14135 SW 93RD AVENUE i
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ADDRESS:
SW 93'0
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WASHINGTON COd tis ELECTRICAL PERMIT
Department of Land lyse & Transportation w
Electrical Inspection Section APPLICATION
155 North First Avenue, #350-12
Hillsboro, Oregon 97124
Information: (503) 640-3470 Fax: (503) 693-41J12
er reit
PLEA'§E MINT
Number __ Date
Please complete all,lsections, 1,-through 5. 4. Complete Fee Schedule below
Number of Inspections per permit allowed
1. Locati n of installation
Address t 1_0 " c r j� Service included: Items Cost(ea.) Sum
E uildingg A. Residential- per unit
City �� � Suite No.
1000 sq.ft.or less _ _ $110.00 4
Tenant Nana Each additional 500 sq.ft -
(if commercial) or portion thereof -___ $25.00 ---
1 C �� ti) ZJ 3Jc'a Limited Energy -_� $25.00 - 1
Map No. �- Tax Lot - Each Manul'd Home or Modular
Dwelling Service or Feeder $68.00 -- 2
Thomas Map Book. rage: Section:_ .__
Directions_ B. Services or FeEders
-. -.- - Installation,alterations or relocation
200 amps or less $60.00 2
Commercial Residential �__� 201 amps to 400 amps $80.00 2
401 amps to 600 amps $120.00 _ __- 2
2a. Contraclor installation onl : 601 to 1000 amps $ .00 _ 2
y Overr 1 10000 0 amps or volts _-. $340340.00 2
Electrical Contractor _ Reconnect u fly $50.00 2
Address __ _
City _ State ZIP— .___. C. Temporary Services or Feeders
Date___ job Number Installation,alteration or relocation
Property Uwner _ 200 amps or less $50.00 2
Contractor's License No. 201 amps to 400 amps __ $75.00 .- 2
Contractor's Board Reg. No. 401 amps to 600 amps $100.00 _ 2
g - - --_ Over 600 amps to 1000 volts see'B'above
Signature of Supr. Elec'n _ D. Branch Circuits
License No. Phono No. New,alteration or extension per panel
a) The fee for branch circuits with
2�. For owner Installations: purchase of service or feeder Ise.
e / on -71
7 Q Each branch circuit $5.00 2
�� Lam_ b) The toe for branch circuits without
rpt Hers ams one o.
���) C' purchase of service or teed r lee. 3R,
A rose �_ -13 First branch circuit � $35.00 2
" 7 . Each add'rll branch circuit $5,00 "-' 2
city tate .l^1E. Miscellaneous (Service or Feeder not included)
Each pump or irrigation circle $40.00 2
The installation is being made on property I own Each sign or outline lighting $40.00 2
v hich is net intended for sple, leae r rent. Signal circuits)or a limited
energy panel,alteration
Owner's Signature �-,7-7,:_ : or extension $40.00 _ 2
F. Each additional inspection rover the allowable
:t in any of the above
n 7. Plan Review section (if required) Per hour Per inspection __ $35.00
� $55.00
Please check appropriate Nem and enter fae In section 5B. In Plant $55.00
-' 4 or mora residential units in one structure
_Service arid feeder, 800 amps or more J. Fees y0 06
Xl
—System over 600 volts nominal A. Enter total of above fees $
_Classified area or structure containing special 5% Surcharge (.05 X!otal fees) $
occupancy as described in N.E.C. Chapter 5 Subtotal $
A. Enter 25% of line A for
Submit 2 sets. of plans with application where any H the Plan Review If required (Section 3) $ -
above apply. Not required for temporary construction Subtotal $
services. ❑ Trust Account $
-------- Balance Due $
For inspections call Ihls Permit I—omea null and void N the weak authodied by the permit is not commenced
640-3561 or 693-4415 within 180 days from :ate of issuance of such permit or If the work aulhodred In
appended or abandoned of any time after work Is commenced for a period of 18o days.
24-hour recorder, one working day in advance of need Electrical Permits are nonrefundable and nontransferable.
8/94
CITY OF TIUARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 business Phone: 639-4171
Inspection:
Footin -- —.�_
S Susp. Ceiling Sprink. Rough-in q
PPr/Sdwlk
Foundation
PltrJ. Underslab Mech. Rough-in Fireplace
POst/Beam Struc+. Plbg. Top Out
Elec. Rough-in FINAL:
Post/Beam Meeh. San. Sewer
Gas Line -Bldg.
I Plbg. Underfloor Rain Drain
Framing -Plumb. `
Alarm Water Line I
Insulation -Mech.
Underflr. Insul. Shear Wall
GYP• Bd. _ I
Date Requested: c U p
Time: qM O PM s
Address:� � -�� � -'i-
Builder:
Permit #:_C�C�j S-0c,41 i
THE FOLLOWING CORRECTIONS ARE REQUIRED:
---—_
In;:pector:
.� �7�-�--
-q :i'VEJ — nISAPPRC QED --APPROVED SUBJECT TO ABOVE
_Call For Rvinsp.
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CITY CSF Ac IGARD m ,rcn .T
COMMUNITY DEVELOPMENT DEPARTMENT PERM T,t- *17. . . . . . . : 1174'TOr
13125 SW Hall Blvd.Tigard,Orogon 97223*8199 (503)634.4171 DATE iSSUET).
-
A)I V I S 1(1-114. . . . . ELPOSE TE70NING: Rket.
RQACE
. . . . .. I . . . . . . . ... .
DU T LD:Nl";
E I rsur: DWELA'.''11 UNITS -.0 nPSEMENT. . . . . . . . .I?
.
. S GAPPc-E. .0
..-ASc S OF WOFUR. ALT '51'DpmF3' '0 BATT 1
:�rcr Cr. USr,. . . r Gr- _!_00P ApE()S"._ __ RE'LlUllf',171)
vPi.-- OF MtNST, -!-IN r 1.17,7) 1(�9 f LEFT. . :0 ft F.1 Cl 1T. 0 ry
:�'e. .1 -- r7-RON7. .C, ft
C!'7p. 4117, �:r T;,I",N.,D f
TORIES. . . . . . . . I F`I NBSMEIN'T:0 f
-*A el I 1
0 r1; TOTAL- I C,`) s r '_', 2�j N L[7. u. i J'.-,
.41a ps f VALUE. . . . . $ s 410 PARKING 0
(irm,,T'r7r,,r,4 or 'Jr1 WALLS IN 17XI7j'1 Tl',('G C'fARAOC
PLUMBTNG
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N V 0 On P r)r�il T W7, , 0 UNT P"". -7
:0 Ws" TC7P HCATERS. . . 0 TRAPT. . . .. . . . . .
' -
0 LAUt"MRIe TlAy7t. . . (7I
ITER M_00C-r,. W E R L I'-'I ft) -0
jai A-11(4CE DI74-,. . . :0 nPIN ORAIN (ft) . ;0
NO 1111A,r_1 :0 ,.,r ROIN DPAINS.
Fr-t'
TYPIrl-, I T 1+7 R I. I t y f'w a -i ri 1-1 v d A 1. I-.,c.1•,
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Residential Building_ Permit Applicdion
City of Tigard h
13125 SW Nall Blvd.
Tigard, OR 972 '3
(503) 639-4171 At--Q-
, , Subdivision:
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/'Jobsite Address: 13r-J
Subdivision: �. '� >+r �' Y V�C� Lot # ? Office Use Only
Planck/Ftec
Valuaticn: _ `'� C)o —
Corner Lot? Y Permit # 1)95fgs Our
Fla Lot? Y V ;ieissue of_
9 QQ
Map & TL # Iry
Owner: J Approvals Required
Address Ni _ sLj 9_->'1-d 1-d Auu - Planning
Z %-2Z� Engineering
Phone: _ (�� �` �� Cpl Other
/G`ontractor: ��Z 1�` Items Required
Address: Subcontractors
-- -- -- Truss Details
Phone: Other
Contractor's License #
(attach copy of current Oregon license)
Contact Name & Phone:
a Subcontractors: ArchitecUEngineer:
Ct
N Plumbing: _—_ _—_ Address'
►- Mechanical:
(attach copy of current OR Contractor's License) �^ —
Phone:
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JOB DESCRIPTION �`00 C-YC C� L�X�`,. �����YX 9 _
C_1<7_loro�!�,�___ 0 0
Applicant Si ature & Phone number
Received by ` � �,r(-�1,r lir-- Date Received: �,✓���/�
Permit# Account Description Amount Amt. Pd. Bal. Due '
i
Bldg. Permit (BUILD)
Plumb. Permit (PLUMB)
Mech. Permit (MECH)
State Tax (TAX)
Bldg: Z
Plumb:
Mech:
r'
Plan Check (PLANCK)
Bldg: )
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) _
Institutior al TIF (TIF-IS) _
Office TIF (TIF-O)
Water Quality (WQUAL)
f-
Water Quantity (WQUANT)
Fire Life Safety (FLS)
Erosion Cntri Permit (ERPRMT)
Erosion Planck/IJSA (ERPLAN) _
Erosion Planck/COT (EROSN)
1
TOTALS: Z �'
CITY OF TIGARD
BUILDING DIVISION
RESIDENTIAL PLANS SUBV `TAL
APPLICANT NAME: &t PLAN CHECK it
ADDRESS: > PHONE #
DATE RECEIVED: �( RECEIVED BY:
i
CHECKLIST (All items must be in packet before plan will be reviewed)
YES NO N/A
1 . [ j [ ] [ ] 3 FULL SETS OF BUILDING PLANS (No red line revisions
or tape-ons).
2. [ ] [ ] '' /SITL PLANS(including tax lot and tax map number, easements,
erosion control provisions, of garage and ma-i-n
,Alf „.�a�s Boor,-set .-wLks,c-ffive-racy ocationraorth arrow, sear*,-location
and-~termirTatiumcf-rain-+ams, corner elevations,andLontours
if'-oyev+ % grade).
3. [ ] [ ] BUILDING PLANS SHALL REFLECT TOPOGRAPHY OF LOT
(if house is designed for a flat lot and the lot is not flat, revised
drawings are required. No red lines accepted).
4. C ] C ] [ ] REVISION TO PLANS MUST BE FOLIOWED THROUGH
FROM ROOF TO FOUNDATION (detailed sections may be
different from the originals as a result of your changes. These
portions of the structure that are affected by the change need to
be reflected on the pians. No red lines will be accepted).
5. [ 1 l 1 1 1 FLOOR PLAN(S)
!>• [ 1 [ ] C l FLOOR FRAMING
I ) [ ) ( ] TRUSS JOISTS (engineering, details and layouts)
��• ( 1 C I [ ] ROOF FRAMING PLAN (all hips and valley supports indicated
and detailed).
- OVER -
"ES 1�10 N/A I
9. [ j [ ] [ ] ROOF TRUSSES (engineering, details and layouts)
10. [ J [ j [ ] COMPLETE CROSS SECTION(S)
11. [ j [ ] [ ] ALL 4 ELEVATIONS ARE SHOWN - 3 ELEVATIONS FOR
ADDITIONS AND REMODELS
12. [ ] [ J [ ] BASEMENT WALL, FOUNDATiON AND RETAINING WALL
,SECTIONS (will need engineering if walls are 8 ft. high or
higher)
13. [ ] [ ] [ ] WALL BRACING (structure must meet table R-402 10, revised
alternate method 93-7, or a lateral design shall be provided)
14. [ ] [ ] [ J ALL. DETAILS REQUIRED BY NO. 13 ABOVE SHALL BE
INCORPORATED INTO THE PLANS. (Attachments must be
clearly legible and fully referenced in the plans).
15. [ ] [ ] [ j BEAM CALCULATIONS (all teams over 10 ft. in length or any
beam that supports a point load).
16. [ J [ ] [ ] ENERGY CODE PATH IDENTIFIFD
DO NO] MAKE CORRECTION IN RED
RCD WILL ONLY CAUSE DELAYS
C. A t30 11 Cr ar S —
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CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspection:
Footing Susp. Ceiling Sprink Rough-in Appr/Sdwlk
Foundation Plbg, Underslab Mer.h. Rough-in Fireplace
Post/Beam Struct. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Vlech. San. Sewer Gas Line -Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm Water Lino Insulation -Mech.
Underflr. Insul. Shear Wall Gyp. Bd. -Elect.
Date Requested: �{'�� ,�cj S Time: AM PM
Address:
Builder:. � Permit
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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Inspector Inspector: Date
4APPROVED —DISAp"ROVED _APPROVED SUBJECT TO ABOVE
—Call For Reinsp. it
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspection:
Footing Swip. Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Pltg. Underslab Mech. Rough-in Fireplace
Post/Beam Struct. P!bg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm Water Line Insulation -Mech. l
Underflr. Insu!, Shear Wall Gyp, Bd. 6ect AQ)
Date Requested: ( 5 Time AM PM
Address:
Builder: -.,,. �;` ,�,`�� Permit q: ��,� 4J fir- C_ (v
THE FOLLOWING CORRECTIONS ARE RE TIRED
Ln
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Inspector. Dater .
APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Reinsp.
CITY OF TIGARD BUILDING !NSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4115 Business Phone: 639-4171
Inspection: CZ�2`r�1_r-f
Footing Susp, Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Pibg. Underslab Mech. Rough-in Fireplace
Post/Beam Struct. Plbg. Top Out Eiec. Rough-in FINAL.
Post/Beam Mech. San. Seller Gas Line -Bldg.
Plbg. Underfloor Rain Dra n Framing -Plumb.
Alarr.i Water Line Insulation -Mech.
Underflr. Insul. Shear Wall Gyp Bd. Elect. '
Date Requested: 7 /( ,7) f `l I Time: A PM
Address:`
Builder:_ 1 Permit #: ZC 5=CSC)(p
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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111
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Inspector:� Date: -7 f/�xGJ
_APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Reinsp. '` l
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-C-Phone): 639-4175 Business Phone: 639-4171
Inspection:_
Footing Susp. Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Plbg. Underslab Mech. Rough-in Fireplace
Post/Beam Struct. Plbg. Top Out Eley,. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line -Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm Water Line Insulation -Mach.
Underflr. Insul. Shear Wall Gyp. Bd. -Elect.
Date Requested:_ a�` S— Time: AM PM
Address:_ z1
Builder: Permit #:
THE FOLLOWING CORRECTIONS ARE REQUIRED:
LO
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Date: _ '
Inspector: -
APPROVED DISAPPROVED _APPROVED SUBJECT A#�V /
Vt Y Lc'�
Call For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 E isiness Phone: 639.4171
Inspection: �-C ' C_l ) -
- c�
Footing Susp. Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Plbg. Underslab Mech. Rough-in Fireplace
Post/Beam Struct. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Ga- Line -Bldg.
Plbg. Underiloor Rain Drain Framing -Plumb.
Alarm Water Line Insulation -Mech.
Underilr. Insul. Shear Wall Gyp. Bd. -Elect.
Date ,1
Requested:/_ (.G 1/1---' c_` Ly� Time: I AM PM
Address: r/ l7 I 3.5 l�� .,a V -`---
Builder: L/ '- �f �jS T _Permit #:ECC
1NE FOLLOWING CORRECTIONS ARE REQUIRED:
Zl 7Z- -3 s
F. do
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Inspector/') T � Date:_ —2-C) ` j
APPROVED _DISAPPROVED _APPROVED SUBJECT TO ABOVE
,4C all For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-41-/5 Business Phone: 639-4171
Inspection:
Footing Susp. Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Plbg. Underslab Mech, Rough-in Fireplace
Post/Beam Struct. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line -Bldg.
Plbg. Underflcor Rain Drain Framing -Plumb.
Alarm Water line Insulation -Mech.
Underflr. Insul. Shear `Nall Gyp. Bd.
/
Time: � y ' °
Date Requested: j, j�_ AM PiA
Address:
-r
Builder. Permit #:
THE FOLLOWING CORRECTIONS ARE REQUIRED:
Inspector. Date��
_LA PP�V E D _DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Ph,ne): 39-4175 Business Phone: 639- 171
Inspection:_
Footing Susp. Ceiling oprink. Rough-in ApprAwlk �
Foundation Plbg. Underslab Mach. Rough-in Fireplace
Post/Beam Struct. Plbg, Top Out Elec. Rough-in FINAL:
Post/Beam Mach. San. Sewer Gas Line -Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm WLter Line n�u a io, -Mech.
U iderflr. Insul. Shear Wall Gyp. Bd. -Elect.
Date Requested:i_ , � c Time:--AM _PM
Address:
(
Builder: _SZJ s=_ `[ 3��I .5i�1.e.ti(Permit #: rJ � t( � S
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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Inspector: Date:L f
( D DISAPPROVED APPROVED SUBJECT TO ABOVE
_Call For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-t,
Inspection:
Footing Susp. Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Plbg. Underslab Mech Rough-in Fireplace
Post/Beam Struct, Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line -Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm Water Line Insulation -Mech.
Underflr. Insul. Shear Wail > -Elect.
Date Requested:_ � l�j _Time: AM __PM
Address:—
Builder Permit #:
THE FOLLOWING CORRECTIONS ARE REQUIRED:
,,7
L _
C.0
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Inspector:_ Date: Z
�►PPROVED —DISAPPROVED `APPROVED SUBJECT TO ABOVE
__Call For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line ((RRe/c-O-Phone): 639-4175 Business Phone: 639-4171
�� � / �f
Inspection: f `-'- ���
Footing Susp. Ceiling Sprink. Rough-in Appr/Sdwlk
Foundation Plbg. Underslab Mech. Rough-in Fireplace
Post/Beam Struct. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line ��j
Plbg. Underfloor Rain Drain Framing Plumb.
Alarm Water Line Insulation r-Mech.
Underflr. Insul. Shear Wall Gyp. Bd. -Elect
Date Requested: -"7 / 3 A 5 Time:�j'A!M � PM
ClAddress:`L /
Builder: `0 Permit #: --C�( � j
THE FOLLOWING CORRECTIONS ARE REQUIRED:
CL
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Inspector_ Date: 7- /3- 2--
—
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4 4
APPROVED DISAPPROVED _APPHOVED SUBJECT TO ABOVE
1VECall For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O--Phono): 639-4175 Business Phone: -4171
inspection:
Footing Susp. Ceiling Sprink. Rough-in Ap r/SdwIk
Foundation Plbg. Underslab Mech. Rough-in Fireplace
Post/Beam Strurt. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line Idg
Plbg. Underfloor Rain Drain Framing Plumb.
Alarm Water Line Insulation -Mech.
Undertlr. Insul. Shear Wall -Elect.
Date Requested:�l / Time- —AM 4_lcm
Address:
c_-,#
Ider:ice. 2,a 5 - (�_3�( Permit #: 2
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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Inspector: Date:
APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
_Call For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspection:
Footing Susp. aing Sprink. Rough-in Appr/Sdwlk
Foundation Plbg. Underslab Meci . Rough-in Firepla
Post/Beam Struct. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Line 0
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm Water Line Insulation -Mech.
Underflr. Insul. Shear Wall /Gyp. Bd. U -Elect.
Date Requested: C1 Time:
AM PM
Address:
Builder: l� �� ( 'f; _ Permit #: f� j ` c ( �
THE FOLLOWING CORRECTIONS ARE REQUIRED:
114 4
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Inspector Date:
OVED DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Reinsp.
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639.4175 Business Phone: 639-417
Inspection:
Footing Susp. Ceiling Sprink. Rough-in Appr/Sdw+k
Foundation Plbg. Underslab Mech. Rough-in Fireplace
Post/Bearn Struct. Plbg, Top Out Elec. Rough-in FINAL:
Post/Beam Mech. San. Sewer Gas Lioe -Bldg.
Plbg. Underfloor Rain Drain CFraming -Plumb.
Alarm Water Line Insulation -Mech.
Underflr. Insul. Shear Wall Gyp. Bd. -Electc�,��
Date Requested: (p 'l(p —�� Time: AM ✓4j PM
Address:_l y 1.35 9,3
Builder i �h 33.5- ! ! Permit # �
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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Inspector: Date.
(APPROVG D _DISAPPROVED _APPROVED SUBJECT TO ABOVE
Call For Rein-M.
CITY OF TTGARD RFct- it:,r oF PflYKNT RE=CEIDT NO, 0 95-266569
CHECK AW)ONT s 26. P5.
NAME n rY T. SMITH CASH (.IMO(.)N,r s 0. 00
A r)r)r4 F,s P. e 691�-' NE. 131ST AV�AIA PAYMUNI DATE' 06/09/14ti
NO. GUBDIVISION t
WANCOUVER, WA 138(.:+BL—
PURPOSE OF PAYMrN*f AMt ILINT PAID PURPOSE OF PAYMENT AMOUNT PAID
vii F UILA)1140 PFRM MST95-019ti R V i rA*1 ST. EIIAILD PFR 1.
ui
i
SlTF. 114135 SW 93RD OWNUE
IrJTAL. AMOUNT PAID 26. 25
CITY OF TIGARD — RECEIPT OF PAYMENT RECEIPT NO. :95—a65174
CV-lEGk AMOUNT 16. �--'b
NAME a CY T. SMITH CASIA AMOUNT 0. (W
ADI)PESS 6912 NE 13161 PAYMENT DPTE a 05/08/95
N0. 23 SUSS(VISION
VANCOLJVF-R, WA 9b6AE----
PtIRPUSE OF' PAYMFNT AMOUNr Pnu) PURPUSF OF PAYMENT AMOUNT 1"-,AID
PLAN CHECK FE PLANCIHV(..'F, 16. 20
14135 SW 93RD AVENIIE9 TIGARD
Pt- iNCHFC V 5-24R
'ro,l,Al. AMOUNT PAID t6. 25
CITY (.4' TIGARD - RF,'('FIP*r OF POYMFNT RFC,FXPT NO.
CHECK AMOUNT c 00
NNME- o GMIl'l-1, r,Y T CASH AMOUNT t op)
ADDRESS s PAYMENT DATF o 06 19/1749
691�.' NE I.3,18T ME #23 SUS D I V T"l I ON
VANC:nl.JVFR WA 9A682-46P3
F'-URPOSE OF PAVWNT AMOUNT PAID PLIPP01,3E nF PAYMENT 0MOUNT PAT-
'T. P. 0
PER11111 40, 00 S BUILD PI-R
AMO1.,lNl MID 4e. 00
iCIV,�9
Address: �`t t' 5 L `Z n,3 rd 4L) g9-z-9
Issued b5 8 9
.� y: daix�x�' Date:
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 will be filed with the permit.
Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 3B:
® 1. 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.
F] 3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
3B. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property O ners_about Construction Responsibilities on the reverse side'of this form.
Signature of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
APPROVED FOR CONSTRUCTION �I r-
CITY OF TIGARD
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