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Permit .n CITY OF TIGARD MASTER PERMIT .k_, COMMUNITY DEVELOPMENT Permit #: MST2010 -00106 �� Date Issued: 06/18/2010 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 2S103BC09400 Jurisdiction: Tigard Site address: 12890 SW BLUE HERON PL Subdivision: BLUE HERON PARK Lot: 11 Project: Jackson Project Description: 361 SF Garage conversion. BUILDING Floor Areas Required Setbacks Required Stories: 1 Bedrooms: 1 First: 361 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 1 Third: 0 sf Right: 0 Detectors: Yes Total: sf Value: $35,000.00 Rear: 0 PLUMBING Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0 Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0 Tubs/Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 0 Bckflw Prevntr: 0 MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 3 Fum<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0 Ea add 500 sf: 0 20 1 -400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr: Limited Energy: 401 -600 amp: 0 401 -600 amp' 0 Ea addl 8r Cir: 601 -1000 amp: 0 601 +amp- 1000v. 0 1000 +amp /volt: 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio 8 Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: Owner: Contractor: Required Items and Reports (Conditions) JUMONVILLE, COLLEEN E BROADWAY CONSTRUCTION LLC 12890 SW BLUE HERON PL 2200 BROADWAY SUITE I TIGARD, OR 97223 Vancouver, WA 98663 PHONE: PHONE: 360 - 907 -1803 FAX: 360 - 397 -7770 Total Fees: $1,648.05 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 952-001-0100. You may obtain - o e • - or direct questions to OUNC by calling 503.246.6699 or 1,800.332.2344. Issued B y : C ! � i � � 7 r 1 0 � ' � ' � Z ‘ . - - - " " - - Permittee Signature: A J 'I1\ \- „....,e .Building Permit Application Residential �� FOR OFFICE USE ONLY City of Tigard �j� weceived `d g ' � 0 `DateB : • � t Permit No.: 1 �` �" I — c ) Id 6 13125 SW Hall Blvd., Tigard, OR 97223 A \ 1 ?, I C .' Phone: 503.639.4171 Fax: 503.598.1960 ,� \`� ` gamin I d Other Permit: TIGARD Inspection Line: 503.639 G +s S d �� 0 See Page 2for Internet: www.tigard or.gov C1 0 . 1 G 4 ■ 7 f d Meth d. i Supplemental Information \ CI - { iL.-...- TYPE OF WORK 8N w REQUIRED DATA: 1 - AND 2 - FAMILY DWELLING ❑ New construction ❑Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all Addition /alteration replacement ❑ Other: equipment, materials. labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. Valuation: $ 36 k '� 1- and 2- family dwelling ❑ Commercial /industrial f� �Accesso building Number of bedrooms: 1:1 Accessory g ❑ Multi - family ❑ Master builder ❑ Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: I 'L J10 S1-.A.1 r6i , A , e _. 't it", 4lct L.-L. New dwelling area: 3 b ` square feet City /State /ZIP: k U �� e OR ° t 1 Z2 Garage /carport area: square feet Suite/bldg./apt. t. P no.: v Project name: JC- tcf tJ Covered porch area: square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet REQUIRED DATA: COMMERCIAL - USE CHECKLIST Subdivision: 0 , Vt`ro r.:v K I Lot no.: Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. G oils.r L. (..‘.:. 1/4.1-Cr $•.�, � Valuation: $ _ Existing building area: square feet New building area: square feet tg PROPERTY OWNER ❑ TENANT Number of stories: Name: Co L 1 e Type e1 L� � ER's T yp of construction: Address: l Z g `t >o S W t Bl.q � H e-rV✓A. OA .(- Occupancy groups: City /State /ZIP: -7 g2.6_ ( O n q 7.-.7.—S Existing: Phone: O3) 430 g 1.1 .3 0 1� Fax: ( ) New: or APPLICANT ❑ CONTACT PERSON NOTICE Business name: gra m., d. C,p�s•� - r�L8 i Oe't k L t_ All contractors and subcontractors are required to be Contact name: l�, A V licensed with the Oregon Construction Contractors Board 1� �` �� V' under ORS 701 and may be required to be licensed in the Address: 1. 7.., CV) ) •� 5 3 - jurisdiction in which work is being performed. if the City /State /ZIP: c kiA+C- ipl.lV ef W p1 if (o 6 3 applicant is exempt from licensing, the following reasons Phone: (3b0) owl .... [ 603 I Fax: : (36,0) 3q•7 . .7 0 E -mail: cat), e b t^.. w° ii G. ©.A S"t v. 4 Cj-tort t 1 e - ( ov1° CONTRACTOR Business name: Bt 6 Co.- Sl"...... `1 O►1 I Li_ L BUILDING PERMIT FEES* Address: Ql7 ' � Td }� (Please refer to fee schedule) Z O �c•t� �� L Structural plan review fee (or deposit): City /State /ZIP: v ,C el-:.0�• L ) t WA °i $ 640 1 r FLS plan review fee (if applicable): Phone: ( 360) ` Ie1— 12o3 Fax: (360) 391 -1710 CCB lic.: t i 3 b 0 ecl� - ) / l v Total fees due upon application: 3/ rn ��� 7 Authorized signature: J `�� Amount received: 3 ` `w -cam This permit application expires if a per it is not obtained l ` within 180 days after it has been accepted as complete. Print name: � A ..) U,,.� � e .� Date: b J j o t 1 0 * Fee methodology set by Tri- County Building Industry Service Board. I: \Building \Permits \BUP- RESPermitApp.doc 10/01/09 440-461 3T( I I /02/COM/WEB) Plumbing Permit Application �y� . -_ 1 �' ^4k tr ^n 4 ra o 4 n-R w y r i tl r Lr i N wE , , Building Fixtures "` fi� ° " "` l ` " �� a ^ f . ;,; ICI :u til'ON I l � l kl c a a a' + . �� ��� , � �L" e '�f , � 4tt��..M��k,'u�V1u ?� ,' ,�+.,, y l 4c,a 1 � +�.�� t'vn� �i al' ,6:'! :�: ed City of Tigard Received No : M S.- " 1 0 -0 D l V 13125 SW Hall Blvd., Tigard, OR 97223 0 Date/B y I' \ cto �� Plan Review IN C Phone: 503.639.4171 Fax: 503.598.1960 " ' ' ' , i , D ate / By: Other Permit No.: Inspection Line: 503.639.4175 G I I ki'A IL n � R ClI Y U lV lS D Date Ready /By: Juris. ® See Page 2 for Internet: www.tigard - or.gov O F Notifred/Method: Supplemental Information K %W% TYPE OF WOR Q . " . FEE* SCHEDULE - . ❑ New construction ❑ Demolition For special information use checklist: Description 1 Qty. 1 Ea. 1 Total ❑ Addition/alteration/replacement ❑ Other: New I- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 312.70 ❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 building SFR (3) bath 500.32 ❑ Accessory g ❑ Multi- family Each additional bath/kitchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 ' JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: 12_ $ q (7 S w g i„`. H��'� Qt c,,...-e_ Catch basin or area drain 18.76 Drywell, leach line, or trench drain 18.76 City /State /ZIP: °T: 9 eu f ° g.. Footing drain (no. linear ft.: ) Page 2 Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain dram 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: I Lot no.: Fixture or item: Tax map /parcel no.: Backflow preventer 31.27 . .,DESCRIPTION • OF -WORK . Backwater valve 12.51 Clothes washer 25.02 T1 ", ,.I-+^ Roo cti'y` e-- losef 5ivo.."-Wri -( 4eN Dishwasher 25.02 fI X j■ t- Drinking fountain 25.02 Ejectors /sump 25.02 ❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 Name: L c 1 IC �c t �•� Fixture /sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: Qj et 0 --Lt 1-t o/` P t c _•,e Garbage disposal 25.02 City /State /ZIP: q a L 0 9 1 223 Hose bib 25.02 Phone: (503) Li 3o g yap + Fax: ( ) Ice maker 12.51 ❑ APPLICANT ❑ 'CONTACT `PERSON Interceptor /grease trap 25.02 Business name: Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: Roof drain (commercial) 12.51 Address: Sink/basin/lavatory 1 25.02 City /State /ZIP: Solar units (potable water) 62.54 Phone: ( ) Fax: : ( ) Tub /shower /shower pan 1 12.51 E -mail: Urinal 25.02 CONTRACTOR Water closet 25.02 Water heater 37.52 Business name: 0 Water piping/DWV 56.29 Address: it: Other: 25.02 City /State /ZIP: Subtotal t .Z 5j`• . Phone:. . ^ Fax: ( ) Minimum permit fee: $72.50 �� Plan review (25% of permit fee) CCB Lic.: Plumbing Lic. no.: State surcharge (12% of permit fee) 8 , ` 0 Authorized signature: . TOTAL PERMIT FEE El ' , 2.0 Print name: Date: This permit application expires if a permit is not obtained within I80 days after it has been accepted as complete. *Fee methodology set by Tri- County Building Industry Service Board. I: \ Building \Permits\PLMU- PermitApp.doc 10/01/09 440- 4616T(10 /02ICOM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities . Q. 'Fee (ea) Total Square Footage: ,Permit Fee: Footing drain - 1' 100' 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 • $233.20 Sewer - 1st 100' 62.54 7,201 and greater $327.54 Sewer - each additional 100' 37.52 Water Service - 1st 100' 62.54 Medical Gas Systems: Water Service - each additional 100' 37.52 • Storm &Rain Drain - 1st 100' 62.54 Valuation: , Permit. Fee: $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for Other Inspections or Fees 'Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to P and including $10,000.00. Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to (minimum charge - 1/2 hour) and including $25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to Reinspection Fees 90.00/hr and including $50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge 1/2 hour) each additional $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping, adding or replacing fixtures? If "yes ", Plan Review for Plumbing,Installations • please indicate work performed by fixture. Failure to Plan review is required for any of the following. accurately report fixtures could result in increased sewer fees * . Please check all that apply. Quantity by (Fixture) Work. Performed . ❑ Any new commercial building with water service 2" and Fixture Type: Replace greater, except systems designed and stamped by licensed . Previous Capped Added Existing engineer. Baptistry/Font Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure -Tub/Shower as defined in OAR918- 780 -0040. Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities. Drive tall ❑ Any multipurpose fire sprinkler system. Cuspidor/Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040. Dishwasher - Commercial Domestic Submit 2 sets of plans with any of the above. Drinking Fountain Eye Wash 'Isometric or Riser•Diag Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings that meet the qualifications above. -4" Car Wash Drain Garbage - Domestic Disposal - Commercial - Industrial Comments regarding fixture work: Ice Mach./Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley - Commercial *Note: If the fixture work under this permit results in an - Service increase of sewer EDUs, a sewer permit will be issued and Swimming Pool Filter fees assessed for the sewer increase must be paid before the Washer - Clothes Water Extractor plumbing permit can be issued. Water Closet - Toilet Urinal Other Fixtures: I:\ Building \Permits\PLMF - PermitApp.doc 2 Jun 18 10 01:44p Home Energy Group, Inc. 360 -892 -6259 p.1 'Jun. 18. 2010 Plan Review °Mar Permit 12:49 t � " l i do 88 P- 2/2 - r r M J. C. Reeves COTQOIDn v } n Y ;t ��I�F ^^��sfr�rll�rrtlll lr � 1 ', i : I, Me haaic»ll !'er><It>tt A lice on �� ' _ ST ,0 /0 slid , Received parrmt No.: ' City of Tigard 4 . 13125 SW Nall Blvd., Tigard, OR 97223 r� �� Phone: 503.639. Fax: 503.598.1960' aandBy: ge.pegeltor `�:,. lospcerionLinc: 503,639.4175 , G ��wo,.. internist: wwwtigard- or.gov Swimmeret brava soon \ N •t. ��� COMMERCIAL FEE' SCHEDULE - DU CHECKLIST TYPE OF WORD C �\� Mechanical peta►it Secs' are based on the value °f e work th j] New construction Additionlaltezation/re e perforated. Indicate the value (rounded to the newest dollar) of ail mechanical materials ui ant labor oveehee and ❑ Demolition 0 Other: Value: 5 CATEGORY Of? CONS rRUCTfON - AESMENTIAL EQUIPMENT' r SYSTEMS FEW l Q � hec For ;pedal information use checklist '1 1- and 2- family dwelling ❑ Com[nezciaUindustrial ❑ Accessory building 0 Master builder 0 Other: Description J , Toed II Multi-Emily . C r.*h ," JOB 3fiE INFORMATION AND LOCATION Ai condiUaning Ct C. � (require, NOG Nan allowing 91aw ) 46.75 Job site address: 1 © { (' Purnaa a 100,000 BTU (duets/vents) 46,75 cttriswtarzlr: `[" g �, R> Z Formar,e 100 ODD+BTU daces/sem 54.91 MI 61.06 9uitelbldg /apt no.: ' Project name: 23.32 Cross street/din cliors to job silo: Dust work H • onic hot water s tern 23.32 Residential boiler (radiator or 21.32 hydronic) Unit heaters (fuel-type, not electnc), 46.75 in -wail in-du• sus ' • • etc. Fluelveru for any of above 23.32 Subdivision: Lot no.: Other: 23.32 Other fuel oppl�xoctl Tax apap/pareel no.: wager heater 23.32 DEBCRIY f1OTI OF WORK Gas fireplace 33.39 1 u0 OR- hR� ''` ti ' is e� Flue vent for watsrboate or as 23,32 �p� }s�•�lrp" p fireplace • SI 2— , A-0 Y -.. 'R-cr log '#'iV_ 4 es ∎ ' LoB IOW 4.[14 23.32 Wood/pellet stove 33.39 Wood fircplaceimaert i 23.32 Chiumeyfline utivent 23.32 ❑ PROPERTY OWNER . 0 TENANT whet: 23.31 1 Enviro� mental exhaust grid ventilation - Name: CO �c G let $ t Range hood/other kitchen 1..0 ♦ i w< � YID',.^ : - • 'al � _ equipment 33.39 Address; � 2 'Lb" 0 5 33.39 Clothes dryer exhaust - 0 ' Single - duct exhau (b athrooms, City/Slate/ZIP: l LLZ [�/ r f 23.32 J toilet compartments, utility rooms) Phone: (5 ) 4 t o _ J �3G 1 Fax: ) ptticJerawls>face farts 23.32 ❑ A>'P j 0 CONTACT PER90N aim 2132 - Business name: _ Fuel pipinst • 514.15 for arm lour; 54.03 for each additional • Conrad d ame: Furnace, etc. Address! Gas heat pump lyalyauspended/nait heater City/State/Z]P: l Water heater Phone: ( ) 1 Fax; : ( ) - Fi lace Renee E-mail: Barbecue c JP1TRACT Q>3 Clothes dryer {has) Business name: !• , u aka t k . ■ G .: r • Other: - t ! MEtCl1AN1CAL PEitMrr ter, Address: P • .. .: Snblolal t City/StatelZlP: ‘)evi ( Qk.�,,jeft _ 4 ,A))1.. q Vogl_ P./Liniment perm fee (590.00) Fax: 0 .') gQ'L.• 6, Plana toview (2554 of permit fee) , phone: ( 1.0) 9 4 '- , b �, b CCB tic: State surcharge (12% of Qerin it fee) 1) $ .� TOTAL PERMIT FEE TM' permit appliradoa aspires if o remit le ew 4bngioed within t80 - ' dens silty kbeebobacapka ascomp Autltonled signature: - — 'Fri-County BoiWhn 6ln Service Board 1} 6, / V Fee neihodolvar s'A b'r etc: Print Haase: $ P iah ' l�? 1 Q . - ...- ... ,.- ,4444.. -- 06/18/2010 11:57 13602537503 PAGE 01/01 .§.L 18. 2010 ..... 6 14c ReevQ,$� ati ,,, ,i ' - A" , �' � N o 0071 'P 2 fr, , r�,a -� �+ '�j�, n• 1 r f �7r;re i '' C ity of Tigard :� ' ` I r���d nevi d : 12123EMIIMI 7 13125 SW Hall Blvd.,Tigard, OR 9' ':< iw ' Phony 503.639.4171 Fax 503.598.1960 `` \\� 1 � • t . � Plan Reve Other Pmoit: (1,',', 1 , i Inspection Lino, 503.639.4175 w 0\ D\\ S\ internal: www,tigard.mgov . y TYPE OF WO _ _ PLAN REVIEW ' ❑ New cons truction ItloNalt<ratio acemen[ Floats docket HIM apply (subti6t 4 ante of piset w/D &uml a t b°tece): ID Srrvlee or recdor 400 amps or Moro O Building over three stories, (] Demolition [] other w the available fault anoint Q Marina card boatyard* CATEGORY OF CONSTRUCTION excaada MOO «raps at F50 volts or ❑ Floating buildings. and 2- family MAMA ❑ Commercial/industrial ❑ Accessory uil • lice w er°nnd, °r e1e"ds atoms ❑ building* agricultural � a , nC, far7Qtntberittstail atinpe. 67u1dingn. N 0 Master builder ❑ Other: El rlre pump, ❑ insultarion of 75 KVA or LlEntorgency system, larger aaparataly 606+44 system. Joy SITE AV1r012MATibN AND LOCATION ❑ addition of saw motor loud of ❑ "A", - e', "1-2", ° 1 -s Job no ( Job Site address: 1 slip b r,A7 AJ ,Bald A 10014P m atom, occupancy. A Q 8175 a mate r„aldsnt(n1 uapa. Q Itemvadonal vehicle parka, Clty/Statv/Z1P: - "V` � F 117_2—S ❑Hustle -rate facilities, CI guppy voltage for more than ❑ Harardaus loodions. 600 volts nominal. SUile/bldg./apt, no.: 1 Project name: LJ servieo or faader 600 MI er prom, FEE SCHEDULE Cross savor/directions to job site: ��� �� New residential dep. or inulti.falnily dwelling unit, - Wind's abetted • :, Subdivision: I Lot no.: 1,000 s.. R or less - 168,54 T U -- Ea. add'/ 500 sq. It or portion = 33.92 r Q - Tax map/parcel n0.. Limited energy, .. residential ■ 13 DESCRIPTION OF WORK with above - fl. Limited energy, multi-Randy 1 t 4d'� A-0 C f t' G' /t c _. yC b 4-�- lr'd 1 .. residential with above ••. ft. � � © d as 11� S. vices or feelers Manilla '�, • Mon and/or Mutation 1 1 ^ fA-Cia i- ea- lost ,tL %r . 200 altos nr leas - 100.70 - LI PROPERTY OWNER 1 �] TEN ANT 201 amps tod00am.s 111111 133,56 IMMO N e: 401 amps to 600 amps 11111 200,34 MIIIIISEI 1, 1 t.. ton 0 L0 3 d tn, 601 amps to 1.000 amp, — 301,04 Addroa 1 ' , ..t e_ �{ r __ __� o, or Loco nmpa or volts — 552,26 �© City/State/ZIP: "•'U 4.• r0 ■ C I 2- relocation iervices or Feeders ina[sUatiou, alteration, and/or Phone: (V3) tt 30 g 43 s Fax; ( ) 200a Of less 1111111E13 © Owtrer Installation: This installation is being made on property tut 1 own which is not 201 amps to 400 on 125.08 — © intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 nm , : Mill 16834 MIND Branch cirenitg- new alteratio or este • on . cr . anal Owner signature: _ Date: , A. Fee ibr branch • fruits with CI APJr1,.ICANT ❑ CONTACT PRR3pN thaw service or feeder fee, 7.42 -1 each bahach c11a01t Businaas name: 8. Fee for br7mch 'circuits wlrhm t am service or feeder fen g7st II Contact nine; ____ branch circuit - Pooh add', branch circuit .1111111131 13 Address: Miscellaneous service or &od n, , City/State/Z1P' 13aoh:ro,m,tAetttreAOrmodulsr 67 - 84 � � ewe 11 ; service and/or ftxtkr Phone: ( ) Fax:: ( ) Reconnect only 67.84 111111•13 &mil: Pa - or litigation circle - 67,84 IIIIM© CONTRACTOR — -- ��� 81 or outline lighting � 1 111© b � Signal circuit(3) rcuit(a) or ilmited4morgp ■ M Business name: d Vv it' L , ,g,� , : , el alteration or =minion. C� Each a , , ' on nit. , ■ • !towable In a , • esf the , boy« Address; P,Q 42 .gOX (p iV 1 '-f Additional ins' - •Uon thrmin) - 66,75/hr —II City/Stet4/ZI IAVestigatinu (1 br min) - 66.73 / hr . Iadusbial plant (I brmin) 111111 71i Taihr II Mee; 6 ) . J S g' L/ t' . b '2, 7 -z,_ Fax (AO Z„5 a ,.. Inspections for which no tie is III ' CCH Lie,. ) T I E lectrical Lie.: s • ec1 ca , listed f4 hr min 90.00/ hr � II .: C N3 Suprv. Lie.: oS ElitCTRICAL PERMIT FM i n Suprv. Electrician signature, required: r - 1 t i t Subtotal: Plan review (25 °A of permit fee : M Print name: � ij 1 ( r te a A ) 4 7 h Date: (41B 1 State surcharge (I VA of permit bee): Authorized ei8n4tu . r T OTAL wpm F +--�T -.. ll This porm application explore if n permit is not nbtained wtlbla tae Ft'Int name; 1 (yep ' R. p r" C 1 , hams: i i i 0 • Number or paps after lo allowed pe r *scooted 7w complete MisendatswermlatELC-PonafAypdoc 10101109 440-401ST[I05/COAalwap Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.055 (4)) This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: rc- iJ CP \- C-N Or\ t 1 8 3 F Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. , j or • 1 .1 I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and 1 hereby certify that the information on this homeowner statement is true and accurate. • Cot lee") JAc_K s o N L m 0,, Print Name of Permit Applicant • • 1. / / / / v/(Q) IP — / Signature of Perm', pplicant ( Date Permit #: Address: • Wiz- veys Issued by: Date: This Copy for Permit Offices Information Notice to Owners About *37 es i n ilities J , r-:r (ORS 701.055 (5)) Homeowners acting as their own general contractors to construct a new home or make a substantial improvement to an existing structure, can prevent many problems by being aware of the following responsibilities: • Homeowners who use labor provided by workers not licensed by the Construction Contractors Board, may be considered an employer, and the workers who provide the labor may be considered employees. As an employer, you must comply with the following: • Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Department of Revenue at 503 - 378 -4988. • Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503 - 947 -1488. • Oregon's Business Identification Number (BIN): is a combined number for both Oregon Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms. • Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs if one of your workers is injured on the job. For more information, call the Workers Compensation Division at the Department of Consumer and Business Services at 503 - 947 -7815. • Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov. Other Responsibilities of Homeowners: • Code Compliance: As the permit holder for a construction project, the homeowner is responsible for notifying building officials at the appropriate times, so that the required inspections can be performed. Homeowners are also responsible for resolving any failure to meet code requirements that may be found through inspections. • Property Damage and Liability Insurance: Homeowners acting as their own contractors should contact their insurance agent to ensure adequate insurance coverage for accidents and omissions, such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not otherwise covered as employees by Workers Compensation Insurance. • Expertise: Homeowners should make sure they have the skills to act as their own general contractor, and the expertise required to coordinate the work of both rough -in and finish trades. CONSTRUCTION CONTRACTORS BOARD 700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052 Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007 Website Address: www.oregon.gov /ccb f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant