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10965 SW MIRA COURT-1 r 10 VNIW MS 59606 a vii ~ U � r W to J � CD to CD 10965 SW MIRA CT re ,A CITY OF T I C�4 R D ELECTRICAL PERMIT PERMIT M ELC2000-00674 DEVELOPMENT SERVICES DATE ISSUED: 1217/00 13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 PARCEL: 2S103DA-03902 SITE ADDRESS: 10965 SW MIRA CT SUBDIVISION: ZONING: R-4.5 BLOCK: LOT : JURISDICTION: TIG Proiec;t Description: Wire A/C and furnaec _ RESIDENTIAL UNIT_— TEMP SRVC/FEEDERS _ MISCELLANEOUS —` 1000 SF OR LESS: 0 - 200 amp: PUMP/IRRIGATION: EACH ADD'L 500SF: 201 - 400 amp: SIGN/OUT LINE LTG: LIMITED ENERGY: 401 - 600 amp: SIGNAL/PARE MANF 4M/SVC/FDR: 601+amps - 1000 v0tht7 MINOR LABEL (10): SERVICE/FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS 0 - 200 amp: W/SERVICE OR FEEDER- PER INSPECTION: 201 - 400 amp: 1 st W/O SRVC OR FDR: 1 PER HOUR: 401 - 600 amp: EA ADD'L BRNCH CIRC: 1 IN PLANT: 601 - 1000 amp: PLAN REVIEW SECTION 1000+ amp/volt: _ > 4 RES UNITS: >600 VOLT NOMINAL: Reco,�riect only- SVC/FDR>=225 AMPS: � CLASS AREA/SPEC OCC: Owner: Contractnr: FIELDS, ANDREA M 4 JASON E WEST SIDE ELECTRIC CO 114C 10965 SW MIRA CT 1834 SF 8TH AVE TIGARD, OR 97223 PORTLAND, OR 97214 Phone: Phone: 231-1548 Rep#: LIC 13306 SUP 1556s ELE 26-135c FEES — Required Inspections _ Type By Date Amount Receipt Elect'I Final PRMT CTR 121'7/00 $53.50 2720000000( 5PCT CTR u12/7/Ou $4.28 2720000000( Total $87,78 This Permit is issued subject to the regulations contained in the Tigard Municipal Code,State of OR. Specialty Codes and all other applicable laws. a 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 i(work is OL 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 or direct questions to OUNC at(503) 246-1987 PERMITTEE'S SIGNATUREMOLJ2VISSUED BY: — W OWNER INSTALLATION ONLY W —� The installation is being made on proper,y I own which is not intended for sale, lease, or rent. OWNER'S SIGNATURE: DATE: _ CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR. ELEC'N: - _ DATE: _ LICENSE NO: —_ (44; e394175 by 7:00pm for an Inspection the) next business day 'il colt y Electrical Permit ppil' V "eteved Yernu 00 7 City of Tigard '0+oJrWApp)nl. �.eyllecinl.; City, 71641d Addren: 1312.A SIX Hldi Ritd,1'l Parc,OR Q;AJF3. �-�<� Lha Iut�Mh p Rec tott� Phone' (]01) 639-4171 rill:(303) SSJM 1940 wC\��\\� tee Qir no.; 1'e,ittenl type: L-A use approval: `� 2 fomily dwell IAL or OcceAsary J Comm el A injim(tirl U Multi-ramu), d TeaMl Irry.rovsmetN J N v Conrnucdt,. O Addhio tfeltetpiirn.rl<rleccmrm U Oiher: loL r- res+: w� M e,lL A f�,. 111 ,ntti: Suite ro.; TU M& 'tu IOVR&OUnt no Loc, Rluci b-ANdlvlcign. Phv�e nenla - " De-cli irto end Incaliun of work,�miuel: Lj .v A -' Bflltn ted dote of cvrtr Ir ttn tvs t u,wr Jab I Rusin a nuns: a C 1.... !_�a+ IDw_A the � Tsui ro.h Addie 1 L rhn+ •cRn�i' nt�i y"pt.r :t+nritlry rroN.ineltlir ettrtrrlel fit. city; r _ Shue: - 'p: 1 pK,ti �tll�hdd66'" ti ,� Ione #-A ► f Ftic ruoila CCO r,: A� 81tc.bcI_hc,nn: (1_1.3 frc. ficcTi IWd Iiatwl. n rK „Itlan thertvl In Won tet r City/ Iry Ik,no: ,_.. I,yi"WE non era un M nn.W MMRor mpJu1N dre11 .R 1 D IU r'tlln +k C Aq ry gMCJ_i ..� D7il Z 9t, a now( rte) . LI:pto no.I illorrim dtcrAlbH or nlnctllaet XT Ane(0l Ira ? Nrnitt 1 i C>S4I dUn rtkfsfr: '�- Slrle;-- 71f t' �o twuo�A R- 1 Phone: ex: Butuil' • r:rectu Ownff 111011:'rhe Inrtxllydon 1+ helm Intldn rA,)cnpeny f9wil I-"Mfltrer+l+erfit ee . which Iwt inlotrdted rut fele,loan),nnt,ar em hanip stm. fdhl j to er releeAtleer UR9 a 7.e79,479.670.701. :Pa Amin orlep 1 �!emYt lu a9_�i+�------ Otvn tit Ols too--M*,all,,rltlq, Nr111! er rllhAuh�n pr erect, r/tor t:r+aehdra•'..0"rN,ForcheAe of �ddr ►etviae,"t.Rrl r.(11,10 call hrcmh 61mutt hru�.�drc,;tt w tb�n pnrcnAt�` hone Rtts; B'fiUll' ortetvl•..lit rto.'u f",[fel+41jLh i.Iri lilt t� ��,,t to nc chi Inv,-'t"•` -- nW, M+tAR roMtrot gtrrrl ov+r2l+Asrplcotttrtterrlrll O hrdth-cArrrecWt RAduylle I tlancitvl• ONni owr32prtrQrartltyollA2 Q Nrlatdonlbwrfrut Paotll nMouJlnal) ._- fZ /Atoll dMtAinp t]RuL'11t,rr�ert!1.:AUAquaternrraurur 14'>1lc7teft(N1brAIlRlle etleryVltoR, Dsyrtr ovw600vehp,notelntd Moto MltIeWillu1t11e1nomSWClcn of Allan.otertenlonr a pulld .ror'tlOmssorfn 0 Fecdcr%0.0M,pt or�aae -------•.•� 3 0 Otka;.•r ,t:•Adover llpenwr 7 Ma�urwu:erl►uvetor»�rR�wit 'Alto! G — 0 Eren 1Gt o u tea s+ert NMar k er a Ihs f ►st - .itninrplAn _ sArYatN ,,tete 101 pfen+nith fey of Oe Aflerw Invn t pq n - e eM+e ole wt ISPOUC1616 to lneNren cewlracllon ottlrkm. w- Kar JI Ar.l f.nt seep rngr ee,'L,FIMN 011far.,.0 Y,►n R � r Nellce:'i'hb permit eppllcrtlnn 1 err.til fee............. W tivin UMatacato exiiuA UA perndt h nut oMrirtcd Plan rcview(at � -J rT,dlt...d ImbW --- L. Ivldt(n Ifti 111ytr rflcr h Ans been State wrcbuBC(/!�),,,,4 ��` q T•r �- = nt r�ovn u,n'dG•iT audep',:n'at vetnp►sb. ■0TAL.n,......,.... -�- e r IlAltq+� -S AmiitN- 41C tet 1 dtrt U-M I I Oll e101a'l9 3Q I C' 11�?M Wel Ivb:S@ 00-1170- 311 M CITY OF TIGARD MECHANICAL PERMIT DEVELOPMENT SERVICES PERMIT 0: MEC2000-00483 13125 SW Hall Blvd.,Tigard, OR 97223 (503)639-4171 DATE ISSUED: 1 PARCEL: 2S 5103 103DA-03902 SITE ADDRESS: 10965 SW MIRA CT SUBDIVISION: ZONING: R4.5 BLOCK: LOT: JURISDICTION: TIG CLASS OF WORK: ALT FLOOR FURN: EVAP COOLERS: TYPE OF USE: SF UNIT HEATERS: VENT FANS: OCCUPANCY GRP: VENTS W/O APPL: VENT SYSTEMS: STORIES: BOILERS/COMPRESSORS HOODS: FUEL TYPES 0 - 3 HP: DOMES. INCIN: GAS 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: I _ AIR_HANDLING UNITS OTHER UNITS: 1 FURN >=100K BTU: <= 10000 cfm: GAS OUTLETS: 10000 cfm: Remarks: Gas Furnace and A/C Owner: _ FEES FIELDS, ANDRE,' M + JA3ON E Type By Date AmountReceipt 10965 SW MIRA CT PRMT CTR 12/8/00 $72.50 2720000000 TIGARD, OR 97223 5PCT GTR 12/8/00 $5.80 2720000000 Total � E78.30 Phone: — – Contractor: �— JACOBS HEATING +A/C 4474 SE MILWAUKIE AVE PORTLAND, OR 97202 REQUIRED INSPECTIONS Mechanical Insp Phone:503-234-7331 Final Inspection Reg#:LIC 1441 Li. OC U) J � m LU This permit is issued subject to the regulations contained in the Tigard Municipal C(-de, State of Ore. Specialty Codes and all other applicable laws. All work will be done in accordp!,ce with approved plana. This permit will expire if worts 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. Thuse rules are set forth in OAR 952-001-0010 through OAR 952-001-0080. You may obtain copies of these rules or direct questions to OUNC by calling (503)246-9189. YY . 1Ze Issue By: � ..R-- Permittee SignaturA: _ Call (503 fi39-417'5 by 7:00 P.M.for Inspections needed the next business day Mechanical Permit Application Permit 11(f.'� City of Tigan! RECEIVIFI, Date received: aoa� ao 3 Address: 13125 SW liall Blvd,Tigard,Olt 23 F'mkcUappl.no.: Expire date: Cit I,of Tigard g - - Phone: (503) 639-4171 ��` - R ZQ Date issued: By: ltecaiptno.: Fax: (503) 598-1960 Case file no.: Payaxnttype: Land use approval: DFV'.l UPME N 1 Building nermil no.: & 2 f unify dwelling or accessory U Commercial/industrial UI Multi-family U Tenant improvement U New conslniction U Addltion/alleration/replacement U Other. FJob adc;mss: /� � _S Indicate equipment quantities in boxes below. Indicate the dollar Ido: Suite nn,: value of all mechanical materials,equipment,Inbor,overhead, pAnx lot/necounl no.: pi»BI. Vnlne IIhrA: 'yui�llvlrhnr 4Vao thw•AINI It,t Itttl,ulluul uly1lholhal 1101ullttnlhat .tu,l Pmject name: F1r�L�Q 1 jurisdiction's fee schedule for residential permit lee. City/county. -T i r2. ZIP: q 'I Description and I alion of work on premises Get.date of completion/inspection: Dewri i�rt on Res.onl RTotal y Tenant improvement or change of use: C: - Res.o Is existing space heated or conditioned?U Yes U No Air handling unit ChM _ is existing space insulated?U Yes O No it con a on n (site p an re wre I) --- Is ex sting system - o er compressors ' - - Business name: /.j E aA i ,F et K) I ,` — State boiler permit nn.: �D 5 F ' f IIP _Tons BTU/H Address:�i t I t, S k-t , t 9 amo cTcTe ampe�s/ou:t smoke etectois City: j> 1r State:Od ZIP: IF,?d)p,, lent pump(site jTan req iir�— - Phone:�S r ) j -,t X: $I E-mail: ,nsta i rep ace urnac urner CCB no.: )`/q �� Including duclwork/vent liner U Yes U No / #fj7 nsta rep ac re ocalcheaters- City/mc(ro lic.no.: )�&5`"~ wall,or Boor mounted Name(please print): N f r?t ( eat ora lance of er t an urnace c Brat on: Absorption units _ BTWH Name: ' I let e e-� t: j Chillers ){p Address: - Com ressors — HP -- �.nr ronrnenU ex ausl anry real at on: City: 1 l �• State: _ ZIP: _ Appliancevent Phone: Fax: Email: Dryerex gust - — II—TsTY_vInfT,r . itcIx Fa mal hood fire suppression system Name- (), f a Exhaust fan with single duct(bath fans) Mailing address: 5 s W v) I,Y,0. 11x Eaust system a art rem cat n or City.' , „ State: ZIP: q Ta7a ae piping adistribution up to out els) -- Ty LPU NO Oil Phone: lit/ Fax: E-mail: ve i m each additional over cut ets -- r roctsr p p ng(sc emancrequire ) Name: — Number of outlets — Other Weed app a-1T nc`e oFeegnTpnrc'n1i M Address: _� Decorative fireplace a City: Slate: ZIP: nserl-t y pe _ -- JPhone: Fax: E-mail; stov pe etslove — Applicant's signature: Date; "her:t +t _I Name(print): — J NM all indsdicriom accept credit cardr.please call iudsdlcdon far mare Inform flon. Permil fee.....................$ _ U Win U MaslerCanl Notice:This permit application Minimum fee................$ -0 expires if a permit is not obtained Cmfit card number._ � Plan review(at _. %) $ F.xplres within 190 days after it has been State surcharge 896 —_gyp Name c ca ntder ns shown on credit c accepted as complete. B ( )....$ S TOTAL .......................$ ---- Ctrdhnitfer sianaiwe ArrwuM 1617(6,ifl mm) �a � 97 .uj � n►atrlionl NoUSE fRoNf lit- -I'D,8 AI,101C�o to s fib ki rhIRA- V 7z Z j a (hoL-)�� ac f- �1 �a LU ��"AC.of35 ra TL, f A l PlioVAUKIC A:'(-, PORT OR `7 7ZDZ _503 23q 73-31 Fax Sv3- �r� !ZS 7 CITY OF TIGARD BUILDING INSPECTION DIVISION MST 24-Hour Inspection Line: 639-4175 Business Line: 639-4171 BUIP - __,mate Requested �2- �� AM PM BLD -- Location l _ 5 4i &l r k G X - — Suite MEC u -oU!{ Contact Person Ph 3Z�3--T6 4;-77YD PLM Contractor _ Ph SWR BUILDING Tenant/Owrer ELC Retaining Wall A ELR — Footing Access: Foundation � � FPS Ftg Drain SGN Crawl Drain Inspection Notes: - Slab —_ _ —_ SIT _ Post&Peam —— Ext Sheath/Shear Int Sheath/Shear Framing Insulation Drywall Nailing 0= __— Firewall Fire Sprinkler Fire Alarm Susp'd Ceiling _—_.— ------._ _ --- Roof Mac: -----— -- --- — -- - Final PASS PART FAIL -- -- — ------ PLUMBING Post&Beam _—�_._---.-----__-- —.. Under Slab __—_�..__�.�--__---- ------------- -- Top Out Water Service Sanitary Sewer Rain Drains Final PASS PART FAIL WffC— H&WAL Post&Beam Rough In Gv s Line ---- -- — '--� -- mpers Ar"ART FAIL ELECTRICAL Service IX Rough H F- UG/Slab Low Voltage Fire Alarm --.-_-_ --------._—_—_—_ --__--- _-- _— — _ _ J Final m PASS PART FAIL 0 SITE Backflll/Grading ---"`�—"- — Sar;, y Sewer Stoma Drain ( ]Relnspe_tion fee —_— required before next Inspection. Pay at City Hall, 13125 SW Hell Blvd Catch Basin ( ]Please call for reln,. t—ilon RE: �_ 4 Unable to Inspect-no access Fire Supply Line ADA zf 000e Other Approach/Sidewalk Date ��12-Y Inspector EXt Other — Final — PASS PART FAIL DO NOT REMOVE this Inspection record from the Jub site. CITY OF TIGARD BUILDING INSPECTION DIVISION MST 24-Hour Ihspec�fion Line: 639-4175 Business Line: 639.4171 -- BUP_ Date Requested 2— 7- AM PM BLD -- LocationL01 K" s S4..' /Iat'Ya G Suite MEC _ Contact Person _ Ph _ PLM Contractor Ph SWR _ BUILDING Tenant/owner -_ ELC Retaining Wall I ELR Footing Foundation '' FPS Ftg Drain --- SGN Crawl Drain Irapection Notes: -- Slab __ _ - SIT Post R Beam Ext Sheath/Shear _ Int Sheath/Shear r Framing Insulation Drywall flailing Firewall Fire Sprinkler - Fire Alarm Susp'c Ceiling Roof Misc: - -- -_ - - Final C PASS PART FAIL - - - -- --. PLUMBING Post&Bean, Under Slab Top Out - - �- Water Service Sanitary Sewer Rain Drains Fins. - PASS PART vAIL MECHANICAL — — Post&Beam ---- - - - Rough In Gas Line ----- _�-_--. _- Smoke Dampers Final -- --- -- - PASS PART FAIL Service Rough In UG/Slab Low Voltage Fire AS PART FAIL Backfill/Grading -- --"� -- Sanitary Sewer Storm Drain [ J Reinspection fee of$�- required hefore next inspection. Pay at City Hall, 13125 SW Hall Blvd Catch Basin Fire Supply Linn [ )Please call for re n spection RE: I I Unable to inspect-no access ADA Approach/Sidewalk � Inspector 'Z.-1 Ext Other Date Final PASS PART FAIL DO NOT EMOVE this Inspection record from the job site. q IF CITY OF TIGARD BUILDING INSPECTION DIVISION MST 24-Hour Inspection Line: 639-4175 Business Line: 639.4171 �'— I . X SUP — — �Date Requested 3-1(o AM�PM LZ _. BLD Location 10R(O'�; SLO rft6tjtL U. �� 1��2 _ Suite MEC Contact Person Ph (nom CQ3)L4 PLM Contractor PhSWR BUILDING Tenant/Owner ELC Retaining Wall ELR Footing Access: Foundation FPS _ Ftg Drain SGN Crawl Drain Inspection Notes: vi tA Slab —, SIT Post& Beam q 66 wi Ext Sheath/Shear ( Q_a.L&J.-- a/k _ Int Sheath/Shear Framing -- Insulation Drywall Nailing Firewall Fire Sprinkler _ -A _ ^_ ,Fire Alarm Susp'd Ceiling Roof Misc: - Final PASS PART FAIL --- PLUMBING Post&Beam Under Slab _ Top Out Water Service Sanitary Sewer Rain Drains Final PASS PART FAIL MECHANICAL Post& Beam Rough In Gas Line - -- - — Smoke Dampers Final — te A•• PA T FAIL LECTRIC 'rvlc3 Rough In UG/Slab _ Low Voltage Fire Alarm FiDaL- )00gART FAIL MR Backfill/Grading - —V ---" --Sanitary Sewer Sewer Storm Drain [ )Reinspection fee of$ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd Catch Basin Fire Supply Line ( ]Please call for reinspection RE: — [ )Unable to Inspect-no access ADA / G Approach/Sidewalk Date 3.__ (� 7 Inspector Ext Other �— Final PARS PART FAIL DO NOT REMOVE this Inspection record from the job site. CITY OF TELECTRICAL PERMIT DEVELOPMENT SERVICES PERMIT #: ELC99-0094 13125 SW Hall Blvd., TigaOOR97223(503)639-4171 DATE ISSUED: 02/17/99 PARCEL : 25103DA-03902 SITE ADDRESS. . . : 10965 SW MIRA CT SUBDIVISION. . . . : ZON I NG:R-4. 5 BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . JURIGDICTION: TIG Project Description: Install anew 210AMP service and one branch circuit. --------------------------------------------------------------.------------------ ---RESIDENTIAL UNIT---- ---TEMP SRVC/FEEDERS---- -----MISCELLANEOUS----- 1000 SF OR LE:SS. . . . : 0 0 — 200 amp. . . . . . . .. 0 PUMP/IRRIGATION. . . . : 0 EACH ATJD' L 500SF. . . : 0 201 — 400 amp. . . . . . . : 0 SIGN/OUT LINE L.TG. . : 0 LIMITED ENERGY. . . . . : 0 401 — 600 amp. . . . . . . : 0 SIGNAL/PANEL. . . . . . . : 0 MANE. HMI SVC/FDR. . : 0 601.+amps-1000 volts. : 0 MINOR LABEL (10) . . . : 0 ----SERVICE/FEEDER---- ----BRANCH CIRCUITS------ ---ADD' L. INSPECTIONS--- 0 — 200 amr. . . . . . .. 1 W/SERVICE OR FEEDER: 1, PER INSPECTION. . . . . : 0 201 — 400 amp. . . . . . : 0 1st W/O SRVC OR FDR. : 0 PER HOUR. . . . . . . . . . . : 0 401 — 600 amp. . . . . . : 0 EA ADD' L BRNCH CIRC: 0 IN PL.ANT. . . . . . . . . . . .. 0 601 — 1000 amp. . . . . : 0 -----.-------------PLAN REVIEW SECTION----------------- 1000+ ECTION----------------- 10Q0+ amp/volt. . . . . : 0 ) -4 RES UNITS. . . . . . . . : ) 600 VOLT NOMINAL. . : Reconnect only. . . . . : 0 SVC/FDR )- 225 AMPS. . : CLASS AREA/SPEC OCC. : ----------------------------- ----------------- ANDREA FIELDS -.--__—_____-----_—.-___--- FEES ANDREA FIELDS type amount by date recpt 10965 SW MIRA COURT PRMT $ 65. 00 GEO 02/17/99 99-312976 TIGARD OR 97223 5PCT $ 3. 25 GEO 02/17/99 99-312976 Phone #: 639--6314 Contractor: ----------------------_------ ANDREA FIELDS $ 68. 25 TOTAL 10965 SW MIRA COURT -------- REQUIRED INSPECTIONS ----- TIGARD OR 97223 Rough—in Elect' 1 Final Phone #: Elect' l Service Reg #. . : F, 0)94- This permit is issued subject to the regulations contained in the Tigard Kunicipal Code, State of Oregon Specialty Codes and all other applicable laws. All Mork will be done in accordance with approved plans. This permit will expire if Mork is not startrd within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. These rules are set forth in OAR 95?AOIAMIR through OAR 952--M-1981' Y u may obtain a copy of the,;e rules or direct questions to OUNC b calling (583)246-1987. Permittee Signat t_tre: 1J`� Y Jssued By:/57S >•iC—"'""- a Ir N -----------------------------OWNEk INSTALLATION ONLY------.------------------_.--_—.- 'The installation is beingde on property I own which is not intended for, sale, lease, or, re t. - /- -� J OWNER' S SIGNATURE:V, _ V� _ _ DATE a _�� __�_ W __._-------_----------------CONTRACTOR INSTALLATION ONLY- - -___.___ SIGNATURE OF SUPR. ELEC.' N: - DATE: LICENSE NO: +++++++++f•++++++++++++++++++++++++t•+++++++++++++++t++++++++++++++++++++++++++++ Call 639-4175 by 7:00 p. m. for an inspection needed the next business clay ++++++++a++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ CITY OF TIGARD Electrical Permit application Plan Check« 13125 SW HALL BLVD. Recd By�'" TIGARD OR 97223 Date Rec'd F Date to F.E. Phone (503)639-4171, x304 ✓ Date to DST Inspection (503) 639-4175 Print or Type Permit M �c`7 o6?5/ Fax (503)684-7297 Incomplete or illegible will not be accepted called_ 1. Job Address: 4. Complete Fee Schedule Below: Name of Development-,_ Number of Inspections pw permit allowed Name(or name of business) AW(fa A1 f(lam Service Included: Items Cost Sum Address kpNole7 M�Ya (AAKp _ 7 4a. Residential-per unit -BVI p- 8 �M '"I�ZG� � 1000 sq.11at less _ $110.00 __ 4 City/State/Zip_ -�_ F.ach additional 500 sq.It.or Commercial ❑ Residential portion thereof $25.00 1 Limited Energy $25.00 Each Manufd Home or Modular Dwelling Serv!cn or Feeder $88.00 2 2a. Contractor installation only: � - (Attach copy of all current licenses) 4b.0',ervices or Feeders Electrical Contractor Install ition,alteration,or rbfocalion 200 amps or leas $00.00 _ 2 Address 201 amps to 400 amps $80.00 2 City _State_ _Zip 401 amps to 600 amps __ $120.Go 2 Phone No. 601 amps to 1000 amps $160.00 _ 2 Job No. Over 1000 amps or volts $340.00 2 Elec.Cont. Lice. No. Exp.Date Reconnect only _ $50.00 2 OR State CCB Req. No. Exp.nate _ 4c.Temporary Services or Feeders COT Business Tax or Metro No. Exp.Date_- Installation,alteration,or relocation 200 amps or leas -- $.50.00 2 Signature of Supr. Elec'n-_ _ 201 amps to 400 amps $75.00 _ 2 401 amps to 6110 amps $100.00 2 Over 600 amps to 1000 volts, License No. _Exp.Date___- "a"b"above. Phone No. 4d.Branch Circuits New,alteration or extension per panel 2b. For owner installatlons: a)The fee for branch circuits with r �^A� purchase of service or Print Owner's NameIU� � nY� e6L kICAS feeder is*. Address YQEach branch circuit $5.00 __ 2 City. State _. ZI b)the fes for branch circuits p --- without purchase of Phone Itld. 1 --_ _ service or feeder fee. First branch circuit $35.00 _ 2 The installation is being made on property I own which is not Each additional branch circuit $5.00 2 intended for sale,lease o rreV. 4e.Mlaceltaneous (Service or feeder not Included) Owner's Signature_ Each pump or Irrigation circle $40.00 V 2 Each sign or outline!ighting $40.00 _ 2 3. Plan Review section (if required):" Signal circult(s)or a limited energy- 4. panel,alteration or extension $40.00 2 FPlease check appropriate Item and enter fee in section 58. Minor Labels(10) $100.00--- N _____4 or more residential units In one structure 4f.Each additional Inspection over Y_ Service and feeder 225 amps or more the allowable in any of the above _ System over 600 volts nominal Per Inspection $35.00 Classified area or structure containing special occupancy Per hour $55.00 ED as described In N.E.C.Chapte:5 In Plant _ - $55.00 W "Submit 2 sets of plans with application where any of the above apply. Jr'. Fees: . J Not required for temporary construction services. 5a.Enter total of above fees $ 5%Surcharge(.05 X total fees) $ NOT(QE Subtotal $ Sb.Enter 25%of line 5a for PERMITS BECOME VOID IF WORT.OR CONSTRUCTION AUTHORIZED IS Plan Review if!Vgul (Sec.3) $ NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK Subtotal $ IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY T IME AFTER WORK IS COMMENCED. ❑ Trust Account 0 _ �� R 5- Total balance Due : I\DST9\ELCW APP Rev 9199 Permit #: 1 _ Date: �—1>�— Issued by: __�_— 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 following statement before a building permit can be issued. This statement is required for residential building -electrical, mechanical, and plumbing permits. Licensed architect and engineer t; :-a- s, exempt from registration under ORS 701.010(7), need not submit this statem, his statement will be filed with the permit. Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 3B: L'J 1. I own, reside in, or will reside in the completed structure. 2. I understand that 1 must register as a construction contractor if the structure is sold or offered for sale before or upon completion. F1 3A. My general contractor is_ _ -- -— ———— (Name) Contractor regis. # I will instruct ►ny general contras: 'hat all subcontractors who work on the structure must he registered with the Construction Contractors Board. ,� OR CJS' 3B. I will be my own general contractor. J If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. If I 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 understand the Information Notice to Property Owne about Const r fiction Responsibilities on the reverse side of this form. (Signature of permit applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant) �f information Notice to Property Owners About Construction Responsibilities Nota: This lnfortn:ilion Noti,r to Property Owners about C'(ttrstruction Responsibilities e,ns developed by the Construction Contractors Board in accordance with ORS 701.055(5). If you are:acting as your own contractor to construct a new home or make a substantial improvement to an existing structure, YOU can prevent many prohlerns by being aware of the following responsibilities and areas of concern. EMPLOYER RESPONSIBILITIES: If you hire persons not rcp; tvwd \%tth the. Construction Contractors Board to do labor in constructing or assisting in the constn►ction or improvement of a residential structure.,you will, in most instances,be ruled to he an employer and the people you hire will he employees. As the employer,you must comply with the following: Oregon's withholding tax taw: As An employer,you must withhold income taxes from employee wages at the time employees ;ere paid. You N ill he liable fear the tax payments everrr if you don't actually withhold Hie tax from your employees. For more information,call the Oregon rept.of Revenue at 945-8091. Unemployment insurance tax: As an employer,you are required to pay a tax for unemployment insurance purposes on the wages of all employees. For wore information,call tht�Oregon Employment Division at the Department of Human Resources at :178-3521. Workers'compensation imorance: As an employer,you are subject to the Oregon Workers'Compensation Law,and'r { t obtain workers'compensation MSUraiwe for your employees. If you fail to obtain workers'compensation insurance,yo",may he sub.Ject to penalties and will he liable for all cl�rim costs if.ne of yonremployees is injured on the joh. For rr'rore infbnmat", call the Division at the Department of Consumer and Business Services at 945-7988. U.S.Internal Reeemw Scr� ice: V,an c.nrplover,you must withhold federal income tax fit4m employees'witges. You will be liable for the tax payrirent c'.cl• :I you didn't actually withholdthe tax. For more information,call the Internal Revenue Service at 1-800-829--1040. OTHER RESPONSIBILITIES AND AREAS OF CONCERN: Code compliance: As the permit holder for this project,you are respow iblc for resolving any failure to meet code requi7,ents that may he brought to your attention through inspections. "'A IL Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for QC accidents and omissions such as falling tools,paint overspray,water damage from pipe punctures,fire,or work that must be H rn re-done. LTime to supervise employees: Make sure you have sufficient time to supervise your employees. _m 0 Expertise- Make sure you have the expertise to act as your own general contractor,to enotdinate the work of rough-in and finish w -J trades, and to notify building officials at the appropriate times so they can perforin the tequittd pections. t! if you have a(�cli ,061 questions,write or call the Construction Contractors BoardPO Bo,4 14 t' 0,Salem,OR 97309 052, 503/378-4621). The Board is located at 700 Summer St. ivE Suite 300,in Salem. prop-own.pm4 1/94