Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT rt
v 0 I
N = Request for Permit Action
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I .,A It f) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ® Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Polygon Homes WLH LLC
Mailing Address: 703 Broadway St., Ste 510
City/State/Zip: Vancouver, WA 98660
Phone No.: 360-695-7700
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MST2020-00069 & SWR2020-00044
Site Address or Parcel#: 14160 SW 165th Ave
Project Name: Polygon at Roshak Ridge
Subdivision Name: Roshak Ridge Lot#: 166
EXPLANATION: Land use changed to ADU plans-ADU2020-00014
Signature: ?iga_741d4.4.e . Date: 11/24/20
Print Name: Tonja Mplrris
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date / By ill
Refund Processed: Date By Invoice Processed: Date 1/f20 2/ By t
Permit Canceled: Date 1/ z t By W Parcel Tag Added: Date By
I:ABuilding\Forms\ReiPermitAction_20518.doc
. ,....
Building Permit Application �c 7_ \ U. U
Residential y,. �VE 1.� FOR OFFICE USE ONLY
City of Tigard Received /n� p �j,�r //y��-yy��//C�
71 - wm EB n/� DateBy: f/���� ��� Permit No.�( Sr24020'C/C�(/(O/
13125 SW Hall Blvd.,Tigard O "p :, V 6 2O Plan Review
Phone: 503.718.2439 Fax: 503 598.1960 Date/By: J/ 11 2/024 I t Other Perm6a#22620'W0T7
TIGARD Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready/By:B / Juris:
ElSee Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method:
Supplemental Information
TYPE OF WORK REQUIRED DATA: 1-AND 2-FAMILY DWELLING
®New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
® 1 and 2-family dwelling ❑Commercial/industrial Valuation: $ 3a a("14
ElAccessory building El Multi-familyNumber of bedrooms:
El Master builder 0 Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors: I 3 0/ l
Job site address: I q "D D V V 1 W(J 9 Q) New dwelling area:) "(p square feet 23qg
# City/State/ZIP:Tigard,OR 97224 Garage/carport area:loa square feet
Suite/bldg./apt.no.: Project name:Polygon at Roshak Ridge Covered elr a�ea a Q square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECIU IST
Subdivision:Polygon at Roshak Ridge Lot no.: l(0(n 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
DESCRIPTION OF WORK work indicated on this application.
New SF Valuation: $
Existing building area: square feet
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name:Polygon WLH LLC Type of construction:
Address:703 Broadway Street Ste 510 Occupancy groups:
City/State/ZIP:Vancouver,WA 98660 Existing:
Phone:(360)695-7700 Fax:(360)693-4442 New:
® APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES*
Business name:Polygon WLH LLC (Pteasere/errn fee schedule)
Structural plan review fee(or deposit):
Contact name:Amanda Gavin
FLS plan review fee(if applicable):
Address:703 Broadway St.Ste 510
Total fees due upon application:
City/State/ZIP:Vancouver WA 98660
Amount received:
Phone:(360)695-7700 Fax: :(360)693-4442
E-mail:permitsubmittals(iepolygonhomes.com PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Business name:William Lyon Homes,Inc. Submit two(2)sets of roof plan with connection details
and fire department access,along with the 2010 Oregon
Address:703 Broadway St.Ste 510 Solar Installation Specialty Code checklist.
City/State/ZIP:Vancouver WA 98660 Permit Fee(includes plan review $180.00
and administrative fees):
Phone:(360)695-7700 Fax:(360)693-4442 State surcharge(12%of permit fee): $21.60
CCB lic.:207247
Total fee due upon application: $201.60
Authorized signat This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name:Amanda Gay' Date: a I / 19 *Fee methodology set by Tri-County Building,Industry
Service Board.
I:Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(Il/02/COM/WEB)
.p.
Mechanical Permit Application FORFOR OFFICE USE ONLY
City of Tigard Received
_ Permit No.. p
Date/By: Msr2020
Il n 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503.718.2439 Fax: 503.598.1960 FEB 0 6 2019 Plan Review
Other Permit:
TIGARD Inspection Line: 503.639.4175 Date Ready/By: Juris 0 See Page 2 for
Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information
BUILDING DIVISION
TYPE OF WORK COMMERCIAL FEE* SCHEDULE -USE CHECKLIST
Mechanical permit fees*are based on the value of the work
®New construction ❑Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit.
Value:$
CATEGORY OF CON51 RLCTION RESIDENTIAL EQUIPMENT/SYSTEMS FEES*
® 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist.
❑Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total
JOB SITE LNFORYLATION AND LOCATION Heating cooling:
Air conditioning I 46.75
Job site address: 1 LiI 00
S W -h Vo Furnace 100,000 BTU(ducts/vents) 1 46.75
City/State/ZIP:Tigard,OR 97224 Fumace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.: Project name:Polygon at Roshak Ridge 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:Polygon at Roshak Ridge Lot no.: ,1q0 Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert I 33.39
Flue vent for water heater or gas
fireplace 23.32
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
® PROPERTY OWNER 0 TENANT Other: 23.32
Environmental exhaust and ventilation:
Name:Polygon WLH LLC Range hood/other kitchen
equipment 1 33.39
Address:703 Broadway St.Ste 510 Clothes dryer exhaust 1 33.39
City/State/ZIP:Vancouver WA 9860 Single-duct exhaust(bathrooms, L
toilet compartments,utility rooms) . .J 23.32
Phone:(360)695-7700 Fax:(360)693-4442 Attic/crawlspace fans 23.32
® APPLICANVT 0 CONTACT PERSON Other: 23.32
Business name:Polygon WLH LLC Fuel piping:
$14.15 for first four;$4.03 for each additional
Contact name:Amanda Gavin Furnace,etc.
Address:703 Broadway St.Ste 510 Gas heat pump
Wall/suspended/unit heater
City/State/ZIP:Vancouver WA 98660 Water heater
Phone:(360)695-7700 Fax::(360)693-4442 Fireplace
Range
E-mail:permitsubmittalsrpolygonhomes.com Barbecue
CONTRACTOR Clothes dryer(gas)
Business name:TBD Other:
MECHANICAL PERMIT FEES*
Address:
Subtotal
City/State/ZIP: Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:( ) Fax:( ) State surcharge(12%of permit fee)
CCB lic.: TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized sigma * Fee methodology set by Tri-County Building Industry Service Board
Print name:Amanda Ga n Date: a J s 1 !G'
w
Electrical Permit Application ECEIVED FOR OFFICE USE ONLY
Tigard Received
Permit
g O
City
. f Date
✓ Date/By:
#: �t/JSfZa2a '✓J �9
III13125 SW Hall Blvd.,Tigard,OR 97223 FEB 0 6 2019
Phone: 503.718.2439 Fax: 503.598.1960 Plan Review
Date/By: Related Permit#:
Inspection Line: 503.639.4175 l.;l fY OF TIGARD Ready DateBy: Juris: 0 See Page 2 for
TIGARD Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
®New construction ❑Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
0 Service or feeder 400 amps or more ElBuilding over three stories.
❑Demolition 0 Other:
where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
® 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building
less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATIONI nAND LOCATION '1O ❑Emergency system. larger separately derived
Job#: Job site address: i(-I 11V D S I(D(sit f 0 / ❑AdditionH of new motor load of system.
100HP or more. ❑"A","E","1-2","1-3",
City/State/ZIP:Tigard,OR 97224 El Six or more residential units. occupancy.
0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bI'dg./apt.#: Project name:Polygon at Roshak Ridge 0 Hazardous locations. 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total I *
New residential single-or multi-family dwelling unit.
Subdivision:Polygon at Roshak Ridge Lot#: Itote Includes attached garage.
`v 1,000 sq.ft.or less 2 168.54 4
Tax map/parcel#: Ea.add'1500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energ
y,residential 75.00 2
(with above sq.ft.)
Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
Renewable Energy 0 See Page 2
El PROPERTY OWNER 0 TENANT Services or feeders installation,alteration,and/or relocation-
Name:Polygon WLH LLC 200 amps or less 100.70 2
Address:703 Broadway St.Ste 510 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Vancouver WA 98660 601 amps to 1,000 amps 301.04 2
Phone:(360)695-7700 Fax:(360)693-4442 Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email:
relocation
Owner installation:This installation 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,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
Branch circuits—new,alteration,or extension,per panel
® APPLICANT 0 CONTACT PERSON A.Fee for branch circuits with
Business name:Polygon WLH LLC above service or feeder fee,
each branch circuit 7.42 2
Contact name:Amanda Gavin B.Fee for branch circuits without
seAddress:703 BroadwaySt.Ste 510 branch
or feederitfee,first 56.18 2
branch circuit
City/State/ZIP:Vancouver WA 98660 Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:(360)695-7700 Fax: :(630)693-4442 Each manufactured or modular 67.84 2
Email:permitsubmittals@polygonhomes.com dwelling,service and/or feeder
Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name:TBD Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy
Address: panel,alteration,or extension. 0 See Page 2 2
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) 90.00/hr
Industrial plant(1 hr min) 78.18/hr
Email:
Inspections for which no fee is 90.00/hr
CCB Lic.: Electrical Lic.: Suprv.Lic.: specifically listed(Y2 hr min)
ELECTRICAL PERMIT } LS
Suprv.Electrician signatur required: Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
TOTAL PERMIT FEE:
Authorized s' atur .
This permit application expires if a permit is not obtained within 180
Print name: Am da Gavin Date: / days after it has been accepted as complete.
* Number of inspections allowed per permit.
I.\Building\Permits\ELC_Permit4pp_ELR_ERE.doe Rev 06/17/2015 440-4615T(11/05/COM/VEB
'Plumbing Permit Application
Building Fixtures RECEIVED FOR OFFICE USE ONLY
City of Tigard FEB 0 6 2019 Received
- City g DateBNogg ��Permit No � .,00��
IIIII • 13125 SW Hall Blvd.,Tigard,OR 97223
Plan Review
Phone: 503.718.2439 Fax: 50359
?Off?OF TIGARD Date/By: Other Permit No.:
TIGARD Inspection Line: 503.639.4175 BUILDING DIVISION y:
Date Ready/By: haiS El See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
®New construction 0 Demolition For special information use checklist
Description Qty. Ea. Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
® 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
ElAccessory building 0 Multi-family SFR(3)bath I 500.32
Each additional bath/kitchen 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 1 q I ( D 1 V V (o I P -7 ) Catch basin or area drain 18.76
1 Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,OR 97224
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: l Project name:Polygon at Roshak Ridge Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision:Polygon at Roshak Ridge I Lot no.: ! (Q`G Fixture or item:
Tax map/parcel no.: 1 Backflow preventer I 31.27
DESCRIPTION OF WORK Backwater valve ' 12.51
Clothes washer 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name:Polygon WLH LLC Fixture/sewer cap 25.02
Address:703 Broadway St.Ste 510 Floor drain floor sink/hub 25.02
Garbage disposal 25.02
City/State/ZIP:Vancouver WA 98660 Hose bib 25.02
Phone:(360)695-7700 Fax:(360)693-4442 Ice maker 12.51
® APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name:Polygon WLH LLC Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:Amanda Gavin
Roof drain(commercial) 12.51
Address:703 Broadway St.Ste 510 Sink/basin/lavatory 25.02
City/State/ZIP:Vancouver WA 98660 Solar units(potable water) 62.54
Phone:(360)695-7700 Fax: :(360)693-4442 Tub/shower/shower pan 12.51
E-mail:permitsubmittals@polygonhomes.com Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name:TBD Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50
Plan review (25%of permit fee).
CCB Lic.: Plumbing Lic.no.: _
State surcharge(12%of permit fee)
Authorized signa e: TOTAL PERMIT FEE
Print name:Amand avin Date: .P., C This permit application expires if a permit is not obtained within 180 days
C� after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
L\BuildingPermits\PLMU-PermitAppdoc 10/01/09 440-46I6Tt10/02/COM/WEBI
r City of Tigard
~ COMMUNITY DEVELOPMENT DEPARTMENT
I
T 1 c A izn Building Permit Review — Residential
Building Permit #: A46 TZQ27-aoo
Site Address: / /C'0 Slit-) , � ?- .9YP.,
Project Name: �� 0/7 ' t A / ', 4t Lot #: /4747
Planning Review (V
Pro osal: Akit) /C__
M Verify address/suite#active in Accela. tld" In River Terrace: ❑ No 1Q Yes,River Terrace Review Addendum
Site lam Elements: ofiosion Control
3 .pies of site plan on 8-1/2"x 11"or 11 x 17"paper at twined trees with drip line and tree protection measures
.wn to scale(standard architect or engineer scale) tprint of new structure(including decks)and FFE
r,Nth arrow J .ty locations&easements(required for new and additions)
q�LS)e address,project or subdivision name and lot number W.Sidewalk/driveway approach
�d .plicant information(name and phone number) , P1 . ation of wells/septic systems
i.r+ 1Q
. dimensions and building setback dimensions �K S eet tree size,type and location
*1 are footage of buildings to be demolished S et names
11t!xisting structures on site VCorner elevations(2'contours if more than 4'diffe tial)
7 r area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replace4? LVJYes ❑N
impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown?QC Yes UN'o
10 lean Water Services—Service Provider Lette (lot platted prior to 9/10/1995):
Required: ❑ Yes,applicant was notified No Received: ❑ Yes ❑ No
N,TYWater Meter Fixture Unit Worksheet—Additiylns,Remodels and ADUs
Required: ❑ Yes,applicant was notified V No Received: ❑ Yes ❑ No
111°.DC Exemption for ADU applied for: ❑ Yes ❑ No Received: ❑ Yes ❑ No
1I, Public FacilitiImprovement (PFI) Permit:
quired: Yes,applicant was notified ❑ No
r1 lied For: 'Y/es ❑ No,stop intake
NJ and Use Case#: ��� ®�� �� NJ Zoning: J —T cl
IJ egnired Setbacks: Front: 0 Rear: /D Side: Street Side: �� Garage: G
Building Height: Max. Height: _ 1 Actual Height:
OPKandscape Area: % of Coverage Max: %
Entrance t back no more than 8'from street-facing wall ❑ Parallel to s or offset 45 degrees or less
Windows ❑ Minim 2%of area of all street-facing facades
Garage ❑ Garage door is . d widest street-facing wall 11 Yes ❑ No,one of the following is met:
❑ Door extends no m an 5'from wall a ere is a covered porch extending beyond garage.
❑ Door extends no more than all and there is a 12 sq ft.window above garage on 2nd floor.
❑ Garage door width is ❑ 1 ' ess °o or less of facade ❑ 60%or less and includes 7 of following:
❑ Covered porc Recessed entrance offset ❑ 1'Roof eave ❑ Roof offset
❑ Fire . g es ❑ Lap Siding ❑ Roof pitch able,hip,or gambrel roof ❑ Dormer
ccent siding Window trim ❑ Window recess Window projection ❑ Balcony
Visual Clearance Urban Forestryan
IV .,-nsitive Lands: ❑ Yes NJ No Type:
IV Conditions met prior to issuance of building permit
No
Approved By Planning: Date:
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
1:\Building\Forms\BldgPermitRvw_RES_122419.docx
Building Permit Submittal `
Original Submittal Date: a2-�(o,2 '20
Site Plans: # a
Building Plans: # 3
Building Permit#: ji4 Enter building permit#above.
Workflow Routing: ie Planning . ] Engineering J Permit Coordinator X Building
Workflow Sign-off: KO Sign-off for Planning(include notes from planning review)
Route Application Documents: fg Engineering: (1) copy of permit application, (1) site plan, (1)building plan and
original plan review routing form.
.I Building: original permit application, site plans,building plans,engineer and
beam calculations and trust details,if applicable,etc.
Notes:
By Permit Technician: _ Date: 02'2C 202o
Engineering Review
13"Slope at building pad: i/
1 Conditions "Met"prior to issuance of building permit
Er"Easements (encroachments) per engineering conditions of approval and plat
Er Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: ❑ Yes E No
Assess Water Quantity Fee in-lieu: ❑ Yes C No
LIDA Facility on lot: ❑ Yes C.--
No
Q Final Plat Recorded:
❑ NOT Approved by Engineering: Date:
Notes:
L 'Approved by Engineering: 7 -e.,,, 1X Date: 2.)2%/2rr26
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Permit Coordinator Review
❑ Conditions "Met"prior to issuance of building permit
❑ Approved,NOT Released: Date:
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant:
Revision Notice 2: Date Sent to Applicant:
❑ S C Exemption: ❑ Received Ld'Does not apply
SDC Fees Entered: Wash Co Trans Dev Tax: 2/Yes ❑ N/A
Tigard Trans SDC: rYes ❑ N/A
Parks SDC: L" Yes ❑ A
LIDA ❑ Yes Pr A
OK to Issue Permit /7-0
Approvedby Permit Coordinator: Date?/
1:\Building\Forms\B1dgPermitRvw_RES_122419.docx