Permit (167) CITY OF TIGARD MASTER PERMIT
IN "y ,A
Permit#: MST2018-00198
I .�N ' ' COMMUNITY DEVELOPMENT
T-1(1 A i+.f3 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 y -",`_ - /!,) Date Issued: 05/16/2019
Parcel: 2S104AC16000
fij
Jurisdiction: Tigard
Site address: 12821 SW 132ND AVE
Subdivision: 2018-026 PARTITION PLAT Lot: 2
Project: Csokas Partition, Lot 2
Project Description: New SF. 12/4/2018: APPLY DEMO CREDITS FOR TRANSPORTATION AND PARKS FROM
BUP2016-00084.9/18/19: REPRINT to add NC. NC unit must meet manufacturers placement
BUILDING
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 5 First: 1499 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 22 Bathrooms: 3 Second: 1503 sf Garage: 420 sf Front: 20 Smoke
Dwelling Units: 1 Third: 0 sf Right: 5
Detectors: Yes
Total: 3002 sf Value: $376,953.50 Rear: 15
PLUMBING
Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 1 Rain Drain: 1 Urinals: 0
Lavatories: 5 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Storm Sewer: 100
Drains: 0
Tubs/Showers: 4 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 1 Hose Bib: 2 Backwater Value: 1
Drywell-Trench Drain: 0 Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: Y Vent Fans: 5 Clothes Dryers: 1
Natural Gas Heat Pump: N Hoods: 1 Other Units: 0
Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 1 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add9 500 sf: 5 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Ecompasing: Y
Other: N Other Description:
BUILDING INFO
Class of Work: Type of Use: Type of Constr. Occupancy Group: Square Feet
NEW SF VB R-3 3002
Owner: Contractor:
HT REMODELING&DESIGN LLC HT REMODELING&DESIGN LLC Required Items and Reports(Conditions)
L._ 21271 ROCK Rb 21271 SW ROCK RD 1 E&Srt Cntrf'503-639-4175 .
ALOHA,OR 97003 BEAVERTON,OR 97003
PHONE: 503-882-8247 PHONE: 503-887-8247
FAX:
Total Fees: $13,298.04
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is-not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtain a copy-of e rules or•irect questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: I,. Al.,�i�Ar�" Permittee Signature: �rr- //P /2/`7
Call 503.639.4175 by 7:00 a.m.for the next available inspection date. L �
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Mechanical Permit Application FC/R(WFC'E..USE ONIA
City of Tigard Received,---- -
, -' ' Date/By (p/? A p795)(47-010/(7--w/11-7
13125 SW Flail Blvd.,Tigard,OR 97223. . •
I: 2 ,
III -..,...#1 ,;.
Phone: 503.718.2439 Fax 503.598.1960 '' Date/By: Other Permit:
TIGARD Inspection Line: 503.6394175 Date Ready/By Juris. El See Page 2 for
Internet: WWW.tigard-or.goy 19 Notified/Method:
' Supplemental Information
,
.. .,...T.„„ii,'l
21,/
-
IsIew construction 0 Addition/alteration/replacement i, 4 al permit tees*are based on the value of the work
ii
-„,„it . :•tined.indicate the value(rounded to the nearest dollar)of all
0'Demolition 0 Other: ' t'l techanical materials,equipment,labor.overhead,and profit.
Value:$
..CAtGORV;OF ctwsnoxrn ------
o$,I,:, ',.:2,,,,-' l' ''
---
IF?
ii 1-and 2-family dwelling 0 Commerciallindustrial 0 Accessory building For special information use checklist.
0 Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total
.49! SOT INIP41
'AP, N'. 0.= 0 W',. A'T0, N . Heating/cooling:
Air conditioning 1 46.75 Is
Job site address: . 2.g2,, 6,4 t3,2,- kv.t.--/i Furnace 100,000 BTU(duct/vents) 46.75
City/State/ZIP: _Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump_ 61.06
Suite/bldg./apt.no.: ' Project name: 0 0-1*- N11/4tR**-1
0, t15.„4 , 4 - ,
Duet work 23.32
Cross street/directions to job site: ''k,'4 . . 4- Hydronic hot water system 23.32
Residential boiler(radiator or
hydronic) 23.32
Unit heaters(fuel-type,not electric),
_ in-wall,in-duct,suspended,etc. 46.75
Floe/vent for any of above 23.32
Other: 23.32
Subdivision: Lot no.: /7_,„_,
_........ . „......tt.7......-........... Other fuel appliances: _
Tax map/parcel no.: Water heater 23.32
' ' ';* ' '' ' '''',/"- ,' ' ' Oas fire lace/insert 33.39
'' '''' '''''''' '''''= '1"'"' '''''''' -'t ' ''l''' Flue vent for water heater or gas
-pla‘e: : ...';;.,.01 .11\triSt-ZedS fir,
23.32
_t....sligtterg( as) 23.32 _
....,, Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chitnnsyniner/flueivent 23.32
. , Other: 23.32
0 rii0Ptiili*;"0**JER'''- '' ''''' " :,C3 itistAkr.1,',4,- ',-- -'
, , , . ,,,, ,„, ill,- , , ,, --- -' - Environmental exhaust and ventilation: ._
Name: Range hood/other kitchen
equipment 33.39
Address: Clothes dryer exhaust . 33.39 -
Single-duct exhaust(bathrooms,
City/State/Z11): toilet conipaninents,utility rooms) 23.32
Phone:( / Fax:( ) Attic/crawlspace fans 23.32
A:1*0*,Pe: .:''' ',' ..,::7" ' ,.'. 'It, lgt.:.- $Tfic7rt Ar,' ,.,,: --"theL- 23.32
Fuel piping:
Business name: hi- . - . " ° . t,.._. 2A- e2i-or Lk--C." -
S14.15 for first four;$4.03 far each dditional
L ontact name: k.--k QA,.• . as...oke-4,6 Furnace,etc.
Address: 2„,t7k s\„/ • ( -k. Uas heat pump
,.....- ------ Wall/suspended/unit heater
City/State/ZIP: Water heater
- 2..at_ige
----------1F\C4-.
E-mail: \i-fr.,5 2„ 60.11 A, L.. c2 ti‘ Barbecue
CONTACT' OR ,' ,' , ",',7-- -,',.1. .,,, ` . ,.., ' Clothes dryer(gas)
Other:_ ,
Businessname: . ''',.= ,:,"=, =:;=.; ....:*1.1a.i=
_ ......_
Address: Subtotal
. ' Minimum permit fee($90.00)
City/State/ZIP:
, ., ..... Plan review(25%of permit fee)
l'hone:(
1._
CCB lie.: / 1 Fax:( )
_,....._
State surcharge(12%of permit fee)
TOTAL PERMIT FEE
_
This permit application expires if a permit is not obtained within 180
Atallori7ed signatt : . if 0 days after it has been accepted as complete.
* Fee methodology set by'Hi-County Building Industry Service Board
i
L Print name: Date: 4 rot 0
. ,
, 10
1\iltiiithirgll'errnits'Alf:C_PerinitApp ')-ii i Li din. , ,'I
' D ( cs,ovis,,5 3.0.7T(I /02'CONTAVI II)
CITY OF TIGARD MASTER PERMIT
}
COMMUNITY DEVELOPMENT Permit#: MST2018-00198
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 05/16/2019
Parcel: 2S 104AC 16000
Jurisdiction: Tigard
Site address: 12821 SW 132ND AVE
Subdivision: 2018-026 PARTITION PLAT Lot: 2
Project: Csokas Partition, Lot 2
Project Description: New SF. 12/4/2018: APPLY DEMO CREDITS FOR TRANSPORTATION AND PARKS FROM
B U P2016-00084.
BUILDING
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 5 First: 1499 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 22 Bathrooms: 3 Second: 1503 sf Garage: 420 sf Front: 20 Smoke
Dwelling Units: 1 Third: 0 sf Right: 5
Detectors: Yes
Total: 3002 sf Value: $376,953.50 Rear: 15
PLUMBING
Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 1 Rain Drain: 1 Urinals: 0
Lavatories: 5 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Storm Sewer: 100
Drains: 0
Tubs/Showers: 4 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 1 Hose Bib: 2 Backwater Value: 1
Other Fixtures: 0
Drywell-Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 5 Clothes Dryers: 1
Natural Gas Heat Pump: N Hoods: 1 Other Units: 0
Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 1 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add!500 sf: 5 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description:
Ecompasing: Y
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
NEW SF VB R-3 3002
Owner: Contractor:
HT REMODELING&DESIGN LLC HT REMODELING&DESIGN LLC Required Items and Reports(Conditions)
21271 ROCK RD 21271 SW ROCK RD
1 Ersn Cntrl 503-639-4175
ALOHA,OR 97003 BEAVERTON,OR 97003
PHONE: 503-882-8247 PHONE: 503-887-8247
FAX:
Total Fees: $13,200.68
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification C:- -r. Th•s• rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may ob y o e� • direct questions to OUNC by calling 503. .198' • 1.8'i0..32. 44.
Issued By: ,,,,A11-1111APermittee Signature: I
C 01.7�39.4175 by 7:00 a.m.for the next available inspection date.
This permit card shaft be-kept ill a cunspicuuus plane in the jib site unlit cvmpieiivn of the • • _
Approved plans are required on the job site at the time of each inspection.
Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard Received
. Permit No.:
Date/By:
q 13125 SW Hall Blvd.,Tigard,OR 97223 E ,,C,,, yI E[ Plan Review
Phone: 503.718.2439 Fax: 503.598.196 J . a,,;'"1^_-� D Date/By: Other Permit:
TIGARD Inspection Line: 503.639.4175 Date Ready/By: Juris: El See Page 2 for
Internet: www.tigard-or.gov J U L 3 2.013 Notified/Method: Supplemental Information
TYPE"OF f� +� t a COMMERCIAL FEE*SCHEDULE-USE CHECKLIST
" " "- 19 V G DIVISION Mechanical permit fees*are based on the value of the work
[ New construction ❑Addition/alteration replacement performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,and profit.
Value:$
CATEGORY OF CONSTRUCTION RESIDENTIAL*EQUIPMENT/SYSTEMS FEES*
�1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist.
❑ Multi-family ❑Master builder ❑ Other: Description Qty. Ea. Total
JOS SITE'INFORMATION..AND LOCATION, Heatinglcooling:
Air conditioning 46.75
Job site address: Furnace 100,000 BTU(ducts/vents) ( 46.75 I
City/State/ZIP: Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.: Project name: Duct work 23.32
Cross street/directions to job site: Hydronic hot water system 23.32
Residential boiler(radiator or
. at!1t± 5' lrc,- /5V't., i 32 '73- AVC hydronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for any of above 23.32
Subdivision: Other: 23.32
Lot no.:
Other fuel appliances:
Tax map/parcel no.: Water heater t 23.32 t
DESCRIPTION OF,WORK Gas fireplace/insert l 33.39 l
Flue vent for water heater or gas
fireplace 23.32
Log lighter(gas) 23.32
KIS AC.
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
Other:
23.32
PROPERTY OWNER ❑ TENANT
Environmental exhaust and ventilation:
Name: wr 17,,...,„,„.44. be 41Range hood/other kitchen
1 4.0, equipment 33.39
Address: Zrz.-n 1 tztyU( RD. Clothes dryer exhaust 33.39
City/State/ZIP: Single-duct exhaust(bathrooms,
14L0MA.% DIC. 97065 toilet compartments,utility rooms) 23.32
Phone:(503) Oto. 92.4.7 Fax:( ) Attic/crawlspace fans 23.32
+AP.PLICANT= d CONTACT"PERSON Other: 23.32
Fuel piping:
Business name: wer RErtrtObe.ldwl6 ` ittES1614 Ll(- $14.15 for first four;$4.03 for each additional
Contact name: -r-Ab A5 ,AICD Furnace,etc.
Address: ZIZ„-1 �. Gas heat pump
IQ�K Wall/suspended/unit heater
City/State/ZIP: AL0A1 0X.0X. Oa3 Water heater
Phone:(sol) $67, g2,ti0 Fax: :( ) Fireplace
Range
E-mail: He_, 01KA$&L. ,64,.. . Cool Barbecue
v `�CONTRACTOR_" Clothes dryer(gas)
Other:
Business name: s1,rDt „f
14€41.tat 1., roag.,46
MECHANICALPERMITFEES*
Address: / 3 $" s l .72, - Subtotal
City/State/ZIP: E [� i 10 I Minimum permit fee($90.00)
- - Plan review(25%of permit fee)
Phone:( ) Fax:( ) State surcharge(12%of permit fee)
CCB lie.: CL171 5
) //G� TOTAL PERMIT FEE
! <e / This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: ^7 * Fee methodology set by Tri-County Building Industry Service Board
Print name: &re �CcVn4-ti Date: / ,?
I:ABuitding\Permits\MEC_PenwitApp_04011oc 440-461 (l1/0 OM/WEB)
• Electrical Permit ApVpjicatin mu ono(.1.. 1 SF()NI ',-
City of Tigard
E . i---( --1tt , n Kwvivrt;
i 1:4125 SW Hall R bal.Tigard.OR 977'.2j3'''"'"'')''''' ' li''''' ' 'pPet'laneRI3e:ci*:ov
I
Pause. 503318.2439 ken: 503.598.19001 11 cl 2 0 1g U Reedy Ie Line: 503.639.4175
Interitel www.ligarti ut.gov JUL t") andy tySee
1);Ieie :
Nonfietilhkrbod; Pernik*:
Kolalcd Parma P-
4.44 Stamndefrel'je!LI farles rat tit inn
Ni
iW
.''.''. ,,,A.:' 5i ::: Vrtlt9 ':....(' 7 )„,4L'!44.''''M 4:';'''1, ''.'"::':'-'';'-. .:'....r.ir": `'14.4:1-Ae4IVI,K.W'::.,::',G'4=...,,,,%.,i,t4;:.4i;W
34 New iantstruotn ioi P.Addition, e4
in rlielliV f,',71!
tj()they Please cheek au thin apply(subruitl seta*rotors Whores checked):
0 Scr‘lee or feeder 400 amps or mart 0 Darling overIhrec stories
LDonolititin .
whore the available faun casein CI Union:4,ml it, yards..
Hilllig".il4':.":.;;;',1''i:lg'i'..' lll'i'lllkliii2:4".4.40.**Wi':-CliO*it*.krkiOliiR :41,:ill' i:l.,,,ii'l,lli..,;:,ii s, ml..10,1)110 anemia 150 was or (]Floating buildings
lcus to ground.or exceeds 14,000 lat I-and 2-family dwelling 0 Coinmercialiindustrial 0 Accessory building 0 Commercial-use agricultural
amps for all other installations. building&
El Multi-family 0 Master builder 00tlicr: 0 tot mm). 0 1.4.11,06u,,0 roe K VA or
I'Jl;-... lg - : iI0i.t:i18.tifil4AifflOiliilif.i4(41.ili.104,7..t.1(.*:-.; , .2,. .:-.•:.: Eimd8meirt, ::.;5:::: ..,,,,ado, largar separatelY dorived
:oaken i
Job it: I Joh site address:
10011P or more.
0 Six or mom residential wits. OCCIlflittley.
City/State/ZIP:
0 Health-me illeilitta. 0 Recreational vehicle palm.
SlIttCtftidgiapt.#: Project name: 0 hazardous locations. CI Supply voltage fur mare then
0 Set vira sum Ccedot 61111 molts Sr more 600 vOit'SDOWipat
Cross street/directions to job site:
,..i.,'.!..;'.ii., :,Y '''.1;...'"Iil*fr# i%fi.Wit,*j.ii:34...4 ,1:Yq' .3i'' :: '-'';';i!.''i::;;F:5:::.-Y.El
______________.• , .,. .. . -P„,--
SV1/4/ Wa(fa(,,i_47 S ir c,,„416‘,A., i 3 2.'N 9.--- A i V.c
heitelotkot I Om 1 Each I Testi f , i
New residential single.or inulti-fandly dwelling unit 1
Suntilvision: 1 Lot 0: 2. includes attached garage.
I,1100 sq.it nr lass 108.54 4•
lax maplparc.el ik _.,........
, . „ . . CA arld'i 500 sq.ft cc portion 3192 1 .
liilill1?,..i;':.,,Jlgi.A.,IillX1FU'iflltlli2f. (4i.e.(1it,lt(!4*,w01.0 .T.AF ::?:.,. .i,::.,::,',.'v•-,,,,.::,:47.;,.:-.:c:i.: i-cimitecienvtgy,iesidential
75.00 2
1 (with above sq.ft.)
NisCe. Limited energy,motti-familY
75.00 2
reuidmitial(with above sq.tr.)
- Reneable ruergy 0 See Page 2;iTe:: ''.lit-0:440-iftvo***:,, ,:fir-4 •';3;:-•;:?,1=j* w
14.4f.,.-..0.':'.."7'.;'''J:.:::::, Services or feeders lastalladon,alit:ration,and/or relocation
Mutat, kr e0...6.‘„44 4 bE,s4ia, t.t.c... N)amps nt tete 100.70 2 .
201 amps to 400 amiss 133.56 2
AtIdMI'l LIZ1 t Sku gtx.st" P.
4 :amps to Cal mods 2.00_34 2 'c
,.
City/Slate/ZIP: ALGA.1,._ 4-logr 601 amps to 1,000 amps 101,04 2 1:
KUM:(5043) etri, $244.) Fax:( ) 1\1,4 Over 1,000 arena or volts
........... 552.26 2 ',..
'remporitry tervictm or feeders Installation,alteration,and/or
Email: 4% 14 cs0144440i seseta.•Lb*" relocation
Owner Installation:This installation is being made on property that I own winch is dot 2000,n14 Or less 59.36 1 .
intended for sale,lease,rent,or=change,according to ORS 447,449,670,and 701, 201 amps to 400 amps 125,00 2
't WIVE signature: Date 401 amps ttl 599 nips
.... 168.5 1 7
Niti
linitwi.,,i,..ill,, ',' ' - , Brunch ei1W10,reuits-rw ,alteration,Orextension,per panel
,..:Dr:.iii.:,:i"--",•: .*.-• ' ''-',."- -ii‘':"q's'.:4,iii,rwitP"''',.'"‘i'2.''',"" A,Fee for branch circuits with
I hisiness name: kr 1204,..46,,,,ii 4 big sita IA c above service or feeder fee,
7.12 2
a each breach circoh
Contact name: . i41R.Fee for Nardi uiretal withoci
%leg viol Ca re4S1dt fan,ri(61
56.1g
Aii(iMeg: 7411i ,64 1E0(.14' pp
iaanch Gioraiit 2
Each midi Mundt tirnail 7.42 2
C.:itylStateaLP: iku,,A4 i be
a"ri Miscellaneous(service or feeder not included)
Phone:(SDI) as". ittiAl Fax::( ) 1,44 Each,namillictunitl us modular 1
(17.84 2
dwelling,set vit.:enlist/or feeder
j3tna": HODitikli 0/414t"r. •.1t,"!fl Rt e4jane°4 only 67.84 2
! li',':;;;-.1...• -e'-'::k..,-..:P,1;;.'':°N '.•.i...':c•MO0,01i.''':i...':',.;..-.:';':::'..,M,N;,',':Aij4'1 .2' ' PtunP tn.iniEtaiOn 6rekr 67.$4 2
Business mime: 'Sr. ascaris,4 C. IA C.. Sign or outline lighting 67.84 2
Signal cinntit(s)er ittniktknallY 0 sae page 2 2 •
Address: ?0, Vett 3111 pond,alteration,orcxtension.
— . Each additional inspeetion over ullowuble In env of the above
City/StatetZW: beliA4.11, 6 c 1)024) Additional inspection(I hr min) 66.25/hr
Phone:(Ce3)dile. i'3‘.5 Fax ( ) investigation(I hr min) 90.001hr
industrial plant(1 hr min) 7L1$/hr
Email: fierftiessr5 e lotost.,SmiZANCsc_,.4AI Inspections for which no fee is
90.00/hr ,
C(ill Lie.: 2041$1 Electrical Lie.:M..talc, Suprv,Lic. 5 „!13Fi ',11,4k!!!'1f1/rIrl1l),.-_-- ,,,,,„,..„
-- - •V• ,•••
Suprv.Electrician signalin e,manna,
11:' '.--T ---ie _ Subtotal:
!trim name; ...„‹...?..„6/.. , ei lcate:4„e..//,?./9, ,,s-- El MAO Review Requited(25%of pet inn tee):
....State surcletrge(12%ot period fro):
Authorized signature: TOTAL PERMIT FEB:
i aflxpermit romliCiSla iua'0
litnires permit is not obtained withinV
I
{ I'tint name:I Date: days after it hes been accepted es minim.
--- I v Nanthet of ircpectloos alio ova per[wail.
1,...1/U,Llintroaliii+ELC_Naw.kApv_bLik,Eik),L,Rev O6.07,20;5 446-4611T(1 latiir:Chu/WOO.
Plumbing Permit Application
Site Utilities �R . IV FOR OFFICE USE ONLY
3
City of Tigard
Date/By:Received Permit No.:
•
13125 SW Hall Blvd.,Tigard,OR 97223 1U L 3 Z018 Plan Review
I Phone: 503.718.2439 Fax: 503.598.196 Date/By: Other Permit No.:
T 1 G A R D Inspection Line: 503.639.4175 ..' '-Y OF r i?--%i"$ c i Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov .x ''/ii } Notified/Method: Supplemental Information
:7..e0 . v.i.1 a4"
e New construction ❑Demolition:44 For special information use checklist
Description Qty. Ea. Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
_p
r IJI[VP t/ 1 OJ /; „ r..i - SFR(1)bath 312.70
1-and 2-family dwelling El Commercial/industrial
v SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family >]
Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler(_sq.ft.) Page 2
r s :o i� 's �� Site utilities:
Job site address: Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
5\,4.j 1Ai'a(n wt 54-1-c-am-€ SIV % 32 �- A v. Rain drain connector 18.76
l Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: 1 Lot no.:2 Fixture or item:
1,-7=74
Backflow preventer 31.27 map/parcel no.: � T 12.51 a, Backwater valve� ''i
_ gMI' .- `i `I =�i ,gy (o ri;itH � ClOtewas washer 1`= ,, ,1,- 1 r -
Dishwasher 25.02
1.4 Q Drinking fountain 25.02
Ejectors/sump 25 1
A. 9E t;l,a '1/4/e/11,/ !i(i.. i
_ Expansion tanky. ic.,":'.4../://1/7/„..,/..,/7-7-„,
.., . ia .- _/„.5„,-,1,t04- {�hi ib'Xi t,= rLr,-
12.51
Name: ({T it1 Fixture/sewer cap 1
Fe»+oa �tt.16 T DESt« , Lt.sr Floor drain/floor sink/hub 25.02
Address: 212.71 ,N,u F.c4C lab Garbage disposal 25.02
City/State/ZIP: AL.K4 t DR, an..S Hose bib 25.02
Phone:(ci3) 12.51
g$, Zy7 Fax ( ) ik Ice maker
Interceptor/grease trap
`, 1„ ild F I _ 111,4 'i q10,0* ,r1
=a 1 �a. �rte "66- '- , '
d
Medical gas(value:$ ) Page 2
Business name: RErsbls.144/ 1 D.516,1, Lt.C�
Primer12.51
Contact name: Teta l4 Skko
5 Roof drain(commercial) 12.51
Address: 242,-)I Rpc4( gab, Sink/basin/lavatory 25 1
City/State/ZIP: ALsN4 1 0 4170b12.51
Solar units(potable water) 62 54
Phone:(Sol) gal, sty-) Fax::( ) Tub/shower/shower pan
Urinal 1
E-mail:
NcsoKasv 6^+At1 c•
;1,1( f c q Water closet 1
/ Water heater 37.52
Business name: „A/ ( f.7'7 l 7k J8/i i.tbiLt Water piping/DWV 56.29
Address: 7 53 7 S 4; C1'✓(u S Other: 25.02
City/State/ZIP: •t/ca(/7 ).-` a,K. 7/2 c. Subtotal
Phone:(spa) Fax:( )
7/i/1-0
Minimum permit fee: $72.50
CCB Lic.:7, 6 d2[tv�iPlumbing 7/1/1.906 Plan review (25%of permit fee)
�'�S Lic.no.:9�(�
State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: �/ Date: 7 G This permit application expires if a permit is not obtained within 180 days
6- e3 ,Sic.,.ter-( / after it has been accepted as complete.
440-4616T(I0/02/COM/WEB)
I:\Building\Permits\PLMU-PermitApp.doc 10/01/09
�
,
Albert Shields
From: Kim McMillan
Sent: Wednesday,August 1, 2018 5:34 PM
To: 'msprague@pd-grp.com'
1 Cc: Albert Shields; Khoi Le; Kenny Fisher
Subject: Stormwater Fees
Hi Matt,
Albert and I dug out the fee schedule and the fees are as follows:
Water Quantity SDC$299.75
Water Quality SDC$245.25
Water Quality fee-in-lieu $2640
These fees are charged to each of the three lots.
Kim
Kim Mv!NUKett
IN , s City of Tigard
i '-g , Assistant City Engineer
503-718-2642-work
503466-5784-mobile
13125 SW Han Boulevard
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules"City General Records Retention Schedule."
,
1 ���
Albert Shields
From: Albert Shields
Sent: Thursday,July 26, 2018 3:24 PM
To: 'Matt Sprague'; Monica Bilodeau; Khoi Le; Lina Smith; Kenny Fisher
Cc: ross@stoneridgecustom.com; 'greg'
Subject: RE:Walnut Street Partition (Csokas Partition) -- MST2018-00196, -00198, & -00199.
Matt, installation of a LIDA might not have been required at the time of the Pre-App Conference on 12/15/15 but,
effective 4/22/18 CleanWater Services(CWS)changed the stormwater treatment requirements to require a LIDA. The 3
permits in question were all submitted on 7/5/18 so they are subject to CWS's revised requirements. Accordingly,
please revise your plans to include LIDAs as per my 7/12/18 email below to Greg.
There are also stormwater quantity and quality fees to be paid,as noted in Condition#15, but these are not fees-in-
lieu. Those fees are$245 for Lot 1 MST2018-00196,$300 for lot#2 MST2018-00198,and$270 for lot#3 MST2018-
00199 and I've added them to each permit.
If you have any further question about the LIDA or the fees please contact Khoi Le in our Engineering Department.
Albert Shields
Permit Coordinator
From:Albert Shields
Sent:Thursday,July 12,2018 11:17 AM
To:'greg@stoneridgecustom.com'<greg@stoneridgecustom.com>
Cc:Allyson Armstrong<AllysonA@tigard-or.gov>
Subject:Csokas Partition, MST2018-00196, MST2018-00198, MST2018-00199
Greg, on reviewing your application and plans for the above 3 permits Engineering has noted that in each case a revision
to the site plan is required to show a water quality facility(LIDA)on thep lan between the home and the storm
line. Accordingly, I am coding these applications as"Revision Required". Plan Review will proceed but the permits will
not be issued until a satisfactory revised plan has been received. Please submit revisions at your earliest convenience.
Please let me know if you have any questions. Albert Shields.
From: Matt Sprague<MSprague@pd-grp.com>
Sent:Thursday,July 26,2018 2:02 PM
To: Monica Bilodeau<MonicaB@tigard-or.gov>; Khoi Le<khoi@tigard-or.gov>; Lina Smith<LinaCS@tigard-or.gov>
Cc:Albert Shields<albert@tigard-or.gov>; ross@stoneridgecustom.com
Subject:Walnut Street Partition (Csokas Partition)
Hi Lina,
Nice chatting with you.You mentioned Monica was on leave which is great but that you would help me track down
someone who could address this with Albert Shields.The builder has been requested by the City Engineering
1
department to provide LIDA rain gardens for each new home as a part of obtaining a building permit. However,at the
pre-app conference it was stated and again confirmed in the conditions that the applicant would pay a fee in lieu for
stormwater quantity and quality instead of constructing facilities. If we were required to construct LIDA's they would
have been initially shown on our Engineering plans.The condition of approval is number 15 which reads "prior to
commencing site improvements,pay stormwater quantity and quality fees." I presume the applicant, in order to
obtain site development permits, has already paid their equivalency fees for each 2,640 SF of impervious area. If they
have not,then it was missed and they need to do so.Could you please help get this rectified?
Thanks,
Matthew Sprague PRINCIPAL I PLANNING PROJECT MANAGER I D 971.708.6249
PIONEER DESIGN GROUP, INC. CIVIL I LAND USE PLANNING I SURVEY
9020 SW Washington Square Rd. Suite 170 Portland,OR 97223 P 503.643.8286 pd-grp.com
Disclaimer:
This e-mail may contain proprietary,confidential,and/or privileged information.If you are not the intended recipient(or have received this e-mail in error),
please notify the sender immediately by email or telephone(503-643-8286)and delete this message along with any attachments without copying or
disclosing the contents.Any unauthorized copying,disclosure or distribution of the material in this e-mail is strictly forbidden.Pioneer Design Group, Inc.
(PDG)shall not be liable for any changes made to the electronic data transferred.Distribution of electronic data to others is prohibited without the express
written consent of PDG.
2
Albert Shields
From: Albert Shields
Sent: Thursday,July 12, 2018 11:17 AM
To: 'greg@stoneridgecustom.com'
Cc: Allyson Armstrong
Subject: Csokas Partition, MST2018-00196, MST2018-00198, MST2018-00199
Greg, on reviewing your application and plans for the above 3 permits Engineering has noted that in each case a revision
to the site plan is required to show a water quality facility(LIDA) on the plan between the home and the storm
line. Accordingly, I am coding these applications as"Revision Required". Plan Review will proceed but the permits will
not be issued until a satisfactory revised plan has been received. Please submit revisions at your earliest convenience.
Please let me know if you have any questions. Albert Shields.
1 -
City of Tigard
71 " COMMUNITY DEVELOPMENT DEPARTMENT
7_ R Building Permit Review — Residential
Building Permit #: /f,5 ) 'l ll—
Site Address: ,&2 2J .gk) `&Q/7L 4V-e i'M,Q
Project Name: C2Eag 7) )171i71,_ Lot #:
(New dwelling=subdivision name;Addition or Alteration=last name of owner)
Planning Review
Proposal: AM) sg79 7VJ _VY
rift'site address/suite#exists and actio in permit system.
e' ''ver Terrace Neighborhood: No ❑ Yes,See River Terrace Review Addendum Attached
Sit lan Elements:
•
ee(3)copies of site plan ,11' . 'sting structures on site
yre plan must be on 8-1/2"x 11"or 11 x 17"paper tt ootprint of new structure(including decks)with finished
awn to scale(standard architect or engineer scale) fl•.r elevations
orth arrow
IF .tility locations&easements(required for new and additions)
VP address,project or subdivision name and lot number in i. walk/driveway approach
plicant information(name and phone number) •
II 0,cation of wells/septic systems
.t dimensions and building setback dimensions Z Existing trees to be retained with drip line,and tree
Al.•uare footage of buildings to be demolished ,. .tection measures
i 11.t area,building coverage area,percentage of coverage and 7A eet tree size,type and location
impervious area(applicable if R-7,R-12,R-25&R-40) Street names
'KJProperty corner elevations(2 foot contour lines if more than >1,000 sf of impervious area created or replaced ' Yes ❑ o
4 foot differential) If yes,is a storm water quality facility shown? Yes No
\lean Water Services—Service Provider Lett (lot platted prior to 9/10/1995):
equired: ❑ Yes,applicant was notified qQ No Received: ❑ Yes 0 No
4a Public Faciliti provement(PFI)Permit: le
Iquired: Yes,applicant was notified ❑ No Applied For: /Yes 0 No,stop intake
nd Use Case#:
Ia Zoning of.._—
,QR�equired Setbacks: Front o20 Rear /� Side S Street Side 13I,K Garage ' 2
O(Landscape Requirement: %
vit i.of Coverage Maximum: iyo
ri Building Height: Maximum Height 50 Actual Height o22
0 1 isual Clearance
ill ;-.ensitive Lands: 0 Yes 0 No Type
FA Urban Forestry Plan
❑ Conditions "Met"prior to issuance of building permit
Notes: ems, drmi 7144=Q/ // .13-P 211.0_7/- nb,*-711j 125
Approved By Planning: .e/ Date: �1,.�/11 a
Revisions (after Building Submittal only) Reviewer Date
Revision 1: 0 Approved 0 Not Approved
Revision 2: 0 Approved 0 Not Approved
Revision 3: 0 Approved 0 Not Approved
I:\Building\Forms\BldgPermitRvw_RES_061417.doex
Building Permit Submittal
Original Submittal Date: 7 (3//r
Site Plans: #
Building Plans: #
Building Permit#: ■r nter building permit#above.
Workflow Routing: P Planning 1ngineering C >Permit Coordinator Building
Workflow Sign-off: i Sign-off for Planning(include notes from planning review)
Route Application Documents: 7 Engineering: (1) copy of permit application, (1) site plan, (1)building plan and
original plan review routing form.
Building: original permit application, site plans,building plans,engineer and
beam calculations and trust details,if applicable,etc.
Notes: / ` i
/By Permit Technician: -,00". , A /jjj Add Date: ____.:7/5724_,
Engineering Review
v
WI-Slope at building pad: �p
[Conditions "Met"prior to issuance of building permit
❑'Easements (encroachments)per engineering conditions of approval and plat
Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: ErNo
Assess Water Quantity Fee in-lieu: Yes LIDA Facility on lot: P*4 v of 1-1 0" Yes pro o
A-NOT Approved by Engineering: 14 , 6 5 Date: '- ( Z-.1
Notes: s}k-e•.,v Ut-D 4- - A-
Q...a 1_4'NI ('Li b 14, o 1,--1-1 //e1 M `l%;1, w., .<41 k c
/4N6 S-rdvi.... I I is i4,p i K- �a7 %-C�.e� . `' � Y� ,S�
Approved by Engineering: Date:
Revisions(after Building Submittal only) Reviewer Date
Revision 1: 0 Approved 0 Not Approved
Revision 2: 0 Approved 0 Not Approved
Revision 3: 0 Approved 0 Not Approved
Permit Coordinator Review
❑ Conditions"Met"prior to issuance of building permit
o Approved,NOT Released: Date:
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant: 1''L/((-7i-if
Revision Notice 2: Date Sent to Applicant:
Revision Notice 3: Date Sent to Applicant
9fF D C Fees Entered: Wash Co Trans Dev Tax: ►`- es 0 N/A T"'I�����
Tigard Trans SDC: IL Yes 0 N/A n --:OW ,
Parks SDC: Yes 0 N/A
i
LIDA ii, i :,. . N/A 8/0//1""
OK to Issue Permit �
Approved by Permit Coordinator: /®%!�'�' l ate: r////
I:\Building\Forms\BldgPermitRvw_RES 061417.docx
Plumbing Permit Application
Building Fixtures SEP 1 ?, Z019 FOR OFFICE USE. t iN i 1
Received
City of Tigard Date/By: �' �L i' ...„' ' # P�7 1�-t,�'>1 �
13125 SW Hall Blvd.,Tigard,OR 97221: T,� Plan Review
Phone: 503.718.2439 Fax: 503.59889§0 DatcBy: Other Permit No.:
Inspection Line: 503.639.4175 Date' :` Anis: ® See Page 2 for
Internet: www.tigard-or.gov .'1 1. :1.....18.1%. 5.;�. •tal[dermatitis'
•
,d -- ---
%IrJ For special information use checldisL
C New construction ❑Demolition {� Ea. Total
Description Qty
❑Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
:- SFR(1)bath 70
SFR(2)bath 437.78
7,1 1-and 2-family dwelling 0 Commercial/industrial SFR(3)bath 500.32
❑Accessory building 0 Multi-family Each additional bath kitchen 25.02
❑Master builder 0(1tl'cl"' Fire sprinkler( sq.ft.) Page 2
til'!1; 111€. I) 1(IC ‘.i i()1 '41 Site utilities:
11111111111111111 - Catch basin or area drain 18.76
Job site address: '� '; P.d *�,..
_4.4p��^(_ Drywell,leach tine,or trench drain 18.76
City/State/ZIP: titrt (-♦ 4: " - ✓T 2- f:
1].� t� Footing drain(no.linear ft.:,__) Page 2
Suite/bldg./apt.no Project name: C 1'-. S F b 4 111N) Manufactured home utilities 50.03
Cross street/directions to job site: /1/4/4 Q..11,4,4, - S- jz 4 Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:__) Page 2
Water service(no.linear ft.:_) Page 2
•Subdivision: Lot no.: _ Fixture or item:
Backflow preventer 31.27
Tax map/parcel no.:
Backwater valve 12.51
Clothes washer 25.02
P ,411S, C. .', erd 62,4VIt Dishwasher 25.02
h Sr- r •l A-- 00198 Drinking fountain 25.02
Ejectors/sump 25.02
,. ,% 4' � Expansion tank 12.51
t / Fixture/sewer cap
25.02
Name: j`
Q a..)„...„0,,,1119 II�{1_, /
_Floor drain/floor sink/hub 25.02
Address: z i �o �(2 (� Garbage disposal 25.02
City/State/ZIP: � 0 e 0/°p3 Hose bib 25.02
Phone:0)1) 8 `�• `Q t 3- Fax:( ) Ice maker 12.51
Interceptor/grease trap
25.02
Medical gas(value:$ ) Page 2
Business name: 12.5 t
Primer
Contact name: Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
' Tub/shower/shower pan 12.51
Phone:( ) Fax::( ) 25 02 Urinal ,
E-mail
y Water closet 25.02
y= Water heater 37.52
Business name: Kb i)116,410.4.4 W
Water piping/DV 56.29
Address: 13 5-(7,_ � 1 r{{lc�e..��- • Other: - 25.02
City/State/ZlP: Ps rk g... .31.7 s 3 Subtotal
3j 5�4 II I i t Fax:( ) Minimum permit fee: $72.50
Phone:( 4 a C7
d 1 i „245 e t. _ Plan review (25%of permit fee)
CCB Lic.: o
Plumbing Lie.no.: State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
q This permit application expires if a permit Is not obtained within 180 days
Print name: Date: ✓1 #'"� 1 after it has been accepted as complete.
"Fee methodology set by Tri-County Building Industry Service Board.
440-46161110/02/COM/WEB)l:tBuilding\Permus\PLMU-PermitApp.doc 10/01,09
Electrical Permit Application IIMIIIIEIIIEIIIIIMIIIIIIIIIIIII
.. .
City of Tigard . Received Date/By
li " 13125 SW Hall Blvd.,ligard,OR 97223 (-,r, '-. ., ts Plan Review
1 2 Phone: 503.718 2439 Fax: 503.598,1966''-' ., , , DaterBy Related Permit
Inspection Line: 503.639.4175 Ready Date/By hills rif See Page 2 for
1(GARDNotified/Me N
Internet. www tigard-or.gov 1 Supplemental Information
— ' ' 1 '• efP- 4.) , PLAN REVIEW
Ill% OF WORK
o0 -
0 ew construction 0 Addition/alteration/replacement
ieck all that apply(submit 2 sets of plans wiitems checked):
= II rvice or feeder 400 amps or more 0 Building over three stories.
El Demolition 0 Other: %k here the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings
I-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all oilier installations. buildings
0 Multi-family 0 Master builder p Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION, 0 Emergency system larger separately derived
0Addition of DeW motor load of system.
Job#: Job site address: 17_82,1 9.4 1 -1,1-4( AY^e,../ loot if)or more
_..,„,.. occupancy.
rk 1 ry.,..,*)
City/State/ZIP: -‘ a.,..- ,J4-,.. -,)-t 2-a3 0 Six or more residential units
13 Healih-care facilities 0 Recreational vehicle parks
Suite/bldg./apt.#: Project name: CCeo te5 Peokrii-."); — Dllazardous locations. 0 Supply voltage for more than
600 volts nominal.
0 Service or feeder 600 amps or more
Cross street/directions to job site: v14 „4„, 4 sk,,,,,...4- ., ,...
, FEE.,SPIEOITLE'
Description I Qty. f Each I Total I •
New residential single-or multi-family dwelling unit.
Subdivision: I Lot 4: 2..... Includes attached garage.
1,000 sq.ft.or less 168.54 4
fax map/parcel#: Ea.add'!500 sq.ft.or portion 33.92 • 1
-:-..... ..-...."...--:-.-4,...--,. ,,:- ,...:, ! :.-,r, ,.7rvi.Irm,.,7 '''' "' - 1--
' ' -,,. .-',"-7.1:4-YA.f,'" ' ',,,' ',,..4. i...,`,,:-..'::A..', • (iWtife;ii'Tt,:" ..f;:''' Limited energy,residential 75.00 2
V‘0"5/C- ' ' r co4crik..44 (with above sq.ft.)
Limited energy,multi-family 75.00 2
Itit ST 2eI‘S — 0 0‘. g residential(with above sq.ft)
7: '''., :.1 ' i Wi6.7.741 'Pk."'",':- :CI': '3-: ,.,i,,-,"- --,4.:-.- Servicesor
Energy Ci
feeders installation, and/oralteraS:ironPage2
i' t` 4:' i
relocation
Name: - - D . il . % . 4. D„,,, - i I C' 200 amps or less 100 70 amps to 400 amps
133.56 2
201
2
Address: 12,‘2__ - 1 9,„1,
401 amps to 600 amps
City/State/ZIP: ' ,,,„.. o . 0 e.••.. .14 0 03 i *
601 amps to 1,000 amps 200.34
301 04 2
2
Phone:(s13.) at - 31,41 Fax:( ) Over 1,000 amps or volts 552 26 2
Temporary services or feeders installation,alteration,and/or
Email: AC,S,0 Ne.,...4vs Gtot A L .‘ G ri relocation
....,
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59 36 1
intended for sale,lease,rent,or exch• : aces sing to ORS 447,449.670,and 7( 1. 201 amps to 400 amps 125 08 2
-..-
Owner signature: . ,, , Date: , IT 1„,`/ 401 amps to 599 amps 168 54 2
" ff, — , ,. ,,,,,,,,,- , Branch circuits-new,alteration,or extension,per panel
aApritt'Ailt-- ..-5,.:,-:..„..1.1,,,,,,i, 1„ ' u,coNTAcr:.....,„,,,,,,,,, -, .
A.Fee for branch circuits with
Business name: above service or feeder fee,
7.42 2
, each branch circuit
Contact name: B.Fee for branch circuits without
service or feeder fee,first
Address: branch circuit 56 18 2
City/State/ZIP: Each addl branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) I Fax: :( )
Each manufactured or modular 67.84 . 2
dwelling,service and/or feeder
Email: ' Reconnect only 67.84 2
. ., _;4;h, ::4:(..7,,-CrOltr: :,1; , ...7t41,ff`:. Punip or irrigation circle 67.84 2
Business name: 1410044ale„e_ 4.4.A.tic4
&sx. _ _ Jign or outline lighting 67.84
Signal circuit(s)or limited-energy ,...., ,..p ., 2
2
Address: Z',11- srp_.4
panel,alteration,or extension. " '-'''`'ag
Each additional inspection over allowable in any of the above
City/State/ZIP: 0 ,..., , 0 9_,,,,,, C33-30 6-
'1 Additional inspection(1 hr min) 66.25/hr
Phone:(503 -
SRI - 1/2_ Fax:( ) Investigation(1 hr min) 90 00/hr
Industrial plant(I hr min) 78.18/hr
Email: Inspections for which no fee is 90 00/hr
CCB Lic.: 16 c 3 sz Electrical Lic.: tk-'S 24'c Suprv.Lie.: 511 3 S specifically listed(y2.hr min),
. •;:,4**Mr.e.
Subtotal:
Suprv. Electrician signature,required:
Print name: 1?....,A 1'14)1 St 1 13.CP„...„,„ Date: "D 1 1Z,\i3 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE:
days after it has been accepted as complete.
This permit application expires if a permit is not obtained within ISO
Print name:
-1---I— ' Date: S It
4 Number of inspections allowed per permit
I tRuildingTennitskELCPerrnitApp_ELR_ERE Rev 06/17/2015 440-4615T(I 1/05/COWWER
k