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CITY OF PORT ANGELES
DEP ARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number
pin number
property Address
ASSESSOR PARCEL NUMBER:
Application description
Subdivision Name
property Use
Property zoning . . .
Application valuation
04-00000398 Date
.975118
119 FOGARTY ST
06_30_09_5_2_2578-0000-
RES ADDITION
5/14/04
RS7 RESDNTL SINGLE FAMILY
2200
1::::(1/ J' f t:::L7
7/-Zg ft) d
Owner
Contractor
------------------------
------------------------
WA 98362
TRIPLE M PROPERTIES
25556 HWY 101 EAST
PORT ANGELES
(360) 457-5752
382.5 SQ. FT. DECK ADDNT
TYPE V NON-RATED
SINGLE FAM & CONGREGATES
TOTAL % LOT COVERAGE
CONSTRUCTION TYPE
HARD SURFACE AREA
NUMBER OF STORIES
EXISTING LOT COVERAGE
LOT SIZE
PROPOSED LOT COVERAGE
TOTAL LOT COVERAGE
NUMBER OF UNITS
LLC
TRIPLE M PROPERTIES LLC
255566 E HWY 101
PORT ANGELES
( 36) 457-5752
Structure Info~mation
Construction Type
Occupancy Type
Other struct info
WA 98362
13.80
V-N
2.00
1074.00
10500.00
382.50
1456.50
1. 00
--
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~
Permit BUILDING PERMIT -RESIDENTIAL
Additional desc 382.5 SQ. FT. DECK ADDNT
Permit Fee 106.75 Plan Check Fee 42.70
Issue Date 5/14/04 Valuation 2200
Expiration Date 11/10/04
Qty Unit Charge Per Extension
BASE FEE 92.75
1. 00 14.0000 THOU BL-2001-25K (14 PER K) 14 .00
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Other Fees
STATE SURCHARGE
4.50
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cy:-+
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Special Notes and Comments
proposal will result in 382 sq. ft. addition to sf residence
in RS-7. Lot coverage will be 14%. Setbacks are okay.
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 106.75 106.75 .00 .00
Plan Check Total 42.70 42.70 .00 .00
Other Fee Total 4.50 4.50 .00 .00
Grand Total 153.95 153.95 .00 .00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection. I h eby certify that I have read and examined this application and know the same to be true and correct. All provisions of
laws an..d ...~dinQl es goverl}in9 this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume" giv authoptfio violate or cancel the provisions of any state or local law regulating construction or the performance of
construct" n. //
....J-'
Sig
Signature of Owner (if owner is builder)
Date
T:IPLANNINGIFORMSIl102,15 [11/14/2003]
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BUILDING PERMIT INSPECTION RECORD
CALL 4] 7-48] 5 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLA WFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE
INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION.
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE.
INSPECTION TY.PE DATE ACCEPTED COMMENTS
YES NO
FOUNDATION:
FOOTINGS Do_<..k" ref-f. Milf's. .5-ZikJY R17
WALLS
FOUNDA TION DRAINAGE/DOWN SPOUTS
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: #
ROUGH-IN
PLUMBING
UNDER FLOOR / SLAB
ROUGH-IN
WATER LINE (METER TO BLDG)
GAS LINE
BACK FLOW / WATER
AIR SEAL
WALLS l4-W'6~ I 1_
CEILING
FRAMING
JOISTS / GIRDERS
SHEAR WALL/HOLD DOWNS
WALLS / ROOF / CEILING '7-/li-O,,-/ . J t,
DRYWALL (INTERIOR BRACED PANEL ONLY)
T-BAR
INSULA TlON
SLAB
WALL / FLOOR / CEILING
MECHANICAL
HEAT PUMP
GAS LINE
WOOD STOVE / PELLET / CHIMNEY
HOOD / DUCTS
PW UTILITIES / SITE WORK (Engineering Division) SEPARATE PERMIT #'5:
WATERLINE / METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT. SEP ARA TE PERMIT #'5 SEPA:
PARKING/LIGHTING ESA:
LANDSCAPING SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTRICAL - LIGHT DEPT. 417-4735 ELECTRICAL
LIGHT DEPT
CONSTRUCTION KW./ PW/ CONSTRUCTION - R.W.
ENGINEERING 417-4807 PW / ENGINEERING
FIRE 4 I 7-4653 FIRE DEPT.
PLANNING DEPT. 417-4750 . ~ PLANNING DEPT.
.
-" " ,,_. - erT] BUILDING
BUILDING 417-4815
.
T:\PLANNINGIFORMS\ 1102. I 5 r 11114/2003 ]
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CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . . . . . . INSPECTION REPORT. . . . . .
REQUEST:
Location of Work to be inspected
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one):
Sewer Foundation Framing Chimney
Ii c; r.~C1 c'Y~
I~." J ,;; 11
,,J
I
e. person I
Date
~ .. --7- r - 0 1
--'
Time
~ .' L-Y) / il ( Received by (5 t~.--+.)
l~/l 0 ;- ~ 1 / I LtJ
INSPECTION NOTES: 0
Inspected: Date 1; "" 2. 4 - 0 L(
Remarks:
Plumbing Final
,::70 v v-
Phone No.
Permit No. 0 t-{ - '
Sewer Excav.cOtS; hi
Time
By
R\.'/
OK
peck ?oc-"t !lore s
RESTORATION REQUIRED. . . . .. YES NO
SURFACE RESTORATION:
SURFACE TYPE: D Unimproved D Gravel D Asphalt D PCC
D Other
D Repaired by City
o Repaired by Permittee
o No Damage Found
Work Order #
o COMPLETE
D INCOMPLETE
BUILDING PERMIT - APPLICATION
FOR OFFICIAL USE ONLY:
Dale Rec:5 - S - eLj
Permit #:.7/- ~q 8
_- :if (,.L'
Dale Appl'Oved:.j-- i ~i" ~
Date Issued:
Fill out COMPLETELY and in INK. Your application and site plan MUST BE
COMPLETE to be accepted for review. If you have any questions, call
PERMITS (360) 417-4815 FAX(360)417-4711
Applicant or Agent: "JO<&'v\. \f\YvV\"&~~ Phone: Lfjl-Slc::,~
Owner: .. Tv \ 'tJ\Q \-\ P~e.v-\1e"5) LLc.. Phone: L\C,l- C:'fl c:, :;;l
Address: dSc:J-~\.D\.O ~. \'t:l\ City: ~v+ lfW\Cje1.~ Zip: q~3\.9"'d.
Archltect/Engmeer:"'Z...ev\O\J\L ~ 'f\~CSoc\o.:u..~ Phone: L\ \\ - Ocoa \
~tJ
ContractorW\~ l--\ ~""e"S State License #:~\~Lt--\f>"~~xp:~\I:?J'()LO Phone: L.\&J 1-'?1?~
Address: c;t::f?- '?~U ~. \0\ City: ~ort ~w..~ Zip: q<60\O~
PROJECT ADDRESS: \\0. t=OQG-.Y~ 1ftJQ...,. ZONING: ~\ds1.M:t\oj
E 'v\C4.\f'U\f'" -
LEGAL DESCRIPTION: Lot: o.ll \'\ Block: ~ Subdivision: r O~~c:tv bo\wi" ~ v:\
CLALLAM COUNTY PARCEL NUMBER: a~~ otA-':> ~Of:>\ ~
-t,0f\
Credit Card Holder Name: -;rO~'v\ ~'stv'D~
Billing Address: O~~ Gv1 ffi~ RJJr V\I\. ~.
Credit CardType VISA X MC #_'
TYPE OF WORK:
o Residential 0 New Canstr. 0 Re-roof
o Multi-family 0 Addition 0 Move
o Commercial 0 Remodel 0 Demolition
o Repair 0 Sign
BRIEF DESCRIPTION OF THE PROJECT:
o Stove
o Garage
)( Deck
o Other
City: SC2..Q 0w~^. \....VA q <r;'~ ~d....
E)...']l. Date:
SIZENALUATION:
~ SF. @ $ C!;). q\ ISF. = $ ~OlOO
SF. @ $ ISF. = $
SF. @ $ ISF. = $
TOTAL VALUATION $
COMMERCIALIRESIDENTIAL: Occupancy Group:
No. of Stories: ~ Lot Size: I05C>C Existing Sq. Ft. 1(:)/1...[
Total lot coverage Is. ~
Occupant Load: Construction Type:
& Proposed Sq. Ft. 3e-z ,S- = TOTAL Sq. Ft. II...( S-~. S-
%
APPROVALS:
PLAN:
BLDG:
DPWU:
FIRE:
OTHER:
PLANNING USE ONLY:
ESAlWetland(s): 0 Yes 0 No SEPA Checklist required? 0 Yes 0 No Other:
BUILDING PERMIT APPLICATION SUBMITTAL: The Building Division can provide you with information on the application and
plan submittal requirements if you have questions.
V ALUATION OF CONSTRUCTION: In all cases, a valuation amount must be entered by the applicant. This figure will be reviewed
and may be revised by the Building Division to comply with current fee schedules. Contact the Pennit Coordinator at 417 -4815 for assistance.
PLAN CHECK FEE: IF a plan check fee is due it must be submitted at the tin1e the building pemnt application and construction plans are
subnntted. All other peront fees are due at the time of permit issuance.
EXPIRATION OF PLAN REVIEW: Ifno pernnt is issued within 180 days of the date of application, the application will expire. The
Building Official can extend the time for action by the applicant up to 180 days upon written request by the applicant (see Section 107.4 of
the Uniform Building Code, cunent edition). No application can be extended more than once.
I hereby certify that I have read and examined this application and know the
understand that it is my responsibility to determine what permits are required
o b e and correct. I am authorized to apply for this permit and
ity's, a d that I must obtain such permits prior to work.
T:\FORMS\APP S\Buildingpermit. wpd
Applicant:
Date:
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CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number
pin number . . . .
Property Address
ASSESSOR PARCEL NUMBER:
Application description
Subdivision Name
Property Use
Property Zoning . . .
Application valuation
04-00000209 Date
.945418
119 FOGARTY ST
06-30-09-5-2-2578-0000-
RES REMODEL
4/07/04
I-~ (\
.;..../ l "'.' -"/( r::J!)
t iV" V[J/",
RS7 RESDNTL SINGLE FAMILY
4000
I I
itA., It;; ,IOd--
(/ ~ , .'
y .
Owner
Contractor
TRIPLE M PROPERTIES LLC
255566 E HWY 101
PORT ANGELES WA 98362
(360) 457-5752
OWNER
Permit BUILDING PERMIT -RESIDENTIAL
Additional desc
Permit Fee 120.75 Plan Check Fee 48.30
Issue Date 4/07/04 Valuation 4000
Expiration Date 10/04/04
Qty Unit Charge Per Extension
BASE FEE 92.75
2.00 14 . 0000 THOU BL-2001-25K (14 PER K) 28.00
--
---
Other Fees
STATE SURCHARGE
4.50
-Q
)\
<-
~
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 120.75 120.75 .00 .00
Plan Check Total 48.30 48.30 .00 .00
Other Fee Total 4.50 4.50 .00 .00
Grand Total 173.55 173.55 .00 .00
-v
C:f)
P
"'r
-\
~
~
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements, This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of
laws and ordinances governing this type of work will be complied with whether specifi herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any state or 10 aw reg Ing construction or the performance of
construction. /
Signature of Contractor or Authorized Agent
Date
T:IPLANNINGIFORMSII lO2,15 [11/14/2003]
BUILDING PERMIT INSPECTION RECORD
CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE
INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCA nON,
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE.
I~SPECTlON TYPE DATE ACCEPTED COMMENTS
. I
YES NO
FOUNDATION:
FOOTINGS !-I _ V",'1 ;;. } L I
WALLS . ..
FOUNDATION DRAINAGEIDOWN SPOUTS
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: #
ROUGH-IN
PLUMBING
UNDER FLOOR 1 SLAB
ROUGH-IN
WATER LINE (METER TO BLDG)
GAS LINE
BACK FLOW 1 WATER
AIR SEAL
WALLS J/ -1--'1.- -D "-/ J1
CEILING I l
FRAMING ~t-J-'t~1 9-"~ .Q~r ~'11-?-r-oJ
JOISTS 1 GIRDERS
SHEAR WALL/HOLD DOWNS
WALLS 1 ROOF 1 CEILING
DR YW ALL (INTERIOR BRACED PANEL ONLY)
T-BAR
INSULATION
SLAB
WALL 1 FLOOR 1 CEILING V-I-~)( -014 I
MECHANICAL
HEAT PUMP
GAS LINE
WOOD STOVE 1 PELLET 1 CHIMNEY
HOOD 1 DUCTS
PW UTILITIES 1 SITE WORK (Engineering Division) SEPARATE PERMIT #'5:
WATERLINE 1 METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT. SEPARATE PERMIT #'s SEPA:
PARKINGILIGHTlNG ESA:
LANDSCAPING SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTRICAL - LIGHT DEPT, 417-4735 ELECTRICAL
LIGHT DEPT
CONSTRUCTION R.W.I PWI CONSTRUCTION - R.W.
ENGINEERING 417-4807 PW 1 ENGINEERING
FIRE 417-4653 FIRE DEPT.
PLANNING DEPT. 417-4750 PLANNING DEPT,
BUILDING 417-4815 (t-_C:-tJ~ JLL BUILDING
T:IPLANNlNGIFORMSI1102.15 [11/14/2003]
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BUILDING DIVISION
CITY OF PORT ANGELES
* *
Correction Notice
Job Located at -'11 r~+-y
/
Inspection of your work revealed that the following is
not in accordance with the codes governing the work in
this jurisdiction:
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/
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These corrections must be made and are not to be
covered until reinspection is made. When corrctions
have been made, please call --.J1 L 7 - C( ~-I
for inspection.
Date ~
DO NOT REMOVE THIS TAG
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"'0
BUILDING PERMIT - APPLICATION
Fill out COMPLETELY and in INK. Your application and site plan MUST
COMPLETE to be accepted for review. If you have any questions, call
(360) 417-4815
Ph c.; ,r7_ .~-(-' {-2-
Applicant or Agent: . ,~ne::2 ~
"..-- { Tr~ p(ii:, M 1'~te.s. L'-C -
Ownec -~=L.-Z~~~J!:):;;~ loi . ~ 1- ,tJl'hon~
Address: -/. r. -= -;:::'" (~7' ~___ CIty: ' or ./1 {p~ <; Zip: 9 D:5 {;Z
Architect/Engineer: 'ZeVlG ()(ck Phone:
Contractor
State License #:
Exp:
Phone:
PROJECT ADDRESS:
/(7
City:
F074 r I-t.a-
Block:
Dt~3 cx::J q' 62"2. c;7 B oCiX::>
Zip:
Address:
ZONING:
LEGAL DESCRIPTION: Lot:
CLALLAM COUNTY PARCEL NUMBER:
Subdivision:
Credit Card Holder Name:
Billing Address:
Credit CardType VISA
TYPE OF WORK:
~/fu:sidential 0 New Constr. 0 Re-roof 0 Stove
o Multi-family 0 Addition 0 Move 0 Garage
o Commercial ~emodel 0 Demolition 0 Deck
~~pair 0 Sign 0 Other
BRIEF DESCRIPTION OF THE PROJECT: J:' "f-. , 11
I, \ .
('c.G~- G--,'" r:'7>C4- ~r) 1/, ~L;-
I
COMMERCIAL/RESIDENTIAL: Occupancy Group:
City:
MC
#
Exp. Date:
SIZEN ALUATION:
SF. @ $ ISF. = $
SF. @ $ ISF. = $
SF. @ $ ISF. = $
TOTAL VALUATION $
(JOe) ....
';;a"' A. J rC :-i-f--
I -
rouK ,j/'Ci(:;' I-
'f'. .1-.
<;, (vt.'''"l.j -e... 'J~
;y,
I~'>L(;J---,,;f-. J~~c~..l,.~,,\ c i-
I ' II
OWe., u./ i v( c., <,; +~'V\ I ~ ~ ..5; ~ c~
I I
Occupant Load:
V;io' L....L)
Construction Type:
No. of Stories: Lot Size: Existing Sq. Ft. & Proposed Sq. Ft.
Existing lot coverage _ % & Proposed lot coverage _% = Total lot coverage
APPROVALS:
PLAN:
BLDG:
DPWU:
FIRE:
OTHER:_
PLANNING USE ONLY:
ESAlWetland(s): 0 Yes 0 No SEPA Checklist required? 0 Yes 0 No Other:
BillLDING PERMIT APPLICATION SUBMITTAL: The Building Division can provide you with information on the application and
plan submittal requirements if you have questions.
VALUATION OF CONSTRUCTION: In all cases, a valuation amount must be entered by the applicant. This figure will be reviewed
and may be revised by the Building Division to comply with current fee schedules. Contact the Permit Coordinator at 417 -4815 for assistance.
PLAN CHECK FEE: IF a plan check fee is due it must be submitted at the time the building permit application and construction plans are
submitted. All other permit fees are due at the time of permit issuance.
EXPIRATION OF PLAN REVIEW: Ifno permit is issued within 180 days of the date of application, the application will expire. The
Building Official can extend the time for action by the applicant up to 180 days upon written request by the applicant (see Section 107.4 of
the Uniform Building Code, current edition). No application can be extended more than once.
I hereby certify that I have read and examined this application and know the"qn, to be tru~d correct, I am authorized to apply for this permit and
understand that it is my responsibility to determine what permits are requirfX1 ,nrlt e City's/~ that I must obtain such permits prior to work.
, I, /' ,
T:\FORMS\APPS\Buildingpermit.wpd ,,"' ,I i i' ------.---------.;--::::Pate: l/l'/',:.U/('~ Cr /r i
----- (
//
{I
ENOVIC
& ASSOCIATES
CML ENGINEERING
LAND SURVEYING
'; I') SOlllh 1\'Jboch' StreeT Suit" 22
[ \ ( () R " () R ,\ T [ D
Port i\nfcle\,\X'a\hinfron ')H5(,2
U6O) 4] -0';01
Fax U!10j 4] ~-O'J] 4
April 16, 2004
E-mJil: ztnmicGl'olrmpus,ncr
Mr. Jim Lierly
City of Port Angeles Public Works & Utility Department
321 East Fifth Street
Port Angeles, W A 98362
SUBJECT: Rough Sawn Lumber used In Residence at 119 Fogarty Street, Port
Angeles, Washington by Sweet Dream Properties, Inc.
Dear Jim:
This office has performed an inspection of the new rough sawn lumber used in the
residence noted above. Based on the on-site inspection the 4 x 8, 4 x12, and 6 x 8
rough sawn beams installed in the structure have been visually graded by this office as
Douglas fir #2 and thus meet the requirements of the plans by this office. The rough
sawn columns of various sizes have also been graded by this office as Douglas fir #2
and are acceptable for use in the residence. Please note that the inspection performed
by this office was limited to inspection of various new sawn members used in the
residence and was not a structural inspection of the repairs being performed on the
residence.
--.Q
~;:J have any further questions on this mailer.
Tracy Gudgel, P.E.
~\
~
~
)
~.
cy~
Alf
\})
-:t
Fc: IN 04111
Cc: Sweet Dream Properties (via fax 457-5753)
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CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number
pin number
Property Address
ASSESSOR PARCEL NUMBER:
Application description
Subdivision Name
Property Use
Property Zoning . . .
Application valuation
04-00000209 Date
.945418
119 FOGARTY ST
06-30-09-5-2-2578-0000-
RES REMODEL
5/18/04
RS7 RESDNTL SINGLE FAMILY
4000
Fill A{ t3-t:;>
g/~:04
Owner
Contractor
TRIPLE M PROPERTIES LLC
255566 E HWY 101
PORT ANGELES WA 98362
(360) 457-5752
OWNER
Permit
Additional desc
Sub Contractor
Permit Fee
Issue Date
Expiration Date
ELECTRICAL NEW RESIDENTIAL
CIR~200A PANEL
BOB'S ELECTRIC INC
76.30 Plan Check Fee
5/18/04 Valuation
11/14/04
.00
o
~
~'-S)
~~
\)\
~~
,~~
-\
\~
"
\"'.
Qty Unit Charge Per
1.00 76.3000 ECH EL-RM-0-200 1ST SRV FEEDER
Extension
76.30
Other Fees
STATE SURCHARGE
4.50
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 76.30 76.30 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.50 4.50 .00 .00
Grand Total 80.80 80.80 .00 .00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of
laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of
construction.
Signature of Contractor or Authorized Agent
Date
Signature of Owner (if owner is builder)
Date
T:\PLANNINGIFORMSII 102,15 [11114/2003]
BUILDING PERMIT INSPECTION RECORD
CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS.
PLEASE PROVlDp A MINIMUM 24 HOUR NOTICE. IT IS UNLA WFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE
INSPECTED AND A CCEPTED POST PERMIT IN A CONSPICUOUS LOCATION
'1'1 KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE.
INSPE~TION TYPE DATE ACCEPTED COMMENTS
YES NO
FOUNDATION:
FOOTINGS
WALLS
FOUNDATION DRAINAGE/DOWN SPOUTS
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: #
ROUGH-IN I
PLUMBING
UNDER FLOOR 1 SLAB
ROUGH-IN
WATER LlNE (METER TO BLDG)
GAS LINE
BACK FLOW 1 WATER
AIR SEAL
WALLS
CEILING
FRAMING
JOISTS 1 GIRDERS
SHEAR WALL/HOLD DOWNS
WALLS 1 ROOF 1 CEILING
DRYW ALL (INTERIOR BRACED PANEL ONL Y)
T-BAR
INSULATION
SLAB
WALL 1 FLOOR 1 CEILING I
MECHANICAL
HEAT PUMP
GAS LINE
WOOD STOVE 1 PELLET 1 CHiMNEY
HOOD 1 DUCTS
PW UTILITIES 1 SITE WORK (Engineering Division) SEPARATE PERMIT #'5:
WATERLINE 1 METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT, SEPARATE PERMIT #'s SEPA:
P ARKING/LIGHTlNG ESA:
LANDSCAPING SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTRICAL - LIGHT DEPT, 417-4735 9/3loL/ A-z:D ELECTRICAL
LIGHT DEPT
, CONSTRUCTION - R.W.
CONSTRUCTION R.W. 1 PWI
ENGINEERING 417-4807 PW 1 ENGINEERING
FIRE 4 I 7-4653 FIRE DEPT,
PLANNING DEPT. 417-4750 PLANNING DEPT,
BUILDING 417-4815 BUILDING
T:IPLANNINGIFORMSII 102,15 [11/14/2003]
~ ,,,,T CITY OF PORT ANGELES
'~i~' PUBLIC WORKS - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
BUILDING PERMIT ISSUED: 4/23/2001 PERMIT NO: 12617
OWNER/APPLICANT PROPERTY LOCATION
119 FOGARTY
VERN PRITCHARD
119 FOGARTY Lot:
Port Angeles, WA 98362 Block: [] Long Legal
360/452-5614 Subdivision: Fo~,~a--r~' ~' t:)o~''o
T: S: Parcel No:
CONTRACTOR ARCHITECT
OWNER N/A
VARIOUS
Port Angeles, WA 99360 , 98360-0000
206/000-0000 360/000-0000
PROJECT INFO
Project Value: $5,000.00 SFD Units: 0 Commercial: 0
Project Type: SFR ADD/REMODEL SFD SQ FT: 0 Industrial: 0
Occupancy Type: RESIDENTIAL Garage: 0
Occupancy Group: MFD Units: 0
Construction Type: MFD SQ FT: 0 .~.~
Zoning Use:
PROJECT NOTES :.:
CONSTRUCTION OFF A 144SQ. FT, ADDITION ,8'X17', TO NORTH SIDE OF HOUSE
FEES ASSESSMENT
Building Permit: $111,25 Misc Fee 1: $0.00
Plan Check: $0.00 Misc Fee 2: $0.00
State Surcharge: $4.50 Misc Fee 3: $0.00
House Moving: $0.00
Manufactured Home: $0.00
Sign: $0.00 TOTAL FEE: $115.75
Plumbing: $0.00 AMOUNT PAID: $115.75
Mechanical: $0.00
BALANCE DUE: $0.00
Radon: $0,00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, pdvate and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection. I hereby certify that I have read and examined this application and know the same to be tree and correct. All provisions of
laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
)resume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of
construction, x' ~.
Signature of Contractor or Authorized Agent Date S~'~a~re of °W%r (if-owner is builder) Date
BUILDING PERMIT INSPECTION RECORD
CALL 417-4815 FOR BUILDING INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. ITIS UNLAWFUL TO COVER,
INSULATE OR CONCEAL ~4NY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION.
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE
INSPECTION TYPE DATE I ACCEPTED COMMENTS
YES I NO
FOUNDATION:
FOOTINGS $'-I0-01 /--~td
WALLS ~---t~ 'C~f L?~
FOUNDATION DRAINAGE
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: #
PLEMRING
UNDER FLOOR / SLAB
ROUGH-IN
WATER LINE
GAS LINE
BACK FLOW / WATER
AIR SEAL
WALLS
CEILING
FRAMING
JOISTS / GIRDERS
SHEAR WALL
WALLS / ROOF / CEILING
DRYWALL
T-BAR
INSULATION
WAEL/ FLOOR / CEILING
MECHANICAL
HEA¥ PUMP
WO()DSTDVE / ?ELkET/CHIMNEY / INSERT
HOOD/DUCTS
P~ UTILITIES / SI I'E WORK (Engineenng Division) SEPARATE PERMIT #'s:
SlWER CONNECTR)N
SANIIARY
SI ORM
PLANNING DEPT SEPARATE PERMIT #'s SEPA:
PARKING/LIGItTI NG ESA:
EANDSCAPING SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTEI~
ELECTRICAL LIGHT DEPT 417-4735 ELECTRICAL
LIGHT DEPT
CONSTRUCTION RW / PW/ CONSTRUCTION - R.W.
FIRE 4174653 FIRE DEPT.
.... CITY OF PORT ANGELES
°~ DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
~ 321 EAST 5TH STREET, PORT ANGELES, WA 98362
BUILDING PERMIT ISSUED: 4/23/2001 PERMIT NO: 12617
OWNER/APPlICANT PROPERTY LOCATION
119 FOGARTY
VERN PRITCHARD
119 FOGARTY Lot: E 1/2 18 & ALL 19
Port Angeles, WA 98362 Block: 25 [] Long Legal
360/452-5614 Subdivision: FOGARTY& DOLANS
T: S: Parcel No: 063009522578000
CONTRACTOR ARCHITECT
OWNER N/A
VARIOUS
Port Angeles, WA 99360 , 98360-0000
206~000-0000 3601000-0000
PROdECT INFO
Project Value: $5,000.00 SFD Units: 0 Commercial: 0
Project Type: SFR ADD/REMODEL SFD SQ FT: 0 Industrial: 0
Occupancy Type: RESIDENTIAL Garage: 0
Occupancy Group: MFD Units: 0
Construction Type: MFD SQ FT: 0
Zoning Use:
PROJECT NOTES
CONSTRUCTION OFF A 144SQ. FT. ADDITION ,8'X17', TO NORTH SIDE OF HOUSE
FEES ASSESSMENT
Building Permit: $111.25 Misc Fee 1: RENEWAL $57.87
Plan Check: $0.00 Misc Fee 2: $0.00
State Surcharge: $4.50 Misc Fee 3: $0.00
House Moving: $0.00
Manufactured Home: $0.00
Sign: $0.00 TOTAL FEE: $173.62
Plumbing: $0.00 AMOUNT PAID: $173.62
Mechanical: $0.00
BALANCE DUE: $0.00
Radon: $0.00
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of
laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any state or local law regulating constj-4Jctior~or the performance of
Signature of Contractor or Authorized Agent Date Signature of Ow.~er i~ builder) .,~at~/
BUILDING PERMIT INSPECTION RECORD
CALL 417-4815 FOR BUILDING INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. ITIS UNLAWFUL TO COVER,
INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION.
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE
INSPECTION TYPE DATE t ACCEPTED COMMENTS
YES I NO
FOUNDATION:
FOOTINGS
WALLS
FOUNDATION DRAiNAGE
ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: #
PLUMBING
UNDER FLOOR / SLAB
RO O.- /'-2'/-05
WATER LINE
GAS LINE
BACK FLOW / WATER
AIR SEAL
WALLS
CEILING
FRAMING
JOISTS / GIRDERS
SHEAR WALL
WALLS / ROOF / CEILING
DRYWALL
T-BAR
INSULATION
SLAB
WALL / FLOOR/CEILING
MECHANICAL
HEAT PUMP
WOOD STOVE / PELLET / CHIMNEy
HOOD / DUCTS
PW UTILITIES / SITE WORK (Engineering Division) SEPARATE PERMIT #'s:
WATERLINE / METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT. SEPARATE PERNiIT #'s ;EPA:
PARKING/LIGHTING ESA:
LANDSCAPING SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTP~CAL - LIGBT DEPT. 417-4735 ELECTRICAL
LIGHT DEPT
CONSTRUCTION R.W. / PW/ CONSTRUCTION - R.W.
ENGINEERING 417 4807 PW / ENGYNEEPdNG
FIRE 417-4653 FIRE DEPT.
BUILDING 417-4815 '~ -- 7 '~)L~
BUILDING
T:\PLANNING\FORMS\ 1102.15 [4/2002]
Applicammd/orAg~t: P~,'~ ~t-r£~,O Phone:. "/5"-7'S"6/Y '
A~: Ci~. ~p:
rRo cx s:: [ q
~ D~N: ~ ~ S~:
B~ag A~s:. C~: ~ ~p:,
C~t C~ ~ R~ ~ ~MC
~ ~fi-~mily ~ Addi~ ~ ~ ~ G~O SF.
~ ~mm~ ~ ~d D ~olifi~ ~ ~ SF.
~ El~d ~ LP-~ D Si~ DUST T~ V~UA~ON $.
COaChmEn: ~~:f ~mt ~:
No. ofS~: ~ ~ ~ % ~ ~, %
E~g ~ ~c /~. · · ~ ~ Co~ /sq. K ~ T~ ~ C~GE: /~.fl
P~G USE O~Y: ~PROV~:
P~ ~ N~: BL~
~ ~t: S~: ~mg: D~.
Site Pin ~d Usc ~ ~ D~
ES~md(s): ~ Y~ ~ No SEPA ~i~ r~? ~ Y~ ~ No ~
~g ~on ~ p~o~ ~u ~ ~ d~ ~ ~ ~c ~p~fi~ ~d pi~ ~ r~m~.
pl~s ~ to ~ ~H~ to ~e ~g
V~UA~ON OF CO~UCTION: h ~ ~ a~h~ ~t m~ ~ mt~ ~ ~ ~L ~ fi~ MB ~ r~
~d m~ ~ ~ ~ &e ~g ~. m ~ ~ ~mt ~ ~ ~
P~ C~K ~ Y~ ~ ~ ~ ~ ~ ~ ~c time ~e ~l~g ~t applic~on
~ON OF P~ ~W: ff no p~t is i~ ~h 180 ~ of
~ ~ ~c ~g ~ ~ ~d ~c ~ ~ ~ ~ &c ~t ~ to 1~0 day~ ~ ~Um r~ ~ &c ~lic~t
(s~ S~on 107.4 of~e Un~ ~g C~ ~ ~fion). No ~
a~ply for tAb pe~iA I un~ ~ ~ ~t t~ Ci~'s ~i ~o~ifi~ M ~e~ifle w~t ~i~ are ~qu~ed; ~ rmai~ the
~p~cam's re~o~b~ to dete~ine ~t ~i~ are req~red and to obtain mcK
City of Port Angeles
Applicant Project Review Sheet
Applicant:
Is the proposed use listed as a "permit~l uae" o~ an "accesso~ u.ne" in this zone? ~Z~ y~: ok [] no: req.u/rea PD
Is this the only use (business, r~idenc~, ~t~.) on this s/te~? [/~yes: ok [] no: requires PD
r~icw
Has there ever been a subdivision, shortplat, or PRD approved for this site, or has one
been submitted and is pending a~,p,,,-ol? Fl yea: reo. uires PD [~ no: ok
Does tim proposed us~ require a new binmess license? [] y~: requites CC 1~ no: ok
Does the project extend into any required sctbecks ot cross any lot lines (interior or
exterior)? [] yes: req.uires PD [~go: ok
Doesthc allowedthe lEO. )ectlot covera~exc~ .t~e..p~mittedm tins zone? height allowance or can.~ the propert~ to exc~ [] yes: r~q.uires PD l~no: ok
Doesin thisthezone?Pr°ject require any additional parkin~,~ or special design/landscape impmvemants [] yes: re .q~s PD ~no: ok
Do~s the project eliminate any existing parking spaces? I-I yes: req.uims PD [~no: ok
Is the project lecated within 200' of the shoreline? E] yin: r ,eq~sPD ~no: ok
Ar~ thcre any enviromn~ntally sensitive areas on or within 200' of the property,
including: [] yes: requires PD ~no: ok
· wcthnds or arces of standing wares (year round or scesonal); review
· areas w~th a slope, of 4055 or ga~at~, or
· areas that hevc cnndcnc~ ofpaat ground movement or crosion?
Have all the required submittals b~n provided by th~ applicant? [~ yes: ok [] no: mark
[] Site Plan D Constmction Drawings
required
[] Parking/Drainage Plan [] Civil Drawi,e~ item(a)
~ Energy Calc [] Supporting Eagr. Calc
13 Landacape/Lighting Plan rn Oth~
19e~nt laerma¢o ts neeaea, me l~taJ~tmg Deina~m~t porntt(s) rn~t be approved prior to the iss~oance of any other permit.
Permit Category # (see reverse side) Building Permit # Master Tracking #
Route to: D BD [] CC D FD [] LD D PD [] PW El File [~ Other
Stafflnitials Date Completion oJ this form is required for all category lb, 2 · $ permits. Completion is not
required for category la permits unless they result in a potential change of use or occupancy,
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
........... INSPECTION REPORT ...........
REQUEST:
Date ~'-- /L~ ~ / Time ~:~ ,'/' (~) Received by ~ ~ (phone, person)
Location of Work ,o be inspected / / ~ ~5
Name of person requesting inspection
Address of person requesting inspection ~/~/~ P' Phone No. ~(, O ~f 0 ~__
Permit No.
Type of Inspection (circle appropriate one):
Sewer (Foundation ~ Framing Chimney Plumbing Final Sewer Excav. Other
INSPECTION NOTES:
Inspected: Date .~ ' Time By
Remarks:
RESTORATION REQUIRED ...... YES. NO
SURFACE RESTORATION:
SURFACE TYPE: [] Unimproved []Gravel []Asphalt []PCC []Other
[] Repaired by City Work Order #
[--I Repaired by Permittee [] COMPLETE
[] No Damage Found [] INCOMPLETE
(Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE)
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
........... INSPECTION REPORT ...........
REQUEST:
Date ~---/0--~) [ Time ~ ~'~- (~ Received by ~-~'~--- (~,~,person)
Location of Work to be inspected //q ~ ~ I~ ~6~
Name of person requesting inspection
Address of person requesting inspection V ~'f~J P~ {' ~-¢/'~/~l~'~ne No.
Type of Inspection (circle appropriate one): Permit No. I~(~ I"~
Sewe~Foundation) Framing Chimney Plumbing Final Sewer Excav. Other
INSPECTION NOTES: J~'
Inspected: Date ~ ?O- ~,~/ Time By
Remarks:
RESTORATION REQUIRED ...... YES. NO
SURFACE RESTORATION:
SURFACE TYPE: [] Unimproved [~Gravel [~Asphalt []PCC ~-}Other
[] Repaired by City Work Order #
[--I Repaired by Permittee [] COMPLETE
E] No Damage Found [] INCOMPLETE
(Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE)
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
........... INSPECTION REPORT .. .
Date 1'-2 [ ~(~'~ Time Received b phone, person)
Location of Work to be inspected I I ~
Name of person requesting inspection
Address of person requesting inspection Phone No.
Type of Inspection {circle appropriate one)~.~__..~ Permit No. .~ .~-/~ ! ?
Sewer Foundation Framing Chimne~f Rli~mbin~ Final Sewer Excav, Other
Inspected: Date / -'~ t~O~ Time By
Remarks:
RESTORATION REQUIRED ...... YES NO
SURFACE RESTORATION:
SURFACE TYPE: [] Unimproved [-IGravel I-~Asphalt I-'IPCC []Other
[] Repaired by City Work Order #
[--] Repaired by Permittee [] COMPLETE
[]No Damage Found [] INCOMPLETE
(Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE)
CITY OF PORT ANGELES
PUBLIC WORKS - ELECTRICAL DIVISION
'~21 F. AST 5TH STREET, PORT ANGELES. WA 983(~2
ELECTRICAL PERMIT ISSUED: 6/18/2001 PERMIT NO 7301
OWNER/APPLICANT PROPERTY LOCATION
VERN PRITCHARD 119 FOGARTY
119 FOGARTY Lot: E 1/2 18 & ALL 19
Port Angeles, WA 98362 Block: 25 [] Long Legal
360/452-5614 Subdivision: FOGARTY & DOLANS
T: S: Parcel No: 063009522578000
CONTRACTOR ARCHITECT
ELECTRIC SERVICE N/A
924 DRAPER RD.
PORT ANGELES, WA 98362 , 98360-0000
360/452-6424 360/000-0000
PROJECT INFO
Project Type: RES. MISC. Project Value: $0.00 ~
Occupancy Type: Construction Type: SERVICE CHANGE
Occupancy Group: Zoning Use:
Electrical Heat:
[] Baseboard 0 KW [] Riser [] Underground Service "~
[] Furnace 0 KW [] Overhead Service Voltage: 120,240 ~
[] Heat Pump 0 KW [] TempService Phase: [] 1 [] 3 ~~
[] Fan Wall 0 KW Service Size: 200 ~
Feeder Size: 0
PROJECT NOTES ~
Change overhead to 200 amp underground and new panel
FEES ASSESSMENT Service: $61,50
Additional Feeders: $0.00
Circuit Wiring: $0.00
Temp Service: $0.00
Misc Fee: $0.00
TOTAL FEE: $61.50
AMOUNT PAID: $61.50
BALANCE DUE $0.00
) N i ;'.1}:~' [ 51/ACTION NEEDED
ELECTRICAL PERMIT INSPECTION RECORD
CALL 417..4735 FOR ELECTRICAL INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT I$ UNLAWFUL TO COLOR,
INSULATE OR CONCEAL ANY WORK BEFORE IT IS INSPECTED AND ACCEPTED.
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE '7 '3 (~) /
DITCH ¢ /// Y/o ! ,7~/t
ROUGH-IN / COVER
SERVICE r,,/,~b! ~,~[.- ~,q z~,',~d., ,,o.~V rd~-cd4f'i tt,_~ ~ ,.0~ ~,'~ ,~ c~ o .,4.
FINAL I .F-/z//ot I :2t4- I
GENERAL COMMENTS:
,. . <440;
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A ",~AL , a Ie / Phone~-"Y'<;"?..t:W7Fax:
OwnercrElec,ContraelCrAgenl:,cDI'<<:K...- A. c-ul". ("'" - --- _
::::Ownor. 9~ CJ.,-nf.<'1~d- ~;U1PI- ,fJNnAf.6" Phone:
Electrical Con\raClCr./t I.], f'LPP'- U~ .J;),/ c..- . LbR~f:.~Z.~EXP:
Address: ,.O;t~ lQ.,1l fJA"'f'(" COly: ..fIr,f- I4tl.Jt?", /'" < Wo
INSTAlI.ATION WIRED BY: 0 OWNER <<ELECTRICAL CONTRACTOR
CredllCardHolderName: 0_,,*/ ~/~~, f .
Billing Address: :l2'i. ~ '/:x;ep &K' City: A.t'T fC/tu't'" (g ~
Credit Card Number: '- Exp. Dale'
;,Gf 1~~ GFt'JC-t4e+cf)
Check all that apply: ~ ~w 0 Alteration/Addition
FROM : BOB'S Electric
PROJECT ADDRESS:
TYPE OF WORK:
FAX NO. : 1 360 452 9943
~
ELECTRICAL PERMIT APPLICATION
Apr. 16 2004 11:07AM Pi
FOR ()FACt,,!.. U$I~ (1'1.:1. Y
Dlwtllfl;;
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DlI&I,,",",",.t.
DlN'lssw.r:
The Electrical Permll Applicalion must b@ filled out comDletelv.
Ol/-,70?
Please type or reprint In Ink. If you have any questions, please call (360. 417~735
Fox number: (360) 417-01711
ge,o -"~:2 - 'ft7S13
Zip:
Phone: </S7 - t,Pf{7
Zip: '7 f ~(, L
Zip: lIlt:< Cj ft2,f&
VISA:.A-MC:-
o Commercial 0 Mobile Home
Sq. Ft.
~esidental 0 Mulli-tamily
o Remote MeIer 0 Detached garage 0 Hot Tub 0 Swim POOl 0 Septic Pump 0 Low Voilage 0 Telecom. 0 Sign
Number 01 Circuits added cr altered:
~~
DESCRIPTION OFTHE ELECTRICAL PROJECT:
7 f(J ;Q.
Service Informallon
Electrical Heat Load Addlllons
_IC-N l/-
_IC-N ~.:S7>'f7 ~~ /9 Overhead Service
IC-N ,j 'UTemp Service
10 t<:W /5(70)( 'f 0 Underground Service
tel
PAMC 14.05.060(8): For Industrial. commerdal. & residenlial projects larger lhan a duplex, a one. fine drawing of Ihe Electrical Service &
Feeders. bulldlng size (sq. It.). load calculallons, and lhe lype & of ecnduclors and/or raceway Is required and shall accompany the
Eleclrical Pormlt appllcallon.
.1
o Baseboard
o Furnace
o Heal Pump
)(Fa ll
Voltage:
Phase: CJ 1 0 3
Service Size:
Feeder Size:
I hereby certify thet I have reed end examined this application and know Ihat same 10 be true and correct, and I arr
authorized 10 apply for Ihis permit. I understand it is nol the CilY's legal responsibilily to delermine what permils
are required; It remains the applicants responsibility to determine whal permits are required end 10 obtain suCh.
o'V .
l~~w:\:~\oi
~. 1~b);i
Credit Card Holder's Signature: V#bHLl ~A,!!/-J/'
Owner or Elec. Cont. Signature: ~ b,t ~ ~.#trl 7.
~~
Date: 1 ;of~
Date:~
. ~ rrb) 30