
Date received: /d /Ze /a e) Permit no.:eS7 a-v .-00 z/9
Ci o f Tigard
�, ��� `J Sewer permit no.: Building permit no.:
Address:•13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date:
Fax: (503) 598 - 1960 Date issued: • By: Receipt no.:
•
• Land use approval: Case file no.: Payment type:
. TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family ❑ Tenant improvement
0 New construction ❑ Addition/alteration/replacement ❑ Food service 0 Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address:
gWzr S- , a) /;� Description Qty. Fee(ea.) Total
Bldg. no.: ` I Suite no.: New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
Catch basin/area drain
Drywells/leach line/trench drain
Est. date of completion/inspection: Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR Manufactured home utilities
Business name: f/zJ ESCCAi//-7 iNe_, Manholes
Address: 6 /6 mg/2. V /9 / Rain drain connector •
City: A/6-w 7LGr State:o/j ZIP: 9'7/ _3 ,2_, Sanitary sewer (no. lin. ft.) i , J S
Phone: S ?_ , / ) ,,r, I Fax: I E-mail: Storm sewer (no. lin. ft.) _L > >
CCB no.: p4.2 qa, 0 I Plumb. bus. reg. no: Water service (no. lin. ft.) I S
City /metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve
• CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s) •
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
OWNER Fixture/sewer cap
Name (print): 7jQ (f 4$ b UE,v pa Floor drains/floor sinks/hub
Garbage
Mailing address: gviz rS J Hose bibb tsposal
City: tate:d2, I ZIP:9 2-3 Ice maker
Phone: a - „ 3 /[f t/ I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ / l/ J
Notice: This permit application Plan review (at %) $
O Visa 0 MasterCard expires if a permit is not obtained
Credit card number: 1 / within 180 days after it has been State surcharge (8 %) .... $ 1 2 4 1
Expires TOTAL $ / ? g ., U
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440.4616, (6/00 /COM)
•
ice •
PLUMBING PERMIT FEES: •
•
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures In PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. . QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San/Storm Sewer 46.40 Lavatory
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
16.60 Urinal
Other Fixtures (Specify) Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 3"
Sewer - each additional 100' 4 "
Water Service - 1st 100' 55.0 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
**PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
** All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
is \dsts \forms \plm- fees.doc 10/10/00
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
DICKENSON'S ELECTRIC
8449 SW BARBUR BLVD.
PORTLAND, OR 97219
Electrical Signature Form
Permit #: MST2000 -00492
Date Issued: 11/2/00
Parcel: 1 S136CB -00500
Site Address: 08418 SW SPRUCE ST
Subdivision: METZGER ACRE TRACTS
Block: Lot: L
. Jurisdiction: WAC
Zoning: R -5
Remarks: Placement of new manufactured dwelling.
Note: fees determined and approved by Jim Hendryx as hardship case.
Your company has been indicated as the electrical contractor for the permit indicated above. .In order for the
electrical permit to be valid, the signature of the supervising electrician is required. Please have the
appropriate individual from your company sign below and return this Electrical Signature Form prior to the
start of the work to the address above, ATTN: Building Dept.'
No electrical inspections will be authorized until this completed form is received
OWNER: ELECTRICAL CONTRACTOR:
DOUGLAS DAVENPORT DICKENSON'S ELECTRIC
8418 SW SPRUCE ST 8449 SW BARBUR BLVD.
TIGARD, OR 97223 .. PORTLAND, OR 97219
Phone #: 503 - 246 -3144 Phone #: 503 - 246 -3550
Reg #: L 1C 65534
ELE 26.140C
SUP 3100S
AN INK SIGNATURE IS REQUIRED ON THIS FORM
„ •.. Signature of Sup •' Electrician
If you have any questions, please call (503) 639 -4171, ext. it 310
•
Permit #: IT .S c Z Q - q 7-D,
p O
L
���.1 _ _ // c S .
�'' Addre ? v
• ,, Issued by: ate: / //Z 7,'),')
5 PARED
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required '
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks an initial boxes 1 and 2, d either box 3A or 3B:
7 1. I own, reside in, or will reside in the completed structure.
I' ' 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
' `� before or upon completion.
n 3A. My general contractor is
I (Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
DI 3B. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Qw ers about Construction Responsibilities on the reverse side of this form.
. .
-ems i �_ :I 0) / , 2c`bd
_....._
(Signature of permit apcant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
CITY OF TIGARD BI 'ILDING INSPECTION DIVISIC"' MST ?.rim/ -00 Z
24 -Hour Inspection Line: I. -4175 Business Line: 639-„,71
• • ` BUP "
Date Requested / Z — 7 AM PM BLD ji" .
Location f 7 / 8 5 cv S�IYN C.c- Suite MEC
Contact Person Ph C -2 f G -3/ yy PLM
Contractor Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing `z..--c--P , ,
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Misc: ---(/� _0-----e.--e.—A
Final
PASS PART FAIL
PLUMBING - ` /rte
Post & Beam
Under Slab
Top Out
Water Service
Sanitary Sewer
Rain Drains
Final
PASS PART FAIL
' MECHANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
S. "ECTRICAO
Service
Rough In !'jlo 1; Iv
UG /Slab
Low Voltage 1
Fire Alarm
Fin
PART FAIL
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA / Approach /Sidewalk Date ! 2 - `� ` , Ins Ext
Other
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.