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9160 SW 69TH AVENUE • ADDRESS : l i \records\microflm\targets\building doc "Mfol'hVM1� '., .., �. .. .':5��p��¢;&:?Eft r•lelp'4 '�'n1II 1ca�t,;r+vt rgl¢. c'�r�" -+s+w. yw-.. ...,r.a _, - ,-.._.....«... . _ � ..:i4AM�.i d'AfG{u"�M a&4��Xr' �Y -:r� -. � ,. .. .Y�a,+MrtnnMn- �r+.+'�Fu+.+.+.R"r r.nfe'•+. a i. .. �. i m'w.MY,I4dLu'i• .. r., � .. 9` -... nM+iw.^ ..+'w�MY.:°,:lntTW bvr!�/�T;iw Idll ##�P ###� Illi i##I P#!l #iPl I#fl PP1! IIII l##d'!c## IIlI IIIP llil !### li#1 l#ll ILII !!I# 1111 1 I II �I I� t� � .� ,. .1, 1{114 LEGIBILITY STRIP cm 1 I I C I # !�# #� I1►II }I ri�llllll#I�IIIIIi""`` i} I### Ilil 1#I#�IIII�PIiI ilillili Illy#III I#illi' ''Illii## ,ILII#I(Ilil I#ll Illliili �;,i ���� ��,� �,;1 „i, „I, � I;t 6 7 1 19 2� ( �' : `� ,.Y� ■� �'" 5 8 10 1 1 1 2 13 d O 21 22 23 24 2°5 28 27 2e 29 30 01 © 9 HOW t 10a ' 0 LIP9 1 w �1 1 RE VISIONS OA TT BY LLI LOT 4o LU A } cp a- Lu o z (J[ � �; ELEV 1023' S 89° 45' 23 E E LE v 01D �--- � 199.30' Q I i i Ex66TING GRAVEL DRIVE �/- SILT FENCE FOR -3 �/� EROSION CONTROL f Lu LLJ o Q) / AIN DRAT JII ITIPROPOSED R / 1818,0'� I I ADDON j c (pu1' -------------- LOT 5 o _�' c� / EXIBTMG STRUCTURE ! Q 1 I I FIN FLOOR ELEV 6085' I O O �} 111 � PROPOSED I � I cp o ADDITION I I O I RAIN DRAIN I — — — — — - — — — — — — -�— — — — — — — — — — - — — — — — — — — — — — — — TO APPROVED STORM DRAIN 30 D' 1 - 4 Z ELEV COD' S 890 45' 23" E ELE`✓ 119.0' (� A \jNORTH 0 - U' LOT 6 � G ALL ELEVATION DATUM ASSUMED 'O c—) _ 0 1 j z ci U � r (f) 0 f=' LAlN "I cl UkAWN BY LOT 5, K ING5 VIEW Mr WAEL �f LOCATED IN THE SOUTHEAST QUARTER OF SECTION 25, Ob iIA Z TOWNSHIP I SOUTH, RANGE I WEST, WILLAMETTE MERIDIAN CITY OF T*ARD, WASHINGTON COUNTY, OREGON Yxi 4 U TAX MAP 01050A, TAX LOT #WOO 1(10 tilt' 64) AVEN1.)1: � o ! 111111111 !II�IIIII 1�I�IIIII IIIIIIIiI I�IIII1,! II��II II Iilllilfl IIII III► I�1� IIIi 11i1 illi ills ill Illi Ilii IIII III IIII iii �� LEGIBILITY STRIP Amo I � 3 4 I ( I � ." =I s � � � >� Io 11 12 13 � 4 18 I � IS II 21 I I I I� ,,I I , � I 9 O 21 22 23 24 2 � 2'6 27 26 29 30 1 r Or HOW �l UZ <,H<w ADDRESS: m GO SW J r-r G7 r. 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Mach, Rough-in Gyp. Bd. Bldg. San. Sawer Gas Line Appr/Sdwlk Reins. Other: _75—"L ,, Date: _ — A.M. _P.M. Un Address: Tenant _ Ste: _ MST: / BUP: Con/Own:�` /�1 _ MEC: PLM: ELC: O THE FOLLOWING CORRECTIONS APE REQUIRED: ELR— atiti I isppeector: Date: �'' APPROVED DISAPPROVED/CALL FOR REINSR CF CO CITY OF TIGARDERMASTR PERMITIT #. . . . . . . : MST95-0301 COMMUNITY DEVELOPMENT DEPARTiMNT DATE ISSUED: 06/28/95 13125 SW Hall Blvd.Tigard,Oregon 97223*8199 (503)639-4171 PARCEL: 1S125DA-02000 SITE ADDRESS. . . ; 09160 SW 69TH AVE SUBDIVISION. . . . : KINGS VIEW ZONING: R-4- 5 BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . :5 ----------------------------------- BUILDING REISSUE: DWELLING UNITS: 1 BASEMENT. . . . . . . . :0 s-F CLASS OF WORK. :ADD BEDRMS:2 BATHS:2 GARAGE. . . . . . . . . . .0 sf TYPE OF USE. . . :SF FLOOR REQUIRED TYPE OF CONST. :5N FIRST. . . . :583 sf LEFT. . :32 ft RIGHT. :21 ft OCCUPANCY GRP. :R3 SECOND— :0 sf FRONT. :74 ft REAR. . :78 ft STORIES. . . . . . . : ! FINBSMENT:O sf REQUIRED-_-__-__._.-____-.__-_ HE I GHT EQUIRED---------------------- HEIGHT. . . . . . . . : 16 ft TOTAL.-------:583 sf SMOKE DETECTORS. :Y FLOOR LOAD. . . . :40 psf VALUE. . . . . 37697 PARKING SPACES. . :O Remarks : ADDITION PATH I PLUMPINE, -- SINKS. . . . . . . . . . : 1 FLOOR DRAINS. . . . :0 BACKFLOW PREVNTRS. . :O LAVATORIES. . . . . :2 WATER HEATERS. . . :0 TRAPS. . . . . . . . . . . . . . :0 TUS/SHOb.LRS. . . . : 1 LAUNDRY TRAYS. . . tO CATCH BASINS. . . . . . . :0 WATER CLOSETS. . :2 SEWER LINE (ft ) . %O GREASE TRAPS. . . . . . . :0 DISHWASHERS. — : 1 WATER LINE (ft ) . .-O OTHER FIXTURES. . . . . :0 GARBAGE DISP. . . rl PAIN DRAIN (ft ) . :O WASHING MACH. . . : 1 SF RAIN DRAINS— i1 ---------------- MECHANICAL FUEL TYPES-------------- UNIT HTRS. . cO type amol.knt by date recpt lGHsl VENTS . . . . . 15 BPRT $ 229. 00 B 08/28/95 95-269850 MAX INPUT:0 BTU VENT FANG . :2 BPLC $ 148. 85 JD 08/08/95 95-268977 FURN ( 100K . . .-0 HOODS. . . . . . : I B5PC $ 11. 45 B 08/28/95 95-269850 FURN ) =100K . . .-0 WOODSTOVES. :O MPRT $ 47. 50 B 08/28/95 95--269850 FLOOR FURN. . . . .0 CLO DRYERS. - I MPLC $ 11. 88 B 08/28/95 95-269850 BOIL/CMP ( 3HP:0 O1'llr--P UNITI-3 :121 1yF;PC 11 i2l. _8 S 03/23/95 951-06 9 8 5 1/1 GAS OUTLETS:O PPRT $ IiI. 1210 B 08/0'8/95 95-269850 Owner, $ 5. 55 D 08/28/95 95-269850 WILLIAM WEST EROS $ 26. 00 B 08/28/95 95-269850 09160 SW 69TH PVE ERPC $ 8. 45 B 08/28/95 95-269850 ERPC $ 8. 45 8 08/28/95 95-269850 TIGARD OR 97223 Phone ff.- 244-4468 Contractors _____.____-_._-_-______________ OWNER Phone - ------ ----- Reg . . : 000000 $---610. 51-TOTAL V; This perelit is issued subject to the regulations contained in the ------- REQUIRED INSPECTIONS Tigard Municipal Code, State of Grp. Specialty Codts and all other Footing Insp Pliimb Top OUt applicable laws. All work will be done in accordance with approved FOLIndation Insp Framing Insp plans, This perait will expire if work is not started within 180 POSt/BC'aM Strutt Insulation Insp days of issiamp, or if work is suspen d or ear# than 180 days. Post/Seam Mechan Gyp Board Insp LJ Crawl Drain Rain drain Insp L t4 k' 0 Permittee at ur 111 m'11-knd1ab Ins), Mpc-1-ianicai Firal PLM/Underfloor Plumb Final Building e sr" Mechanical Insp Pet lssk.ied Dyi Final Call for inspection - 639-4175 Residential Building Permit Application City of Tigard 13125 SW Hall Blvd. r Tigard, OR 97223 (503) 639-4171 Jobsite Address: ` / / �� ' ` ( e (C�/!lt ,i 16 e- ' Office Use Only Subdivision:� ��� yle.c.c.1 Lot # Valuation: Permit # h9,5 o .�t'_�___.___ Corner Lot? y CN j Flag Lot? Y /�� Reissue of Map & TL I �t _ Owner: 1,11i dru /la/ �h- GGlSf Approvals Required Address: Planning �tta�2�� 6L Q7 Engineering _ Phone: 07 VV& Other Contractor: �� Items Required Address: Subcontractors Truss Details Phone: Other Contractor's License # (attach copy of current Oregon license) Te C-.e Contact Name & Phone: Subcontractors: Architect/Engineer: �. lf?�I N& I' e Aye— Plumbing;_ - Address: Mechanical: Cir' e-1- 12-1 (attach copy of current OR Contractor's License) Phone: JOB DESCRIPTION: � til U `L m Applicant Signature IS P one numb _ Fwcmved hy: Date Received: N1WORDICOMDEWESAPP Permit# Account Description Amount Amt. Pd. Bal. Due Bldg. Permit (BUILD) el Plumb. Permit (PLUMB) Mech. Permit Permit (MECH) State Tax (TAX) Bldg: Plumb: s•S S Mech: �•.3,�' / Plan Check (PLANCK) Bldg: l '��• �,r Plumb: Mech: Sewer Connection (SWUSA) Sewer Inspection (SWINSP) Parks Dev Charge (PKSDC) Residential TIF (TIF-R) ______ Mass Transit TIF (TIF-MT) Commercial TIF (TIF-C) Industrial TIF (TIF-1) Institutional TIF (TIF-IS) Office TIF (TIF-O) Water Quality (WQUAL) Water Quantity (WQUANT) CL Fire Life Safety (FLS) cn Erosion Cntrl Permit (ERPRMT) Erosion Planck/USA (ERPLAN) Ca W Erosion Planck/COT (EROSN) y�� J 1-- TOTALS: CAN OF TIGARD ELECTRIC.' PERMIT 0 PERMIT if:: ELC95--0C�Q16 DATE= ISSUED: 12/07/95 COMMUNITY DEVELOPMENT DEPARTMENT 13125 SW Hall Blvd.Tigard,Oregon 97223+8199 (503)339-4171 PAFiCCI_: 113125DA•-0''17100 SIl L i'�D iRE-JS. . . : 01:i iL.0 SW i,9 l ti ilii. SUBDIVISION. . . . : KINGS VIF_W ZONING: R-4. 5 BLOCK- - . . . . . . LOT. . . . . . . . . . . . . 13 !"'r^oject Description: Addition of existing residence. _--KESIDENTIAL UNIT----- ---TE MP SRVC/FEEDERS---- -----MISCE'LLANEOUS.____- 1001P SF= OR L.ESS. . . . : 1 lb - 200 amp. . . . . . . : 0 PUMP/IRRIGATION. . . . : 0 EACH ADD' L_ 500SF. . . : 1 201 - 400 amp. . . . . . . : 12, SIGN/OUT LINE LTG. . : 0 LIMITED ENERGY. . . . . : 0 4.01 --. 600 amp. . . . . . . . 0 SIGNAL/PANEL. . . . . „ . : 0 MANF. HM/ SVC/FDR. . : 0 60i+amps-1000 volts. : 171 MINOR L-ABEL ( 10) . . . : 0 1ERVICC/FEEDER--_____. CIRCUI.TS-.__._._- --_..-ADD' L INSPECTIONS—-- 0 -- _.'00 amp. . . . . . : 0 W/SERVICE OR FEEDER: 0 PER INSPECTION. . . . . : 0 21711. 400 amp. . . . . . : 0 1st W/O 5RVC OR FDR. : 171 PER HOUR. . . . . . . . . . . : 0 401 - 600 amp. . . . . . : 0 EA ADD' L BRNCH CIRC: 0 IN PLANT. . . . . . . . . . . : 0 61211 - 1000 amp. . . . . : 0 _._._.____..__ _____.__.__._.PLAN REVIEW SECTION--- 1000.+ N.____100 1•+ aMp/volt. . . . . .. 0 > =4 RES UNITS. . . . . . . . : > 600 VOLT NOMINAL. . : Reconnect only. . . . . : 0 SVC/FDR > = 2'215 AMPS. . : CLASS AREA/SPEC OCC. Owner: ___.._._____._._________._____._____._______.____•___________.__ FEES DEAR F::I_ECTRIC type amol.lnt Fav date recpt PO BOX 389 PRMT $ 135. 00 CJS 12/07/95 95-•27367- 5PrT 7 6. '75 CJS 12,/07/95 95--c_73f�7,i DONALD OR 1370.80 Phone #: 503-678-1.355, Contractor,: _._---_.._____.____.__.__..___.__..___.________.__.__.________.____._____._.____...___._...._..__ BEAR ELECTRIC R 141 . 75 TOTAL. E='O PDX :389 -_- - REQUIRE-D INSPECTIONS DONALD OR 97020 Ceiling Cover Elect' 1 Set-vice Phone #: Well Cover Elect ' l Final Rr.,n #. . This oeru t is issued subiect to the regulations contained in the _ ._ Tigard Municipal Code, State of Ore. Specialty Codes and all other Perm i t t ee Signature aoolicable laws. All work will be done in accordance with approved plans. This permit will exoiro if work is not started within 18@ days of ;ssuance, or if work is suspended for more than 180 days. Issued By _._...__...-------_---_......__. __.._._..._._._..__ - OWNER INSTALLATION ONLY___ The installation is being made on pt-oper`ty I own which is not intended for ale. lea-*. or- rent. 4NE.R' S S I GNAT URE» _...... _.__... DATF I N'3 T AL.Ln r i of\i ONLY•_._._._._ I GNATURE OF' SUF='R. EYLE.C:' N: D/7 C . _ DATE: I CE.N5E: IVO Call for- inspection - 6339--4175 Community Development ELECTRICAL PERMIT APPLICATION 13125 SW Hall Blvd. Tigard, OR 97223 Planck/Rec. # Permit # 4� r�rnl Phone (503) 639-4171 Date Issued 13- 7—?S _ CITY OF TIGAR® FAX (503) 684-7297 Issued by TDD No. (503) 684-2772 Inspection (503) 639-4175 1. Job Address: 4 Complete Fee Schedule Below: Name of Development /(f/ApDEc fADD/f/Ong Emit/ 44-S, Number of Inspections per permit allowed Address %/667 SW (9 Az/E• Service included Items Cost(ea) Sum City/State/Zip Z/J� (J�EGa/flf�71�3 4a. Residential-per unit + 1000 aq It or less / $11000 Name (or name of business) Each portadd ion re,, Ga it or dv 1 portion thereof $2500 2-3', Commercial ❑ Residential limited Energy $2500 Each Manul'd Homs or Modidor 2 Owelling Service or Feeder 568 00 2a. Contractor installation only: 4b.Services or Feeders Ins,tallahon,alteration,or relocation 2 Electrical Contractor &-1/L �L,6-C-�-It l c,. /� 200 amps or lose $6000 2 Address PIP, 6"x -1g g 201 amps to 400 amps $8000 2 Cit yi / State DA V-0 Zip 401 amps to 800 amps 2 [7 �/V.�_ 601 amps to 1000 amps $$12000 1 80 00 2 Phone No. & /,Y 13$ Over 1000 ampe or volts $34000 2 Contractor's License No. Z —147e- Reconned only $5000 Contractor's Board Reg. N Le 9/�T 4c.Temporary Services or Feeders Installation,alteration,or relocation 2 Signature of Supr. Ele ' 200 amps or less $5o 00 2 License No. Ph9de No. 7pv–/_tis 201 amps to 400 amps $7500 2 401 amps to 600 amps $10000 _ Over 600 amps to 1000 volts 2b. For owner installations: ,ee W above 4d. Branch Circuits Print Owner's Name New,alteration or extension per panel Address a)The lee for branch arcu4s Leith City State, Zip purchase of N/vlCe or Nader Ma. —--- Each branch circuit $6 00 Phone No. b)The Iee Ior branch circuits wlhM The installation is being made on property I own which is purchase or e.rvice or It*dw Ne. Frat branch circuit $3500 not inte,ided for sale, lease or rent. Each additional branch circuit $600 Owner's SirinaturP 4e. Miscellaneous (Service or feeder not included) 3. Plan Review section (it required): Each Pump or irrigation circle $40 00 Each sign or oullme lighting $4000 Signal crrcuit(s)or a limited energy Phase check appropriate ilem and enter tee in section 50. panel,alteration or extension son no 4 or more residential units in one structure Minor labels(t0) sron no Service and feeder 225 amps or more 4f. Each additional inspection over System over 600 volts nominal P Classified area or structure oontaining special occupancy the allowable in any of the above as described in N.E.C. Chapter 5 Per inspection $15 00 Per hour $5500 Submit 2 sets of plans with applicatinr,where any of the above In Plant $6600-- apply. Not required for temporary construction services. 5. Fees: NOTICE So. Enter total of above fees $ 5%Surcharge(.05 X total fees) $ PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $ AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF Sb. Enter 25%of line A for CONSTRUC rION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Review if required(Sec 3) $ A A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal s COMMENCED. ❑ Trust Account N S .t Balance Due $ / /• 7� CITY ELECTRICAL PERMIT OF TIGARD DATE1 f #: D: 12/15/95 2--i1'i5/9 DATE I SEGUED: 1 c/1�19 5 COMMUNITY DEVELOPMENT DEPARTMENT 1312.6 SW Hall Blvd.Tigard,Oregon 97223.8199 (503)839.4171 PARCEL. 1 C 1;'5DA--0,DZiii 0 SITE I,; 'j;w i1 i r,'JL SUBDIVISION. . . . : KINGS VIEW ZONING:R-4. 5 BLOCK. . . . . . . . . . . LOT. . . .. . . . . . . . . . :5 project Description: One temp servir..e or feecler 200 amps or less. -- RESIDENTIAL. UNI-f----_ -.---TEMP, SRVC/FEE.UERS----- ------MISCELLANEOUS­---- 000 SE OR LESS. . . . : 0 16 - 200 amp. . . . . . . : 12, PUMP/IRRIGAT ION. ,. . . : 0 PCH ADD+ L 5005F+. . . : 0 201 - 400 amp. . . . . . . : 0 SIGN/OUT LINE L.TG. . 0 1111 TED ENERGY. . . . . 0 401 •- 600 amp. . . . . . . . 0 STGlgAl_/F'ANf I.._. „ . . . . . 0 ,!ANF. HM/ SVC/FDR. . 0 601+amps.--1000 volts. : 0 MINOR LAPEL ( 10) . . . : 0 - - - -SERVICE/1=ELDER-._--_ --____DRANCI-1 L IRCUi'15- -___ _....._ADD' L_ INSPECTIONS-— 0 NSPECTIONS•--•--- 0 _. _:14)0 amp. . . . . . : 1 W/SERVICE OR FEEDER: 0 PIER INSPECTION. . . . . : o 201 _ 400 amp. . . . . . . 0 1st W/O GRVI, OR FDR. : lb PER HOUR : Ql 401 6iT0 amp. . . . . . : 0 EA ADD' L PRNCH CIRC: Ql IN PLANT. . . . . . . . . . . : 0 rf01. 1000 amp.. . . . . : 12+ -..--------------.._.__-PLAN REV IF_-W SECT ION- _...._.__..._._.�._�_..__._.__. 1000+ amp/vo.lt. . . . . : 0 > =•4 RES UNITS. . . . . . . . : ) 600 VOLT NOMINAL. . Reconnect only. . . . . : Qi SVC/FDR i = 2.2'' AMPS. . : CLASS AREA/SP1.=C, OCC:. Owner: _.__..______._.____.___.__. ._.._.___W._.______ _._____________._._ FEES BEAR ELECTRIC type date recpi, F'O BOX 389 FIRM`T' $ ,vQ►:Vn7l' CJS 12/1'5/95 95-: ,b;! ' 5PLT $ v_ CJ:. 3.2/1.5/95 95--27394'. DONALD OR 97020 �•� Phone #: 503--6711-1. 55 BEAR ELECTRIC 63. 00 T0TAL. PO BOX 389 �- - -- REQUIRED INSPECTIONS -.___...._ DONALD OR 97020 Ceiling Cover f_:ler_t' 1 Service Phone #: Wall Cover Elect' I Final Reit #. . : This pewit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Soecialty Codes and all other Permittee Signature applicable laws. All work will be done in accordance with aooroved plans, This perait will expire if work is not started within 180 days of issuance, or if wurk is suspended for Bore than 180 days. ISSLIed By ------ _.___.._. _. . ._.__......____.._-13WINIFIl INSTALL ATIISN Pl a installation is being macie on property I own whicf► is not intendecl for sale, lease, or rent. OWNLRI S SIGNATURE: DATE:: INSTALLATION i UNAJURE OF SUPIR. ELLEI N: 0I9 9DATE: CE.INISE N(1: Call for inspect ion 639--4175 i Community Development ELECTRICAL PERMIT APPLICATION 13125 SW Hall Blvd. pLI Tigard, OR 97223 Planck/Rec. # Pe,mit # L�"q5 Phone (503) 639-4171 Date Issued FAX (503) 684-7297 Issued by Lhcye, CITY OF TIGARD TDD No. (503) 684-2772 Inspection (503) 639-4175 1. Job Address: 4. Complete Fee Schedule Below: Name of Development:rA:2- v4 rl 1, .r-A lc� SE,<✓I C- Number of Inspections per permit allowed Address D Su/ l0 9 i9yE Service included Items Cost(ea) Sual City/State/Zip / /��� 0A"-"V !? 1Z 3 4a. Residential- per unit 1000 scl It or less $11000 _ Name (or name of business) _ Each additional 500 sci It or — portion thereof $2500 Commercial ❑ Residential Limr'ed Energy $2500 _ Each Manurd Home or Modular 2 Dwelling Service or Feodor $6800 _ 2a. Contractor installation only: 4b. Services or Feeders Installation,alteration,or relocation 2 Electrical Contractor_ Ems[f4/C-, //V L. 200 amps or lose $80 no 2 Address D box 3g9 201 amps to 400 amps $80.00 o v ` State O/1 Zi g7caZo 401 amps to 100 amps $12000 Ci ty P , � p 801 amps to 1000 amps $18000 _ Phone No. & I8—/?S5 Over 1000 amps or volts $34000 Contractor's License No. - /e7c- Reconnect only $5000 Contractor's Board Reg. No. 4c.Temporary Services or Feeders Installation,alteration,or relocation Signature of Supr. Elec'n 200 amps or lose —L $5000 0.190 , License No. 1_73�tS Phone N !6 �� - /3�.� 201 amps to 400 amps $7500 - 401 amps to 800 amps $10000 Over 800 amps to 1000 volts 2b. For owner installations: see V awe 4d. Branch Circuits Print Owner's Name New,alteration or extension per panel Address a)The tee for branch circuits with Zip purchase of service or feeder An. 2 City State Each branch arcual __ $5 00 Phone N0. b)The fee for branch arcurls wlthour The installation is bel,l j made on property I own which i5 purchase of eerviae or Neder Am. First branch not intended for sale lease or rent. $6 Earh adankddronal branch circuit $6rcuit statin E 00 2 r 00 Owner's SignaturA 4e. Miscellaneous (Service or feeder not included) 3. Plan Review section (it required): Each pump or irrigation circle $4000 Each sign or outline lighting $4000 Signal circuit(s)or a limited energy Please check appropriate item and entet fee in section 5B panel,*Notation or extension $4000 _ 4 or more residential units in one structure Minor Labols(10) _ $10000 Service and feeder 225 amps or more System over 600 volts nominal 4f. Ear_h additional inspection over Classified area or structum containing special occupancy the allowable in any of the above as described in N E C. Chapter 5 Per Per hour hour hon $$5566 o0 1N1 in Plant $5500 Submit 2 sets of plans with application where any of the above apply Not required for temporary construction services. S. Fees: NOTICE 5s. Enter total of above fees s 5%Surcharge(05 X total fees) $ a_ PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $ AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF sb. Enter 250 of line A for CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Review if requirr, ►c.3) $ A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal $ 5U•SL COMMENCED ❑ Trust Account N s Y Balance Due $ MEMO i Permit #: -5� 0 3 1 Address: :z n lssued by: t,— Date: '7_24 —fM� Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli- cants who are not registered with the Construction Contractors Board to sign the following statement Before a building permit can be issued. This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt.from registration under ORS 701.010(7), need not submit this statement. This statement wi11 be filed with the pernzit. Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 3B: DO-,I I own, reside in, or will reside in the completed structure. 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale before or upon completion. ❑ 3A. My general contractor is (Name) Contractor regis. # I will instruct my general contractor that all s Wractors who work on the structure must be registered with the Construction Contractors Board. OR 3B. I will he my own general contractor. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. It I change my mind and hire a general com:ractor, I will contract with a contractor who is registered with the CCB and will immediately notify the office issuing this builaing permit of the N name of the contractor. lI hereby certify that the abo%a information is correct and that I have read and do understand the Int'ormatiom °' Notice to roperly (Ober.~ about Construction Responsibilities on the reverse side h►f this form. Cz (Signature of permit applicant) (Date) (White copy to issuing agency permit file, pink cony to applicant)