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CITY OF TIGARD BUILDING INSPECTION DIVISION IwsT
24-Hour Inspection Line: 639-4175 Business Lir:c: 679-4171
BUP _
Date Requested_ >� _ 4M_ PIkA BLD _
Location_ ''� _�(�,3 Suite
Contp:t Person ! Ph ;
Contractor _ Ph _ SWR
BUILDING Tenant/Owner
Retaining Wall ELR
Footing ACS;ess: FPS
Foundation � r � � �'l --
Ftg Drain —._ CJ SGN
Crawl Drain InspectionotP:}: n / �� — —
Slab � / SIT
Post& BL-am
Ext Sheath/Shear ---
Int SheathiShear
Framing
Insulation
Drywall Nailing —1� (•vim -
Firewall
Fire Sprinkler -
Fire Alarm
Susp'd Ceiling
Roof -
Misc -
Final
PASS PART FAIL --
LUMBING
Post& Beam -
Under Slab _ —
T op Out
Water Service
Sanitary Sewer —
P Drains _
PART FAIL
HANICA
Post& 9e.. ---- -- -- --- —
Rough In
Gas Line -- --- - ----
Sr re Dampers
AS PART FAIL
URI
r� Rough In — --- -- ------- --- -----
cn UG/Slab - ---- -—---— --_
Low Voltage
Fire Alarm
J
F
A PART FAIL - --_._-
8ackfill/Grading --_ --- - --- -- -
Sanitary Sewer
Storm Cain ( ] Reinspection fee of$ required before next inspection. Pay at City Hall, 13125 SW Hale Blvd
Catch Basin ( )Please call for reinspection RE: — [ ]Unable to inspect-no acs-3ss
Fire Supply Line - ----
ADA
Approach/Sidewalk nate MY
Inspect FX1
Other —
Final
PASS PART FAIL DO NOT REMOVE this Inspection record from the Job site.
CITY OF TIGARD
DEVELOPMENT SERVICES ELECTRICAL PERMIT
PERMIT #: ELC99-0002
2
13125 SW Hall Blvd., Tigard,OR 97223(503)639.4171 DATE ISSUED: 01/04/99
F,ARCEL. 2SI A 1 i'-L-00900
SITE ADDRESS. . . : 14430 SW 103RD AV1..
SURD I V I S ION. . . . :T I GARDV I L1_E HEIGHT 7.ON I NG: R--•3. 5
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . :01') Jl_1R T SD I CT I fiN ; T I G
Project D?scri.pt ioTr : Matias job #98-884
..-REST DENT IAL_ UNIT----- --__TEMP SRVC/FEEDEPS--_-_ ___..--•---MISCEi r_ANEOUS- __....
1000 SF OR LESS. . . . : 0 0 - 200 amp. . . . . . . : 0 RUMP/I RR,I CAT T 01\1. . . . : 0
EACH ADD' L 5O(,5F. . . : 0 201 4izi0 amp. . . . . . . : 0 STEN/OU'f LINE LTG— 0
LIMITED ENERGY— _ : 0 401 - 600 amp. . . . . . . : 0 SIGNAL/PANEL. . . . . . . : 0
MANF. FIM/ 3�C/FDR. . : 0 601-amps--1.000 volts. : 0 MINOR LPBEL ( 10) . . . : 0
- ----SERVICE/FEEDER---- ------BRANCH CIRCUITS-----,-- --.-ADD' I- INSPECTIONS-— -
0
NSPECTIONS- - -0 -- 200 amp. . . . . . . 0 W/SERVICE ON FEEDER: 0 RE'R INSPECTI=ON. . . . . : 0
201 - 4O0 amp. . . . . . : 0 i st W/0 SRVC OR FDR. : 1 PER HOUR. . . . . . . . . . . : 0
401 - 600 amp. . . . . . : 0 EA ADD' L BRNCH CIRC: 0 IN F"._ANT. . . . . . . . . . . . 0
601 - 1000 atop. . . . . : 0 --__-._________..____-F'L.AN REVIEW SECT I ON------•-----.--------
1000+ amp/volt. . . . . : 0 ) =4 RES UNITC. . . . . . . . : ) F,OO VOLT NOMINAL. . :
Reconnect only. . . . . : 0 SVC/FDR ) = 225 AMPS— : CLASS AREA/SPEC OCC. :
Owner: _-____.-._.___-___.-____..___._____.._.______._..__ rEES
CATHY MATIAS type amor_rnt by date recpt
14480 SW 103RD RRMT $ 35. 00 JSP 01 /04/99 99--3111301.
T I GARD OR 972,23 `;PCT is I. 7C JSD 01/04/99 99-.311881
Phone #:
Contractor,:
130139 9, ACTION ELECTRIC INC $ ;sE,. 70 TOTAL.
2700 NE BUP i ON ROAD
!;TE'. A ---- --- REQUIRED INSPECTIONS
- -
VANCOUVER WA 98662 Roi.rgh-in E=lect' 1 Final
Phone #: 360-254-7200 Elect' l Service
Reg #. . 000531
This permit is 'issued subject to the regulations contained in the Tigard Municipal Code, State of Oregon Specialty Codes and all other
applicable laws All wor4 will be done in accordance with proved plans. This permit will expire if work is nct started within 180
days of issuance, or if work is suspended fcr more tl*vT 1800 ays. ATTENTION: Oregon law requires yo tb follow the rule3 adopted by
the Oregon 1ltility Notification Center. Those rules"are , frrth •n OAR 952-001-0010 through OAR , 1 You may o n a copy
of these rules or direct questions to O1K calling f e)2Ab-
d Flf ri mittee Sigrrati.rre . / Issoed
R
r
------------------------------OWNER INSTAL..L.ATION
~ The installation is being rade on property I own which is not intended for
J
sale, lease, -ir rent .
OWNER' S SIGNATURE: DATE:
LL)
INSTALLATION
SIGNATURE OF SI.1RR. ELEC' N: DATE:
I-TCENSE NO:
++++4+ F++++++++-+-1-+-+4++++++f-+++++4+++4++++++++++++-+-+++++++++++-+-+++++++++4+++++4 f
Call 639-4175 by 7:00 p. m. for an inspection needed the next bmsiness day
+++++•++++++i.++++++++++•++++++++++++++++++++++++.4-+++++++++++++++++++++4++f•++++++i +
RECENED
ommunity Development ELECTRICAL PERMIT APPLICATION
AA N (i 4 199 111 2:t avv hall Blvd, C,
Tigard, OR 97223 Permit If _ G C I I — 0 bra L
MI DEVELUI WNW
Date Issued
Phone (503) 630 4171
CITY OF TIOARD rnx (,01) ) 6.4.2 7
TDO No (503) t38A•2772
Inspection (501) 6,10-4175 i
1. .lob Addmss: 4. Complete Fee Schedule Below:
Name of Development Numbev of inepwctlons
pwr payroll ■IlnwSd
Address 14480 SW 103rd Ave. _ T Service Included: ►toms cost(es) Sum
City/State/Zip 'r.igard, OR 97223 4 Ronlrinntlpl .per unh
iWd IQ II or wit x'1000 �
Name (or name of business) Cathleen jLLLL s I;arr •'1°N10^"'No•4 ^ 'x
p.m kn thm-. R125 M
Commercial Irl Residential ® I HM44 Fnwr01. -" ss"oo '
EVh 1.11nvrd IV-4 or tis,.hrin
�
2a. Contractor installation only: OewAMp 9ervfraa a seder sea 00--
Alb. Services or Feeders
F44.1r',cai Contriclor Bob's Action T>n t-l.a' -tr c 11111111W) o1,Muatklrl,anlocaltnrr
...�.d M11 IrSO M 2
Address_ 2700 Nli Burton Its_•"AA' Y le,-100 , moon - ^-
City—Val-L ,obi tt,r Staley! _ Zlp_S86fi2 ant■"r/to eon saps 1120 oA
Pht)nC NO. 601 amps 10 Innal amp/ Ilan on --- ;
r �1.(ll] ()vn•crest rasa a Vas/ 170 no
Joh NO ~ 98-884 n•eannxt any iso 00 -
co�tractor'6 (icnns+t NO. 37-
ac. Temporary Bervlces or Fawdars
(;nntraclnr S flonrd RegNo. r3 —� Insl.nelkn..Me.Nkv.,es abtMlorl
5(gn>ahtre of Supr Elec'n 2n)sant.ew%.. 2
License No 43225 Phone No,360-254-71111,' ?fi w po to 4nn&-r' _ Slut — t
.n1 ai tis In noel ammo s rS M 2
retro (,!cense No. 0000'1861 mor 6 fa.p•Io1000voAa 110000
2b. For owner Instillations: Soo'b•above
4d, drench Clreulls
Print Owner's Narne "trot ane(vk.n to 0.1—ohm res pane
Address __ r)TTM IN Iv bra"th t►cvA.nIM
,►thoso er•rvrreer Nadal M
(•.(Iy— — ----.---- Ste teZIP 14
� yarn hrenrh rkrrrM 1100
Phone No. — e)it,"ars ler Hench tlrcuAe eaMrout
The Inpinllnlinn Is hnin9 properlymadn nn own n which Is r-Rhs•e dr•.rvree of tr«sw res 2
; rkcvl �. M 1-i•(iO 2
mol Inlendcrf Fnr sale, (ease or rent, rkv t— 115
lash odd
tonal bnrwh acral _ 1e oo
twnllr'& Slpnrture M. Mlscellansous —�
(Serv" nt fnwAer not hcWed) 2
3. Plan Review section (i(required), f itch rxtrnp d►.1p+ltnn roma 0o 2
Fvh.k.•.v o^19 N10.9 No 00 -------
91pn111 rknin(1)m•ty.rlod MVgy
Ple"s ctlwck appr vrlale Item any' enter tee In lection 6e. panar.ano"okn or•damson _ _ $4000 _
E rw"res r05Nnn1,91 unriS in one 9lrudure Lft"tL•M11110) _ 810000
Snrvkkp and fP^clet 275 amps or ngre
Syelpm over 600 Vohs nondnal 41 Lodi additional Inapo�ctlon over
Claq-0N d area or Almoure cnnlalnlnp special occupancy the allowable In spy of the above
os 06110Wd In N 15.0 Chapter 5 Per nlpoe" 11100
Par ham see M
SuMnh 7 eels of plans with anptlrellnn where any of the shove In Moot
apply. Not required for Wmpnrary conelructlon services, e, Fee-:
t (ia, Fnlar Intal of above fe+t s 35.00
NOTICE !l% r•1urherge (.05 X tolyl fees) ! _1. 75
PEnMITS BECOME VOID Ir WORK On CONSTRUCTION subfOW � r
AU1110RIZE0 13 NOT COMMENCE!')WITIIIN lRf1 MY-,; 6b. Cnlr'r 2W. of line A for
, on I� Plan Breslow N s
rUf1STRUCTION on'vonK IS SUSPENDED On ADANDONED rOR repvlred (Sec]) _
A rCRIOD or 180 DAY: AT ANY TIME AFTER WORK 19 3uhrofal =
COMMENCED. .+«.,......r Intel Account
P-w f
9efnnce Dut1 $ 36. 7 5
I -�
CITY CSF TIGARD
- DEVELCP'14ENT SERVICES Pt-UMBING PERMIT
131255th Hall Blvd., !"igard,OR 97223(503)639-4171 PERM iT #. . . . . . . : PLM98--0471
FITE ISSUED: 1.'/30/98
-'ARCEL: 2S 1 1 1 BC- 009OO
SITE ADDRES10. . . : 14481" SW 103RD AVE
SUBDIVISION. . . . TIGARDVILI-.E HEIGPTS 79NING: R--3. 5
FLOCK. . . . . . . . . . LOT. . . . . . . . . . . . . :019 JURISDICTIOV: T'IG
--------------------
CLASS OF WORK. . :ALT GARBAGE DISPOSALS. -. 0 MOBILE HOME SPACES. : 0
TYPE OF USE:. . . . :SF WASHING MACH. . . . . . : 0 BACKFLOW PREVNTRS. . : 0
OCCUPANCY GRP. . : R3 FLOOR DRAINS. . . . . . . 0 TRAPS. . . . . . . . . . . . . . 0
STORIES. . . . . . . . : 0 WATER HEATERS. . . . . : 1 CATCH BASINS. . . . . . . : 0
LAUNDRY TRAYS. . . .. . : 0 5F RAIN DRAINS. . . . . : 0
SINKER. . . . . . . . . . 0 URINALS. . . . . . . . . . . . 0 GREASE TRAPS. . . .. . . . . 0
LAVATOR T F_S. . . . : 0 OTHER FIXTURES. . . . : 0
TUB/SHOWERS. . . : 0 SEWER LINE (ft) . . . : 0
Wf1TER CL..OSETS. : 0 WATER LINE (ft ) . . . : 0
D I SHWASHE RS. . . . : 0 RAIN DkP I N (ft ) . . . : 0
Remarks : gas water heater
Owner: —__._ __.____________.__.__._____ FEES
CATHY MPTTgS type amoiinta by date recpt
14480 SW 103RD F'RMT t 25. 00 B 12/3O/98 98-31182L2
TIGARD OR 972'23 SPCT $ 1. 25 B I.2/30/98 98-31182:'
Phone #:
RODE HEAT l:NG CO
9945 NE 6TH 1`R
PORTLAND OR 97015 _...__.._..._.__.____________..--_—___.________._..._.._._......._ _
Rh a n e #- 283—5 i 83 $ 26. 25 TOTAL
Rey #. . . 2084
—.--........ ___._... REQUIRED INSPECTIONS
This persit is issued subject to the regulations contained in tF.e Misc. Inspection
Tigard Municipal Code, State of are. Specialty Cores and all other Final Insper_t ion
_ applicable laws. All work will b� done ii, accordance with
aporoved plans. This pereit will expire if work is not started
within [Be days of issuance, or if wnrk is suspended for sore _
`n than 180 days. ATTENTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those rules are
set forth in DAF 952-0001-6010 through OAR ?52-0001-0080. You say
obtain copies of these rules or direct questions t; OUNC by calling
ca (500246-1987.
J
I s s 1,t e d B y :�� '� �L`L '`-�' Permittee Signature : _
+++-+-►++++++++++++++++f++++++-+++-1.+++++++++++ r+++•4•M+++++-+++-+++4- +-4+•+++++++++++++
Call 639-4175 by 7:00 p. m. for an inspec.ion needed the nex b+.isiness day
*1 { ++++ . +++++-F.+++++++++++f+++++++++++++++• +++++++++++++i-+f•++++++i•+++-+++++++++-+
10/22/88 TMJ 14:54 FAX 503 598 191,0 CITY OF TIGARD [(7_.]002
CITY OF TIGARD Plumbing Permit Application PlanChec
Commercial and Residential Redd By
13125 SW HALL BLVD. Date Redd
TIGARD, OR 9722 Date to P.E. —
(503) 639-4171 Date toD T
Print or Type Permit 1 6 -
Incomplete or illegible applications will ;not be accepted Related SWR#
Called
F�X�,URES '(Indlvf if ll:, s , dill°� ° p :PRICE' M,T
Name of Development/Projed h: d:••— 9,00
(�1 c�r I c-�c, Sink
ob C -- 1 e.en Lavatory
Address Street �'.s+� Suite -- 9.03
J�� (�. Tub or Tub/Shower Comb. _9.0(T-
Bldg
.0(_Bldg i CI /State ZIP � Shower Only
T o pt p'0 q 7 22 Water Closet 9.00
Name Dishwasher 900
C.a�-��IeeI') 1 c�l�t�?`-� -
Sults Garbage Disposal 9. 0
Owner Mailing Address . ` 9.,00
I I i J�&V I& -t> Was Machine
City/6tat� Phr�hone Floor Orelrt Fioar Sink 2- _ 9'�
z7. (OC, "� '-��� 3. 9.00
('7
Name 4' 8.00
Suite Water Heater Aconversion O like kind 9.00 q r�o
Occupant Malling Addrect _
Gas1ping requires a separate mechanical permit. 9,00
City/State — Zlp Phone Laundry Room Tray _
9.00
Urinal
Name Other F�dures(Specify) 9,OU
1 (✓ CU 9.00
Contractor M "4 c- t E �,{ [�2 suite _ 9.00
-t Zip Phone ,, Sewer-1 at 100' 30.00
Prior to permit city/State L / 25.00
issuance,a copy �',p T� N n�� �` I 1 Z���' `� �`� Sewer-each oddlticnal 100'
of ell licenses are Oregon 4-116.. -u�•Boats Llc.e
Exp.D+� Water Service•1st 1l r�' 30.00
C SII Irl — 25.00
required If U Water Servlw-each tddlllonal 200'
expired In COT Plumbin o K Earp.Date 30.00
database
ZIOL Storm b Raln UrPln-1st 100'
Storm b Rain Drain-each additional 100' 25.00
Name
Mobile Hon;o Sp_ace 25.00
Architect nm25.00
Mulling Address Suite Cmerdal Beck Flow Pravonllon[hrvlco or Antl-
or Pollution Device
r,ItylState 7_Ip Phone
Reslden0al Bec!cflow Prevention Device' 15.00
Engineer (Irtpalloh liming devices require a separate
_ __ -- — restricted ens Leertmlt.) 9.00
Describe work to be dono Any Troo or Waste Not Connected to a I iKture
New O Repair O Replace with like kind. Yes No 0 Catch Basin 9.00
Residential Commercial 0 40.00
Additional ddeestA U n cf/work: Insp.of Existing Plumbing rlhr
k40.00
Specially Requested Inspections
er/hr
_J Rein Drain,single family dwolling 30.00
Are you capping,moving or replacing any fixtures? 9.00
Grouse Tre,
Yes O No 0. QUANTITY TOTAL
If yes,see back of form to Indicate work performed by "
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Isometric w rover din nm is rsqulred N t]uant Total le >9
WORK COULD RESULT IN INCREASED SEWER FEES,
'SUBTOTAL #f . ; `, L�,c>n
I hereby or that!have reed this eppllcatlon,that Ute Information 6•�SURCHARGE " 125
given Is cored,that I am the owner or authorized agent of the owner,and
t t tans submitted are In compliance with Ore on State Oa s• ••-LAN RFT—EW SUB
, EW 25%OF TOTAL
Ig ature of Owner/A ant Re uhed on N riidure total Is>i
c Z -9TOTAL
fact Pe n me Phona
t •Yllnlmum permit lee is$25+5%sur citerge,except Residential Backflow
C 3 Prevention Device.which Is$I5+5%aurch0119e
"All New Commercial Buildings require plains with Isomotrfc or riser diagram
and plan review
:•wstsWwmepp doe 1rL9+
GIT' OF TIGARD MECHANICAL
DEVELOPMENT SERVICES
PERMIT
13125 SW Hall Blvd., Tigard,OR 97223(503)639-4171 PERMIT #. . . . . . . : MEC'38-0576
DATE ISSUED: 12/30/98
PARCEL-: 2SIlIBC-00900
SITE ADDRESS. . . : 14480 SW 103RD AVE
`SUBDIVISION. . . . : TIGARDVILLE HEIGHTS ZONING: R—?. 5
1. 5
BLOCK,. . . . . . . . . . . LOT. . . . . . . . . . . . . :019 JURISDICTION: TIG
CLASS OF WORK. . :AL7 FLOOR TURN. . . . : 0 EVAP COOLERS: 0
TYPE OF USE. . . . :SF UNIT HEATERS. . : 0 VENT FANS. . . , 0
OCCUPANCY GRP. . : R,1 VENTS W/O ADPL: 0 VENT SYSTEMS: 0
STORIES. . . . . . . . : 0 BOILERS/COMFIRESSORS HOODS. . . . . . . : 0
FUEL 0-3 HP. . . . : I DOMES. INCIN- 0
:GAS 3--1 HP. . . . : 0 COMML. INC.IN: 0
IIAX INPUT: 0 BTU 15--30 HP. . . . : 0 REPAIR UNITS: 0
FIRE DAMPERS?. . : 30-50 HP. . . . : 0 WOODSTOVES. . : 0
GAS PRESSURE. . . 50+ HP. . . . : 0 rL.O DRYERS. . : 0
NO. OF UNTTS AIR I lnlqr)L-.If\lCj UNITS OTHER JNITS. : 0
TURN ( 10QK BTU: 0 1.0000 Cf1fl : 0 GAS OUTLETS. : 1.
FLJRN ) =100K BTL): 0 10000 cfm : 0
Remarks : gas boiler
FEES
("ATHY MATIAC type amo,_tnt by da} e recpt
14480 SW PRMT $ 25. 00 B 12130198 98--311821
TIGARD OR 971223 50CT $ 1. 25 B 12/30/98 98-311.821
Phone #:
C:a Tit r-a c t or
ROSE' HEATING CO
9945 NE 6TH DR
26. 25 TOTAL.
PORTLAND OR 97211
Phone #: 503--28,-3--51BI-11
Reg #. 0000120
REQUIRED INSPECTIONS --------
This permit is issued subject to the regulations contained in the Gas Line Insp
ligard Municipal Code, State of Ore. Specialty Codes and all other Mechanical Insp
applirable laws. All work will be done in accordance with Misc. Inspection
approved plans. This permit will expire if work is not started Final Inspection
within '80 days of issuance, or if work is suspended for more
thou 180 days. ATTENTION; Oregon law requires you to fudow rules
adopted by the Oregon Utility Notif'catint, Center. Tho-,@ rules are
set forth in OAR 952401-0010 through OAR 1752-081-0088. You may
obtain copies of these rules or direct questions to OMC by calling
03 (5031246-9187.
1.
f 5s 1.1 e By -
Perm v-m i b t e e S i g n a t i_t r-e
+++4.+4.++++4-++++4........4......4............4-+++.-f..........4-+++ +++++++++++++++++
Cal. 1 639-4175 by 7:00 p. m. for, inspections needed the next bLISinpss day
+++++•++•+++•++++++++ ...............4................4....... .+++++++
OCT-13–'99 TUE 11:42 ID: FAX HO: #0e2 P02
Plan Ch
M'W e9F TIG ARD Mechanical Permit Application Recd Beck
13125 SW HALL BLVD. Commercial and Residential diteRecd___
TIGARD, OR 97223 Date to P.E.
(503) 639.4171, x304 Date to DST
Print or Type Permit# FC 1? .- S 7
Incomplete or illegible piicatians will not be accepted called
Name of 04velopmenl0ro19C1 i Description
a113 1 _ -n M a+ Table lA Mechanical Code Q Pr':e Amt
Jot Street AddressSchee A) Permit Fee 0 1000
1 Address �' y-��� 1) Furnace to 100,000 BTU
Dldge coy/state ZIP
n including ducts d vents 6 00
�) Furnace 100,000 BTU+ --
� (',r Ct7��' including ducts 6 vents 7.50
Name(or Hama nr business) 3) Floor Furnace
Owner It, NACA I ��. including vent 8.00
Meiling Aaa(sa 4) 5uspertded heater,wall heater
^ nr floor mounted heater_ 6.00
w Iq Vent not Included In appl)ance permit
CRyIStYle LID Phone
_ 3 00
TI f �QI( (� c f>ti'r�{'?(C'/(' CHECK ALL -Esoiter� Meat
�+ Nems(or name or bus ness) THAT APPLY: or Pump Cond Qty Price Amt
_Com ••_
11r,Im�ddro» -- $)-3HP;ab9orb unit to II
Occupant 9 100K BTU I 6.00 ?�L
'1 3-1F HP;absorb unit
C11y1 tate ZID Phone 100k to 500k BTU 11.0r,
B) 15-30 HP;absorb
I— .---------- Name unit.5-1 trill BTU 15.00
Contractor 9)30.50 HP;absorb
-C-34 �C 4 Inn unit 1-1.75 mil BTU _ 2250
Prior to permit mallmyA dote 10)>50HP;absorb unit
13suance a copy C � C> �✓v tL�6� ��� �1,75 mil BTU __ 37.50 _
or all licensese I I b noes 11)Air handling unit to 10,000 CPM
are required H ?QIJ> Com) _ 4,50
expired In COT Oregon const.Cont.9oard L c.0 Exo.Date 12)Air handling unit 10,000 cpw
�I l2(t
Architect Nem. 13)Non-portable evaporate cooler
_ 4 50
i
or M.IIIr,g red rase
141 ehl fan connected to a single duct
300
15)Ventilation system not Included in
inglnaQr CnylSlMe liP Phone appliance permit 4.50
I@)Hood served by mechanical exhaust
Cleacribe work to be done. _
4.50
I
17)Domestic incinerators
New Ck Repair O Replace with like kind: Yes O No O . 50
Resloontfal commercial 0 18)Commercfal or Induguial typo incinarator
_ 30.00 �
Addltlonai Information or description of work: -Y 19)Repair unila
a.90
�- —
,�7 20)Woad stove
�~ I 2-i Clothes dryer,etc
4 50
I Type or Nuel: oil O natural gas ? LPQ O electric O 22)Other units
_ 4 50
rJ I hereby acknowledge that I have read this application,the',the information 23)Gas piping one to four outlets
given Is(}-feet.that 1 am the caner or euthonzerl agent of 200
the owner,that plane submitted are in compliance with Oregon State laws. 24)Mora than 4-par outlet(each)
.50
re of ow"811 lent Date
I 1'2 Minimum Pernlll Fee$25 00 _ 5UH10TAl 25�
t
ZG� 5%SURCHARGE I '2
Contact person ams phone FLAN REVIEW 2596 OF SUBTOTAL
Required for ALL commercial penrlits ooh
f 'N F �z� � � _ _ T TAL
'State Boller Certificatinn required
"Residential A1C requires site plan showing placement of unit
1.lrnechpemt dor. rev 0"20/98