Permit allik WASHINGTON COUNTY RESTRICTED
Department of Land Use & Transportation
Electrical F tien Section ELECTRICAL ENERGY
ihip 155 North First rst Avenue, #350 -12
Hillsboro, Oregon 97124 APPLICATION
Information: (503) 640 -34470 0 Fax: (503) 693-4412
PLEASE PRINT
Please complete all sections, 1 through 5. Permit No. ' L R 9 5 — ( 3
1. Location of installation 7) Date 6,1 2 9.5
Address i3?3S $ — / ears/
City / ' 4 Zip Code 4. Type of work:
Map 110. Tax Lot RESIDENTIAL Restricted Energy Fee
A gy $40.00
Thomas Map Book: Page Section (for all systems)
Check type of work involved:
Directions
— Audio and Stereo Systems*
Commercial Residential 0 _ - Burglar Alarm
T elephone Systems*
Tenant Name — G arage Door Opener*
�yJ
(if commercial) �S /v/� /17,4 S --/ _ F ire Alarm
H eating, Ventilation and Air Conditioning Systems*
2. Contractor application: _ Vacuum Systems*
� Other
Electrical Contractor p>i✓v - i'f�•9•e.)
Address c/7i7c3 4'7"� I
/" COMMERCIAL Fee for each system $40.00
City "gena.✓e' Statee& Zip (see OAR 918 - 260 -260)
Date 6 -a-7.-9.5 Job Number Check type of work involved:
Property Owner
Contractor's License No. .5 "/3
Contractor's Board Reg. No. ✓rA.3 ^ Boiler Controls
Clock Systems
Phone No. 77 —6/.50 J
Data Telecommunications Installations
— Fire
3. Owner application: - HVACIarm Installation
- Instrumentation
Print Owner's Name Phone No. — Intercom and Paging System
5( Landscape Irrigation Control*
Address — Medical
— Nurse Calls
City State Zip — Outdoor Landscape Lighting*
This permit is issued under OAR 918 -320 -370. The applicant agrees - Protective Signaling
to make only restricted energy installations (100 volt amps or less) — Other
—
under this permit and to do the following:
1. Only use electrical licensed persons to do installations where
required. (Certain residential and other transactions are exempt I Number of Systems
from licensing. These have asterisks ('F). All others need licens-
ing.)
2. Call for an inspection when all the installations under this permit * No licenses are required. Licenses are required for all other installations.
are ready for inspection.
3. Purchase separate permits for all installations that are not ready 5. Fees
for inspection when the Inspector is out to inspect under this
permit. Enter fees $ •
4. Assume responsibility for assuming that all corrections required
by the inspector are done, and
5. Assume responsibility for calling for a final inspection when all of 5% Surcharge (.05 X total above) $ 2 - the corrections are completed.
The person signing this permit must be the applicant or a person Trust Account $
authorized to bind the applicant.
Signature Total $ q2.
Authority if other than applicant This permit becomes null and void if the work authorized by the
permit is not commenced within 180 days from date of issuance
For inspections call of such permit or if the work authorized is suspended or abandoned
O', 41"x- at any time after work is commenced for a period of 180 days.
Electrical Permits are non - refundable and non - transferable.
24 -hour recorder, one working day in advance of need BL24 -114
639- 9 7s
� �:AC��^ :1 ` , 1101 S.E. 3RD AVENUE • PORTLAND, OREGON 97214 • (503) 238 -5700
850 CONGER • EUGENE, OREGON 97402 • (503) 683 -9333
=WYE SAFETY COMPANY 2600 AIRPORT WAY, SOUTH • SEATTLE, WASHINGTON 98134 • (206) 340 -4300
CERTIFICATION - INSTALLATION%INSPECTION
Customer Name
Address
SYSTEM
Model(s) and serial numbers
Number of nozzles and Part No.
Number of detector(s) and degree rating
Energy shut -off devices — type and size
Other accessory equipment provided (pull station, electric switches, etc.)
COOKING /VENTILATING EQUIPMENT
Number of duct(s) and size
Hood size and plenum size +
Cooking Appliances and size of cooking surface. (NOTE: List appliances from left to right and indicate those
being protected.)
1. 4.
2. 5.
3. 6.
TO BE COMPLETED BY INSTALLER
❑ YES ❑ NO
The fire suppression system is installed in accordance TO BE COMPLETED BY CUSTOMER
with the manufacturer's instructions, NFPA Standard
96 and 17 (current issue), and all applicable state and
local codes. Exceptions to other provisions of NFPA 96 0 YES ❑ NO
that were observed are noted below.
I understand that it is the recommendation of ANSUL
Exceptions: and of the National Fire Protection Association
Standard 96 and 17 that the fire suppression system be
inspected and maintained every 6 months to ensure
continued efficiency and reliability and that failure to
do so may result in failure of the system to operate
properly.
CUSTOMER NAME AND TITLE
❑ VES ❑ NO
All electrical work or work provided by others to SIGNATURE
complete this system installation has been completed. DATE
INSTALLER NAME ' K)
SIGNATURE wf°I -
DISTRIBUTOR ?f
ADDRESS •
DATE
3