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13815 SW ASHBURY LANE _,
CITY OF TIGARD
DEVELOPMENT SERVICES
' 13125 SW Nall Blvd„ Tigard,OR 97223 (503)639-4171
C'ERTIFTcrirc OF
OccUCjHiJCY
PEPMIT #. . . . . . . c MST96 •08,53
DATE ISSUED: 113/17/96
PARC.ELc IS133CD-16700
;ITE 4ClDREGS. . . : 1.3845 SW AGHBURY LN
'IJBDIVIf IL1N. . . . c PESSLCC;REEK #3 70NING:R-25
{LOC:K. . . . . . . . . . . LOT. . . . . . . . . . . . . P57
i;LAaa OF WORK. :NEW
TYPE OF UGE. . . :SF
I 'YPE Of CON!'TR c IN
tLCUPANCY r,K'P. :R3
;r1::tJPANC:Y l ()A():
IamAr•IAc c PATH I
lwner•r _..__.-_.---_•---._._..__.._...._.._....._ -....___._ ... ..___
I
;O':iTf1 PAC'I v I c EIOMF_' -.;
,1625SW CASCADE FALUD
,UTTE #606
I�EAVERT'ON OR 97008
Ohnne #c 646---3888
;OGTA_PACIFIC HOMES
'i625 5W C'ASC:ADF AVE SIF. 6:7U6
;EAVERTON On 97005
'hctne #: 503-6468868
65)115 7
!his Certificate grants oc_Cupartcy of the above referenced building or poo-tion
thereof and confirms that the bui ldi has been inspected for compl ianr-e wii I
he citart a of Oreyon lahec tail ty CociPs for the gr-c!t.1p, ac: .. _1pmnr.y, d tc,e ander
•ihich the rel=erw,nced p—)mit was igat. ed.
l f f/'
(AIJ I LT)7 NO INSPECTOR HtJ I L.D I NI, OFF IAL.
I
POST IN (:ONGP I C UOUb PLACE
MASTER P'ERMI1' ✓
T #. . . . . . . il _,
CITY OF T t GARD DATE I'ERMIISSUEL): . 0-6/07/S96`196—& 5J
COMMUNITY DEVELOPMEUTD7_:PAPTMENT
13125 SW Hall Blvd. Tigard,Ore On SON 639-4171 1�:IARCEL: 1 F3133CC—PIB35 7
1 .97223*8199
W ( I �
-A�,,F D 1t'( L-N
SUBDIVISION. . . . VIEBBL-E-CREEIA #3 ZONING: R-25
BLOCK. . . . . . . . . . .
Remarks: PATH I
----------------------------------------------------------------- BUILDING ------------••------------------------------- -------- - ----.
REISSUE:
----------------------------------------------------------
REISSUE: STORIES.......: 2 FLOOR AREAS---------- BASEMENT...: 0 sf REQUIRED SETB)r.KS---- REQUIRED-
------------CLASS OF WORK.:NEW HEIL4T........ 23 FIRST....: I-,'b s f GARAGE.....: 546 s f LEFT..........: 10 SMOKE DLTECTRS: Y
TYPE OF USE...:SF FLOOR LOAD....: 40 SECOND—: 853 st FRONT.........: 2e PARKING SPACESi
TYPE OF CONST.:5N MLLING UNITS: I FINBSMENT: @ if RIGHT,........: 15
OCCUPANCY GRP,:R3 BDRM i 4 BATH: 3 TOTAL-.--..--: 2081 s, VALUE—$, 143894 REAR........... 47
----------------------------------------------------------- PLUMBING -------------------------------------------------------------------
SINKS......... I WATER CLOSETS.: 3 WASHING MACH.. ; I LAUNI,ky TRAYS.: 0 RAIN DRAIN ft: 0 TRAPS.........: 0
LAVATORIES....: 4 DISHWASHERS...: I FLOOR DRAINS.. : 0 SEWER I INE ft: @ SP RAIN DRAINS: I CATCH BASINS..: 0
T'UB/SHOWERS... 2 GARBAGE DISP..: I WATER HEATERS. : WATER LINE ft: 100 BUFLW PREVNTR: I GREASE TRAPS..: 8
OTHER FIXTURES: @
----------- ——----------——------------------------ MECHANICAL ---—----—------—----------I—---------------------------
FUEL TYPES----------- FURN ( INK @ BOIL/CMP ( 3HP: @ VENT FANS.....: 4 CLOTHES DRYERS: I
/GAS/ / / FURN )=IW I UNIT HEATERS..: 0 HOODS.........: I OTHER uNITF,,..: I
MAX NP.: 0 BTU FLOOR FURNACES: @ VENTS.........: 0 WOUDSTOVES.... 0 GAS OUTLETS...: I
--------------------------------------------------------------- ELECTRICAL ------------------------------------------------
UNIT--- ---SERVICF/FEEDER---- ---TEW SRVC/FEEI)ERS-- ---BRANCH CIRCUIT',— ----MISCELLANEOUS----- --ADD'L INSPECTIONS--
000
NSPECTIONS—000 15F OR LESS: 1 0 - LIN amp..: 0 0 - 200 amp..: @ W/SVC OR FDR..: 0 PUMP/IRRIG411ON: @ PER INSPECTION: 0
-A ADD'L 5006F.: 4 201 - 400 asp..: @ 201 - 400 asp.. : 0 let WID SVC/FDR: @ SIGN/OUT LIN L.T: 0 PER HOUR......: 0
LIMITED ENFRGY,: 0 401 - 600 amp..: 0 401 -- 600 amp., : 0 EA ADDL BR CIR: 0 SIGNAL/PANEL...: 0 IN PLANT......: 0
MANF HM/SVC/FDR. 0 601 1000 amp.: 0 601 amps-1000 v: 0 MINOR LABEL -10: 0
1000+ amp/volt.: 0 PLAN REVIEW SECTION -----------------------------------
Reconnect only.: @ )=4 RES IJNITS..,. SVC/FDR)=225 A.. ) 60 V NOMIIAL: CLS AREA/SPC DCC:
- --------- ------------------------------- ELECTRICAL - RESTRICTED ENERGY -------------------•-_-----------•-------------------
A.
--------------------------------------------------
A. SF RESIDENTIAL----------------------------- B, COMMERCIAL----------------------------------------—----------------—-----------------
%DIO A STEREO.: VACUUM SYSTEM..: AUDIO & STEREO. FIRE ALARM.....: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM..: 0TH: X BOILER.........: HVAC...........: LANDSCAPE/IRRIB: PROTECTIVE SIGNL:
GARAGE OPENER_: LLOCK............ INSTRUMENTATION: MEDICAL........: OTHR:
HVAC...........: DATA/TELE COMM.i NURSE CALLS....: TOTAL # SYSTEMS: 0
Omer: ----------------------------------Contractor; —----------- TOTk FEES1 4505.95
COSTA PACIFIC HOMES COSTA-PACIFIC HOMES
86255W CASCADE 81.0 8625 SW CASCADE AVE STE.606
SUITE 06@6
BEAVERTON UR 97folib BEAVERTON OR 97@P3
Phone 0: ')46--88136 Phone Jl! 503-641,-8888
Reg C. : 65157
This permit it, issued sub)ect to the regulations contained in the Tigard MUnlLipdl Code, State of Ore. Specialty Codes and all other
applicable lhws. All work will be dare in accordance with approved plans. This permit gill expire if work is not started within IN
days of issuance, or if work is suspended for more than 180 days.
-------------------------------------------------------------- REQUIRED INSPECTIONS ---------------------------------
Erosion Contol Underfloor insul Electrical Servi Gas ',in@ Insp Water, Service In Building Final
!ooting Insp Crawl brain Electrical Rough Insulation Insp Appr/Sdwlk Insp
Foundation Insp PLM/Underfloor Framing Insp Gyp Board Insp Electrical Final
Post/Beam Struct Mechanical lnsp, Shear Wall Insp Rain drain !9sp Mechanical Final
Pest/Beam Mechan Plumb Top Out VOW voltage Water Line Insp Plumb Final
I'ev-m i t t ee E) q n a 47
S�.ted By a
Cal I for- inspertion — 6:,:- 4175
bLWEH LUNNEC, i 1 U
PF h.h I T
CITY OF TIGARD DATE[ ISSUED: . 06/07/1966 0• �;c,
COMMUNITY DEVELOPMENT DEPARTMENT
ggyy� c�p3 3 4 7 PARCEL: 1 S 133CC-F'I33`,7
I Tk"'l!ll}t..la�avd..Tipud.OTM04 "7 RJ8I; 11t_Hip I�fv
SUBDIVISION. . . . . PEBBLECREEN. #3 ZONING: R-25
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . ..5-/
I-HNANT NAME. . . . .
USA N`7. . . . . . . . . . . FIXTURE UNI'f S. . . . 0
CLASS OF WORE:. . . ;NEW DWELLING UNITS. . : 1
T'YK'E OF USE. . . . . :SF NO. OF BUILDINGS: 1
INSTAL[_ TYPE. . . . :BUSWR I11PE:RV SURFACE: 0 sf
Remarks : PATH 1
(Jer: -- FEES
COISTA 1='ACIFIC HOMES type amorant by date r,ecpt
8625SW CASCADE BLVD F'RMT $ 2200. 00 B 06/07/96 96-280339
5,UITF- #606 1NSF' 8 35. 00 B 06/07/96 96-�_QO:s r3
Bf•_AVERTCIN OR 97008
1-'horip #: 646"-8888
Contractor-:
CONTRACTOR NO1` ON FILE
Phone #: L 2235. 00 TOTAL
Req #. .
-- ----- REQUIRED I NSPECJ IONS -- -This Applicant agrees to comply with all the rifles and regulations Sewer, Inspection
of the Unified Sewage Agency. The permit txpires 180 days from
the date issued. The total amount paid will be forfeited if the
permit expires. The Agency does not guarantee the accuracy of the
side sewer laterals. If the sewer is not located at the measurement
given, the installer shall prospect 3 feet in all directions from
the distance given. If not so located, the installer shall purchase
a "Tap and Side Sewer" permit and the A ncy will install a latell.
Perm i t t e e Signature : ,✓.-__-._�.±��__. —Z _..__-_
s red By :
I
Lt 1 (_c
c
Call for inspection - 6.39 4175
I
TO U,Fi
Residential Building Perm Application
City of Tigard
13'125 SW Hall Blvd.
Tigard, OR 97223 C a.c
(503) 6394171
JobsiteAddress: 13845 SW Ashbury Lane
Subdivision: Pebble Creek #3 Lot # 57 Office Use Only_
Contact Date / / _Initials
Valuation: I �y _--� Result
New Construction nnl�: (Square Footage) Planck/Rec # r-?�
House: 2081 Garage: _5 4 f, _ Permit # _6Fglr_v Z 5-3
Reissue of
Map & IL#.),`,,I
Corner Lot? Y N Flag Lot? Y N Zone -ZS —_—
Plat # 16 - T
Owner: —r.,,�t.a�,�; f i r ilriM Q S : y
Address:
APProy_als Re uu,�rati
.gb�s_S.W _
Planning Setbacks 51� Solar
Raayortnn ,1 R 47nng _ Engineering -i
Other
Phone ( 5n i) 64F,-888B
Items Required
Contractor: _ SAME _ _—
Subcontractors
Address: —. Truss Details �—
Other
-- - Notes Ejt=4 4 ajn j_.--
Phone.
Contractor's License # _65157
(attach copy of current Oregon lirense) �-{ _`
Contact Name Marti Weber .
Contact Phone L__503 ) 646-88eg_ —
Subcontraciors: Architect/Engineer: Lys-inn A or a h.as
Plumbing: —ldnlrnti PIumn9� Address: �t KatmusI)riv.e_L_-1 -4Q
Mechanical: Arrn Tn-,;ta t t atlpnG �nct MA. _gyp_—gZb16 _
(attach copy of current OR Contractors License)
Bear Electric Phone ( 719 �_ 549-3479
JOB DESCRIPTION:
Applicant Signature Applicant Phone number
I
Received by: "n�' �? f`t `� , _— Date Received:
v wP,,.anv naw
Permit S A ;daunt 7eacairdon Amount Arm. Pd. Bal. Due
;r, ,ryi• Bldg. Permit `BUILD)
Plumb. Permit (PLUMB]
Mech. Permit (MECH)
/ <.
�t/( cc-.�q.� 02 u U
Bldg:
Plumb: /` Z. >
Mach: Z '
Plan Check (PLANCK) �sZ�� 150
Bldg: 5 Z
Plumb: _
Mech: ? � _
6 4it%�o Sewer Connection (SWUSA) r U V
3ewe:Inspection (SWINSP) .3 1 ' j
Parks Dow Charge (PKSDC) 0
Residential TIF (TIF-R) ./ VlJ-
Mass Transit TIF (71F-,MT) 1-cJ
Commercial TIF (TIF-C)
Industrial TIF (TIF-4)
Institutional TIF (71F-IS)
Office TIF (-rlF-0)
Water Quality (WQUAL)
Water Quantity ('NQUANT) u
Fire Life Safety (FLS)
=rasion Cntr1 Permit (ERPRIW)
Erosion PlaincrJUSA (ERPLAN)
Erosion PlanckJCOT (CRCSN)
TOTALS: �� Q. �'� 2 `)0
Box B. continued Box B:
2. Measure change in elevation from front property line to finished floor elevation. If
the lot slopes up from the front lot line to the foundation, the figure is positive. If
the lot slopes down from the front lot line to the foundation, the figure is negative. ft
3. Measure distance from finished floor elevation to the affected peak/eave. 2 ft
4. If the roof line runs North-South, deduct three feet. If the roof line runs East-West, it
deduct nothing.
5. Subtract one foot for each foot of difference in elevation from the front property
line to the rear property line, if the lot slopes up from the front to the rear. If the
lot has no slope or slopes up from the rear to the front, deduct nothing. rt
6. Total figure for box B:
Box C. Distance to the shade reduction line. Box C:
1. Measure the distance from the North property line to the foundation near the
affected peak/eave.
2. Measure the distance from the foundation to the affected peak or eave. _ ft
3. Total figure for box C: �f ft
It is most useful to draw a vertical line to represent the appropriate figure found in box"A"and a horizontal line to represent the
appropriate figure found in box "C".The intersection of the vertical and horizontal lines determines the value found in box "D". The value
in box "D"should be compared to the value in box"B"; if the value in box "B"is less than or equal to the value found in box"D", then
the building is in compliance with the solar balance code. If you have any questions, please contact us at 639-4171,x304 or at the
Community')evelopment Counter.
MAXIMUM PERMITTED SHADE POINT HEIGHT (In Feet)
Distance to North-south lot dimension(in feet)
shade 100+ 93 90 85 80 75 70 65 60 35 50 45 40
reduction line
from northern
lot line in feed
70 40 40 40 41 42 43 44
65 38 38 38 39 40 41 42 43
60 36 36 36 37 38 39 40 41 42
55 34 3.4 34 35 36 37 38 39 40 41
50 32 32 32 A 34 35 36 37 38 39 40
45 30 30 30 31 32 33 3.4 35 36 37 38 39
40 28 28 28 29 30 31 32 33 34 35 36 37 38
35 26 26 26 27 28 29 30 31 32 33 34 35 36
30 24 24 24 25 26 2.' 28 29 30 31 32 33 34
25 22 22 22 23 24 25 26 27 28 29 30 31 32
20 20 20 20 21 22 23 24 25 26 27 28 29 30
15 18 18 18 19 20 21 22 23 24 25 26 27 23
10 16 16 16 17 18 19 20 21 22 23 24 25 26
5 1-4 14 14 15 16 17 13 19 20 21 22 23 24
Box D. Maximum alln ved shade point height: 1� feet
l
Solar Balance Point Standard Worksheet
Address
Box A calculations: North-South dimension for the lot. Box A:
This dimension is determined by finding the midpoint of the North lot line and drawing
an intersecting line perpendicular i.o that point.
First, determine which property line is the `forth lot line. Th,� North lot line is the line
with the smallest angle from a line drawn east-west and intersecting the northern most
point of the lot.
450
* X
LOT I o �
N ; North-South
`_-' Dimension for Lot:
Measure the distance from the midpoint of the North lot line to the South lot line along
the described line.
� feet
1
i N
NCR6OAM'.DWENSICN.':;::J
Box B calculations: Shade point height for your residence. Box B:
1. Determine whether measurements will be based on the peak or eave of your Which describes
structure. The orientation of the ridge is also important. your residence?
1 a: If the roof line runs North-South, measurements will
"""`°""WIN your
one)
be based on the peak of the roof. T coo c
^�°M—► 1 A 1 B 1 C
1 b: If the roof line runs East-West and the roof pitch is
less than 5112, measurements will be based on the
eave.
90CE
1 c: If the roof line runs Fast-Nest and the roof pitch is
5,12 or steeper, measurements will be based on the
peak.
J
Isar-09-1996 10 31 CES F r'
N 01'37'52" E
-- 2.06'
F
WAFER
I METER �,� �?? 10' 51DE YARD
IQST
�� SEDIMENT SETBACK
wa rER FENCE_ ' 88'22'08" E
v
LATEF2A� 97.02' ` .204.0J'� � �
<I n6.
ry S\o'2358
[ATE AI. npafpyl�l
�
RR 1
GFF 200.5 15' REAP.
kp IT I YARD
\� LCI I 5 I 1401).4-----�—
PLA
ISETBACK
N 2028 '
FF = 201.0CINI
cli
!c N� 9y ( • � , I I� I
z •�• �g9� 10' SIDE YARD
SETBACK I
1• �
.n
10' SIDE YARD
SETBACK
VEL C TIRUCTION S 85'40'45-'E
TRAN �. , S 85'40'43" E
58'18'41" \ 34.98'
R = 79.00'
T = 44.07' `\\�� N 01'34'35" E
L - 8U.40' � `�� - --- --- - 1.00'
CH = 76.98'
(.B - s 27'31'29" E SW ASHBURY LAW
6 - 20'26'15"
R = 109.67' —
T = 19.77'
L - 39.12'
CN = 38.92' TAX
CB N 75'27'36" W TAX
NOTE• CONTOURS AND UTILITY INFORMATION
TAKEN FROM CONSTRUCTION PLANS PREPARED
SCALE' 1' 20' BY THE SUBDIVISION ENGINEER. VERIFY INFORMATION
SH0w1 BEFORE BEGINNING CONSRUOTION. CORNER
ELEVATIONS OBTAINED FROM CONTOUR/GRADING PLAN
20 10 U 20 AND SHOULD ALSO 9E VFRIFFD.
CONSULTING ENGINEERING SERVICES, INC. LOT 57 DATE
,..� s/e;ee
15256 N.W. GREENBRIER PARKWAY I PEBBLE CREEK N0. .3[Iry FIGURE
9EevFnro�I Ca 97005 (503) 630-6600 TIGARD, ORFGCN
177
1�
City of Tigard PLUMBING PERMIT APPLICATION Planck/Rec. #
13125 SW Hall Blvd. Permit #
Tigard, OR 97223
(503) 63q-4171
MINIMUM $25.00 PERMIT FEE + ST. SURCHARGE
N•^'•+'D-Ow-t - New SinIg a Family Residences only
A"••• ❑ 1 BATH HOUSE$140.00 ❑ 2 BATH HOUSE$195.00
Job I �'n q 5 - St,) `15 u.r n, ❑ 3 BATH HOUSE $225.00
Address Jar Fee includes all plumbing fixtures in the dwelling and the first t00 feet
of water service, sanitary sewer and storm sewer. See fees below.
N.mia�.m.a eo.•,...t FIXTURES QTY PRICE AMT
Sink 9.00
MNng Ad&.. Ph@^• Lavatory 9.00
Owner Tut•, or Tub/Shower Comb. 9.00
M s•'• :IP Shower Only � 900 -
Water Closet 9.00
_- Nm (n ohm•.1 MMnw•i Dishwasher 9.00
Garbage Disposal 9.00
Occupant M•�oAd*.. pha Washing Machine � 9.00
Floor Drain 9.00
3717•'• m Water Heater 9.00
Laundry Room Tray 9.00
"•^+ Urinal 9.00 -
r _
Other Fixtures (Specify) 9.00
�..m:Ae�«• Ph- � - .- -- 9.00
Contractor
/'(-). C106 . _51 9.00
°�x'�• no 9.00
,,�. (') c� " ✓ f Sewer 1st 100' 30.00 -�
�'"•"• •tk.a.. M'a'T.rb, jv:er-ea. Addit. 100' 25.00
]
)'71 , ., 5 s Water Service 1st 100' -- 30.00
I hereby acknowledge t'iat I have read this application, that the Water Service ea. Addit. 200' 25.00
information given is corre:t, that I am the owner or authorized agent of - ---the owner, that plans submitted are in compliance with State laws, !hat Storm &Rain Drain 1st 100' 30.00
1 am registered with the Construction Contractor's Board, that the Storm &Rain Drain Addit. 100' 25.00
number given is correct. (If exempt from State registration. please -
give reason b low.) Mobile Home Space 25.00
�- Back Flow Prevention
Device or Anti Pollution Device 9.00
Sign.". �^�w ^'� � - °"• Any Trap or Waste Not
Connected to a Fixture 9.00
Describe work new O addition v alteration Q repair O Catch Basin 9.00
to be done residential n non-residential O Insp. of Exist. Plumbing - 40.00/hr
Specialty Requested Inspections 40.00/hr
Existing use of r -�-
building or property _ I - Rain Drain, single family dwelling - 3000
Residential backflow prevention
devices 1500
Proposed use of
building or property -_ - -- - -
'(Excepf residential backflow
prevention deevices)
NOTICE 'Minimum Fee $25.00 SUBTOTAL
PERMITS BECOME VOID IF WORK.OR CONSTRUCTION -
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5% SURCHARGE
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED - --FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS
COMMENCED PLAN REVIEW 25`/. OF SUBTOTAL
TOTAL
Special Conditions -
- _ - - Date issued by
L
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
WOLCOTT PLUMBING CONT. INC
P O BOX 2007
GRESHAM OR 97030
Plumbing Signature Form
Permit # . . LMST96-0253
Date Issued . : 06/07/96
Parcel . . . . . . : 1S133CC-PB357
Site Address : 3.3845 SW ASHBURY LN
Subdivision. : PEBBLECREEK #3
Block. . . . . . . L()t_ : 57
Zoning. . . . . . . R-25
Remarks :
PATH I
Your company has been indicated as the plumbing contractor for the permit indicated above. In order
for the plumbing permit to be valid, please have the appropriate individual from your company sign
below and return this Plumbing Signature Form prior to the start of work. No plumbing inspections
will be authorized until this completed form is received.
AN INK SIGNATURE IS REQUIRED ON THIS FOPM
( )W qEP : PLCJMBING CONTRACTOR :
COSTA PACIFIC HOMES WOLCOTT PLUMB114 CONT, INC
8625SW CASCADE BLVD P O BOX 2007
SUITE #606
BEAVERTON OR 97008 GRESHAM OR 97030
Phone it : ( - 5-8888 Phone # :
Reg # • . : 23847
x - ��,Ci9-t,c�S /✓Cc c.11-'4-- - --
Signature of Authorized Piumber
Please return this completed form to the address above.
ATTN: Building Dept.
If you have any questions, please call 639-41 i ext. #1310
OF TIC AAD
''3?25 S.W HALL BLVD.
I KY&PO, OH 972.'.3
iivirufsTr '�;J "'Era�',I' fV�;,�T!('�.•.
BEAR
PO BOX
28OPS BI1'',-AVI'..I.jE RD 1:E
Di%NALD Oh 97020
Electrical Signature Form
Permit # . . . MST96-0253
Date Issued. : 06/07/96
Parcel . . . . . . : 1S133CC-PB357
Site Address . .13845 SW ASHBURY LN
Subdivision. : iEBBLECREEK #3
Block. . . . . . . . Lot : 57
Zoning. . . . . . : R-25
Remarks :
PATH I
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 work. No electrical inspections will be authorized until
this completed form is received.
AN INK SIGNATURE IS REQUIRED ON THIS FORM
?WNRR : ELECTRICAL CONTRACTOR.:
COSTA PACIFIC HOMES BEAR ELECTRIC
8625SW CASCADE BLVJj PO BOX 389
SUITE #606 28085 BUTTEvTLLE RD NE
BEAVERTON OR 97008 DONALD OR 9720
Phone # : 646-8888 Phone # : Ft3'- '87-1108
Reg # . . : 205.:.:,
X
Signature -61 ;sing ectrician
Please return this completed form to the address above. �' S
ATTN: Building Dept.
If you have any questions, please call 639-4171 , ext. #310
t