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16350 SW COPPER CREEK DRIVE
CITYOF TIG /� R� ELECTRICAL PERMIT
CITY
/� PERMIT#: ELC2002-00567
DEVELOPMENT SERVICES DATE ISSUED: 10/25/02
13125 SW Hall Blvd., Ticlard, OR 97223 (503) 639-4171 PARCEL: 2S114BA-12300
SITE ADDRESS: 16350 SW COPPER CREEK DR
SUBDIVISION:
ZONING: R-7
BLOCK: LOT : Orfs JURISDICTION: TIG
Project Description: Reconnect furnace.
_
RESIDENTIAL.UNIT _ _ TEMP SRVC/FEEDE_RS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMPi IRRIGATION:
EACH ADD L 500SF: 201 - 400 amp: SIGN/OUT LINE LTG:
LIMITED ENERGY: 401 - 600 arnp: SIGNAL/PANEL.
MANF HM/SVC/ FDR: 601+amps - 1000 volts: MINOR LABEL (10):
SERVICE/FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 200 snip: W/SERVICE OR FEEDER: PER INSPECTION:
201 - 400 a,np: 1st W/O SRVC OR FDR: PER HOUR.
401 - 600 a np: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 arnp: _ _ PLAN REVIEW SECTION
1000+ amp/volt: _ >=4 RES UNITS- >600 VOLT NOMINAL:
Reconnect only: _ SVC/FDR -225 AMPS: C'_ASS AREA/SPEC OCC:
Owner: Contractor:
TIM TURNER PIONEER GAS FURNACE
16350 SW COPPER CREEK DR 3615 NE BROADWAY
TIGARD,OR 97224 PORTLAND.OR 97232
Phone: Not available Phone: 503-249-5000
Reg #: I I 79MAIS
___ --`-- FEES ----- -
De�-crlption Date � Amount
Required Inspections
II I.I'It%I I I FIA- Permit lu ' rr' $46.85
f titan Tax 1 u n? $3.7, Elect'I Final
Total $50.60
This Permit is issued subject to the regulations contained in the Tigard Municipal Code. State of OR Specialty Codes ar i all other applicable laws.
All work will be done in accordance with approved plans This permit trill expire if work is not started within 180 days of issuance,or if work is
suspended for more than 180 days. ATTENTION. Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center Those
rules are set forth in OAR 952-001-0010 through OAF 952-001.0100. You may obtain copies of these rules ordirect questions to OUNC at(503)
246-6699 or 1-800-342-2344
Issued By: e_ , r.L L L Permit Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not rntendPd fcr sale, lease, or rent.
OWNER'S SIGNATURE: DATE:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC`N: [-: � +_______________ DATE:_ _
LICENSE NO:
Call 639-4175 by 7:00pm for an ir,spection the next business day
(12 Cr . 39a 503-249 -F326U p- 1
10/2+/2002 18;14 FAX 5036b81960 G.:'Y OF TIGARD 4002/003
J) >'6:j dooms ��
Electrical Permi#Appli ation '
•� -" Deaerecolved:1r) _. �-0�Y Permitno.r-I-Gpm)-0
AWkZWM City. of Tigard "' Projeodappl.no.; Expiredate:
('lryafTigard Adalmss: 13125 SW Hall Blvd,Tigard,OR 972.23 pateiswed: Ay` Receiptno..�
Phone: (503) 639.4171
Fax: (503) 598A WCase file n.: Payrrlent Type;
I-Rnd use approval:
Tde 2(mnily dwelling or acc"sory O COmmrtcialfinduslrial U.Multi-ram(ly O Tenant imprmrnenl
O New construction 'U Addihonl21eet2donlrep)aoement 0 Other U Partial
lob address: r !'5*110101�1
7g.ria.: Suitt no.: ITRX rnapiftax lot account nu..
bou 118lock: Subdlvlxfo
Project name: r Description and location of work on premises: ,,--r
[sbma%d date of comp tedon/inspeccioa:
yob oa J 2 Fa IMat
f--------- llncrtprlon ea Twat ne.leR
Busineaennmc'_��n r Y�'•e__ .eJ�WR,iatiy,NeejIyp„w
Adchett+' (s,l•J" _�A - C1 dn.lr.�r�it 4teMr/es.ttseJr.��rr yr
eery: vtiC�. State: 73P: '72 s.r,io.irrcirdnl
lfionc: Frtx:a '25 -mail: 1000 aq.r1.or teas 4
CC_o no.: Blre.bus.lie-no:"lq L.M GaehOddirioq S00 .h.orpartioo thtmor
---
Limlr etre resVdended 1
City/metro lie.n_v-..- (�-Q�_ -- -`- t fmitrdemr .rwn reaWentVal z
h rrunuractured home or modules dwelling
Si�nntrn of.u�ervitinf electrician(inquired Se�ice.ndlot fender J ]
It
Sup,til.cr same(print)' zp b-Q r-'r t.icenre nu (-1r 1 nim air n- bees,
rralien or rriecotlen.
I2 �'"� � 7
20
001.anoomrpa two alaoos.rot. — - iName(pnt) a
Mailing addtrbs_' 401 amp.ma amps 2
�� Ov w oto trio 2
City: - $tatr•� .Ova�00pm(navohe --- _ -2—
Phone - _ IPax rF.•ruail: - nrwct � I
owner installatium'17be insteJatio^is being made on property I own 7emporatyaelslceaor�c+ra-
which is not inwnded for a,It,leme,rent,or exchange according to iaatsdltatan alse+atien,orMstaueo:
ORS 447,455,479,670,701. 2003ropsor tet. - --
I vtrr to 4 10 sopa t
Owner's signature: Date: 401 to G00 em s
taraaNe oaltt-eerr,altrtation,
sr.ascaaioe per pw,t:
Name: A Foe for branch rnrnita with purchase or
Add(CSE' _ asnioe a(teder fee,wen bruvh rircuit 2
City - State: ZIP: P. Re rat breach eirastiowkheurpurchu4
- - - =- - - -- of stivice or reeler fix.frat ttma circuit �J t
Phone: Fax lrma►l: - --_— --
Erb addivaual brattch drtarlt;
ULGIAly thie.(Serviciverfrtlrrowt oeioded)•
0 Servrer met 27-5 amps oommar*ial 0 Health carehcnity _Fach pump or irrition'rrtde --- 2
U Sarvino"er32i11"Tt-rtrloeofldtl U Ilararriwslocuion Eachairnofottdinelialrtiryt 2
rarritydVAlltnaa ❑Ruitdinaover l0.000squuelieet(rmor Sigriaciptwt(a)nratimitedMerltypmet,
U Syr tem ever 600 vats nominal more Mwenttal rarity In one nrartun: alveration,orextaolon• _.._ 2
0 9vlldingev«tlttte tbria R 14modas.40Damps or more °Deacd pion_
-
t] omasa
:)ccvpitt load ower 99 perrtur V flarnn -��� retlsw iVaetmrd rtrunu•rt Nv port aifeoeros trwiMlor►aaea U say of IIM aWnsrr
U hsnaa/lighungplst O Ori- _ Teri tion �---t-
-
9tsbrak___ ieU of pAsu with any of the r►err. tmrau on he ---_
The abMn we not a p11t•ab a to ern mirmy coRrbwion ierrice, Other
- - Permit fee
Na an Jarirl:rv,w asters nwdir nems.eia.e r,tt I n;rAl e4e fb,arose of nnvrinn Not cze This permit application s
U vha 0 tN.,rirrGrd errpirea it a permit is sot obhined Plan review(at -- %) 9
wllhin 1110 drys after it has bran Sate surcharge(896)_.S •. . _
aecipted at mnrplete TOTAL........................S
lire ToiidM`I�ei-u ii�aii�
s
--.... o•wtars'--- .^... _ Aller _ ar►rr411(e.v►rcwi
CITY OF T I G A R D MECHANICAL PERMIT
DEVELOPMENT SERVICES PERMIT#: MEC2002 00465
13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 10/17/02
PARCEL: 2S1 14BA-12300
SITE ADDRESS: 16350 SW COPPER CREEK DR
SUBDIVISION: COPPER CREEK STAGE 3 ZONING: R-7
BLOCK: LOT:Ob8 JURISDICTION: TIG
CLASS OF WORK: ALT FLOOR FURN: EVAP COOLERS:
TYPE OF USE: SF UNIT HEATERS: VENT FANS:
OCCUPANCY GRP: R3 VENTS W/O APPL: VENT SYSTEMS:
STORIES: BOILERS/COMPRESSORS HOODS:
FUEL TYPES 0 - 3 HP: DOMES. INCIN:
LPG 3 - 15 HP: COMML. INCIN:
MAX INPUT: BTU 15 -30 HP: REPAIR UNITS:
FIRE DAMPERS?: 30 -50 HP: WOODSTOVES
GAS PRESSURE: 50+ HP: CLO DRYERS:
FURN < 100K BTU: AIR HANDLING UNITS OTHER UNITS:
FURN >=100K BTU: 1 <= 10000 cfm: G
> 10000 cfm: AS OUTLETS:
Remarks: Install 4as furnace.
Owner: FEES
TIM TURNER Description Date Amount
16350 SW COPPER CREEK DR.
TIGARD, OR 97224 I'MI4,111 Permit FCC 10/17/02 $72.50
I h114,111 Permit I"ec 10/17/02 $0.00
I FAX I8 State! ix 10/17/02 $5.80
Phone: Nit availahle [TAXI 8 Statc lax 10/17/02 $0.00
Contractor: Total $78.30
PIONEER GAS FURNACE
3615 NE BROADWAY
PORTLAND, OR 97232 REQUIRED INSPECTIONS
Phone: 249-50u0 Heating Unt Insp
Final Inspection
Reg #: 36102
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted in the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR
952.-001-0100. You may obtain copies of these rules or direct questions to OUNC by calling
(503)246-6699. /
Issued By: r,v�Cc �r c-��`t Permittee Signature: ( )1
Call (503) 639-4175 by 7:00 P.M. for Inspections needed the next business day ✓%
OCt 16 02 03: 100 503-249-8260 P. 1
Till' 12: 32 1,A\ M13 rillh 191111 ('l l'\ 11D 'I'lr;;\Ill) (4,1004
Mechanical Permit f 1pplication
Ditto received: ,/ O PcrmiU►o7-
Buildirigpr.unif
Q�—CSU
City of Tigard ProJcci/appl.no.: `Ci o , and Address: 13125 SW RRll Blvd,'ripntr,t)lt 07223 Date issued: Br no�Phone: (503)639-3171 Fax: (503)598-1960 Case Me no.: Payment no.:
Land use approval: -- ---
8c 2 family dwelling or accessory
1y L7
�;ornmctcial/industrial U Mnlli-Catnily G'fc,rnnl imprcncmcnt
❑New construction U Addition/nitcrulion/replacement U Other:
.job address: �� indicate equipment quanulics in loxes bolo Y. Indicate the dollar
S Wino..; —_ _ value of all mechanical matcrinls,equipment.labor,o,�erfiead,
profit.Value$ _
Tax MAD/tax lodac_count no.:_
l„ot; block: Subdivision: ^- J 'Ser:checklist for important application informotiuu acrd
jurisdiction's fee schedule for residential permit tee.
Project name:
Cit /cuunly: ZIP: Q 7
Description ind to on of work on premises:_ - TOW
[�scti tiun llty.and Ices,ani
Est.date of completion/inspection:
Tenant improvetrient Of change of use. Air handlinp unit
Is existing space heated or condilioncd'/U Yet U Nn icon i on n (sic plan rc- quT cd) _
Is existing space insulated?0 Yes 0 No Alictalro-n-oreRT39 ng 11 V A U syatcln
o rr compressorn
Jul state bailer permit no.:
Bir®inesa name: Fl l mart HP
Address: WrX re artio c am ers uc sma a electors
SMtc i.Il': eat um s a antequ
Cit : ns rep use rnec runt• i�`
Phone: Fax: �} &mall:_ Including duetwork/verrt liner Yes U No 7 70 17-0119
CC$n� 0 _ cera I rep arc tc ooatc tentars-suspen el
—
City/metro lic.no.: 0 1 0___ __._ wall,or fluor mounted
Will fa ap ce other III-tin urnace
N (please stag: O 2 k o e gen on:
Absorption units
Chillets i 1"
Nattte- - ---- - - -- Com ressors ll;'
Address'1nAg n�__ n ramnents a a+ an rcitlihtlon:
Cit Slate: :'ll': _ Appllancevent _
y —--- -- t
cr ex mus
Phone: Fax: E-mail - --
a s. 'ypa rrs. tc ct tnzmat
flood fire suppression system — -
_Nacne_ �m__- �� r� -. Fxhaustfan With aingleduct(bathfans)
aust system u Tom,he!llss of AC
Mailing address: (yt�_ _.� p nR and up to ou ets
City: Sla �L1P: T pc. LPf3 No oil _
Pbonca 1'ax: F:-mail: c piping car o Dna Duct outlets
rocesa pip emai c required)
MM Number of outlets _ -
Name: tter lisfig slip ante or equ pmcnh
1)ecocativetirep ace _
ZIP: -----
City:
Phone: Pax: r
Applicant's signature: liir"'�� 1 er. -
Name(print): get
Penni(fee.....................6 ��
NtiotlJ,rirycUaruaceeplerwiteudf,plnsecailjefivtcdonfor,nrneln'smatlw. NOUce:'llsieperulilnpplicatfon Minimum fee........,....... •.'_ _-
U Visa ❑MnsrerCard axpirea Ir a pennit is not obtaincti Plan review(at , `361 1: �r
ctedlt cull number - -- --' ,ef-- widiiu 180 days after it has been Statr,surcharge(8%)....f �-
_--
uacepted as complete.
Mune or cena�o—'tomer m r+own on a r e s 'i'OTAi. .......................
CaEo er r�nanae —�c'01�nr OAU 4RtY(eVeIT:OA!1
CITY OfFTIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175
INSPECTION DIVISION BusineGs Line: (503) 639-4171 MS'f
BUP
Received Date Requested_ � �— AM--- --- PM -_----- _ BLIP
Location _z6_3J___ �v `�'`-�� �r --Suite --- --- Mac
Contact Person A-- - -- Ph( --—) ',SOU c1 - PLM ------ -
Contractor Ph( _ ) SWR
BUILDING Teriant/Owner ELC
Footing ---- — --
Foundation ELC
Ftg Drain Access: _
ELR
Crawl Drain - --�- ---
Slab Inspection Nates: SIT _
Post& Beam
Shear Anchors — -- -_
Ext Sheath/Shear
In! est /Shear / ,
-- -
Framing `//� _�Nst;- -✓12�e��. �,c
Insulation
Drywall Nailing
Firewall
Fire Sprinkler _--_ --- - __--- -
Fire Alarm
Susp'd Ceiling ---
Roof
Other
Final
PASS PART FAIL -
PLUMBING
Post& Beam
Under Slab
Rough-In -
Water Service
Sanitary Sewer
Rain Drains
Catch Basin/Manholc
Storm Drain
Shower Pan
Other:
Final --
PASS PART FAIL ------ - - -.__ .._--- __.-.-
EC
Post& Beam —'
Rough Ir _
Gas Line
Srr,)ke Dampers -
f
1A,S-SL)PART FAIL
ELECTRICAL
Service -
Rough-In
UG/Slab - - — —-
Low Voltage
Fire Alarm ---
Final Reinspection fee of$_ —. required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
_PASS PART FAIL
Please call for reinspection RE:_. I inable to inspect--no access
Fire Supply Line
ADA ,
Approach/Sidewalk Date G'- - '" d- - Inspector Ext
Other:
Final DO NOT REMOVE this Inspection record front! the Job site.
PASS PART FAIL
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639.4175
INSPECTION DIVISION Business Line: (503)639-4171 MST
I `t� BLIP
Received _. Date Reque ted _ ���--�— AM PM BUP — --�
Location3_, � ite _-- MEC
Contact Person Ph _--.__
( ) --__-- _ __ PLM _---_--
Contractor _ Ph(_ ) - SWR _
BUILDING Tenant/Owner ELC
Footing
Foundation -- ELC
Ftg Drain Access:
!vl ELR
Crawl Drain – —
Slab Inspection Notes: SIT _
Post&Beam
Shear Anchors --.._ ---__ ---------------- -- - — - -----
Ext Sheath/Shear
Int Sheath/Shear --
Framing
Insulation
Drywall Nailing ---- �✓
Firewall Z rooA_ O
Fire Sprinkler
Fire Alarm
Susp'd Ceiling -- ---
Roof
Other: -
Final —
PASS PART FAIL —
PLUMBING
Post& Beam
Under Slab
Rough-In
Water Service —
Sanitary Sewer
Rain Drains
Catch Basin/Manhole
Storm Drain - - -- - -
Shower Pan
Other: - - ---
Final
_PASS PART FAIL
CH -- — — - -- --
MEANICAL
Post 8 Beam -----
----- -- __---- ---
Rough-In —
Gas Line
Smoke Dampen: -- ---- -- — --
Final
PASS PART FAIL — — --- -- --- --
ELECTRICAL
Service
Rough-In —
UG/Slab - ------ ------ —
Low Voltage —
Fire I Wrm -- -- --
Final ) El Reinspection fop of$ _ required before next inspection. Pay at City Hall, 131 W Hall Blvd.
PASS PART_ FAIL
SITE _ Please call for reinspection RE: —_ able to inspect-no access
Fire Supply Line
ADA Data_ � L_ Z-- InspaatOr Ext
Approach/Sidewalk —
Other:_
Final DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL
PLUMB NU PL HM I I
------ PERMIT #. I . . . . . : F'LM96 0166
CITY OF TIGARD DATE ISSUED: 06/24/96
COMMUNITY DEVELOPMENT DEPARTMENT PARCEL: 23114PA-12300
.1. 13126)&I� Ivd.Tlp�rd 1 k� ,��54J�e '1- 31I FK
DR
bUBDIVISION. . . . : COF'F'ER CREEK STAGE_ 3 ZONING: R-7 RD
BLOCK. . . . . . . . . . . 1-01.. . . . . . . . . . . . . :88
GLASS OF WORK. . :ALT GARBAGE DISPOSALS. : 0 MOBILE HOME SPACES. : 0
TYPE OF USE. . . . :SF WASHING MACH. . . . . . : 0 BACKFLOW PREVNTRS. . : 1
OCCUPANCY GRE='. . : R3 FLOOR DRHINS. . . . . . . 0 TRAPS. ,. ,. . . . . . . . . . . 0
STORIES. . . . . . . . : 0 WATER HEATERS. . . . . : 0 CATCH AINS. . . . . . . : 0
FIXTUhCS- - ----- ---- LAUNDRY TRAYS. . . . . : O.1 SF RAIN DRAINS. . . . . : 0
SINKS. . . . . . . . . . . 0 URINALS. . . . . . . . . . . : 0 GREASE TRAPS. . . . . . . . 0
LAVATORIES. . . . . : 14 OTHER FIXTURES. . . . : 0
TUB/SHOWERS. . . . : 0 SEWER LIRE (ft ) . . . - 0
WATER CLOSETS. . : 0 WATER LINE (ft ) . . . : 0
DISHWASHERS. . . . : 0 RAIN DRAIN (ft ) . . . : 0
Remarks : Install residential back flow prevention device
Owner: --- ----____..-._._._____.__.___._____________.___________.____ FEES ----•-•-----
EDDIE MORRIS type amor_%nt by date recpt
16: 50 SW COPPER CREEK RD. PRMT $ a5. 00 BON 06/24/96 96-•280931
SPCT $ 0. •75 BON 06/2,4/96- 9E+•-280931
T I GARD OR 97224
Phone #:
Contractor: --- --- -- -
OWNER
Phonp #: $ 15. 75 TOTAL
-------- REQUIRED INSPECTIONS
This permit is issued subject to the regulations contained in the RF'/Bacl(f l ow Prev
Tigard Municipal Code, State of Ore. Specialty Codes and all other Final Inspection __.�•_..___ ____,.__..
applicable laws. All Mork will be done in accordance with
approved plans. This permit will expire if work is not started
within 188 days of issuance, or if work is suspended for so,•e
than 188 days.
1-'e r m i t t e e S i. n a t lr r•e ^
I ss 1-1 e M. J IL 4
Lail for inspection — 639 4175
i'ermit -016(D
.Address
Issued by: f,—, Date:
l
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential comtruction permit appli-
cants who care not registered with the Construction Contractors Board to sign the
f)lloii•ing sYatem�•nt hefi)i,e a hrrildinglrermit c•an be iss•tred. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt.i•or" registration under Offs 701.010(7),
need not sub►nit this statement. This slateinent will he filed ivith the permit.
I ill in the ,appropriate blanks and initial boxes I and 2,and either box 3A or 3B:
1. 1 own,reside in, or will reside in the completed structure.
2. 1 understand that i must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
3A. My general contractor is
(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
311. 1 will be my own general contractor.
If I hire Fubcontractors, 1 will hire only subcontractors registered with the Construction Contractors
Beard. If f 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.
hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Cons►rnction Responsibilities on the reverse side of this form.
(Signature ol'permit applicant) (Date;
(While ropi•to issuing agenrt•permit file,
pink copy to applicant)
I ntormation Notice to Property Owners
About. Construction Responsibilities
IINI l+llt,1/'lll.Nir:R .�1!!f(C !0 /,1,)/;L I/I
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EMPLOYER RESPONSIBILI I IES:
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City Of Tigard PLUI4BING PERMIT APPLICATION Planck/Rec. #
13125 SW Hall Blvd. Permit #
igard, OR 97223
(503) 639-4171
MINIMUf 1 $25.00 PERMIT FEE + ST. SURCHARGE
N^ °'rxvibuM°^' New Single Family Residences Only
_a+�••+ r ❑ 1 BATH HOUSE$140.00 ❑ 2 BATH HOUSE $195.00
Job / ❑ 3 BATH HOUSE$225.00
Address u;,sut• zip Fee includes all plumbing fixtures in the dwelling and the first 100 feet
of water service, sanitary sewer and storm sewer. See fees below.
Name(m nme.1 Bu-.. FIXTURES QTY• PRICE AMT
L2 p, 1 011 1 PjS Sink 900
M•Mnp^dd••• Lavatory 9.00
Owner /6,3So •5k �G1P�� c'ktCK D�1vr
Tub or Tub/Shower Comb. 9.00
"r'''•'^ zip Shower Only 9.00
V7 a;`- Water Closet 9.00
--- N•m•'«^•^•°'° °•• /1 Dishwasher - 9.00
C A-Re V� Garbage Disposal 9.00
f Occupant ,•,,,u Washing Machine 9.00
Floor Drain 9.00
,af.w. zm Water Heater 9.00
Laundry Room Tray 9.00
N.- - Urinal 9.00
1 , Other Fixtures (Specify) _ 9.00
leeu.a MIA... Rn°^. 9.00
Contractor _ _
9.00
900 -.
Sewer 1st 100' 30.00
stele Repi.°enmi N.. --- �,�Y� �• r,^ Sewer-ea. Addit. 100' 25.00
1 _
Water Service 1st 100' 30.00
I hereby acknowledge that I have read this application, that the Water Service ea. Addit. 200' 25.00
information given is correct, that I am the owner or authorized agent of -
the owner, that plans submitted are in compliance with State laws, that Storm &Rain Drain 1st 100' 3000
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 below) Mobile home Space 25.00
Back Flow Prevention
c(�r t �( ✓ l(�rj,6� �L%��/� Device or Anti-Pollution Device 9.00
�^•^^ ^w^^ M•o^^ -"r--�` °nin Any Trap or Waste Not
Connected to a Fixture 9.00
escribe work new Q addition Q alteration U repair Q Catch Basin 9.00
to be done residential O non-residential Q Insp. of Exist. Plumbing 40.00/hr
L, (Al Specially Requested Inspections 40 OO/hr
Exishn� use ui -
building or property --_ _ Rain Drain, single family dwelling ------- - 0.00
Residential backflow prevention
devices �- 15.00
Proposed use of
building or property _ -
,Except residential backflow
prevention devices)
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 h, ANY TIME AFTER WORK IS
COMMENCED PLAN REVIEW 25%OF SUBTOTAL
TOTAL
Special Conditions
__ Date issued by