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10260 SW Greenburg Rd #170
Cury OF TIGARD _GERTIFICATE OF OCCUPANCY
DEVELOPMENT SERVICES PERMIT#: BUP2002-00A14
13125 SW Hall Blvd., Tigard, OR 97223 (503)639-4171 DATE ISSUED: 9/19/2002
PARCEL: 1 S135AB-03400
ZONING: C-P
JURISDICTION: TIG
SITE ADDRESS: 10260 SW GREENBURG RD 170
SUBDIVISION: LINCOLN TOWER-TOWN OF ME".ZGER
BLOCK: LOT:C"I4
CLASS OF WORK: ALT
TYPE OF USE: COM
TYPE OF CONSTR: 2FR
OCCUPANCY GRN: B
OCCUPANCY LOAD: 52
TENANT NAME: F IRST AMERICAN TITLE
REMARKS: Tei!=.nt improvement, combine 2 suites into one
Owner:
EOP LINCOLN, LLC
10260 SW GREENBURG RD
SUITE # 100
P��16e D89 AW'
624-7100
Contractor: 9a571 nn
JOSEPH HUGHES CONSTRUCTIORINC
7035 -W HAMPTON
TIGARD, OR 97223
Phone: 624-710`)
245-7100
Reg M IAC 45645
This Certificate issued 11/`x/2002 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 t e group, occupancy,
and use under whi a referenced permit w i ue
BUILDING INSPECTOR B17ILDINU OFFICIAL
POST IN CONSPICUOoj3 PLACE
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 MST -----
INSPECTION DIVISIONBusiness Line: (503)639-4171 BUPI-Lt --
Received 1 y f Date Requested__— AM---#
Location —__ ��6– Suite-- MEC — ----
Contact Person Ph( ) PLM
Contra for Ph( ) SWR
UILDING Tenant/Owner _ — EL'C
Footing ELC
Foundation Access: ELR
Ftg Drain
Crawl Drain SIT
Slat. Inspection Notes: '
Post&Beam /N Fe/C ,
Shear Anchors ��
Ext Sheath/C hear
Int Sheath/Shear
Framing --
Insulation
Drywall Nailing ----
Firewall --
Fire Sprinkler --- — - .—"
Fire Alarm
Susp'd Ceiling
Root /3(r)jg CO Z-^ aC)
In -
PART FAIL ---~- —�--
PBING _ ------
Post&Laam
Under Slat, ---
Roug:rin
Wat3r Service
Sanitary Sewer _
Rain Drains --_—"
Catch Basin/Manhole _ —
Storm Drain —_-
Shower Pan —
Othei:---- --- --- — ^-7
Final _
PASS PART FAIL
MECHANICA_ L --- —
Post&Beam 1 —
Rough-In
Gas Line
Smoke Dampers
Final _ — -
PASS PART FAIL --- —
ELECTRICAI.-�__ _
Service �� —
Hough-In --
UG/Slab
Low Voltage -----
Fire Alarm
:nal Reinspection fee of$ requfied before next Inspection. Pay at City Hall, 13125 S0, Hall Blvd.
PASS PART FAIL
SITE _— F] Please call for reinspection RE: Unable to inspect-no access
Fire Supply Line /�
ADA y( /�_� Ir,�t�Pectar
Approach/Sidewalk
Dab�-�-.* _ Ext --
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 -_
I"AcPECTION DIVISION Business Line: (503)639-4171 UR cp -00
Received -__ ___ _ Date Requested. 4 l AM PM _
Location Suite
.,i �T---=�--, PLM —
Contact person �__ __._ Ph( )
Contractor_ — Ph( ) SWR
BUILDING Tenant!Owner EL -
Footing I-C -- -
Foundation Access: ELR
Ftg Drain
Crawl Drain _"- SIT
Slab Inspection Notes: `J
Post&Beam - - -
Shear Anchors 1AJ�J�
Ext Sheath/Shear
Int Sheath/Sh�Hc,�,,,,,
_ - - - -
in
Insula t
—
all NCty - S —It
i�c.O L2 -,-�z ---
- r
7
Fire Sprinkler — ;..,"/
Vj
Fire Alarm ( ( _A L
Suep'd Ceiling .r
Roof ,!/__—Q /L �� (/✓'E�✓��`-- -
Other:
Final --
PASS PART FAIL
PLUMBING__-_ -- -
Post&Beam _-
Undbr Slab - --- /
Rough.Iii @ (
Water S 3rvice -
Sanitary Sewer —
Rain Drams -
Catch Basin/Manhole _ _ —
Storm Drain
Shower Pan --
Other:
Final _-
PASS PART FAIL
MECHANICAL
Post&Beam
rias gF
-
i tmoke Dampers --"
! final
PASS PART FAIL --_ - - -- - - - -�
ELECTRICAL
Service
Rough-In —_ --- -- --
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of$_ required before next Inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL E] Unable to inspect-no access
SITE _ _--__ [� Please call for reinspection RF --
Fire Supply Line �.� /G -�
ADA Dab _ f/ _)P --- Inspector.--- Ext --
Approach/Sidewalk
Other: _ _
Final DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL
Gil _ r TIGARD 2.4-Hour
BUILDING Inspection Line: (503) 639-4175 �t _ -
INSPECTION DIVISION Business Line: (503) 639-4171
BLIP
Received ___ ___.___ Date Requestgd-___� AM _......—_PM BUP
-- --
Location
�C'U *-�w ._SuiteMEC� ( .z --
Contact Person � PLM
Ph
ContractorPh SWR
— - -
BUILDING Tenant/Owner _ _ — ELC
Footing ELC
Foundation, Access: ELR _ _ --
Ftg Drain
Crawl DrainSI
-- -—--
Slab Inspection Notes:
Post&Beam -
Shear Anchors
Ext Sheath/Shear _
Int Sheath/Shear
' 1 .1 -� �.- � ---
am —7 - w. L/yl S Com✓` - - ---
Insulation -
Drywall Nailing % / /� 70
FirewallU' 2� V ('/�(� 10 0.�� _ �/ -
Fire Sprinkler
Fire Alarm / - --
Susp'd Ceiling
Roof
Other:
Final - - --- "-"-�
PASS PART FAIL t _
PLUM'
Most&Beam --
Under Slab
Rough-In -- -
Water Service -
Sanitary Sewer
Rein Drains --_ -- ------- __
Catch Basin/Manhole ---
Storm Drain
Shower Pan
Other:
Final
PASS PART FALL___
MECHANICAL
Post&Beam -
Rough-In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL - -
Service
Rough-In - - - -- -
UG/Slab -_--_
Low Voltage — -
Fire Alarm
Final ❑ Reinspection fee of$ __-_requir^ before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE F] Please call for reinspection RE:__.____ ----�.--.----_---- -- ❑ Unable to inspect-no access
Fire Supply Line c c
ADA Date t G// �� Inspector ��rls -- .-- --KXt
Approach/Sidewalk
Other:--.--_-
Final DO NOT REMOVE this Inspection record 'rorn the Job site.
PASS PART FAIL
CITY OF TIGARD 24-Hour
BUILO;NG Inspection Line: (503)635-4175 ���-�
INSPECTION DIVISION Business Line: (503) 639-4171
BLIP --L/
Received Date Requested.-_—__�_�_- AM___ PM_ bUP
_
Location __ ��Z Suite
MCC -
Contact Person Ph(_._- __) PLM -_---_-_
Contractor.---- - - _— -- --- -- Ph( ) — — SWR -
rBUILDING Tenant/Ow ier _ _
----_ ELG
Forting
Foundation _ .,,p s� ELC
Ftg Drain Access: j �M S �Vd P" V
EI.R - - --------
Crawl Drain _
Slab Inspection Notes: SIT
Post&Beam
Shear Anchors -- --
Ext Sheath/Shear
Int Shgath/Shea.r
Insulation
Drywall Nailing
Firewall S ��
Fire Sprinkler ff
Fire Alarm J"
Susp'd CeilingRof
Other: _ .. �_ ez-
Final
PASS PART A
PLUMBING AJ
Post 8�Beam ��
Under Slab
Rough-In
Water Service - __'' _(fin C�-0). _ ,4LAk S'
Sanitary Sewer <�
Rain Drains
-AtchStorm Basin/Manhole
Storm
Drain --� - - —
Show6r Pan
Other:_ I -a -----
Final V�
PASS PART FAIL ----
MECHANICAL
Post&Beam
Rough-In 1
- -- -- - -
Gas Line
Smoke Dampers --
Final
PASS PARI' FAIL ----
ELECTRICAL
--
Rough-In
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of$_ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
_PASS PART FAIL
SITE F] Please call for reinspection RE: n Unable to inspect-no access
Fire Supply Line
ADA
Approach/Sidewalk Date _ Inspector_ V�:A_
Other:
Final DO NOT REMOVE this Inspection record from the Job site,
PASS PART FAIL
CITY OF TIGARD 24-Huur
BUILDING !nspection Line: (503) 6394175 MST
INSPECTION DIVISION Business Line: (503) 639-4171
BUP - --- -----
Received Date Requested AM _ r'MBUP
..S —Suite - j—j.L_ MEC 2'c
Location
Contact Person h9/��.__- Ph( ) PLM
Contractor Ph( ) — - - SWR
BUILDINGTenant/Owner -_ -
Footing _LC _
Foundation Access:
Fig Drain E,.R
Crawl Drain —
Slab Inspection Notes: C4, c SIT
Post&Beam V -
Shear Anchors U�^! ('. p
Ext Sheath/Shear - ----
Int Sheath/Shear
Framing _
Insulation
Drywall Nailing
Firewall
Fire Sprinkler ——_
Fire Alarm
Susp'd Ceiling
Root
Other.
Final �- -
PASS PART FAIL
PLUMBING
Post&Bean,
Under Slab
Rough-In
Water Service ,,
Sanitary Sewer
Rain Drains - - ----------------.._------- -
Catch Basin/Manhole
Sturm Drain
Shower Pan
Other:
Final
PASS PART FAIL
os Be:.m
Rough-In
Gas Line
Sawke Dampers
F'
SS PART FAIL.
_ TP
RIC
Service ---—
Rough-In
UG/Slab
Low Voltage —
Fire Alarm
Final Reinspection fee of$— —._._____required before next inspection. Pay at Citv Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE v Please call for reinspection RE: - _____ [� Unable to inspect-no access
Fire Sjppiy Line
ADA Ext
Approach/Sidewalk
Date
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL
ELECTRICAL PERMIT
TY OF
T I G A R D _
PERMIT M ELC2002-00517
DEVELOPMENT SERVICES DATE ISSUED: 10/4/02
13125 SW Hall Blvd.,Ticiard, OR 97223 (503) 639-4171 PARCEL: 1S135AB-03400
SITE ADDRESS: 10260 SW GREENBIJRG RD loiLf 17C
SUBDIVISION: LINCOLN TOWER-TOWN OF METZGER ZONING: C P
BLOC!:: LOT : 014 JURISDICTION: TIG
Proiect Description: Job No. 52670
Tenant Improvement
_ 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/PANEL:
MANF HMI SVC/FDR: 601+amps - 1000 volts: MINOR LABEL (10):
—.-SERVICE/FEEDERBRANCH CIRCUITS _ _ADD'L_ 114SPECTION_S _
0 200 amp: yAI/SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: 21 IN PLANT:
601 - 1000 amp: _ _ PLAN REVIEW SECTION
1000+ amp volt: >=4 RES UNITS: i > 600 VOLT NOMINAL:
Reconnect on'�r: _ SVC/FDR >= 225 AMPS CLASS AREA/SPEC OCC:
Owner: Contractor:
EOP LINCOLN, LLC STONER ELECTRIC
10260 SW GREENBURG ,;D 1904 SE OCHOCO STREET
SUITE # 100 MILWAUKIE, OR 97222
PORTLAND,OR 97223
Phone: 892-2.500 Phone: 503-462-6500
Reg #: I IT 26-122C
_ FEES Required Inspections —_
Description Date Amount Wall Cover
— -- — Elect'I Final
IEL,PRM"I I ELC Permit 10/4102 $186.50
[ELPRMT1 ELC Permit 10/4/02 $0.00
[TAX] 8%State Ta% 10/4/02 $14.92
(additional fees not listed here)
Total $211.42
This Permit is issued suhjed to the regulations contained in the Tigard Municipal Code.State of OR Specialty Codes and all other applicable laws All
work will be done in accordance with approved plans This permit will expire if work is not started within 180 days of issuance,or if work is suspended
for more than 180 days ATTENTION Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center Those rules are set
forth in OAR 952-001-0010 through OAR 952-Ool-0100 You may obtain copies of these rules or direct questions to OUNC at(503)246-6699 or
1-800-332-2344
Issued By: _ Permit Signature:___ �� ic.�,c�--�—
09/27/2002 FRI 12:28 FAX 5036592824 STONER SERVICE
Electrical Permit Applipligla
hate reg eived
. Permit no.
City of Tigard i?rojeci/apphno.: - Expiredate:
Cuyt/ffigard Address: 13125 SW Ilall DIvd,Tigard,OR obiI)ateassued: By: Receiptno.:
Phone: (503)63911171
ax: (503) 598-1960 ( Caic file no. Payment type:
Land use approval: s
U I &2 family dwelling or accessory Commercial/industrial U Multi-farnily ❑Tenant improvement
,J New conttr rclion 0 Addition/alteration/replacement CI(niter U'0111%IA.1011 SITE INt
TI(LN
Johaddress. 1))1 bo 5U) I, ip.Rne MDQ i lilrlg,nu.: Swtc nub Tnx map/tax Iot/account no.:
Lot Block:` Subdivision:
Project name; . ��rY I)esch ion anti location of wort:on premises: r C-_ \14 t(
Estimated date of completion/ins tion:
f
Job no: � a�'�� _ Fee Max
Business name:$,i I -ormuhi-rrouhl- I,Nl- ca.) 1'01,1 no.hup
Address;fo)oy --- -- New r•r<tdr„rt�l•artgtefamllytw•r
dwelling unit.Includes attached garage.
City:MrewrWirfe _ Statcz a-I LP;q7Servlcefncluded:
Phoneso,3 sV4Z_65'ou f.'aXZ0-y968 I E-mail: 1000 sq ft.or less 4
CCB no.: yy,�Z_3 Flee.bus.tic.no: Z46_r,:. 2_ Each additional SW sq.f1.or portion thereof
Limited energy,residentiO 2
City/metrolic.no.: 44x14, Limited energy,non-residential 2
_ _ ��. Each manufactured home or mod aar dwelling
Sig to Ici - put S�ry{ox aiorl/nr feeder 2
Sup.elect.name(print). /HireTiT71-7- Licenser, Wit/ � Services orfeedert-Inslailstion,
,iteration a.relocation:
9 MIM 200 amps or las _ 2
Name(p1 iul): 201 arnps to 400 amps 2
`-� - -- 401 amps to 600 amps 2
Mailing address: 601 unps to 1000 amps — 2
City: Slate: ZIP: Over 1000 amps or volts -- -- 2
Phone: Fax: E-mail: Reconnecturd — I`—
Owner installation:The installation is being made on propen, I own Temporary services orfeeden-
which is not intended for side,lease,rent,or exchange accordion to Installation,alteration,or relocation:
(ORS 447,455,479,670,701. 200 arrps or less _-- 2
201 an.s to 400_amps 1
"Name:
' ure: L ale _ _ 401 c06IXlarn s A -- 2
NN” Branch eircults-new,alteration,
ore%ensfon per panel:
— ----- -- ___ & U•a for hranch circuits with purchase of
Address: service or feeder fee,each branch circuit _ 1
City: b Fee for branch circuits without purchase
P
of service at feeder fee,first branch circuit �6•D 1
Fa:1 hone: I: mall: Each additional bracch circuit:
Walul o Mist.(Service or feeder not Included):
t]Serviceover 1 t 5 amps-commercial U I1rs,ldi carefaciiity Each pump or irrigation circle __ 2
U Service ower 320 amps-rating of 1&2 U IWArdous location Each sign or outline li Ming 2
ramilydwetlings U building over 10,000 squ t a i,ur no Signal circuits)or a limited energy panel,
U System over 6(10 volts nominal more residential uNis in c: v.mre alteration,or extension 2
U building over thrae stories U Feeders,40n amps or mate 'Desefi tion.
Cl Occupant load aver 99 periom U Mumfocnored structures no R V rack Each additional inspeetlon over tlre.allowable ldany of the above:
O Egiess/lighongplan U Other — perinspectlon ��`�—�
Submit_ _sets of plans with any orthe above. Investigationfer
_—
� the above are out applicable to Irmuorary ruttsttyctlon senile. Qaher
— —
Na all)urisdkrlar accept cal canto,please call)uddiction As mac Inforrutloo Notice:This permit application Pertnit fee.....................S ._
U Visa U MasterCard eNpires if a permit is not obtained Plan review(at _, %) S —
Credit cud number _ tt ithin I R0 days after it has been State surcharge(8%) .. .$
i—
Export accepted as complete TOTAL .......................$ .
-13iimr?� oa�oT�u sTiown on c r ear• ' —`-
— Crt1tro13er slgnaioue s AOauni "IAA It iNnnKY)M1
r BUILDING_PERMIT
\
CITY O F T I G A R D � PERMIT#: BUP2002-00414^-
DEVELOPMENT SERVICES DATE ISSUED: 9/19/02
13125 SW Hall Blvd., 'rivard, OR 97223 (503) 639-4171 PARCEL: I S13 5AB-03.300
SITE ADDRESS: 10260 -`W GREENBURG RD 170
SUBDIVISION: LINCOLN TOWER TOWN OF METZGER ZONING: C-P
BLOCK: LOT: 014 JURISDICTION: TIG
REISSUE: _ FLOOR AREAS _ EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: ALT FIRST: 5f N: S: E: �W:
TYPE OF USE: COM SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 21"R sf N: S: E: W:
OCCUPANCY GRP: B TOTAL AREA: 000 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: 52 BASEMENT: sf AREA SEP. RAT .D:
STAR: HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT?: MEZZ?: P,EQD SETBACKSREQUIRED Y_
FLOOR LOAD: psf LF FT: � ft RGHT: �ft � FIR SPKL: SMOK DET:
DWELLING UNITS: FRNT: ft REAR: ft FIR. ALRM : HNDICP ACC:
BEDRM�;: BATHS: IMP SURFACE: PRO CCRP.: PARKING:
VALUE: $ 00,000 00
Remarks: -i errant improvement, combine 2 suites into one.
Owner: Contractor:
EOP LINCOLN, LLC JOSEPH HUGHES CONSTRUCTI(-)N,INC
10260 SW GREENBURG RD 7035 SW HAMPTON
SUITE# 100 TIGARG, OR 97223
P�Po e NR)P?22�4?p Phone: 624-7100
Reg #: LIG 45645
FEES _ REQUIRED INSPECTIONS
Type By Date Amount Receipt Mechanical Permit Require
PRMT CTR 9119/02 $689 60 272002Electrical Permit Required
00000 Sprinkler Permit Required
5PCT CTR 9/19/02 $55.17 27200200000 Framing Insp
PLCK CTR 9/19/02 $448.24 27200200000 Gyp Board Insp
FIRE CTR 9/19/02 $275.84 27200200000
Final Inspection
Total $1,468.85
This permit I- issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable law. All work will be done in accordanrr 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 follo the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 thro7gh OAR 952--001-1987. You may obtain a copy of these rules or direct questions to OUNC by
calling 503 246-8699 r 1.-86 332-2344.
c 9 ( ) /
permittee
Slgnature;,�—
Issued
Call 639-4175 by 7 p.m. for an inspection the next business day
Building Permit Application
City of Tigard
Date received: 7 />�p;l permit no.:BUPA
City qJ"1'igurd
Address: 13125 SW Hall Blvd,"Tigard,OR 97223 Project/appl. no.: Expire date:
Phone: (503) 639-4171 Date issued: By: Receipt no,:
Fax: (503) 598-1960 Case file no.: Payment type:
Land use approval• - 1&2 family:Simple Complex:
U 1 &2 family dwelling or accessory U Commercial/industrial U Multi-family U New construction U Demolition
UAddition/alteration/replacement JCTenanl improvement U Fire sprinkler/alarrn U Other:
1 ' INFORMATION
Joh address: p pr �L �e Bldg.no.: Suite no.: p
Lot: I Block: Subdivision: Tax map/tax lot/account no.:
Project name:
Description and location of work on premises/special conditions: (.Oh�•IlL Z =5- M -
_Sl 'h1 DYie S yr >� � -_
Name: ant A��,
Mailing address:d2o Ave, -- _- I &2 family dwelling:
City: — Sta(c:alZ !I('_ '17pL Valuation of work ......................................... $
Phone: 7W Fax QqE-jnail:A No.of bedrooms/baths..................................
Owner's representative: Total number of floors ..................................
Phony. Fax: I(-mail New dwelling area(sq.ft.)............................
- -
arra�ge/carport area(sq.ft.) ..........................
Naniv. _ �� y� Covered porch area(sq.ft,) ..........................
Deck areas ft. _
Mailing address: � l •.� pp ( q. )..........................................
City: Scute: LIP: 1 -� Other structure area(sq.ft.).......................... _
o reial/industriallmulti-family:
Phone: ov I a� p f? until utl/t%/4 �J�1,• y:
a nation of work ......................................... $ _!ODO
Business name: v �llG'{��5��ab Existing bldg.area(sq,ft.)............................
New bldg.area(sq.ft.).................................. 'f
Address: Number of stories
City: Stat�: ZIP: Z, -----
Type of construction
one: Faa E-mail: ---
CCB no.: Occupancy group(s): Existing:
-- New:
City/metro lic.no.: Notice:Ali contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board under
Name. �` t�ItiS j _f�Cl'1� 2 provisions of ORS 701 and may he required to be licensed in the
Address: �p jurisdiction where work is being performed. If the applicant is
City- I State:M ZIP: 2
exempt from licensing,the following reason applies:
Contact person: Plan no.: - ---- --
Phone: Fax Z 4S7. ----
Name: Contact person: Fees due upon application......................... _ $
Address:_ Date received:
City: Stale: ZIP: Amount received...........................................$
Phone: Fax: Email: Please refer to fee schedule.
hereby certify I have read and examined this application and the No ail iurhdictions accept credit cards,please call jurisdiction for more information.
attached checklist.All proviso of laws and ordinances governing this LJ visa U Mastercard
work will be complied wth her specified herein or not. crewu card namher
Expires
Authorized signature: Date: 2 - — _
gn Name of cardholder as shown on credit card S
Print name: _ t aratml er anatare
ti - nmount
Notice: This permit application expires il'a permit is not obtained within 180 days offer it has been accepted as complete. 440-461+ttiAWOMi
/\
CITY
I T ' O F T I G A R D ELECTRICAL PERMIT-
(V' Y RESTRICTED ENERGY
DEVELOPMENT SERVICES PERMIT#: ELR2002-00216
13125 SW Hall Blvd„Ticiard, OR 97223 (503) 639-4171 DATE ISSUED: 10/10/02
SITE ADDRESS: 10260 SW GREENBURG RD 170 PARCEL: 1S135AB 03400
SUBDIVISION: LINCOLN TOWER-TOWN OF METZGER ZONING: C-P
BLOCK: LOT: 014 JURISDICTION: TIG
Proiect Description: Install cabling for phone and data.
A. RESIDENTIAL _ B.COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE/IRRiGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: ['ATA/TELE COMM: X NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
_ TOTAL# OF SYSTEMS: 1
Owner:.—'------ —�-- Contractor: � —�-- --�----_._
EOP LINCOLN, LLC WEST SIDE ELECTRIC CO INC
10260 SW GREEN0URG RD 1834 SE 8TH AVE
SUITE # 100 PORTLAND, OR 97214
PORTLAND, OR 6 3
Phone: 231-1548 Phone: 736-0077
892-2500 Reg#: L2(3'I-15483306
Sul' 1556s
_ ELE 26-135r
_ FEES — Required Inspections
_Description _ Date Amount Low Voltage Inspection
[ELPRM'T j ELR Permit 10/10/02 $75.00 Elect'I Final
[TAX] 8%)State Tax 10/10/02 $6.00 i
Total $81.00
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 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 OAR 952-001-0100. You may obtain copies of these rules or direct questions to OUNC at (503)
246-63699. ll
Issued by �/d !' ei Le= r r ( —/`J Permittee Signature '
OWNER INSTALLATION ONLY
The installation is being made nn property I own which is not Intended for sale, lease, or rent.
OWNER'S SIGNATURE: DATE:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N ) I �J/T -�_ DATE:_ `
LICENSE NO: cc (r
Call 639-4175 by 7:00 P.M. for an inspection needed the next business day
Electrical Permit Application
Dntc rcccived,llPermit no.4W�d
City of l igalyd nu.: - r�xniK d,l� -
CilvujTil urd Addre,,,: 13125 SW hall lily �.,,. Date issued: By:
Receipt no.:
Phone. (503) 639.4171 t Carl file no.:
Payment type:
Fax: (503) 598-1960
Land use approval:
U I &2 fr,miiy dwelling;or accessory U Commercial/industrini U Multi-family .. cnant in,provcmcnt
U Now construction U Add ition/alteration/rcpluccment U Other.-_-.. . . U spial
JOB SI-FE INFORMATION
Job nddress: I 'L _ Lildi;.110. Suilc no.: '1'nx n)ap/tax lot/account na_-
l'ot. �(lluck; subdivision:
me:
I'rvject na �, 114- Do,
cription and location of work on prellike :
I islitnaled dale of corttpletiun/inspection;
Erluxi � t 1
R!a Matt
Jab rKr_��' C C f'� L/crerip6ion 1 . P4 Igld ntl.lnrp
fiusincss nnmc: ►ep Fy_� -1 Nrrrrcnldcntfrl-einglrormuhl-fsmllyprr
Addrew �J-1 r dwellltugwdl.lnctudivrH+rla•J�n.rut[c.
— — State: LII' 7 !.) Service city: d, t- t- 0... ,..._...___�.1 4
Phone; {-t C,���Fnx:7 I E-mail: �. -
+- - �I•uch i1tlJuion;d 3lm)sq,11,ur punwn Ihcn•uf
CCR no.: i Zs';O(rr }.lee. bas.tic.no' Ula cli crwrl(,v, raddcnual
City/ n 1 ic.no.: Limited energy, non•roaidential
Z. Iipch numuNclumd honml or modular dwellinti
sae a Q Service unNor feetkr Z
,nnrote n}'et Iain cicclriclan rc
sired) i)nlc
Still.deet.1WnK ninl: •-� License no; 7-4to icerleouorrrrdrn-Inatapatlnn,
I G ) d [_�•^-�O. wr. dten.lenornlncatlnn!
Sol—
PROPERTY200 ands Itr ICM_ 2
201 entps ut 4tNl unps -... - 2
r1a111C
(print)-4Q1 amps to 600 amps - __. 2 ._
Mailing;tiddross; _ . 601 ampr to 1000 stripsI-
City: State: ZIP: _ Ove. Ilan)nmpp or vollp — '2 '
Phonc: Fax; E-mail: lirconntxl'Mlv _ - -
I-Temporary vrrvicen or ferdery-
Owner installation:Tile inSlallation is being muds on prupurty 1 own imimilxlion,olictation,orrclocntion:
which is not intondmd I'or Palo,lease,rent,or cxchang;o;recording to 2.II0 amps in test, 2 ..
ORS 447,455,479,670,701. 201 am Is its 4M anquv
Owner'P sicnature'. _. Date: 401 in rluil am ' _2
BtanchclrenUv.now.Alteration,
orexlrvadunprr pnncl:
Nat". A. Iroc fist hraltull cncadn with pulch"st of
Adllres,: service or I'mlcr 1' each branch tacuii _.. 2
_ -_
C itv $tale; ZIP I1, hes lar bmttrh circuitswithout pure `
or service or feeder fee. fust httuvch eiluuil:
Pli'me Nax' h.-mail Bachcircuit:inital branch circuit:
Mlµ,(Service or rceder not Included);
U service ovG .J anyrcatnnnrn'�.1', ' U Hrallhran� lacihly _Yln:lt peunp or inil;alion t:inar 2
U Scrvitx Iver 1211:unpr-roti w U linfliplotu location I+ech sign or outline lirhiing 2
rumily dwellings U Building over 10,000 squafr feet friar a Signal citeuiirs)or a limikd energy Itutcl, I 2
❑sysicn,over 6(x)volts nominal nw-c+ew,dcrlfud ua&,1,1 1110 Anschlm allernlNM, fit titlenpion,
LA U llulldinx over ihm-p4ttica U Perdue,400 antra or ntrxe •Draeri pion: r' 1L' v, -----
U(hcupnnl loaf over )I)persolta U Manufactured structures m RV rusk —Each ddltionad n+prtiiouover the dtoeahtr.ha, yortheabove;
U 11irosstlighiing plan U Olhcr 1'et inspection ice_
Subunit yeta of plan,with anv of thr above. iavtx ii,:niiun fee
The above are not applicable to temporary construction vcrvice. Vti.
-_�- --- __ r . ...._� -
_ Permit fcc .....................E
e:nee ��Q—
NM alt jluitAiN�nitr noexi4 dd cent.•p .0
ler call IuriulknlM for more Infmmniinn. Notice: '1)119 PcIntil npplleativa flan review(r,l_ %) E
❑Mavft'eet_:.'m expitell If s permit In not obtained n A
1 �•,'�bC; OAR�/J Sap_ _�f r1 Lll, within 190 days■Rm it hsv hcen Stals wri:hur.;C(3 io).....S �• C V
h
Ccrtht c' J mtmllcr
' r _�U_. . /�h�{xpir.,.11 accepted as compklc, TOTAL....... S
I 1,CAI IW y,plrV ttnl .erJ - S �Ir r V/V
l _ Cen111uIJrr.Iltwuro _ Am.lunt _j
AAG�AIf IfJO(IN'trM�
I •d LL90-9EL 10051 •03 01L.t204-413 aptg asath es* :9u 20 1.0 700
CITY O F T I GA R D _ MECHANICAL PERMIT
DEVELOPMENT SERVICES PERMIT#: MEC2002-00454
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 1 5135 2
PARCEL: 1S135
SITE ADDRESS: 10260 SW GREENBURG RD 170
SUBDIV131ON: LINCOLN TOWER-TOWN OF METZGER ZONING: C-P
BLOCK: LOT: 014 JURISDICTION: TIG
CLASS OF WORK: ALT FLOOR FURN: EVAP COOLERS:
TYPE OF USE: CUM UNIT HEATERS: VENT "ANS:
OCCUPANCY GRP: VENTS W/O APPL: VENT SYS"-F-MS:
STORIES: BOILERS/COMPRESSORS _ HOODS:
FUEL TYPES 0 - 3 HP: DOMES. INCIN:
3 - 15 HP: COMML. INCIN:
MAX INPUT: BTU 1: - 30 HP: REPAIR UNITS:
FIPF DAMPERS?: 30 - 50 HP: WOODSTOVES:
Gi PRESSURE: 50 + HP: CLO DR`r ERS:
FURN < 100K BTU: AIR HANDLING UNITS
OTHER UNITS:
FURN >=100K BTU: <= 10000 cfm:
>
GAS OUTLETS:
10000 cfm:
Remarks: Relocate grills and VAV boxes
Owner: _ FEES
FOP LINCOLN, LLC Description Date Amount
10260 SW GREENBURG RD N1L(1I I Permit Fee 10/14/02 $72.50
SUITE # 100
PORTLAND, OR 97223 I N11�.('I I 1 Permit Pee 10/14102 $0.00
ITAX] 8°-„StateTax 10/14/02 $5.80
Phone: 892-2500 11 AX]8%,StatcTax 10/14/02 $0.00
Contractor: Total _ $78.30
HVACINCORPORATED
5188 SE INT'L WAY
MILWAUKIE, OR 97222 REQUIRED INSPECTIONS
Mechanical Insp
Phone: 462-4822 Final Inspection
Reg #: 50897
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Specialty Codes
and all other applicable laws All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION. Oregon law
requires you to follow rules adopted in the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-00
Issued By: / Permittee Signature:
Call (502) 39-4175 by 7:00 P.M. for inspections needed the next business day
Mechanical Permit Application Na
\ — Datereceived: IQ tl- Permit rhl&� „Ze&2 oo y
City of Tigard Project/appl.nu.: Expire date: —
Chyof Tigard Address: 13125 SW I tall U.Ivd,Tigard,OR 97223 pate issued: By: Receipt no.: -
Phone: (503) 6394171
Fax: (503) 598-1960 Case file no.: Payment type:
Land use approval: it no.:
U 1 &2 family dwelling or accessory 41 Commercial/industrial U Multi-familq GJ Tenant improvement
U New construction Id Addition/alteration/replacement U Other:.�
Job address: t Indicate equipment quantities in boxes below.Indicate the dollar
Suiten .: _ value of all mechanical materiaeyuipment,labor,overhead,
Bldg.no.: profit.Value$ LA
Tax map/tax lot/account no.: _ �?5�--
Lsit: Block: Subdivision: 'See checklist for important application information and
E•r iurisdictirm's fee schedule for residential permit fee.
Project name: tT —ow
City/county: Z(P:
Description and I c,.tion of work on premises:- L(_�sg�
x ,` t2'qx F-S Fee(ea.) Total
Est.date of completion/inspcction: Description Qty, Res.only Res.only
Tenant improvement or change of use: Air handling unit
Is existing space heated or conditioned?WYes U No Air conditioning(site plan require— _
Is existing space insulated?§9 Yes U No Alteration of .Is
HVAC system
os er compressors
State boiler pertn;t no.:
Business name: __ HP Tons BTU/H _
Address: ! SE. 4 A t it smo a amper, uct smoke detectors
City: 11 t- State: ZIP: q-7,21'2— Heal pump(site plan require )
Fax:f cj E-mail: nsta Urep ace urnace/burncr ft
Phone:I -L4 I Including ductwork/vent liner U Yts U No —_
CCB no.: -7 nsta rep nc relocate caters-suspen ed.
City/metro lic.no.: l wall,or floor mounted �.
Vent fora lance othert an fnrnace
Name(please print): �- ��tSU r� a ration-
Absorption
at on:Absorption units BTU/1I
Chillers HP
Namc: Com ressors________ — lip
Address: nv xhoust and ventilation:
City: - — — State: ZIP: Appliancevent _
Phone: Fax: E-mail: I)ryercxhaust
foods,Type 11 111re,. itche har.nmi
hood fire suppression system
Nance: Exhaust fan with single duct(bath fans) _
Mailing address: Ea mxhausts stem art froIon
or AC
ue p p ng an st ut on(up to nal els)
City: — Slate:-- 71P:` --- Type: _ _L.IY; WG Oil --
Thune I$x: 1?-mail: uel ruin caci adeinana over out ets
roses pi-ping(w sematic required)
Num$ -r of outlets
Name: t h erllvt altp Ince or equ pment:
Address: —s _
Decorative fireplace
City: Stats:: '1p: nser-type
F - — Woo stov pc etstove
Phone: E-mail' Other: _—
Applicant's signature: 1 , , Date: �U�, 'i ("
C
Name (print): r r E u4� t I C` ) ---
Permit fee.....................Not all)orixtictinns accept ctrdit earls.pleaw call)udsdictinn for Me tnhxntetion. Notice: 11iisrmit a lication
Pe Pp Minimum fee................$ —.---�_--
Uvisa U MasterCard expir,,s if a permit is not ohtained Plan review(at _ %) $
CrAt card number ^�
------- Expires within IRU days after it has been ,
_ State surcharge(89h) ....$
as
-- accepted as complete
Nems nr cardhnldn shnwi nn credir�— car-- s p t TOTAL .......................$ _
('erdholder signature Amount 440 4617 innrvt WIMl
MECHANICAL PERMIT FEES
COMMERCIAL FEE SCHEDULE: 1 &2 FAMILY DWELLING FEE SCHEDULE:
TOTAL VALUATION: PERMIT FEE: Description:l� Price Total
Table
$1.00 to$5,000.00 Minimum fee$72.50 Mechanical Code Dry (Ea) Amt
$5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and 1) Furnace
ce to 100,000 B�U
$1.52 for each additional$100.00 or including ducts 8 vent 14 00
_
fraction thereof,to and including 2) Furnace 100,000 BTU+
$10,000.00. including ducts&vents _'/k0
$10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and 3) Floor Furnace
$1.54 for each additional$100.00 or ince fink vent 14.00
fraction thereof,to and Including 4) .t. 3nded heater,wall heater
$25,000.0_0. it flu )r mounted heater 14.00
$25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and 5) 'At not included in appliance permit 6.80
$1.45 for each additional$100.00 or --
fraction thereof,to and including 6) Repair units
12.15
$50,000.00. _
$50,001.00 and up $742.00 for the first$50,000.00 and Check all that apply: Roller Beat Air
$1.20 fo•each additional$100.00 or For Items 7-11,see or Pump Cond
fraction thereof footnotes below. comp*
7)<3HP;absorb unit
Minimum Permit Fee$72.50 SUBTOTAL: $ to 100K BTU 14 00
_ 8)3-15 HP;absorb
- 8%State Surcharge $ unit 100k to 500k BTU 25.60
9)15-30 HP;absorb
'- 25%Plan Review Fee(of subtotal) $ unit.5-1 mil BTU 35 00
Requlred for ALL commercialpermits onlX 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
12)Air handling unit to 10,000 CFM
ASSUMED VALUATIONS PER APPLIANCE: 1000
Value Total 13)Air handling unit 10,000 CFM+
DescripUorl; O Ea Amount 20
Furnace to 100,000 BTU,Including 955 14)Non-portable evaporate cooler 1000
ducts&vents -
Furnace> 100,000 BTU including 1,170 15)Vent fan connected to a single duct
6.80
ducts&vents
Floor furnace Including vent 955 _ 16)Ventilation system not included in i 1 �n
Suspended heater,wall heater or 955 appliance permit
floor mounted heater 17)Hood served by mechanical exhaust 10 00
Vent not Included In appiicance 445 -
permit 18)Domestic Incinerators
Repair units 805 17 40
<3 hp;absorb.unit, 955 19)Commercial or Industrial type incinerator
to 100k BTU ___ 69.95
3-15 hp;absorb.unit, 1,'700 20)Other units,Including wood stoves
10.00
101k to 500k BTU M
15.30 hp;absorb.unit,501k to 1 2,310 21)Gas piping one to four outlets
5.40
mil.BTU
30-50 hp;absorb.unit, 3,400 22)More than 4-per outlet(each) 1.00 _
1-1.75 mil.BTU �-
>50 hp;absorb.unit, 5,725 Minimum Permit Fee$72.50 SUBTOTAL: $
>1.75 mil.BTU 8°/.State Surcharge $
Air handlin unit to 10 000 cfm 656
Air handlin�unll>10.000_cfm 1,170 -
Non-portable evaporate cooler 656 TOTAL RESIDENTIAL PERMIT FEE: $
Vent fan connected to a single.duct 446
Vent system not included in 656
appliance permit other Inspectlons and,Fees:
Hood served by mechanical exhaust 656 1. Inspections outside of normal business hours(minimum charge-two hours)
Domestic Incinerator 1,170 $72 5o per hour
Commercial or Industrial Incinerator 4,590 2 Inspections for which no fee is specifically Indicated (minimum charge-half hour)
$72 50 per hour
Other unit,Including wood stoves, 656 3 Additional plan review required by changes,additions or revisions to plans(minimun
Inserts,etc. charge-one-half hour)$72 5o per hour
Gas piping 1 4 outlets _ 360 -
Each additional outlet 63 _ "State Contractor Boller Certification required for units>200k BTU.
Residential AJC requires site plan showing placement of unit.
TOTAL COMMERCIAL $
VALUATIONS:
i:\dsts\forms\mecli-fees.doc 08/06/01
CITY OF TIGARD BUILDING PERMIT
PERMIT#: BUP2002-00452
DEVELOPMENT" SERVICES DATE ISSUED: 10/14/02
13125 SW Hall Blvd., Tiqard, OR 97223 (503) 639-4171 PARCEL: 1 S 135AB-03400
SITE ADDRESS: 10260 SW GREENBURG ,RU 170
SUBDIVISION: LINCOLN TOWER-TOWN OF METZGER ZONING: C-P
-- BLOCK: y ^ LOT: 014 JURISDICTION: TIG
REISSUE: FLOOR AREAS _ EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: AL-� r—�'5 FIRST: sf, — N: S: E: W:�
TYPE OF USE- COM SECOND: sf PROJECT OPENINGS? _
TYPE OF CONST: sf N: S: E: W:
OCCUPANCY GRP: TOTAL AREA: 0.00 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED:
STOR: HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT?: MEZZ?: __ RE_CID SETBACKS REQUIRED
LE
FLOOR LOAD: psf FT: ft RGHT: ft FIR SPKL: SMOK DET: -
DWELLING UNITS: FRNT: ft REAR: ft FIR AL-RM : HNDICP ACC:
BEDR NS: BATHS: IMP SURFACE: PRO CORR: PARKING:
VALUE: I (n UC• GCS
Remat s: Shorten and relocate (9) sprinkler heads
Owner: Contractor:
EOP LINCOLN, _LC PATRIOT FIRE PROTECTION INC
10260 SW GREI_NBURG RD 3012 NE MINNEHAHA ST
SUITE # 100 UNIT A
PORTLAND, OR 97223 VANCOUVER, WA 98663-1409
Phone: 892-25nn
360-699-4403 Phone: 360-699-4403
Reg #: MET 0po08802022Z503
_ FEES LIC REQUIRED INSPECTIONS _
Description Date Amount Sprinkler Rough-In ~
BUILD] 11ctnnt Fcc 10/14/02 _ $62.50 Sprinkler Final
ITAXj R%,Sauc I'ax 10/14/02 $5.00
Total $67.50
phis pertnit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is
riot started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law
requires you to follow the ries adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0100. You may obtain a copy of these rules or direct questions to OUNC by
calling (503) 246 6699 or 1-800-332-2344.
Issued By:
Permittee
Signature: l
Call 639-4175 by 7 p.m, for an inspection the next business day
OCT-00-02 TUE 12:57 PM FAX NO, P. 02
Building Permit A P0"fta
City of Tigan �; ,;,�I.no -� >:Wiry dam:
Crry,fr��A►r AAnm%'%' 13125 SW 11811 Blvd I'iitaM OR 97213 paiei.�vcd. �;crcivtrx'_-
Pltcmr.: (501) 639.4171
Faz: (5U3)599-1960 (".au:filo r►o.; I Paynuutttm': ..
1&2 fuWIY;Sltrola Complex:
Land use approval- — - - -- '-
U 1 6c 2 family dwelling or accessory U Conlmerclal/industtial r►�11111j-�1111'1-�
New ronstrucdrm 0 Deaco!idon
CFAddinon/8ltcraurut/tt plxrrmcnt U'renanl irnprovur�t iP Ffr��nklrr/alxr� 0 Other,
---
logo r
bldg.no.: Suite no.: 1
Job addles.: — Tax me Ax l(thccc�unt no.: T.
L;. Block Subcfivlsion: -- -- -
Pro'cc;l -
Dcst:ripuon and lrx:ation of work on pr,rnIsea/specia]condinuw: —S--t-- E
---------------
Name: ('01 rJ Lt3l 1J ,r�1Tt=Z. .�_
------ ------------ l &L family dwNlis:<r
Mailing addrmv -- S
city: State. ZIP. --- Valuation of wort... — —�
FNC S mail. No.of brAr(,orne/hadiS.............................
Phone: --
Tntel nurnber of flCA-,j"................................
Owner's rcir-Wtativr• --- -
-- -- New AweWng U't �tq.fL)
1'Iwne• Par: E-rttul: ......................... --,.
Gam8e/c8rport area(sri,IL).................
_ f'nvrrrA porch AMA(SQ.fl) ---
neck area(Sq. ........... -
iK ��►,�.�� �,n a ) (sfL�........................
rJlfkr tavcttfre Bret►(, _--
State.V,) �'• �t���' 1. -�.�ru.frd+auerwfmaen.aedly:
Phonr. :r 1. x: 0 i nil; Vatuanr,n c+f work................... S_-\ IDC
Existing WAS am(sq.fQ ..............
....I........
Budnnty;name:_ �b.�_ t2 ---- New Mdj.sew(sq,M)............I................... ^
A� ddrrab; - Munher of stotim--.........
....................,,... r
City - t—) 54tel�Z1Y' Type of c(WIrur:ticm ..............
dng
Fax: ks foul: - OCCUVailcY grnup(s): ExiNew:
Phoftc. --
_ _.— - .
cc A no.: 1 '��-�. - - -- - _ New:
city/metry be no.: 1--` C� Notice.All matrarxnrs and sulwontrulft ore reyuued to br
licenscd with rhe Oregon Conseuc bon rentr&jon B,wid under
provisions 010"'10 1 and may be requlrod to be licensed iu dw
Naru�' !fit 3 e-L 1 Z O l )uriullcion where wort k bring performed.If the.npplicrrnt iS
Address: L? W ►� t V r r-t�A�1 \CQ rxcmyq flora lioewing.the following 1-5011 applies::
City: -
Contact person: Pian no.: - - - - --
Plwac: k5-'I\oo Put: _ — J .-----
N �_ Coatart pet70tt: Fees due upon application ....... ..................
sme:
- 17atf+rrccivrd: ._--
Address: -- Stale: ZIP: Amount rrn!ive-A ...................... ...
City: _- - pJew refer to fee schedule.
Pax: B mail. M --
1 hcrrhy cettify I have read and examined WE applicatinn And tiu A ,N'a"" c"'d"�
aaachcd checklist.All pmvistntu of lxwa xnd otdinmacs Sovet111ng this rj�aua
W ork will be compiled with,whet .pled humin ar not
lutnortlCti sif{rtamrt: � __ Atte; _ -- - s
Print aame:_x -- •'` E��'--Boc
ifsfro loft -
tis not oMAln 4 within 110 dans ait a emrvtni tv comrlrfr 4"D(WtR'�
NMtcc:Titin fyRr+n apl+licasitw Wtyirt+
tuop
OHvnl.L d0 Alin 0961669cos Tvcl zS:ll zoos%90-01