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Permit ,, CITY OF TIGARD MASTER PERMIT ' ,.- COMMUNITY DEVELOPMENT Permit #: MST2011 -00141 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/17/2011 Parcel: 2S102BC00104 Jurisdiction: Tigard Site address: 12555 SW BROOKSIDE CT Subdivision: WALNUT ACRES Lot: 3 Project: CARTER Project Description: Interior remodel. BUILDING Floor Areas Required Setbacks Required Stories: 1 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Yes Total: 0 sf Value: $40,000.00 Rear: 0 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0 Drains: 0 Tubs /Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Other Fixtures: 0 Drywell- Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 2 Clothes Dryers: 1 Heat Pump: N Hoods: 0 Other Units: 1 Furn <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: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 4 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: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ALT SF VB R -3 0 Owner: Contractor: CARTER, LESLIE E & BENNETT S OSMON DESIGN & REMODELING Required Items and Reports (Conditions) 12555 SW BROOKSIDE CT 17801 SE HWY 224 TIGARD, OR 97223 DAMASCUS, OR 97089 PHONE: PHONE: 503 - 803 -8529 FAX: Total Fees: $1,388.37 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 - • - - . th 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. • NTION: Oregon -w =• ires you to follow the rules adopted by the Oregon Utility Notificatio enter. Those rules are set forth in OAR 952 -0r -0010 through OAR 9 r' 1 -009+. 'u may obtain a copy of the rules or direct questions to OUNC b ' 503.2 2.1987 or 1.800.332.2344. Iss ed By: k - / £ /,±/4/41_,A % Permittee Sig •ture: =.' ' - :4.4r/fLll' Call 503.639.4175 by 7:00 a.m. for the next available inspection . a 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. • Building Permit Application Residential ....„-40 FOR OFFICE USE ()NIA City of Tigard �j Received iI, Perm No . . �f� 1.---00 ' DateB t J t. n 13125 SW Hall Blvd., Tigard, 0T? ' @UI 1% Plan Rev, '• I I C � Other Permit: Phone: 503.718.2439 Fax: 51s . Q. 8.1960 , % 1, DateB : �� _ TI G A R D Inspection Line: 503.639 (�t \� Date Ready /: y: a H See Page 2 for Internet: www.tigard or.gov P IkG °off _I � Notified/Method: 6 I Supplemental Information Off' el %O!/ A ry /l- TYPE OF ; ' 06 / REQUIRED DATA: 1- AND 2- FAMILY DWELLING ❑ New construction 0' d emolition 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. ® 1 - and 2- family dwelling ❑ Commercial /industrial Valuation: $40,000 ❑ Accessory building ❑ Multi - family Number of bedrooms: 1 El builder ❑ Other: Number of bathrooms: 1+ JOB SITE INFORMATION AND LOCATION Total number of floors: 1 Job site address: 12555 SW Brookside Court New dwelling area: 300 square feet City/State/ZIP: Tigard, Oregon 97223 Garage/carport area: -300 square feet Suite/bldg. /apt. no.: I Project name: Carter Residence Remodel Covered porch area: square feet Cross street/directions to job site: Deck area: 110 square feet SW Walnut north of SW Pacific Highway, turn east (right) at SW Brookside, Other structure area: square feet trim left (north) at SW Brookside Court - house on left (east(VV eS -f) REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: I Lot no.: Permit fees* are based on the value of the work performed. Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. Light demolition - remove partitions - add headers at three new windows openings ' ' Valuation: $ Add partitions, reconfigure restroom, add shower, relocate MUD _ Y ,{ J Existing building area: square feet New raised floor level in shop area (old garage) for new studio - add deck s p3 New building area: square feet ❑ PROPERTY OWNER , ❑ TENANT i VG l` � • Number of stories: Name: Benn and Leslie Carter e Type of construction: Address: 12555 SW Brookside Ct �� Occupancy groups: City/State /ZIP: Tigard, OR 97223 Existing: Phone: (503)443 -6052 Fax: ( -) New: ® APPLICANT ' ❑ CONTACT PERSON BUILDING PERMIT FEES* • Business name: Ken Klos, architect (Pleasere/erro/eesehedwte) Structural plan review fee (or deposit): Contact name: Ken Klos FLS plan review fee (if applicable): Address: 2407 NE 9 Avenue Total fees due upon application: . City/State /ZIP: Portland, OR 97212 Phone: (503) 358 -8422 I Fax: : ( - Amount received: E - mail: kenklosarch @gmail.com PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* CONTRACTOR Commercial and residential prescriptive installation of roof -top mounted PhotoVoltaic Solar Panel System. Business name: Dan Osmon, Contractor Submit two (2) sets of roof plan with connection details and fire department access, along with the 2010 Oregon Address: 17801 SE Hwy 224 Solar Installation Specialty Code checklist. City/State /ZIP: Damascus, OR 97089 Permit Fee (includes plan review $180.00 and administrative fees): Phone: (503) 803 -8529 Fax: ( -) State surcharge (12% of permit fee): $21.60 CCB lie.: i © 8.5 "6 ( ?not/ /3 Total fee due upon application: $201.60 Authorized signature: ' ( (/- -1 This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. I Print name: Kenneth Klos Date: 08 -09 -2011 * Fee methodology set by Tri- County Building Industry Service Board. I:\ Building \Permits\BUP- RESPermitApp.doc 02/ 24/2011 440- 4613T(I 1 /02 /COM /WEB) Building Permit Application - Building Fixt lreS = i iIH 4: i. `1 , i I i 1.', . City of Tigard R ,. Permit ND.: *fool!) J 0!)/ 13125 SW Hall Blvd., Tigard, OR 97223 Review Phone: 503.639 4171 Fax: 503.598.1960 parlay_ Other Pit No.: • 1 ; s. i Inspection Line: 503.639.4173 pp Ready/By: had 61 Set Page 2 for Internet: www.tigard•or.gov Notified!Medlod: Sue plemestallnformatIon . :. - TYPg OF.WORK - - var.. SGEIRO _ - • . ❑ New construction 0 llemolition For speciallnformetion use chadt/fsx Description I Qty. I Ea I Total ❑ Addition /alteration/replacement ❑ Other New I- 2-family dwellings (includes 100 ft. for each utility connection) CATEGORY: OF. CONtSTRUCTION , . i SFR (1) bath 312.70 - It I- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 • SFR (3) bath , ❑ Accessory building ❑ Multi- family _ • Each additional bath /kitchen - 25.02 ❑ Master builder ❑ Other: Fire sprinkler (_ sq. R) Page 2 JOB SITE INFORMATION 'AMP I.00ATION Site utilities: Job site address: I Z 5 'scto rs zoo Kam' NE c ,. Catch basin or area drain , 18.76 City /StateiZIP: -("[ G F - 4 O r a - or'2 z Z.3 Drywell, teach line. or trench drain 18.72 _ i Footing drain (no. linear R.: _) Page • Suite/bldgJapt. no.: I Project name: Ma wlhtxured home utilities 30.03 Cross street/directions to job site: Manholes I 18.76 I . • Rain drain connector 18.76 Sanitary sewer (no. linear ft.: _) Page 2 . .. . Storm slaver (no. linear R: _ ) Page 2 Water service (no. linear it: _) Page 2 - Subdivision: f Lot no.: ' Fixture or Item: Tax mup/paroel no.: Backflow preventer , 31.27 • Backwater valve . 1251 ' • ntgelt 'riON 40 WORK • � . i2(A Clothes h erher 25.02 C Dishwasher 25.02 • Drinking fountain 25.02 • . Ejectors/sump 25.02 • . Cl :PROPERTY OWNER ( - • . -Q TENANT _ Expansion tank - 12.51 Name: . COY t /l/ Fixture/sewer cap 25.02 • c, Floor drain/floor sink/hub 25 - 02 Address: I Z" " " f � ` Garba disposal 25.02 City /State/ZIP: �( G( _ Dr-. 1-7 .2_3 , Hose bib 25.02 . Phone: ( ) + Fax ( ) Ice maker 12.51 • . •' Q APF`IcJCANT :_ U. CONTACT pgp9011 • lntcrceptor /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 • 25.02 City/State/ZIP: . Solar units (potable water) • 62.54 Phone: ( ) I Fax: : ( ) . Tabshower /shower pan I 12.51 E-mail: - Urinal 25.02 ' • Water closet 25.02 GQ➢VTAAI~TQ11' Water heater 37.52 ' Business name: 100 ifj J7 . 1 14 (5 R Oa Water pipin8/I3WV f . 5629 ! L Address: "7472. 5&O F( R 577 Other: 25.02 Cuy /State/ZIP: 7 Subtotal TI 2 D r 122' Subto INinimum permit fez: 512 30 Phone: ( �jZO �- 76 Q Fax: ( (�3 ✓ NQ -q355" Plan review (255i of permit fee) CCB Lic.: 61 5'3 Plumbing Lie_ no.: 34. -257 - • State surcharge (12% of permit fee) Author ;zed signature: I TOTAL PERMIT FEE I Print name: 04e14 I F,_4FG0 i4 (K Date: t / • If This permit application expires lie permit to not obtained within 1811 days after it bast been accepted as eom kt& *Foe methodology set by Tri- County naitding Industry Service Hoard I: 1BuamagtPatmitslPi2tU- PamitAppdos lo/M^os 44046 16T(10/02/COSIN/FB) ' Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information • Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: . . Permit Fee: • Footing dram - l" 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 & Drain - 1st 100 62.54 Valuation: Permit Fee: _ $1.00 to $5,000.00 Minimum fee 572.50 Storm & Rain Drain - each additional 100' 37.52 $5.001.00 to $10,000.00 $72.50 for the fast $5,000.00 and $1.52 for Other.InS t efitions or Fees Q* * ... Fee {ea) • Total each additional $100.00 or fraction thereof, to and including $t0,000.00. 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 fcc 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 550.000.00 5379.50 for the first $25,00000 and $1.45 for hours (minimum charge - 2 hours) each additional 5100.00 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 , .$74100 for the first $50,000.00 and $130 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. Quatlttby (Fixture) Work Perforated - ❑ Any new commercial building with water service 2" and Fixture Type:. R eplace greater, except systems designed and stamped by licensed .. Prrtrioas . Cooped Added galsdni engineer. Baptistry/Ford . ❑ New exterior plumbing site utilities for any complex structure Bath - Tub/Shower as defined in t7AR9I8 780 - 0040. - Jacuzzi/Whirlpool ' Car Wrack -Each Staff 1:1 Medical gas and vacuum systems for health care facilities. - Drive toff ❑ Any multipurpose fire sprinkler system, Cuspidor/Water Aspirator ❑ Any complex structure as defined in MAR918- 780-0040. . Dishwasher - Commercial Dranestic Submit Z sets of plans with any of the above. Drinking Fountain . - Eye Wash - Isometric Or Riser Dlagm Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings 3., • that meet the qualifications above. -4" Car Wash Drain - . Garbage - Domestic Disposal - commercial - Industrial Comments regarding fixture work: Ice Mactt./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 EDEN, 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 Onset - Toilet Urinal Other Fixtures: • I:\ Building \Permits\PLMF- PennitApp.doc 2 Mechanical Permit Application FOR OFFICE USE ONLY City of Tigard Received .( PermitNo.: L IN Ty g Date/By: 0 4 I%1 t�5 0 - 0. 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review C Phone: 503.718.2439 Fax: 503.598.19 ` y P Date/Fly: Other Permit: T I G A R D Inspection Line: 503.639.4175 Date Ready/By: I3 See Page 2 for Internet: www.tigard-or.gov 0) , • otified/Method: Supplemental Information TYPE OF WORK 1 ` COMMERCIAL FEE* SCHEDULE - USE CHECKLIST (we, QU ` Mechanical permit fees* are based on the value of the work ❑ New construction ® Addition/alteration/ret'nent performed. Indicate the value (rounded to the nearest dollar) of all ® Demolition ❑ Other: `4' 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 JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning Job site address: 12. ,553 s W 3 . r Dbi(s, a( (. • (requires site plan showing placement) 46.75 O City /State /ZIP: -- r t,5 q � dl Z O. L Furnace 100,000 BTU (ducts/vents) 46.75 J I O i _ Furnace 100,000+ BTU (ducts /vents) 54.91 Suite/bldg. /apt. no.: Project name: 6.,,,„A-1. (Z, R Heat pump (requires site plan showing placement) 61.06 Cross street/directions to job site: Duct work -3• 30 23.32 a-3. - 31 Hydronic hot water system 23.32 S w w GaKJ no.,,M,, Ci Sw PD- C kvJ`1 4 - v V1 ekatf' Residential boiler(radiatoror (tit k t) ® S i afeokSlae -\- , r vt 1 { k t t. Mo{ t K) ,@ hydronic) 23.32 ( Unit heaters (fuel -type, not electric), S W . 64 D•&C &C. C---V 1 • - ►'10 U S C 0 tt-c ( G07/ in -wall, in -duct, suspended, etc. 46.75 Subdivision: Lot no.: Flue /vent for any of above 23.32 Other: 23.32 Tax map /parcel no.: Other fuel appliances: DESCRIPTION OF WORK Water heater 23.32 Gas fireplace 33.39 l< G.E D - b-e .4.14 1A- (W L .tK1N' - � A 4 'f'N e Flue vent for water heater or gas 3 t� IA W � w b e t '- e fireplace 23.32 1L � C t Log lighter (gas) 23.32 I C 4013 [ 0.4 /Q S ( I 1-(•f 0'1 W I I> Wood/pellet stove 33.39 Ae,w r c t -Fl o o 1 g j stmee 0.4,e4., C N g h Wood fireplace /insert 23.32 ❑ PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32 Other: 23.32 Name: a. [ h t. N. K 4 l. el 1 1.e l /� a.4 t. G V Environmental exhaust and ventilation: _ Address: 1. 2 S S S S W B reek S id e CA . Range hood/other kitchen equipment 33.39 City /State /ZIP: - „Al, U 2 1 'T 22 3 Clothes dryer exhaust 1 33.39 3"3 Single -duct exhaust (bathrooms, \\ UU Phone: ()b ) 4. 3 - (p 0 V... Fax: ( ) toilet compartments, utility rooms) C 23.32 -lCO, " v / / p APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32 Other: 23.32 Business name: I c..(�‘,.. K fps Fuel piping: Contact name: (.4 e tot KI 9 5, ` eve ( -e LA" $14.15 for first four; $4.03 for each additional Address: ( b' , ( "t w' 2.4 O t G - "7 * , IV � ex. i ,� Furnace, etc. ` CI Gas heat pump � City /State /ZIP: ?4 (f`Q_ l 1 Z ( 1- Wall /suspended/unit heater Phone: (5 5 0 • 't.# tL Fax:: ( ) Water heater E -mail: ktK k k •S t9Vr LA Range � a IVY M� ' [ 0"1� Range e CONTIdCTOR Barbecue q Clothes dryer (gas) Business name: ,�bJ���'� �1���� ,F}l2 CotJntr/G�//Jt�c `- Other: Address: 5 gas ' ..f 6 srE4 kb MECHANICAL PERMIT FEES* " ° Subtotal ) G . 3 ' City /State /ZIP: PQQn��r Ole- /' 3.: � Minimum permit fee ($90.00) Phone: (' 0 , 77Lj'- 0/ (p ! Fax: (603) 77[1 -43 Plan review (25% of permit fee) CCB lic.: 9 g 57 3 State surcharge (12% of permit fee) a , k 0 TOTAL PERMIT FEE /(5 - 7 ---- 1A 1A- 4V) This permit application expires if a permit is not obtained within 180 Authorized signature: days after it has been accepted as complete. Print name: b . €V1 Y1 eh. K 1 6 5 Dater $ • • j ( * Fee methodology set by Tri- County Building Industry Service Board I1Building \ Permits \MEC- PermitApp.doc 09/09/10 440 -4617T (11 /02/COM/WEB) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial & Multi- Family Fee Schedule: Total Valuation: Permit Fee: $0.00 to $500.00 Minimum fee $69.06 $500.01 to $5,000.00 $69.06 for the first $500.00 and $3.07 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and $2.81 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and $2.54 for each additional $100.00 or fraction thereof, to and including • $50,000.00. $50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and $2.49 for each additional $100.00 or fraction thereof, to and including • $100,000.00. $100,000.01 and up $2,608.71 for the first $100,000100 and • • • $2.92 for each additional $100.00 or • fraction thereof. Note: All new commercial buildings require 2 sets of plans. • • . I:\ Building \Permits \MEC- PermitApp.doc 09/09/10 s y'lz•- 1 9(190 Electrical Permit Application _ , `' City of Tigard ` r RR i 6 t�lj PennitNo.: , f s • 't 13125 9W 1-lall fllvd., Tigard, OR }722 kl � L ' Plan Review " +�� 1 hone: 503.7 l 8,2439 Fax: 503.598.1960 Dcldl) ; Other Permit . 1 . i n 1t 11 Inspection .Line: 503.639.4175 AUG 17 2011 Data Rcady /By Julia: Pi Son Page 2 fur intemet: www.tigard- or.gov Notifiod/Method; - Supplemental information TYPE OF WORK CITY OF i IGA D PLAN REVIEW 0 New construction .. ❑ Addition /alt'ciatior /repliieeinerii Vii' 1� Please chock all that apply (submit 2 vets of plans w /items uheuked below): : v r 1 =L ° � "" " t ' ❑ Serviwt or feeder 400 amps or more ❑ Building over three stork's. ❑ Demolition ❑ Other; whore the available fault carrenl 0 Marinas and boatyards. CATEGORY OF CONSTRUCTION ' exceeds 10.000 amps at ISO volts or ❑ Floating buildings. - • • • -• lass to around, or exceeds 14,000 ❑ Commercial -use agrioullurat ❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for a ll other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Other: ❑ Fin pump. ❑ installation 4)1775 KVA or JOB SITE INFORMATION AND LOCATION ❑ Emcrgensy system. larger sotauataly derived system. ❑ Addition of new motor loud of ❑ "A", "E ", "I .2" "1 -3 ", Job site address: { - s -° ' S S ki j366,∎GS,&,_ L00111tor roai occupancy, Job no,: � _�_,•, El Six or more residential units. ❑ Recreational vehicle parks, Cit /Shale /ZIP: ❑ Hcaltlt ous tnoilitiva. © Supply voltage for more than y J 5 �r v Cra� crt 7 Z �, - ❑ H Hazardous locations, 600 volts nominal. Suite/bldg. /apt. no.: Project name: ❑ Serviuo or louder 600 amps or mote. ..... - F ....,.. —._..° FEE SCHEDULE Cross street /directions to job site Description _ _ rbe• �' at�l ' - New residential single- or multi-family q ti- family dwe ling unit. - Includes attached garage. Subdivision: Lot no.: 1,000 sq. 11. or less _ . 168.54 4 .-w. Pa. add'I 500 sq. ft, or portion 33.92 3 Tax map /parcel n0.: Limited energy, residential 75.4)0 M.. 2 DESCRIPTION OF WORK (with above ; .. ft. _• --- 1.imited energy, multi- tatnity 75.110 2 residential (with above sq. ft.),.. — •._ Services or feeders Installation alleratfon and /or relocation 200 amps or less I 100,70 2 ❑ PROPERTY OWNER T ❑ TENANT 201 amps to 400 amps r, 133.56 2 Name • 401 amps to 600 lama 200 2 -- .............•....• -.� 601 (unps to 1,000 amps 301.04 2 Address: Over 1,0110 amps or volts 552.26 2 City/State/ZIP: -. •. _. ` - Temporary setwlees or feeders installation, alteration, and /or relocation -- 200 amps or less 59.36 1 Phone: ( 0 am _ ) _ wax; ( ) — .....•. Owner installation: This installation is being made on property that I own Which is not 201 amps to 400 amps �^ 125.08 2 unleaded for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701 • 401 snips to 599 amps 168.54 2 Branch circuits -• new, alteration, or extenslothper panel Owner signature: ... ...., Date: ,_,_. - , __,_, hate: ., A. Fee for brunch circuits with 0 APPLICANT ❑ CONTACT PERSON alcove service or feeder fee, each 7.42 2 .- branch circuit 1Business name: B. Fee for branch circuits wirhord service or feeder fee, first branch 56.18 2 Contact name: circuit _• - - - - w.. - _......: , ii; ch asld'1 branch circuit 7,42 2_ Address: Miscellaneous (service or feeder not included) Each manufactured or modular 67.84 2 City /State/ZIP: dwelling, service poor feeder Phone: ( ) Fax:: ( ) Reconnect only ... 67.84 2 y - - Pump or irrigation circle 67.54 2 E -mail: .•.. Sign or outline lighti 67.84 2 CONTRACTOR Signal circuit(s) or limited•enrrgy - C , L L C- Pesch, sdtrnttian,Or extension. Page 2 2 Business name: b u`� , Each additional Ins edo _n over allowable in atty of the above Address: I - ' � , L. er e _ CT Y ep Additional inspection (1 hr min) 66.25/ hr City /State/ZIP: (38 4v �tiQk.. -- Ulm 7 ott Investigation plant (1 Ir Mini 66 hr _._.. _•. , Industrial (1 hr min) 78.18/ hr Phone (rg,.1 ) 9 1- t.� - 9 Fax (}yll.I ) C 3 z - 3 2 Inspections for which no fee in 90.00/ hr �. .r• specifically listedsi4lir nnin) _ CCB Lie.: \'517_1 3 1 Electrical Lic,; `z� -- -- It 1 2L. Suprv. Lie.: s .S ( � - ELECTRICAL PERMIT FEES _ _ � m Subtotal: Suprv. Electrician signature, required: x2`'"'A" .� �� — ���� flan review (25 °/n of permit foe): Print name: j oyk,.;rl - 0.1/2-1,tnJ si im Date:: S ._ - 1 j \ 1 State surcharge (12% of permit fee): .N TOTAL PERMIT F RP,: Authorized signature: This permit applkeden expires Ifs permit is not ohtahted within 180 ..T Print name: �.._ -. Date: days after it has been accepted as complete. • Number of inspections allowed per permit. I :\Bultding\PmmiutEl C- PmmitApp.oc 07N1/10 440•4615-rtt 1 /OS /COMIWLB Q LeA vL i4 P D s i 1 rw - 5 - " 1 -'t'`r 4S, T IT •zova SZSCZC9COS AEC AesED NV LT:80 TTOZ'8T-bng