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Permit l �t CITY OF TIGARD MASTER PERMIT ;r7 COMMUNITY DEVELOPMENT Permit#: MST2015-00103 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/22/2015 Parcel: 1S136CB03700 Jurisdiction: Tigard Site address: 11085 SW 83RD AVE Subdivision: STEVE& HUGHIE'S PLACE Lot: 9 Project: Simser/Arnsberg Project Description: Kitchen remodel and exhaust fan in bathroom. 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: Total: 0 sf Value: $3,000.00 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: 0 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: 1 Clothes Dryers: 0 Heat Pump: N Hoods: 1 Other Units: 0 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'I 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 1 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 Ecompasin N Other: N Other Description: g BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ALT SF VB R-3 0 Owner: Contractor: SIMSER,SARAH N OWNER Required Items and Reports(Conditions) ARNSBERG,ERIC SARAH SIMSER/ERIC ARNSBERG 11085 SW 83RD AVE 11085 SW 83RD AVE TIGARD,OR 97223 TIGARD,OR 97223 PHONE: 503-913-7630 PHONE: 503-913-7630 FAX: Total Fees: $214.71 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. ATT • -• • -,• law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-00 9010 through OAR 95 9 9 •9 I. ou may obtain a copy of the rules or direct questions to OUNC by calling 503. 32.1987 orr 1.800.33 .2344` / aka m Iss ed By: � �� � Perm Signature: /' 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. . a Building Permit Application Residential 1 (m 01 I I( I I s l ()NI 1 Received f' 1� J S7,C !O3 gi City of Tigard Date/By:� � ( Permit No.: 7 Q�� 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Phone: 503.718.2439 Fax: 503.598.1960 Date/By: ��� Other Permit: Inspection Line: 503.639.4175 Date Ready/B �J kris Fa See Page 2 for Internet: www.tigard-or.gov Notified/Method: Gel,'/jS`� Supplemental Information ❑New construction ❑Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all lit Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the work indicated on this application. I-and 2-family dwelling ❑Commercial/industrial 4 Valuation: $ VCR El Accessory building ❑Multi-family Number of bedrooms: ❑Master builder ❑Other: Number of bathrooms: JOB SITE INFORMATION AND' OC TO Total number of floors: 0- Job site address: I I IA6 (EIIV b#3 111 hie,iv New dwelling area: square feet City/State/ZIP: Ti Qard l or `22 J Garage/carport area: square feet Suite bldg./apt.no.:�j Project name: st j1, �- S Covered porch area square feet job site: �i Cross street/directions to j Deck area: square feet Other structure area: square feet 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 IIIIIIIIIIIIIIITIIIL DESCRIPTION OF WORK work indicated on this p cation. rein odd Kitchen ro� Valuation: $ Y f�f t I Existing building area square feet New building area: square feet **NW PROP RTY.OWNER . _ _ - ❑ TENANT Number of stories: /l i f l Name:Gr i C 5 /Sa t r'Y 'ii Type of construction: Address:I k D%5$.,w V Ave, Occupancy groups: City/State/ZIP: 1 J f Old °Il Z23 Existing: Phone:( 5O? 1�l —7 VJO Fax:( ) New: .❑ APPLIC• Q CONTACT PERSO. Business name: Structural plan review fee(or deposit): Contact name: FLS plan review fee(if applicable): Address: Total fees due upon application: City/State/ZIP: Phone:( ) I Fax:;( ) Amount received: 7 7. 5-40 E-mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM Co •rcial and residential prescriptive installation of roof-top .unted PhotoVoltaic Solar Panel System. Business name: A kJA/6---X___ Submit two -is of roof plan with connection• .ils and fire departmen •• •ss,along with the 21 . Oregon Address: Solar Installation Specia ,•• chec . City/State/ZIP: Permit Fee(includes plan .ew $180.00 and admini• .i ve fee . Phone:( ) Fax:( ) State surcharge • /o of permit fee): $21.60 CCB lic.: • . fee due upon appication: 01.60 Authorized signature: a/Ui'( 14 , 4 This permit application expires if a permit is not obtai .�(, Print name:Lc ant. Si msek- Date: 5/2j/ 5 within 180 days after it has been accepted as complete. ` *Fee methodology set by Tri-County Building Industry Service Board I:\Huilding\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB) r . Building Permit Application Checklist One- and Two-Family Dwelling FOR OFFICE USE ONLY City of Tigard Received IP/ 13125 SW Hell Blvd.,Tigard,OR 97223 Associated permits: I Phone: 503.718.2439 Fax: 503.598.1960 FIGARL) 24-Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing [] Internet: www.tigard-or.gov ❑ Other: THE FOLLOWING ITL.IS ARE REQUIRED FOR PLAN REVIEW 1es No N/A 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ El ❑ 2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. ❑ ❑ ❑ 3 Verification of approved plat/lot. ❑ ❑ ❑ 4 Fire district approval required. Name of district: . El El ❑ 5 Septic system permit or authorization for remodel. Existing system capacity ❑ ❑ ❑ 6 Sewer permit. ❑ ❑ ❑ 7 Water district approval. ❑ ❑ ❑ 8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑ 9 Erosion control ❑plan ❑permit required. Include drainage-way protection,silt fence design and location of catch- ❑ El ❑ basin protection,etc. 10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state El ❑ ❑ building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if copyright violations exist. 11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if T ❑ El El there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements and driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction indicator;lot area;building coverage area;percentage of coverage;impervious area;existing structures on site;and surface drainage. 12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size El ❑ ❑ and location. 13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, ❑ ❑ ❑ furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc. 14 Cross section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- ❑ Cl ❑ floor,wall construction,roof construction. More than one cross section may be required to clearly portray construction. Show details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings and foundation,stairs,fireplace construction,thermal insulation,etc. 15 Elevation views. Provide elevations for new construction;minimum of two elevations for additions and remodels. ❑ El ❑ Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope. Full-size sheet addendums showing foundation elevations with cross references are acceptable. 16 Wall bracing(prescriptive path)and/or lateral analysis plans. Must indicate details and locations;for non- ❑ ❑ ❑ prescriptive path analysis provide specifications and calculations to engineering standards. 17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing ❑ ❑ ❑ locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑ systems,see item 22,"Engineer's calculations." 19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ El El over 10 feet long and/or any beam/joist carrying a non-uniform load. 20 Manufactured floor/roof truss design details. ❑ ❑ ❑ 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required El ❑ ❑ for four or more appliances. 22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or d ❑ El architect licensed in Ore:on and shall be shown to be :.ilicable to the .ro-ect under review. Jt'RISUI(' IION.U. SPF:('1FI('S 23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". ® ❑ ❑ 24 Two(2)sets each are required for Items 16, 19,20 and 22 above. El ❑ ❑ 25 Building plans shall not contain red lines or tape-ons. "Mirrored"buildingplans will not be accepted. ❑ ❑ ❑ 26 "Reversed"buildingplans must meet criteria outlined in the Permit&System Development Fees document. ❑ Cl ❑ _ 27 "Drawn to scale"indicates standard architect or engineer scale. ❑ Cl ❑ 28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard ❑ ❑ ❑ Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, El ❑ El and protection measures must be drawn to scale and must include the project arborist's signature of approval. 30 A Clean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, ❑ ❑ ❑ including decks,patio covers(over non-impervious surface)and accessory structures to existing residential dwellings on a lot of record approved prior to September 9, 1995. _ I:1Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-46131(11/02/COM/WEB) • Electrical Permit Applicatiollt ��� E I()I' ()1 1 1 t 1 I ;,N I 1 City of Tigard Dea: i r Perini `i - A -0014- ;N .. 13125 SW Hall Blvd.,Tigard,OR 97223. ,,,i 1 g 2015 Plan Review Phone: 503.718.2439 Fax: 503.598.l96t�' Date/B : Related Permit#: Inspection Line: 503.639.4175 y Ready Date/By: Juris See Page 2 for Internet: www.tigard-or.gov ��'�� �)j 1l�A IJ Notified/Method: Supplemental Information I ❑New construction p Addition/alteration/replacement Please check all that apply(submit 2 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. . exceeds 10,000 amps at 150 volts or ❑Floating buildings. !1: 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural El Multi-family ❑Master builder ❑Other: ['Fire amps for all other installations. buildings. pumm p. 0 Installation of 150 KVA or , . ❑Emergency system. larger separately derived Job#: Job site address: j/ ❑Addition of new motor load of system. II D$s 5I g3re Ave, 100HP or more. ❑"A" °E" "1-2""1-3" City/State/ZIP: v' 3 ❑Six or more residential units. occupancy. � / 0 7 ZZ ❑Recreational vehicle parks. 0 facilities. P Suite/bldg./apt.#:' I 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: Description Qty. Each Total • New residential single-or multi-family dwelling unit. Subdivision: I Lot#: Includes attached garage. 1,000 sq.ft.or less 168.54 4 Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 33.92 1 Limited energy,residential 75.00 2 1 Q yt �n mo, , (with above sq.ft.) �I► ri Limited energy,multi-family 75.00 2 residential(with above sq.ft.) Renewable Energy ❑ See Page 2 _ Services or feeders installation,alteration,and/or relocation Name: Or/G /t'rvl S berg &trail S t mser 200 amps or less 100.70 2 Address://O5 S1'V 63 '/Iv& 201 amps to 400 amps 133.56 © � �/ 401 amps to 600 amps _ 200.34 -© City/State/ZIP: !( a U/ Dk '7 7223 601 amps to 1,000 amps 301.04 2 Phone:(503) -76)30 I Fax:( ) Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or Email: _ei1, '-nsbero 6 c ma//.C CIfl relocation Owner installation:This ins allation is being made on property that I own which is not 200 amps or less 59.36 1 intended for sale,lease,rent,or exchange,according to ORS 447,449,670 an. 701. 201 amps to 400 amps 125.08 2 04 Owner signature: ,4/.. _!�L �, Date: 5 21 401 amps to 599 amps 168.54 2 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 Address: service or feeder fee,first 1 56.18 2 branch circuit City/State/ZIP: Each add'l branch circuit 7.42 2 Miscellaneous(service or feeder not included) Phone:( ) I Fax: :( ) Each manufactured or modular dwelling,service and/or feeder 67.84 2 Email: Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 Business name: D 1 v I t L lc Sign or outline lighting 67.84 2 Signal circuit(s)or limited-energy ❑ See Page 2 2 Address: panel,alteration,or extension. g City/State/ZIP: Each additional inspection over allowable in any of the above Additional inspection(1 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.: s., ificall listed %]hr min Suprv.Electrician signature,required: Subtotal: Print name: Date: ❑Plan Review Required(25%of permit fee): State surcharge(12%of permit fee): 74".4.Authorized signature: a( (_ TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 Print name: S 1 6/mser Date: S/Zf JS days after it has been accepted as complete. /// * Number of inspections allowed per permit. I:\Building\Permits\ELC_PamitApp_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 for all residential systems combined: $75.00 Description E.eh Total • 3' Renewable 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 over 25 7.42 3 ❑ Vacuum Systems* >100 kva—no additional charge 1 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(1 hr min) Inspections for which no fee is 90.00/hr 7 s.•cif-mall listed %hr min /� Subtotal(Enter on Pagel): Fee for each commercial system: $75.00 • Number of inspections allowed per permit. (SEE OAR 918-309-0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other: Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\Building\Permiu\ELC_PermitApp_ELR_ERE.doc Rev 04/21/2014 . . Mechanical Permit Application FOR OFFICE USE ONLY City of Tigard Received t Date/By: /g / Permit No. i , ,,AL/ .J ` < i 1 IIIII se 13125 S W Hall Blvd.,Tigard,OR 97223 Plan Review m Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit: TI G A R l Inspection Line: 503.639.4175 Date Ready/By: Juris: ® See Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information Mechanical permit fees*are based on the value of the work ❑New construction rxi Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all ❑Demolition ❑Other: mechanical materials,equipment,1 rioverhead,and profit Value:$ IN 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist. ❑Multi-family ❑Master builder ❑Other: Description I Qty. I Ea. I Total Heating/cooling: Ave, r conditioning 46.75 Job site address: I1 V S sw 0 p / IV 6 Furnace 100,000 BTU(ducts/vents) 46.75 City/State/ZIP: -R 6a,trj R q 7223 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 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: I Lot no.: Other: 23.32 Other fuel appliances: Tax map/parcel no.: Water heater 23.32 DESCRIPTION OF WORK Gas fireplace/insert 33.39 �/ p N u /`y� n' J Flue vent for water heater or gas k i I t M. 1 I e fOcJ G!/ pa,ih rvom � fireplace 23.32 Log lighter(gas) 23.32 Wood/pellet stove 33.39 Wood fireplace/insert 23.32 Chimney/liner/flue/vent 23.32 Other: 23.32 Environmental exhaust and ventilation: Name: ETU,'limber-9 t,h 5i m�v- Range hood/other kitchen �d equipment I 33.39 53-31 Address:/l0 S5 � s Ave, Clothes dryer exhaust 33.39 City/State/ZIP: I I G ,- DR 9 7223 Single-duct exhaust(bathrooms, + toilet compartments,utility rooms) 1 23.32 23-3Z Phone:( ) ,3-- 7L 3p Fax:( ) Attic/crawlspace fans 23.32 Other: 23.32 Fuel piping: Business name: $14.15 for first four;$4.03 for each additional Contact name: Furnace,etc. Address: Gas heat pump Wall/suspended/unit heater _ _ City/State/ZIP: Water heater Phone:( ) I Fax::( ) Fireplace Range E-mail: Barbecue Clothes dryer(gas) �'n , l,ly/ Other: (/(/ Business name: eR Address: Subtotal City/State/ZIP: Minimum permit fee($90.00) Phone:( ) I Fax:( ) Plan review(25%of permit fee) State surcharge(12/o of permit fee) _ CCB lic.: TOTAL PERMIT FEE This permit application expires if a permit is not obained within 180 n days after it has been accepted as complete. Authorized signature NL / n/L/LLL • Fee methodology set by Tri-County Building Industry Service Board Print name: a& m SJrl 'ek I Date: 5/2i/is I:\Building\Permits.MEC_PermitApp_040113.doc 440-4617r(11/02/COSt/WEB) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial & Multi-Famil Fee Schedule: $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$100,000.00 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_040113.doc 2 t RECEIVED Property Owner Statement JUN 18 2015 Regarding Construction Responsibilities • . . avaKD Oregon Law requires residential construction permit applicants who are not licensed with the "VISION 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 per mits. 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: Name CCB# Expiration Date I will inform my general contractor that a II subcontractors who work on the structure must be licensed with the Construction Contractors Board. or 01- I will be performing work on property I own, a residence that I reside in, or a residence that I w ill 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 hom eowner statement is true and accurate. & Ya h csrmser Print Name of Permit Applicant /2I45 PALA- v,44/1 5 Signature of P rmitApplicant Date Permit#: 1-16T go 1 5-oo/ 3 Address: (0% 61Z 33 C4P n )e- ~ �� ?` Issued by: '6 Date: 264i5' /4 This Copy for Permit Offices City of Tigard 13125 SW Hall Blvd. Tigard, OR 97223 Tel: 503.718.2439 Location: Inspection Date: 11085 SW 83RD AVE, TIGARD, OR, 97223 July 7, 2017 at 2:13:23 PM Record Type: Record ID: Residential - Master Permit MST2015-00103 Inspection Type: Inspector: 199 Electrical final David Young Result: PASS Comments: Violation Summary: Inspector Contractor City of Tigard 13125 SW Hall Blvd. Tigard, OR 97223 Tel: 503.718.2439 Location: Inspection Date: 11085 SW 83RD AVE, TIGARD, OR, 97223 July 7, 2017 at 2:13:48 PM Record Type: Record ID: Residential - Master Permit MST2015-00103 Inspection Type: Inspector: 299 Final inspection David Young Result: PASS - NoCofO Comments: Violation Summary: Inspector Contractor City of Tigard 13125 SW Hall Blvd. Tigard, OR 97223 Tel: 503.718.2439 Location: Inspection Date: 11085 SW 83RD AVE, TIGARD, OR, 97223 July 7, 2017 at 2:13:40 PM Record Type: Record ID: Residential - Master Permit MST2015-00103 Inspection Type: Inspector: 699 Mechanical final David Young Result: PASS Comments: Violation Summary: Inspector Contractor