9044 SW HILL STREET (1
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_ 9044 SW HILL f
CIT` OF TIGARD
DEVELOPMENT SERVICES
13125 V Hall Blvd., Tigard,OR 97223 (503)63.4171 r
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is persit is issime sA)jp:�t '.c the regulations ciinllairp4l 11.t ('cicil fy)Q Uri,, Tli,,F)
-'iyard Municipal rode, State 0 Ore. Spelrjmlty Codes and a"' Ws- -i T -t I I v
;J;Plir•ablf larks, All wn,'o ;Al', be ellore in accirdamf wits
1 ppmed plats, This per Nit will expire if work i., not StA;Ierl
ojth;r IV daj,e or, if work is suspended frr 1,,'r
the Oregon 1.1ility klotificatior center-,-. Plos-
�Pt forth in DAR IMP-ft-?*I@ throuO., MR WWI-•@@F4,
atair ropir, of 'hese 1"qles it direct queO",f-,s to k1p.m
Plan Check#
CITY OF TiGARD Mechanical Permit Application Recd By L-1-7p7--
13125
1-7p7 __131125 SW hALL BLVD. Commercial and Residential .ate ReGd4Z17
TIGARD, OR 97223 Date to P E.
(503) 639-4171, x304 Date to DST_
Permit#
Print or ,i'ype Called
Incomplete or illegible applications will not be aczepted
Name of Development/Project Des,option
�_` Table to Mechanical Code CITY PRICE AMT
Job Street Address Suite# A) Fee -0- U- 10.00
Address ` �) (
Bldg# ji�iflyiStaie p 1 Furnace to 100,000 BTU 6.00
_ -;UTA,yf_ b CJ �� � inctuding ducts s vents
Nar,a for name of pusiness) ( 2.) Fumace 100,006 BTU+ 750
Owner (It 0-k IV (he!,jz a, olQ eu) including ducts a vents _
Mailin
I. f 3) Floor Furnace 6.00''
J
including vent _
C tatene Phone 4 —'
(� -71 ` �1�_��� ) Suspended heater,wall heater 6.06
or floor mounted heater _
Nam for name of business) 5) Vent not ircluded in appliance permit 3.00
Occupant Mailing Address —` 6) Boder or coinp,heat pump,air coed. 6 00
_
to 3 HP,absorb unit to 1001 B
Cdyrsmte Zip Phone 7) Boiler or comp,heat pum{f,air Gond. ' 1 1,00
3-151IR absorb unit to 56MSTV _
contractor N'P1tl 8) Boiler or co,,p,heat pump,air cond. 15.00
q� mb ( 15-30 HP;absorb unit,5-1 m,l BTU"
Prior to permit M iling Address I 9.) Boder or comp,hest pump.air cond. 2250
issuance,a copy c�7i G� 30-50 HP;absorb unit 1-1.75mil BTU— _
of all licenses /state /� zip Phone 10,; Boder or comp,heat pump,a, and 37 50
are required if G 1 ,J- OK._, 1 `J f�t >50 HP;absorb unit 1.75 and BTU— _
expired in COT Ore on Const.Cont Board Lic# Exp.Datq 11.) Air handling unit to 10,000 CFM 450
database _ (p(E J J � r
Architect Name 12.) Air handling unit 750
_ 10,000 CTM+
or Mailing Address 13.) Non-portable evaporate coo!x 4.50
Engineer ;nyrstaih_ zip Phone 14.) Vent fan connected to a`single duct 300
Describe work New O A ition O Alteration 0 Repair O 15.) Ventilation system not ircluded 4 56
,s done Residential Non-residential O in appliance permit
Additional Descriptio/n of work. I6.) Hood served by mechanical exhaust 4.50
k l/�,Q ( �t fl i�. 17.) Domestic incinerators 7.50
Existing.Is.of ,( - 18) Commercial or industrial _ 1000
budding or property.. /1X oe incinerator _
i
19) Repair units i 4.50
l Proposed use of 10) Wood stove _ 450 �~
budding or property
21 ) Clothes dryer,etc. _ 4 5n
Type of fuel-oil O natural gas LNG O ele,aric O 27 I Other units4 50
I hereby acknowledge that I have read this application,tha'the information 23.) Gas piping one to four outlets 200
given is correct,that I am the owner or authorized agent of
the owner,that plans submitted are in compliance with Oregon State laws 24 1 More than 4-per outlet(each) 50
Signature of Owner/Agent Date ~� -----*SU O-TOTAL
—_— 'SUBTOTAL
15%SURCHARGE ..
Contact Person Name Phone FLAN RQVIEW 25%OF SUBTO T AL
r � �1
Required for all commercial permits oniy. ��
P►' l ! Y�Q �-I�t.f /`l )�0 1 J TOTAL
Win)mum permit fee is$25+5%surcharge
"Residential AIC requires site plan showing placement of unit
I imechprml.doc rev 4/15198
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MECHANICAL PERMIT
CITY O 1 1 I GARD !^
DEVELOPMENT SERVICES PERMIT#: MEC2002-00011
13115 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 1/8/02
PARCEL: 2 S 102 D B-09000
SITE ADDRESS: 09044 SW HILL ST
SUBDIVISION: CHELSEA HILL 1\10.2 ZONING: R-4.5
BLOCK: LOT: 067 JURISDICTION: TIG
CLASS OF WORK: ALT FLOOR FURN: EVAP COOLERS:
TYPE OF USE: SF UNIT HEATERS: VENT FANS:
OCCUPANCY GRP: R3 VENTS W/O APPI_: VENT SYSTEMS:
STORIES: BOILERS/COMPRESSORS HOODS:
_ FUEL TYPES 0 3 HP: DCMES. INCIN:
LPG 3 15 HP: COMML. INCIN:
MAX INPUT: BTU 15 -30 HP: REPAIR UNITS:
FIRE DAMPERS?: 30 - 50 HF:
GAS PRESSURE: 50 + HP: CLO DRYERS:
CLO DRYERS:
FURN < 100K BTU: 1 __ AIR HANDLING UNITS OTHER UNITS:
FURN >=100K BTU: <= 10000 cfm: GAS OUTLETS:
> 10000 cfm:
Remarks: Replace of gas furnace.
Owner: FEES
MACAFFIF, SCOTT A+ Type By Date Amount Receipt
NANCY J MILLIS PRMT CTR 1/8/02 $72.50 272002000C
9044 SW HILL ST 5PCT GTR 1/8/02 $5.80 2720020000
TIGARD, OR 97223
Phone:
Total $78.30
__._�__._ �.� _
Contractor:
B + S HEATING
17104 S OUTLOOK RD
OREGON CITY, OR 97045 REQUIRED INSPECTIONS
Mechanical Insp
Phone: Final Inspoction
Reg#:LIC 00045838
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
952-001-0080. You may obtain cgpies of these rules or direct questions to OPNC by-Qo-ipg
rr,na 19aa-Q 1 RQ --
Issue By: ( "f Guy Permittee Signature
T ..
Call (503) 639-4175 by 7:00 P.M. for inspections needed the next business day
7
/� Mechanical Permit A_ pli tion
Date received: Permit no.: -�7
City Of Tigard Project/appl.no.: Expiredate:
Ciryq/Tigard Address: 13125 SW Hall Blvd,Tigard,OR 97223 Date issued: eceiptno.:
Phone: (503) 639-4171
Fax: (503) 598-1960 Case file no.: Payment type:
Land use approval: Building permit no.:
U(1 &2 family dwellink of accessory U Conuuereiai/indu.sutal U Multi-family U Tenant improvement
U New construction 6�(Addition/alteration/replacement U Other:_
INFORMATION
Job address: Indicate cqu.pment quantities to boxes below. Indicate the dollar
Bldg.no.: Suite no.: _ value of all mechanical materials,equipment,labor,overhead.
Tax tap/tax lot/account no.: profit.Value I
Lot. Bltx k: J Subdivision: 'See checklist for important application information and
rroject name: jurisdiction's flee schedule for residential permit lee.
City/county: ZIP:
Description and location of work on premises: -f F1,� L f
rte(ra.) roW
Est.date of completion/inspection: - _ - Description Ree.od Res.o0
Tenant improvement or change of use:
Is existing space heated or conditioned?LSoes U No Air handling unit
Air conditioning(site plan required)
Is existing space insulated'?�U'Yes U NoAlteration of existing 14VAC system
o er compressors
G State boiler permit no.:
Business name: .$ 1' f h _ tip Tons BTUAI
Address: P, G' L3 ig x_ 2- it smoke dampers/duct smoke etectors
City: C.Tj State:0 ZIP: O cat pump(suepan require )
Phone:;k5 _j9 55�r I Pax: E-mail: _ nsta I Ureplacefurnace/burner JV _BT U1Hptl
Including ductwoWvent liner Yes U No /1 —
�- �B no,: � �11-U�� Insta rep ace relocate enters-suspen e
City/metro Imc.no.. �� v,nll,or floor mounted
Name please print): Vcuifon ar>lanceof
er t anunace
fer goat on:ri
Absorption units _ BTU/H
Name: RAO Si- !•e1 Chillers____� HI' -
Address: Com ressors __ HI'
r onmenta ex ant an vrM at On:
City: State: ZIP: Appliance vent _
Phone: Fax: E-mail:
)ryerex east
1111111101 Hoods, ype res.kitchenthazmat
hood fire suppression system
Name: a C_ �� +s L m C h ick Exhaust;an with single duct(bath fans)
Mailing address: � S.W.
t Exhaust;-s-tem apart rom healingor A
�i t l S � _
State6 ZIP: 2'sfFuel piping an st ut on(up to 4 outlets)
Type: LPG NO Oil
Phone: I) Fax: E-mail Fuel piping eachadditional over out et•,
rocesepiping(schematic requtre )
Name: Number of outlets
t spoils-nee or erqu pm it:
Address: IMcorative fireplace
City: State: ZIP: nsert=type �_ v!
Phone: Fax: al E-mail, Woodstove/pellet stove
UI Cf;
Applicant's signature: Date: -IF.2n0 ter:
Name (print):
Not all jurisdictions acce(a cue fit cards,please call Jurisdiction fa mote information Permit fee.... . ........... ..
CJ Visa U MasterCard Notice:This permit application Minimum fee................$ _ '� r
expires if a permit is not obtained Plan review(at ^ %) $
Credit cad namher, _ -- --�-1- -- within 180 days after it has been State surcharge(8%)....$
n
y` vane of
cardholder as Mown on c t cad accepted as complete. -
s TOTAL .......................$ 7 X• ?,G _
' Catd►toltkt•ty..:.+e Amount 1101517(GMCOM)
MECHANICAL PERMIT FEES
COMMERCIAL FEE SCHEDULE: 1 & 2 FAMILY DWELLING FEE SCHEDULE:
TOTAL VALUATION: PERMIT FEE: Description: - �T Price Total
$1.00 to$5,000.00 Minimum fee$72_.__50 Table 1A Mechanical Code I ON (Ea) Amt _
$5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and 1) Furnace to 100,000 BTU
$1.52 for each additional$100.00 or including ducts&vents 1410
fraction thereof,to and Including 2) Furnace 100,000 BTU+
$10,000.00. Including ducts&vents _ 17.40
$10,001.0^to$25,000.00 $148.50 for the first$10,000.00 and 3) Floor Fu,nace
$1.54 for each additional$100.00 or Includingvent 14,00
fraction thereof,to and including 4) Suspended heater,wall heater
$25,000.00. or floor mounted heater 14.00
$25,001.00 to$50,000.00 $379.50 for the first$?5,000.00 and 5) Vent not Included In appliance permit 6.80
1 $1.45 for each additional$100.00 or -
fraction thereof,to and including 6) Repair units
_ $50,000.00. 12'15 -
$50,001.00 and up T $742.00 for the first$50,000.00 and Check all that apply: Boller Heat Air
$1.20 for each additional$100.00 or For Items 7-11,see or PUrTip Cond
fraction thereof. footnotes below. Comp '•
Minimum Permit $Fee$72.80 SUBTOTAL: 7)1absorb unit
to?00KOOK BTU 14.00
A% Surcharge $ 8) t 15 k t absorb
State
unit 100k to 500k BTU 25.60
/.Plan Review Fee of subtotal 9)15-30 HP;absorb
25°
Required for ALL commercial (ermits on l $_ unit.5-1 mil BTU 35.00
g
- -- A---- 10)30-50 HP;absorb
TOTAL COMMERCIAL PERMIT FEE: $ unit 1-1.75 mil BTU 52.20
11)>50HP;absorb
_---�-- - -- - unit>1.75 mil BTU 87.20
ASSUMED VALUATIONS PER APPLIANCE: 12)Air handling unit to 10,000 CFM 10.00
Value Total -it Air handling unit 10,000 CFM+
Description: Q Ea Amount 17.20
Furnace to 100,000 BTU,including 955 14)Non-portable evaporate cooler
ducts&vents 10.00
Furnace>100,000 BTU including 1,170 15)Vent fan connoted to a single duct
ducts&vents 680
Floor furnace Includingvent 955 16}Ventilation system not included in
Suspended heater,wall heater or 955 appliance permit 10.00 -
floor mounted heater 17)Hood served by mechanical exhaust
Vent not Included In applicance 445 10.00
permit 18)Domestic incinerators
Repair units _ 805 17.40
<3 hp;absorb.unit, f 955 19)Commercial or Industrial type Incinerator_to 100k BTU 6995
3-15 hp;absorb.unit, 1,700 20)Other units,includ):i7 wood stoves
101k to 500k BTU _ _ 10.00
15-30 hp;absorb.unit,501k to 1 2,310 21)Gas piping one to four outlets
mil.BTU5.40
30-50 hp;absorb.unit, 3,400 22)More than 4-per outlet(each)
1-1.75 mil.BTU 1.00
>50 hp;absorb.unit, 5,725 Minimum Permit Fee$72.50 SUBTOTAL: $~
>1.75 mil.BTU
Air handling uNt to 10,000 cfm 656 8%State Surcharge $
Air handling unit>10,000 chn _ 1,170 _
Non- orteble eva rate cooler 1158 TOTAL RESIDENTIAL PERMIT FEE: $
Vent fan connected to a single duct 446
Vent system not InrJuded In 6513 - -
a Hance permit
Hood served by mechanical exhaust 858 0_!(14r�3L�!! and Fees:
Domestic Incineratorr 1'170 1 Inspectionnss outside of normal business hours(minimum charge-two hours)
$62 50 per hour
Commercial or industrial Incinerator 4.590 2 Inspections for which no fee Is specifically indicated (minimum charge-half hour)
Other unit,Including wood stoves, 658 $62.50 per hour
Inset etC 3 Additional plan review required by changes,additions or revisions to plana(minimum
Gas I Ing 1 4 OUtiets _J 360
charge-one-half Incur)$62.50 per hour
Each additional outlet 83 1 'State Contractor Boller Certiflc-ition required for units>200k BTU.
TOTAL COMMERCIAL '' a "Residential AJC requires site plan showing placement of unit.
VALUATION: All New Commercial Buildings require 2 sets of plans.
I:\dsts\forrns\mech-fees.doc 12/26/01
CITY OF TICARD 24-Hour
BUILDING Inspection Line: (503)639-4175
INSPECTION gIVISION Busthess L�nR: (503)639-4171 MST
v
�
P41 SUP
Received 2 ` Date Requested AM PM
SUP
Location . ��! 1 �l _ �'l� Suite MEC - �'Gc?�.
Contact Person 4dz Ph( ) O C) !Z!Z__e PLM
Contractor Ph( ) SWR r
BUILDING Tenant/Owner _ ELC
Footing
Foundation c6m—: ELC _
Ftg Drain ELR
Crawl Drain _ — --
Slab Inspftion Notes: SIT
Post&Beam —
Shear Anchors — — — — —_
Ext Sheath/Shear
Int Sheath/Shear
Framing ? Ar.L Lc-' 1113 26"(Vo
Insulation -----
Drywall Nailing
Firewall
Fire Sprinkler ---- --- - — -- _ _ _,
Fire Alarm
Susp'd Ceiling -----
Roof
Other: --
Final
PASS PART FAIL --- ��- — -- --
PLUMBING
Post 8 Beam ---
Under Slab
Rough-In — ----�-
Water Service
Sanitary Sewer
Rain Drains -- ---- ---- - ---- —_�_�.— — --
Catch Basin/Manhole -- --
Storm Drain --- ------------ ---- — —
Shower Pan _
Other:- __-- - —------- —^_T__�— — _--- ---- —
Final
PASS PART FAIL
MECHANICAL
Post&Beam
Rough-In
Gas Line — -- -
SmokQ Dampers -----
in
AS PART _FAIL —
ELECTRICAU
Service
Rough-In
UG/Slab --
Low Voltage
Fire Alarm
Final
PASS PART FAIL Reinspection fee of$— required before next inspection. Pay at City Hail, ;x'25 SW Hall Blvd.
SITE — ❑ Please call for reinspection RE:. Unable to inspect-no access
Fire Supply Line
ADA
Approach/Sidewalk Ditb �t Insprator
Other:
Final -- DO NOT REMOVE this Inspection record froitn the Job site.
PASS PART FAIL
CITY OF TIGARD BUILDING INSPECTION DIVISION
24-Hour Inspection Line- 639.4175 Bi., iness Line: 639-4171 MST
BLIP
e nes
Date Rted_• --� __` �� AM PM ��--.__�-_---
r/ � ; JI - - }--_ BLD
Location `1 't `>�lJ �� "1_ -_ Suite
Contact Person �r Ph PLM
Contractor �hi�✓ ,� C i', _ Ph SWR _ __-
BUILDING Tennant/Owner l MJ4i_/ --
Retaining Wall CLR
Footing
Access: FPS
Foundation
Ftg Drain -
Crawl Drain Inspection Notes SGN
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 -- - - _
PASS PART FAIL ----- -- -_
PLUMBING
Post& Beam -- ----------- - _- —_ ---
Under Slab
Top Out - _ ------ --
Water Service
Sanitary Sewer ------
Rain Drains
Final
PASS- FAIL
CHANICAL -- --
Po - --- -- _ - _
Rough In
Gas Line - ----
e Dampers
T FAIL - -----
ER i ICA -- --- - --
Rough lig - - _. . - ----- ----
UG/Slap
I_.w Vnnage
harm
P SS PART FAIL.
Backfill/Grading - - --- --- --- ----
Sanitary Sewer
Storm Drain [ ]Reinspection fre of$ _ required before next inspection. Pay at City Hall, 13,125 SW Hall Blvd
Catch Basin
Fire Supply Line [ J Please call fc !inspection RE ] ]Unable to inspect-no access
ADA r�Approach/Sidewalk
Other --- Date �._ Inspector Ext
Final
PASS PART FAIL 00 NOT REMOVE this inspection record from the job site.
CITY OF "rIGARD ri.-Er"rRTM... PERMTT
DEVELOPMENT SERVICES PFRMIT *I : 17IX -J98 -037,2
13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171 DATE ISSUFD' 06/1.7/96
PARCEt.—
OCK, OG7 JURISDT 1.'T ION.-, Yr.['!
().j.ect Detsr;r'iv)tj,i)yi : Alteration of residence.
r7F!7 I 01-7NIT T(-)L UH I T-- 11 19-iCE1.L ANFr)jjS -
00 Sr OR I F1131 S. . . . : 200 ,amp. . . . . . . 0 PUMP/TRRIGnTION, . .
CH ADW L. 54x07". . . : 0 201 400 .�i In p. . . . . . . . 0 5 1 GWOUT L 11,47. LT'G.
'11717D ENFROY. . . . . . 401 600 antp. . . . . . . . 6TGN0L,/PANFJ...
NF'. HM/ GVUFDR.. 1-;01. 1 a In rl!: 020 IM ,,,0 1 0, 11 T NO R l..!•BE;
SER V I ME./FE FDE R I N5r,17(.7 I OK!
amp. . . . 0 t1j/r3r-,.RV,rCE OR F,EEW'..Pc 0 P T NS'PEC T r)N.
400 amp. . . . . .. .. 0 ist wIn "Pvc nR FVP. I PER HO(M. . .
61210 AIPP. . . . . . 0 rTA A D D I I BRNCIA Cjpc: 0 IN r1l fINT. . . . . . . . .
1000 anip. . . . (11 AN RFVTEW Sr=CT T ON---,-.-,
iti ij,-4-
0 4 t IN I T 7.,. Isoo vni 'r 1'.1'7MT1q0L. . .
0 !:WC/FDR CLP86 AREA/SPEC nCr..
FEES
r1J. RARTNn-nmFw typp ameftnt by date r-prpt
44 cj'W HILL 9TP1.7F-..'!" PRMT t 3111. 00 DL I1 06 17 11,11 `°Ii 311
GqRn np 97 5PET $ 1 . 75 T)t-H OF;/.17/9N !4 6 0
60!4 0J 17
1W R -G. 711 Tfl'l
Rr,01..17RVD 1NF3PFrTTnW,
Wr7PTON OR 07007 P ;T1-1 i (I E I PC't I I F'i
j ri(? it,- (>4F'..-W.3737 F r t I F3.b,r,V i i."e ------
�eq
'his pewit is issued Subject to the regulations contained in the T'gard Municipal Code, State of Oregon Specialty Codes and all
Applicable laws, All wTY,P will be done in scrordenre with approved plans. This persit will expire if wark is not started within
Jays if issuance, or if work is suspended for sore than 188 days. ATTENTION: Oregon law requires you to follow the r,fles adopted by
'he 'Irpoor Utility Notification Center. Thosp i Jes Atp set fnrt!j j!j ("tip th4,nl:q!� VP 1',P W11387. You say cbtaiti a rnny
these --les or direct questions tr, lir by calling (593)246-1987.
0 A jj
CITY OF CIGARD Electrical Permit Application Plan Check#
13125 '00 HALL BLVD. Rric'd By Z c yy
TIGARD OR 97223 Date Rec'd4z/
Date to P.E.
Phone (503)639-4171, x304 Print Or Type ��j`� Date to DST-_
`
Inspection (503) 639-4175 Inc,inp!ete or illegible will not be accepted Permit 9 C cC 9� 03 3,�_
Fax(503) 684-7297 Called
1. Job Address: F4. Complete Fee Schedule Below:
Name of Development_ Number of Inspections per permit allowed
Name(or name of business) r Service included: Items Cost Sum
Address 1 .L-1. 4a. Ros'dential-par unit
ph, "
CI /Stat@/zl a I ij e 1000 sq.tt.o Ids;s --- $110,00 q
tY p Each additional 500 sq.ft.or
Commercial❑ Residential portion thereof $25.00 f
Limited Energy _ $2500
Each Manut'd Home or Modular
Dwelling Service or Feeder $68.00
2a. Contractor installation only: -�- `
(Attach copy of ell rrent licenses 4b.Services or Feeders
Electrical Contractor /ICt f hl C. 1 F^ C Installation,alteration,or relocation
- e^ 200 amps or less V $60.00 _
AddreAs�w _ 201 amps to 400 amps $60.00 _T _ 2
City -V Ctate 401 amps to 600 amps $120.00 2
Phone No. 14 Vj a 601 amps to 1000 amps $180.00 2
Job No. Over 1000 amps or volts - $340.00 2
'�' Reconnect only $50.00
Elec.Cont. Lice. No. ~-
Exp.Date - -
OR State CCB Req. IBJ _Exp.Uate. - 4c.Temporary Services or Feeders
COT Business Tax ur Metro + r` x Exp.Date Installation,alteration,or relocation-
/ 200 amps or less $50.00
Signature of Supr. Elec'n 1. �' 201 amps to 400 amps $75.00
401 amps to 600 amps _-� $100.00
J p p Over 600 amps to 1000 volts,
License No. % Exp.Date In-1` (C? see"b"above.
Phone No.-- ¢ t1 i
4d.Branch Circuits
New,alteratir-or extension per panel
2b. For Owner installations: a)The fee for branch circuits with
purchase or service or
Print Owner's Name feeder tae.
Address Each branch circuit $5.00 2
b)The fee for branch circuits
City_ State Zlp wfthout purchase of
Phone No, service ot feeder fee. 3 S
First branch circuit $35.00
The installation is being made on property I own which is not Each additional branch circuit $5.00
intended for sale,lease or rent. 4e.Miscellaneous
Owner's Signature (Service or feeder not included)
9 Each pump or irrigation circle $40.00 _
Each sign or outline fighting $40.00
3. Plan Review section (if required):* Signal circuit(s)or a limited enerSy�
panel,alteration or extension $40.00 _
-
Please check appropriate item and enter fee in section 5B. Minor Labels(10) $100.00
4 or mora residential units in one structure 4f.Each additional Inspection over
Service and feeder 225 amps or more the allowable In any of the nbove
System over 600 volts nominal Per inspection $15 00 -----.-
_Glassified area or structure containing special occupancy Per hour $1�5 00 __---_--_-
ac da-rood In N.E.C.Chapter 5 In Plant $55 00
*Submit 2 sets of plans with application where any of the above apply. 5. Fees: Q
Not required for temporary construction services. 5a.Enter total of above fees $ J 4�
5%Surcharge(.05 X total fees) $ `
NOTICE Subtotal $ ------
5b.Enter 25%of line 5a for
PERMITS BECOME VOID IF WORK C CONSTRUCTION AUTHORIZED IS Plan Review If required(Sec.3) $
NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK Subtotal $ -
IS SUSPENDED OR ABANDONED FOR A PERIOD OF 160 DAYS AT ANY 11----11
TIME AFTER WORK,IS COMMENCED. 0 Trust Account#, _ Z5*
Total balance Due
iMSTS ICnc APP 11tw11,96 ..