Permit Building Permit Application
Re-Roof G „ \ /ED FOR OFFICE USE ONLY
City of Tigard ~q� +" �( Date/BReceiv : ,f
_ Permit No.: * !
It 13125 SW Hall Blvd.,Tigard,OR 97223 q �� � ' "�if
g 1�L� Plan Review
Phone: 503.718.2439 Fax: 503.598.196013j Date/B : Other Permit:
TIGARD Inspection Line: 503.639.4175 'ARE) Date Ready/By: la See Page 2 for
Internet: www.tigard-or.gov ,} ,tlaA Notified/Method: Fag.M1Supplemental Information
I DINC ,-vltiiSION
TYP WQ E OF „ ,i;r' DFIiEI>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
14,Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
�evCATEGORY OF CONSTR1YC`I'I_ ,x i_0
work indicated on this application.
Valuation: $
❑ 1-and 2-family dwelling ❑Commercial/industrial
ElAccessory building Multi-family Number of bedrooms:
El Master builder El Other:
Number of bathrooms:
«IOB_SITE INFORMATION AND LOCATION Total number of floors:
Job site address:got IS Sk.,,) c-eLdur1ca. ,-k- New dwelling area: square feet
City/State/ZIP: -1-1 G3 a-i OI_ a,2'L5 Garage/carport area: square feet
Suite/bldg./apt.no.: J Project name: Olr'Gvnar t pou,--\ Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA CO ME .0 E cIIECKLIS§T
Subdivision: Lot no.: Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: ,,,,,, equipment,materials,labor,overhead,and the profit for the
----Or''
Valuation: $ 135 8i l
Tear Of f Coth oSkfior. r oo-F5 D✓\ 1ou,�du cto
Nap
ap d DLL
C 11n5-AIA „� n, 1 1. „I tl,k,t j� it Existing building area:1 I�c square feet
S1 VI VI 1 C-. a &G�S J „eS• V-�' T New building area:2,1 1�DO square feet
PRO'ERTY OWNER l'R'j �iiTEN, '0 Number of stories: Z
Name: 1\AMo 9- ?t t,I-e M�y,aca n l v A vvi--- Type of construction: n _ c_
Address: _� ' "`"` Occupancy groups: n A1" - �1�,t/1,.
City/State/ZIP: Existing: 1"`
Phone:( ) Fax:( ) New:
"'APPLICANT ❑ CqI A � ' RSON` E �'' _NOTICE a i4'
Business name: lv1A- +Q.. Qc .0-, All contractors and subcontractors are required to be
Contact name: 76NrrIDA M�� ���� licensed with the Oregon Construction Contractors Board
r under ORS 701 and may be required to be licensed in the
Address: `cb LaS S� "1 ,h jurisdiction in which work is being performed.If the
City/State/ZIP: �' a.r�t� 0L-1 Z Z,t+ applicantp is exempt from licensing,the following reasons
apply:
p 1
Phone:( )Cobq—S D `l Fax::( )
°� 1 t @ Wv i-ee-Sfit�} nt-F'► ' •t�
E-mail:
fir' �,
!yam Ii' /411 COiIT CT4,,li I r � ui� yj'
Business name: py n hl_ 1
t r 4i i k i icuse re,�er'to ec..Irc lute ii61��i,"
Address: (9)QS S LA) 4�^ . ,nv--� Structural plan review fee(or deposit):
City/State/ZIP: Doc -\0..Y _/ f`V Ct1 2-7 J.
l FLS plan review fee(if applicable):
Phone:(5%3 )(D Pl.}-'S($`1 Fax:( )
CCB lic.:'C'S L 5 S Total fees due upon application:
Amount received:
Authorized signature: pt. �1()C., p_ This permit application expires if a permit is not obtained
r I J �l�-/'�`" within 180 days after it has been accepted as complete.
Print name: �'�r� M�/.�`� Date: ��I(0 pZ Z * Fee methodology set by Tri-County Building Industry
l Service Board.
I:\Building\Permits\ROOF-PermitApp.doc 10/01/09 440-4613T(11/02/COM/WEB)