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Permit CITY OF TIGARD ELECTRICAL PERMIT Permit#: ELC2014-00256 _ COMMUNITY DEVELOPMENT Date Issued: 05/19!2014 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 1 • Parcel: 1S134CD03900 Jurisdiction: Tigard Site address: 12020 SW 121ST AVE Project: Cebula Subdivision: LERON HEIGHTS NO.3 Lot: 69 Project Description: Grounding for new water service. 6/4/14: Reprinted permit to include(1)220 amp feeder. 6/12/2014: REPRINTED permit to correct scope of work to(2)branch circuits only. Contractor: OWNER Owner: KENT CEBULA KENT CEBULA 12020 SW 121ST AVE 12020 SW 121ST AVE TIGARD, OR 97223 TIGARD, OR 97223 PHONE: 503-270-9087 PHONE: 503-270-9087 FAX: FEES Quantity Description Date Amount 2 crt Branch Circuits wo/Purchase 06/04/2014 $63.60 Specifics: Service or Feeder 2 ea 12%State Surcharge- 06/04/2014 $7.63 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $71.23 Required Items and Reports(Conditions) 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 OA 952- 090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: dN ,7 it /(09-%/ON OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale,lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR.ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m.for the next available inspection date. 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. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request Permit Action r c;,\l;l) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov TO: CITY OF TIGARD RECEIVED Building Division Services Supervisor 13125 SW Hall Blvd.,Tigard,OR 9 223 JUN 0 5 2014 Phone: 503.718.2430 Fax: .598.1960 www.tigard-or.gov CITY OF TIGARD FROM: ❑ Owner Applicant ❑ Contractor El3PIElfliiit DIVISION (check one) REFUND OR Name: INVOICE TO: (Business or Individual) USG (f3j I c Mailing Address: 12020 SW 121 St" ken City/State/Zip: �/j( X 1 or-1223 Phone No.: 1 ' D 14°10- 23 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): H.........C.OricrCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: E - 002567 Site Address or Parcel #: 12020 Sv3 j Z 1 S k 1 e, G�t� OYZ 1 7223. Project Name: C-e butte- U Subdivision Name: Lot#: EXPLANATION: Clot inu) ect per► we Signature: Date: Q /05 j Print Name: 1 SGt Cebt,,,lci ( 7 Refund Polity ,t'6. ?f,.- 3 4 Q t 1-e 7?. 3P 1. The Director or Building Official may authorize the refund of: /, a) any fee which was erroneously paid or collected. /4 ' 'Fa � /-•'0 9..29 b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort h?fiaexpended. G4 �6 7 c) not more than 80%of the land use application fee for issued permits. O d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80%of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date 5 £ By rtj E: Rte to Bldg,\dtnin: Date 4; / • /r/ By Refund Processed: Date 6// //y By 4;!a Invoice Processed: Date By Permit Canceled: Date /(/hi By '�' Parcel Tag Added: Date By Receipt# Date Method Amount$ I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012 CITY OF TIGARD ED ELECTRICAL PERMIT COMMUNITY DEVELOPMENT ( Permit#: ELC2014-00256 T t G A R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 ■G7© � Date Issued: 05/19/2014 Parcel: 1 S134CD03900 Jurisdiction: Tigard Site address: 12020 SW 121ST AVE Project: Cebula Subdivision: LERON HEIGHTS NO.3 Lot: 69 Project Description: Grounding for new water service. 6/4/14:Reprinted permit to include(1)220 amp feeder. Contractor: OWNER Owner: KENT CEBULA KENT CEBULA 12020 SW 121ST AVE 12020 SW 121ST AVE TIGARD, OR 97223 TIGARD, OR 97223 PHONE: 503-270-9087 HONE: 503-270-9087 FAX: FEES Quantity Description Date Amount 1 ea Services or Feeders-201 to 06/04/2014 $133.56 Specifics: 400 amps 1 crt Branch Circuits w/Purchase 06/04/2014 $7.42 Type of Use: SF Service or Feeder Class of Work: ALT 1 ea 12%State Surcharge- 06/04/2014 $16.92 Electrical Type of Const: Occupancy Grp: Total $157.90 Required Items and Reports(Conditions) 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 • :• .••• -d by the Oregon Utility Notification Center. 'Those rule :re set forth in OAR ` 952-001-0010 through OAR 952-001-0090. You may obtain a .•y of the rules or direct questions to OUNC by calling Sp3.232.198 •r .:00.332 .4. 111111111111°' - Issued By: `� �±�-� •-- .1'ttee Signatu '• `` _ '4. MSC/ /s /OWNER INSTALLATION ONLY---- The installation is being made on property I own which is not intended for sale,lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR.ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m.for the next available inspection date. 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. Electrical Permit Application i }� FOR OFFICE USE ONLY City of Tigard `�' ' � \) Datee/Bea /� Permit#: An.' '...".C)(24:2.4-' IN - 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review jive, �J Phone: 503.718.2439 Fax: 503.598.1960 1�'ij Date/13 : Related Permit#: Inspection Line: 503.639.4175 - Ready Date/By: Mil El See Page 2 for TI G A R D Internet: www.tigard-or.gov Notified/Method: Supplemental Information ❑New construction ❑Addition/alteratio replacement Please check all that apply(submit 1 sets of plans w/items checked): ❑Service or feeder 400 amps or more ❑Building over three stories. ❑Demolition ❑Other: where the available fault current ❑Marinas and boatyards. OF.CONgrittletiON i exceeds 10,000 amps at 150 volts or 0 Floating buildings. ❑ 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural amps for all other installations. buildings. ❑Multi-family ❑Master builder ❑Other: ['Fire pump. ❑Installation of 150 KVA or i JOB srl'E INFORMATION AND itemI l ❑Emergency system. larger separately derived Job site address: nn ��++ ❑Addition of new motor load of system. Job# `2.)2)tJ J a\51- Pkwil l le_ 100HP or more. ❑"A" "E" "1-2","l-3" /^ ❑Six or more residential units. occupancy. City/State/ZIP: V 912.23 ❑Recreational vehicle parks. 0 facilities. 1� Suite/bldg./apt.#: ) Project name: ❑Hazardous locations. ❑Supply voltage for more than ❑Service or feeder 600 amps or more. 600 volts nominal. Cross street/directions to job site: FEE SCHEDULE Description I Qty. 1 Each I Total 1 • New residential single-or multi-family dwelling unit. Subdivision: Lot#: Includes attached garage. Tax map/parcel#: 1,000 sq.ft.or less 168.54 4 • Ea.add'I 500 sq.ft.or portion 33.92 1 DESCRIPTION OF WORK Limited energy,residential 75.00 2 (with above sq.ft.) - I'IN.) l 0 C(rnp (--"- +�✓- Limited energy,multi-family �J f�, p� residential(with above sq.ft.) 75.00 2 III �� 1':/ ' " Y` M�� i��� ���(X�5 Renewable Energy ❑ See Page 2 ❑ PROPERTY OWNER ❑ TENANT Services or feeders installation,alteration,and/or relocation Name: USA Ce1ov \ck 200 amps or less 100.70 2 Address: ,202 S O 12,`S n U . 201 amps to 400 amps 1 133.56 1 33,Qi 2 ty T� 0 IR. G-7 3 401 amps to 1,600 amps amps 301.04 _ 2 City/State/ZIP: 601 amps to 1,000 amps 301.04 2 Phone:(5()5) 4c 622$ Fax:( ) Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or Email: t`Sa. W e . • CvlQ 6 (a rr,a(( . corn relocation Owner installation:TIN i .llation Ybeing m de on property that I own which is not 200 amps or less 59.36 I intended for sale,1-ase,re I or„ bran_- .r, o,4 ing o ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2 Owner signature: —- — - • #' Date: (Nv/CX-1i 11-4 401 amps to 599 amps 168.54 2 ❑ 'eliPCANT 1 ❑ CONTACT PERSON Branch circuits-new,alteration,or extension,per panel A.Fee for branch circuits with Business name: above service or feeder fee, each branch circuit 7.42 2 Contact name: B.Fee for branch circuits without service or feeder fee,that 56.18 2 Address: branch circuit City/State/ZIP: Each add'l branch circuit 7.42 2 Miscellaneous(service or feeder not included) Phone:( ) Fax: :( ) Each manufactured or modular dwelling,service and/or feeder 67.84 2 Email: Reconnect only 67.84 2 CONTRACTOR Pump or irrigation circle 67.84 2 — Business name: Sign or outline lighting _ 67.84 2 Address: Signal circuit(s)or limited-energy ❑ See Page 2 2 panel,alteration,or extension. City/state/ZIP: Each additional inspection over allowable in any of the above Additional inspection(I hr min) 66.25/hr Phone:( ) Fax:( ) Investigation(1 hr min) 66.25/hr Email: Industrial plant(1 hr min) 78.18/hr Inspections for which no fee is 90.00/hr CCB Lic.: Electrical Lic.: Suprv.Lic.: specifically listed(1/2 hr min) ELECTRICAL PERMIT"FEE Suprv.Electrician signature,required: Subtotal:— Print name: Date: ❑Plan Review Required(25%of permit fee): T State surcharge(12%of permit fee): - - Authorized signature: TOTAL PERMIT FEE This permit application expires if a permit is not obtained within 180 Print name: Date: days after it has been accepted as complete. • Number of inspections allowed per permit. 1:1BuildinglPermits\ELC_PermitApp_ELR_ERE.doc Rev 04/21/2014 440-4615T(11/05/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Fee for all residential systems combined: $75.00 Renewable I Qty. I Each I Total 3' Renewwaable electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 2 5.01 to 15 kva 133.56 2 ❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2 Wind generation systems in excess of 25 kva: ❑ Burglar Alarm 25.01 to 50 kva 301.04 2 50.01 to 100 kva 552.26 2 ❑ Garage Door Opener* >100 kva(fee in accordance 552.26 2 with OAR 918-309-0040) ❑ Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva: System* Each additional kva over25 7.42 3 ❑ Vacuum Systems* >100 kva—no additional charge 0.0 3 Each additional inspection over allowable in any of the above: ❑ Other: Each additional inspection is 66.25/hr 1 charged at an hourly(I hr min) Inspections for which no fee is 90.00/hr specifically listed(/2 hr min) COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES Fee for each commercial system: $75.00 Subtotal(Enter on Page 1): y ' Number of inspections allowed per permit. (SEE OAR 918-309-0000) Check Type of Work Involved: ❑ Audio and Stereo Systems [1 Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical El Nurse Calls ❑ Outdoor Landscape Lighting* ❑ Protective Signaling El Other: Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 04/21/2014 CITY OF TIGARD ELECTRICAL PERMIT 11111 a COMMUNITY DEVELOPMENT Permit#: ELC2014-00256 T( A R 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 05/19/2014 G L7 Parcel: 1 S134CD03900 Jurisdiction: Tigard Site address: 12020 SW 121ST AVE Project: Cebula Subdivision: LERON HEIGHTS NO.3 Lot: 69 Project Description: Grounding for new water service. Contractor: OWNER Owner: KENT CEBULA KENT CEBULA 12020 SW 121ST AVE 12020 SW 121ST AVE TIGARD, OR 97223 TIGARD,OR 97223 PHONE: 503-270-9087 PHONE: 503-270-9087 FAX: FEES Quantity Description Date Amount 1 crt Branch Circuits wo/Purchase 05/19/2014 $56.18 Specifics: Service or Feeder 1 ea 12%State Surcharge- 05/19/2014 $6.74 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $62.92 Required Items and Reports(Conditions) 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 rough 0 52-00 90 You may obtain a copy of the rules or direct questions to OUNC by calling 50Y3.23�2/.11/�r 1.800.332.2344 ///� Issued B : _ / t Permittee Signature: '\ / X OWNER INSTALLATION ONLY L "� The installation is being made on property I • hich is not intended fo :le,lea-- •r rent. OWNER'S SIGNATUF�E 8,- ..-,�. _�_� � Date: r/ ` / "' CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR.ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m.for the next available inspection date. 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. Electrical Permit Application u FOR OFFIC E USE ON I City of Tigard RECEtV s : ' ffAMM i -w.,25- 13125 S W Hall Blvd.,Tigard,OR 97 Plan Review ' a Phone: 503.718.2439 Fax: 503.598.1960 Daze/By: Other Permit: I 1 G 1 K I Inspection Line: 503.639.4175 MAY 1 9 2014 Date Ready/By: Juris: ® See Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information TYPE OF WORK c% (or Tl--RU ^ PLAN REVIEW "� �NEERING Please check all that apply(submit/sets of plans w/items checked below): ❑New constructionddition/alteratjon/replacement ❑Service or feeder 400 amps or more 0 Building over three stories. ❑Demolition ❑Other: where the available fault current ❑Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings. less to ground,or exceeds 14,000 ❑Commercial-use agricultural A-and 2-family dwelling ❑Commercial/industrial ❑Accessory building amps for all other installations. buildings. ❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system. ❑Addition of new motor load of ❑"A","E","1-2","1-3", Job no.: Job site address: _2,() �N 2 100HP or more. occupancy. 1 V t �. ❑Six or more residential units. ❑Recreational vehicle parks. City/State/ZIP: —prat-�G�,fI G--1)-2...-3 ❑Health-care facilities. ❑Supply voltage for more than ty l '�" l ❑Hazardous locations. 600 volts nominal. Suite/bldg./apt.no.: Project name: ❑Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total I " New residential single-or multi-family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq.ft.or less 168.54 4 Ea.add'I 500 sq.ft.or portion 33.92 1 Tax map/parcel no.: Limited energy,residential 75.00 2 DESCRIPTION OF WORK (with above sq.ft.) Limited energy,multi-family 75.00 2 C,,\J o . 1 5, v 1 cc ry9\V�A residential(with above sq.ft.) t` Renewable Energy ❑ See Page 2 Services or feeders installation,_alteration,and/or relocation PROPERTY OWNER I ❑ TENANT 200 amps or less 100.70 2 ' ` 201 amps to 400 amps 133.56 2 Name: K e�-� C�(Olt/ ,G, 401 amps to 600 amps 200.34 2 Address: (-IV�U lW 1.3 I -- ¢�( 601 amps to 1,000 amps 301.04 2 � Over 1,000 amps or volts 552.26 2 City/State/ZIP: L\ ✓( u)Q �n 2'2- ' Temporary services or feeders installation,alteration,and/or Phone:( 5'(y-i) a.t"0]Y�07 �1� I Fax:( ) relocation 200 amps or less 59.36 1 Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2 intended for sale,leas., ent,or exc ••■_e,according to ORS 447,449,670,and 70 401 amps to 599 amps 168.54 2 Owner signatur-. _ , _ Date: / Branch circuits-new,alteration,or extension,per panel ❑ APPLICANT ❑ CONTACT P RSO A.Fee for branch circuits with above service or feeder fee, 7.42 2 Business name: each branch circuit B.Fee for branch circuits without Contact name: service or feeder fee,first • 56.18 % 1 b? 2 branch circuit Address: Each add'l branch circuit 7.42 2 City/State/ZIP: Miscellaneous(service or feeder not included) Each manufactured or modular 67.84 2 Phone:( ) Fax: :( ) dwelling,service and/or feeder , Reconnect only 67.84 2 E-mail: Pump or irrigation circle 67.84 2 CONTRACTOR Signor outline lighting 67.84 2 Business name: 0 OiLV Signal circuit(s)or limited-energy See panel,alteration,or extension. Page 2 2 Address: Each additional inspection over allowable in any of the above Additional inspection(1 hr min) 66.25/hr City/State/ZIP: Investigation(1 hr min) 66.25/hr Phone:( ) Fax:( ) Industrial plant(1 hr min) 78.18/hr _ Inspections for which no fee is 90.00/hr CCB Lic.: Electrical Lic.: Suprv.Lie.: specifically listed(%hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: Subtotal: , 54 - /I Print name: Date: Plan review(25%of permit fee): State surcharge(12%of permit fee): ( -'7 1 _ Authorized signature: TOTAL PERMIT FEE:,, G co, This permit application expires if a permit is not obtained within 180 Print name: Date: days after it has been accepted as complete. • Number of inspections allowed per permit. I:\Building\Permits\ELC_PerrnitApp_ELR_ERE.doe Rev 05/21/2013 440-4615T(11/05/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Fee for all residential systems combined ... $75.00 Description f Qty. 1 Fee I Total 1 Renewable electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 2 5.01 to 15 kva 133.56 2 El Audio and Stereo Systems* 15.01 to 25 kva 200.34 2 ❑ Burglar Alarm Wind generation systems in excess of 25 kva: 25.01 to 50 kva 301.04 2 ❑ Garage Door Opener* 50.01 to 100 kva 552.26 2 >100 kva(fee in accordance with 552.26 2 ❑ Heating, Ventilation and Air Conditioning OAR 918-309-0040) System* Solar generation systems in excess of 25 kva: Each additional kva over 25 7.42 3 ❑ Vacuum Systems* >100 kva—no additional charge 0.0 3 ❑ Each additional inspection over allowable in any of the above: Other: Each additional inspection is 66.25/hr charged at an hourly(1 hr min) Inspections for which no fee is 90.00/hr specifically listed(%3 hr min) COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES Fee for each commercial system $75.00 Subtotal: (SEE OAR 918-309-0000) Plan review,if required(25%of permit fee): State surcharge(12%of permit fee): Check Type of Work Involved: TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within ISO ❑ Audio and Stereo Systems days after it has been accepted as complete. ' Number of inspections allowed per permit. El Boiler Controls ❑ Clock Systems n Data Telecommunication Installation El Fire Alarm Installation El HVAC El Instrumentation ❑ Intercom and Paging Systems El Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* El Protective Signaling El Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations 1\Building\Permi ts\ELC_PermitApp_ELR_ERE.doc Rev 05/21/2013 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 701.325 (2)) 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 I own, reside in, or will reside in the completed structure and my general contractor is: 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. / llbe 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 I hereby certify that the information on this homeowner statement is true and accurate. kCdoL'!c rin Name o,,ermit Applicant L /� /, �vet ` f Sjigrrature of ermit Applicant Date Permit#: PLIy /y L`O%(i/ EiC.C;td-COo15-6. Address: �rurf.+�. ►1 r�/L7j O2 5'7;1-.2. 3 Is sued by� - Date: S/y�i / 14-- This Copy for Permit Offices Location: Record Type: Inspection Type: Result: Comments: Inspection Date: Record ID: Inspector: City of Tigard 13125 SW Hall Blvd. Tigard, OR 97223 Tel: 503.718.2439 12020 SW 121ST AVE, TIGARD, OR, 97223 Residential - Electrical 199 Electrical final PASS - No C of O June 23, 2014 at 9:10:40 AM ELC2014-00256 Jeff Grove Violation Summary: Inspector Contractor