11510 SW 92ND AVENUE L
11510 SW 92nd AVENUE
CITY O F T I G A R I. RIGI MASTER PERMIT
AL PERMIT#: MST1999 00274
DEVELOPMENT SERVICES DATE ISSUED: 09/2.3/1999
, N
13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171
SITE ADDRESS: 11510 SW 92ND AVE PARCEL: 1S135DC-08500
SUBDIVISION: MLP97-0010 DOWNING ZONING: R-4.5
BLOCK: LOT: 001 JURISDICTION: TIG
REMARKS: PATH I: New single family dwelling w/attached garage.
BUILDING
REISSUE: STORIES: I FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: NEW HEIGHT: 12 FIRSI: 1.394 at BASEMENT: at LEFT: 5 SMOKE DETECTORS:
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: at GARAGE: 410 at FRONT: 20 PARKING SPACES: 2
TYPE OF CONST: 5N DWELLING UNITS: 1 FINSSMENT: sl RIGHT: 19
VALUE: S 106.590 96
OCCUPANCY GRP: R3 BDRM: 3 BATH: 2 TOTAL sl REAR: 24
PLUMBING
SINKS: WATER CLOSETS: 2 WASHING MACH: 1 LAUNDRY TRAYS: 1 RAIN DRAIN: 100 TRAPS:
LAVATORILS: I DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: 100 SF RAIN DRAINS: 1 CATCH BASINS:
TUBISHOWERS: 2 GARBAGE DISP: 1 WATER HEATERS- 1 WATER LINES: 1C l 13CKFLW PREVNTR: 1 GREASE TRAPS
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN<100K: I BOIL1CMP<3HP: VENT FANS: 7 CLOTHES DRYER: 1
GAS FURN>-100K: UNIT HEATERS: HOODS: I OTHER UNITS: 1
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: 1
ELECTRICAL
RESIDENTIAL UNII SERVICE FEEDER TEMP SRVCIFEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 1 0 200 amp: 0 200 amp WISVC OR FOR: 1 PUMP/IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 2 201 400 amp: 201 •400^mu. 1st WIO SVC/FDR: 00 SIGN/OUT LIN LT: P'.R HOUR:
LIMITED ENERGY: 401 600 amp: 401 400 amp: EA ADDL OR CIR: SIGNAUPANEL: IN PLANT:
MANU HMISVCIFDR: 601 • 1000 amp: 1101#amps•1000r MINOR LABEL:
1000•amp/volt:
PLAN REVIEW SECTION
RecannectanlY: � - -
>-4 RES UNITS: SVCIFDR>-225 A.: >600 V NOMINAL: CLS AREAISVC OCG,
ELECTRICAL•RESTRICTED ENERGY
A.SF RESIDENTIAL B.COMMERCI4L
AUDIO&STEREO: VACUUM SYSTEM: AUDIO 8 STEREO: FIRE ALARM: INTERCOMIPAGING: OUTDOOR LNDSC LT:
HURGLAR ALARM: 0TH: BOILER: HVAC: LANDSCAPFARRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION. MEDICAL: OTHR
HVAC: DATAITELF.COMM: NURSE CALLS: TOTAL N SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 5,428.91
ALEXSANDR KOLYGAROG OWNER This permit is subject to the regulations contained in the
12810 SW MORNING STAR SIGNED RESPONSIBILITY FORM TlMunicipal Code,State Specialty Codes ar:1
TIGARn,OR 97224 IN FILE alll 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 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
Rep a 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
I
Erosion 844-8444 Underfloor insulation Plumb Top Out Gas Line Insp —*Appr/Sdwlk Insp -ip-Bullding Final
Footing Insp Crawl Drain/Backwater Electrical Service Gas Fireplace Electrical Final
Foundation Insp Footing/Foundation Drl Electrical Rough In Insulation Insp Mechanical Final
Post/Beam Structural PLM/Underfloor Framing Insp Rain drain Insp Plumb Final
PosUBeam Mechanica Mechanical Insp Shear Wall Insp —r Water Line Insp Final Inspection
Issued By Permittee Signature, k ~'
Call (503) 6319-0175 by 7:00 p.m. for an inspection needed the next business day
SEWER CONNECTION PERMIT
CITY OF �'IGAR
R I G I N A PERMIT#: SWR1999-00170
DEVELOPMENT SERVICE TE ISSUED: 09/23/1999
13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 PARCEL: 1S135DC-08500
SITE ADDRESS; 11510 SW 92ND AVE ZONING: R-4.5
SUBDIVISION: MLP97-0010 DOWNING JURISDICTION: TIG
BLOCK: LOT: 001
TENANT NAME: KOLYGAROG, ALEXSANDR FIXTURE UNITS: 0
USA NO:
DWELLING UNITS: 1
CLASS OF WORK: NEW
NO. OF BUILDINGS: 1
TYPE OF USE: SF
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection for a new single family dwelling.
FEES
ALEXSANDR KOLYGAROG Type By Date Amount Receipt
12810 SW MORNING STAR PRMT DST 09/23/199E $2,300.00 99-318568
TIGARD, OR 97224
INSP DST 09/231199S $35.00 99-318568
Phone: 503-521-9825 Total $2,335.00
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires
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, thou installer shall purchase a"Tap and
Side Sewer' Pernit and the Agency will install a lateral ATTENTION Oregon lav requires you to follow rules adopted
by the Orecon Ut-lity Notification Center. Those rules are set forth in OAR 952.001-0010 through OAR 952-001-0080.
You may obtain a)pies of These rules qr direct questions to OUNC by calling (503) 246-1987.
Issued by: Permittee Signature:
Call (503) 639.4175 by 7:00 P.M. for an inspection needed the next business day
CITY OF TIGARD Residential Building Permit Application Plan Ch �'- 7�
13125 SW MALL BLVD. New ConstruRecd BYE Construction Recd
'-`-�
TIGARD, OR 97223 Single Family Detached Date to P.E.
V 503-639-4171 Date to DST -/0-
F 503-684-7297 Permit it
Print or Type Called I
Incomplete or illegible applications will not be accepted
-------___---
.lob Name of Project I�V� � --�_-- -- Name �J /
C-CSE' r � / ��/��/�=fr�-f-'C.S%r•
Architect Mailing Address
Address Site Address � 2 S"f
/ City/Sta a Zip Phone
Naameme y�7 c?S7 -A'-
Owner Mailing Address r Name
Engineer Mailing Address
Cit /State Zip P ne ����
�� �,-*o -'Q1 V&`:`; City/State Zip Phone
General Nam
Contractor Describe work New O Addition O Alteration O Repair O
Mailing Address to be done:
Prior to permit Additional Description of Work: !
issuance,a copy City/State Zip Phone
of all licenses
are required If Oregon Const.Cont. Board Exp.Date PROJECT
expired in COT Lic.# VALUATION $ VE-
__
database
Mechanical Name P.o G I"� _ NEW CONSTRUCTION ONLY:
Suy- Sq. Ft. House: / y.� Sq. rt. Garage
Contractor Mailing,Address
.S�_ r
/67 /t L1 ��.� Indicate the restricted energy installation by the electrical
Prior to permit
issuance,a copy Cit State Zip Phone subcontractor in the followjn areas
of all licenses Restricted Audio/Stereo
are required if Oregon Const Cont.Board Exp.Date Energy
System Alarms
expired In COT Lic.# Installations Vacuum Irrigation
database �'�1t -o%269 y �� /t System System
Plumbing Name r it2cyA Pry K.41w,6•-if (check all that Other:
Sub- Ci al;eIr apply) ---
Contractor Mailing Address Number of Units in Building Unit Number Designation
Has the Subdivision Plat recorded? N/A YEJS NO
Prior to permit City/State ?ip Phone
issuance,a copy i �C t� "e 0/�?
of all licenses are Oregon Const Cont. Board Exp.Date
required If Lic.# ��
expired In COT 1. / 6v< / -
database Plumbing Lic # Exp. Date I hearby acknowledge that I have read this application,that the
3 ,y,a pe information given is correct,that I em the owner or authorized agent
of the owner, and that plans submitted are in compliance with
Name r Oregon State laws. _
Electrical `T ��/ > ��-- � Signature of Owner/Agent �y�� Date
Sub- Wiling Address ��� �---�--- / mak•(LS
r Contact erson Na)me Phone#
Contractor /// —W/ t�C'�Cc��� c_ �" (Fe? 1
City/State Zip Phos e
Prior to permit j, �/�t�l� �ly./ ��/
issuance,a copy J� FOR OFFICE USE ONLY: _
of all licenses are Oregon Const Cont Board Exp Dale Plat Maprr 4#.
required if Lic.# O) L._ eg /y0 �� 1-7-00/0 3S -O$S4d
expired in COT � S (Xr' _ 5/
datobase Electrical Lic # Exp Date S_e"cks: ZonilL
Electrical Superviror Lic.IN Exp Date gEngi"r�rJrriing.Noproval. Planning Approval: TIF
I Asts\forms\std-new doc 11/20/98
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Permit#: ;7
Address: _.----
N ,` 1
Date:
- -- — ---
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
followin,s 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 DRS 701.010(7),
need not submit this statement. This statement will be,filed with the per►nit.
Fill 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
r �r before or upon completion.
(� 3A. My general contractor is —————
I_J (Name) Contractor rebis. #
1 will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
3B. I will be my own general contractor.
if I hire subcontractors, I will hire only suhcontrartors registered with the Construction Contractors
Board. If [ 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 understana the Information
Notice to Property Owners about Construction Responsibilities cin the reverse side of this form.
(Signature of permit applicant) `- (Date)
t White copy to issuing agent-Y permit file.
pink cotes,to applicant)
CITYOF T I GA R D CERTIFICATE OF OCCUPANCY
PERMIT#: MST1999-00274
DEVELOPMENT SERVICES DATE ISSUED: 09/23/1999
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 PARCEL: 1S135DC-08500
ZONING: R-4.5
JURISDICTION: TIG
SITE ADDRESS: 11510 SW 92ND AVE
SUBDIVISION: MLP97-0010 DOWNING FILE COPY
BLOCK: LOT:001
CLASS OF WORK: NEW
TYPE OF USE: SF
TYPE OF CONSTR: 5N
OCCUPANCY GRP: R3
TENANT NAME:
REMARKS: PATH I: New single family dwelling w/attached garage.
Final Building Inspection and Certificate of Occupancy
Approved 2/18/00 by Rick Bolen, Building Inspector
Owner:
MILES DOWNING
11600 SW GREENBURG RD
TIGARD, OR 97223
Phone:
Contractor:
OWNER
SIGNED RESPONSIBILITY FORM
IN FILE
Phone:
Reg #:
This Certificate grants occupancy of the above referenced building or portion thereof and
confirms that the building has been inspected for compliance with the State of Oregon
Specialty Codes for the group, occupancy, anduse under whic the referenced permit was
issued.
BUILDING INSPECTOR BUILDINd OFFICIAL
POST IN CONSPICUOUS PLACE
CITY OF TIGARD BUILDING INSPECTION DIVISION 4Is1'�1�� _�>��-�y
24-Hous Inspection Line: 639-4175 Business Line: G39-4171 --�
BUP
Date Requested
_ ,�- �l C AM PM — BLD
Location_—_��_? 1 CJ `I �y� Atk4e, Suite MEC _
Contact Person ' Ph rJ "(�' �' PLM - I
Contractor Ph SWR
UILDI Tenant/Owner ELC
Retaining Wall ELR _
Footing Access:
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab 54 o Q
Post& Beam ( r �� SIT
Ext Sheath/Shear L ��l� /h,"(�
Int Sheath/Shear A V ---
Framing �l/fQi
Insulation ► /
Drywall Nailing I I 1 0
Firewall
Fire Sprinkler `�._
Fire Alarm
Susp'd Ceiling —�
Roof
Irl
AS PART FAIT_ _PrUMBING
Post& Beam — - - --- --- - - - --- -
Under Slab
Top Out _.-_- -- --__ -— - --- ---- --- ---
Water Service
Sanitary Sewer --- - ------- --�__ __ ---.--..-- ------- -- --
Rain Drains
PASS PART FAIL _-
MECHANICAL ---------------- ..- ------- _-- ------ -----._
Post& Beam --- ----------- -- -- _-
Rough In --- _------- ----------
Gas Line ------ __ ----- ------ ---- -- - -- -- -----
Smoke Dampeis
FinalV - -------- -- - - ------------ --
PASS PART FAIL
ELECTRICAL -- - ----- __ - ------ - —. -. ---------
Service
RoughIn -- ---------- --- --- ----- --._.--_-_—.
UG/Slab
Low Voltage — --- -- - ---------._ _____ --_—_--
Fire Alarm —
FInaIJ ---
3 PART FAIL -
T
Backfill/Grading -
Sanitary Sewer�`1 !-
Storm Drain 1 ( J Reinspection fee of$ —required before next inspection Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Lina ( J Please call for reinspection RF - _ - ( j Unable to Inspect-no access
ADA
Ap roach/Sidewalk Date 2 I b -- Inspector � �G Ext3 1q
`
PART FAIL 00 NOT REMOVE this Inspection record from the job site,
CITY OF TIGARD BUILDING INSPECTION DIVISION
24-Hour Inspection Line: 539-4175 Business Line: 639-4171 �S _LI " -COG 7q
BUP
—Date Requested AM PM _ BLD
Location^_ l I S j G 2 2�r � Suite MEC
Contact Person _ ,4rT, Ph SIO 4.--(/ _ PLM _—
Contractor _ Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR _
Footing Access:
Foundation FPS
Ftg Drain
Crawl Drain Inspection Notes: SIGN -
Slab SIT
Post&Beam —--
Ext Sheath/Shear
Int Sheath/Shear -
Framing
Insulation — -
Drywall Nailing —
Firewall —
Fire Sprinkler __-
Fire Alarm - - —
Susp'd Ceiling _
Roof - - ----
Misc:
Final
PA PART FAIL
LUMBI
Post& Beam _-----_-- -- - - ----- --
Under Slab
Top Out
-------
Water
---Water Service
Sanitary Sewer --
Ra n Drains
-anal.
PART FAIL
,WCHANICNt7p
_ -- ----- — -
Post&Beam --
Rough In
Gas Line - -
Smoke Dampers
-
A PART FAIL
ftECTRICAL -
Service
Rough In
UG/Slab - --- --
Low Voltage -
Fire Alarm
Final ------
PASS PART FAIL
SITE - - - ----- -----
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 ( J Please call for reinspertion RE: _ _ ( J Unable to inspect- no access
ADA
Approach/Sidewalk Gate /
Other _ Inspector -- Ext --
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.
CITY OF TIGARD BUILDING INSPECTION DIVISION Msr�
24-Hour Inspection Line: 639-4175 Business Line: 639-4171
BLIP
!
Date Requested L. �� AM PM � BLD
Location I ��/ Suite MEC
Contact Person �,f' y�7X Ph l�' ""G'�f _ PLM
Contractor Ph _ SWR
BUILDING Tenant/Owner _ _ CELLO
Retaining Wall
R
Footing Access: FPS
Foundation
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab SIT
Post& Beam
Ext Sheath/Shear
Int Sheath/Shear
Framing _ --
Insulation
Drywall Naiiing --— — ---
Firewall _
Fire Sprinkler �7c— — — -
Fire Alarm /`�� Yf j----- —
Susp'd Ceiling
Roof -
Misc: //
Final yy1 S7--
PASS
7 _PASS PART FAIL
PLUMBING ------
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 - — -----.—_ - ---------
pART FAIL
TRIC
LEC -----
Rough In
UG/Slab
Low Voltage
Fire Alarm
PASS ART FAIL — r_ ----- _ — - --
Backfill/Grading —
Sanitary Sewer
Storm Drain [ I Reinspection fee of$ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin [ Please roll for reinspection RE: _. j I Uneble to inspect-no access
Fire Supply Line
ADA i ID
Approach/Sidewalk Date/�
Inspector EXt
Other _
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.
CITY o F T I G A R® ELECTRICAL PERMIT
PERMIT#: ELC1999-00575
DEVELOPMENT SERVICES DATE ISSUED: 09/24/1999
13125 SW Hall Blvd., Tiqard, OR 97223 (503) 639-4171 PARCEL: 1S135DC-08500
SITE ADDRESS: 1 1510 SW 92_ND AVE
SUBDIVISION: MLP97-0010 DOWNING ZONING:
BLOCK: LOT : ('( TIG
_11 JURISDICTION: TIG
Proiect Description: Temporary service
_ RESIDENTIAL UNIT 'TEMP SRVC/FEEDERS _MISCELLANEOUS
1000 SF OR LESS: 0 200 amp: 1 PUMP/IRRIGATION:
EACH ADD'L 500SF: 201 400 amp: SIGN/OUT LINE LIG:
LIMITED ENERGY: 401 600 amp: SIGNAL/PANEL:
MANF HM/ SVC/ FDR: 601+amps - 1000 volts: MINOR LABEL (10):
SERVICE/FEEDER -----BRANCH CIRCUITS _ ADD'L INSPECTIONS
0 200 amp: W/SERVICE OR FEEDER: PER INSPECTION:
201 400 amp: 1st W/O 3RVC OR FUR: PER HOUR:
401 600 amp. EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: _ _ PLAN REVIEW_SECTION_
1000+ amp/volt: >=4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC/FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
ALEXSAI`IDR KOLYGAROG OREGON ELECTRIC CONST/GROUP
12810 SVS' MORNING STAR 1010 SE 11TH AVE
TIGARD, OR 97224 PORTLAND,OR 97214
Phone: 503-521-9825 Phone: 234-9900
Reg #: LIC 203
SUP 1302S
ELE 26-95C
_ FEES Required Inspections
Type By Date Amount Receipt Elect'I Service
PRMT BON 09/24/199 $53.50 99-318611 Elect'I Final
SPCT BON 09/241199 $3.74 99-318611 _ ORIGINAL
Total $57.24
This Permit is issued subject to the regulations contained in the Tigard Municipal Code,State of OR. 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 rf 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 OAR 952-001-0080. You may obtain copies of these rules ordirect questions to OUNC at(503)
246-1987
PERMITTEE'S SIGNATURE gi" I l(("A WlAl6i
ISSUED BY:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease, or rent.
OWNER'S SIGNATURE: . DATE: —
CONTRACTOR INSTALLA110N ONLY
SIGNATURE OF SUPR. ELEC'N: ,''Vyl DATE: _
LIC�7NSE NO: -
Call 639-4175 by 7:00pm for an inspection the next business day
CITY OF TIGARD E� flan Che #
13125 SW HALL BLVD. RECEIVETTctrical Permit Application
Recd By
TIGARD OR 97223 Date Recd (—
Phone503 639-4171, x304 SEP 2 4 1999 Date to P.E.
Phone (503) Date to DST
Inspection (503)639-4175 COMMUNITY DEVELOPMENT Print of Type Permit#
Fax 1,503) 598-1960 Incomplete or illegible will not be accepted Called
1. Job Address: 4. Complete Fee Schedule Below:
Name of Development� Number of In. jctions per permit allowed
Name(or name off/business) . fr.' ?'6e c cl(a 2'C x C Service included: Items Cost Sum
Address 1 4a. Residential-pe r unit +
CitylStatelZip 1000 sq,ft.or less $ 117.75 4
7r " Each additional 500 Eq.ft or
portion thereof $ 26!15 1
Commercial ❑ Residential ® Limited Energy S 60.00
Each Manufd Home )r Modular
2a. Contractor installation only: Dwelling Service or Feeder $ 72.75 2
(Prior to permit issuance,applicants must provide contractor license 4b.Services or Feeders
Information for COT data se►.( LInstallation,alteration,or relocation
Electrical Contractor k, , C��bl- ,c "' 200 amps or less $ 64.25 2
r, - I 201 amps to 400 amps $ 85.50 2
Address ti C�� /` 401 amps to 600 amps $ 128.50 2
City f( , 1'G lc State /�c ZIp 11 ' 601 amps to 1000 amps $ 192.50 2
Phone No. 6 e 7 3 Over 1000 amps or volts $ 363.75 2
Job No. 'S, I/7Reconnect only $ 53.50 2
Elec. Cont. Lice. No. 1$
_tExp.Date ylcjjf 4c.Temporary Services or Feeders
OR State CCB Reg. No t -�;` Exp.Date ` Installation,alteration,or relocation
COT Business Tax or Metro No.aNki 6 Exp.D a 200 amps or less �_ $ 53.50 SL 2
201 amps to 400 amps S 80.25 2
Signature of Su r. Elec'n 401 amps to 600 amps $ 107.00 2
9 P — Over 600 amps to 1000 volts,
License No. G S Exp.Date i 1(�l see"b"above.
Phone No -G' 4d.Branch Clrcults
— New,alteration or extension per panel
a)The fee for branch circuits
2b. For owner installations: with purchase of service or
feeder fee.
Print Owner's Name Each branch circuit _ $ 5.35 2
Address b)The fee for branch circuits
without purchase of service
City _State Zip— or feeder fee.
Phone No. First branch circuit $ 37.50
Each additional branch circuit $ 5 3F
The installation is being made on property I own which is not 4e.Miscellaneoun
intended for sale,leaso or rent. (Service or feeder not Included)
Each pump or irrigation circle S 4275
Owner's Signature _ _ Each sign or outline lighting $ 4275 _
Signal circuits)or a limited energy
panel,alteration or extension S 6000
3. Plan Review section (if required):* Minor Labels(10) $ 10700
Please check appropriate Item and enter fee in section 5B. 4f.Each additional Inspection over
_ 4 or more residential units in one structure the allowable In any of the above
Service and feeder 225 amps or more Per inspection $ 5000
- — Per hour _ $ 5000
—System over 600 volts nominal In Plant $ 5900
Classified area or structure containing special occupancy as
described in N E C Chapter 5 5. Fees:
Sa.I tiler total of above fees
* Submit 2 sets of plans with application where any of the above apply 7 p,f^Surcharge 105 x total fees) $Not required for temporary construction services Subtotal $ —_
Sb.Enter 25%of line 6a for
NOTICE Plan Review H required(Sec 3) S
PERMITS BECOME VOID IF WORK OR CONSTRUCTION AUTHORIZED Subtotal 5
IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS ❑ Trust Account#
AT ANY TIME AFTER WORK IS COMMENCED Total balance Due $ .S
i d,t,lormoclectric dnc