Permit 0 o
B uilding Permit Applicat
Date received: //< 4 :7',.. �� Permit no.: Brt/'J09 '� / 7
" '�� ,y
^: " City of Tigard
Project/appl.no.: Expiredate
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223
Phone: (503) 639 -4171 1•6`;,,,..''
t� Date issued: By: Receipt no.:
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: 1 &2 family: Simple Complex:
TYPE OF PERMIT
0 1 & 2 family dwelling or accessory )4 Commercial/industrial 0 Multi- family 0 New construction 0 Demolition
Addition/alteration /replacement 0 Tenant improvement 0 Fire sprinkler /alarm 0 Other:
JOB SITE INFORMATION
x Job address: 0 D / 1 ."1wir r 7-76.,,,z_4 Bldg. no.: Suite no.:
Lot: 1 : lock: Subdivision: 1Tax map /tax lot/account no.:
Project name:
Description and location of work on premises/special conditions:
• OWNER FOR SPECIAL INFORMATION, USE CHECKLIST
Name: 7 of Or (Floodplain,s■ ()tic capacity, solar, etc.)
7 Mailing address: /1 i,L S / 0 A/ J J 1 2 family dwelling: City: 716 ; - i' - ISta ,_I ZIP: uation of work
.... .... ...
Phone: IFax: E -mail: No. of bedrooms/baths.. .
Owners representative: Total num. .f fl ■ .... ...
• Phone: Fax: E -mail: New d mg are • fr ft ....
Gara: . . _.
Name: .56 G T N/ N Cove • • • . • a (sS
Mailing ad ss: /6 ; _ OLD w-, Deck are .. ft.) ... ..
City: al' State: ZIP: Other structure • - sq.
Phone: 1i - k I Fa a.5 E -mail: if/t/L Commercial/' 1 .1/ ti- , , 1 i vG
CONTRACTOR Valuation of ork $ Z)� /
Z \
Existing bldg. area (sq. ft.) 1
A Business name: ' fC7 / E G /TY N/ A}6. New bldg. area (sq. ft.)
Cdyress: 1;1 - I S I Z � Number of stories
Phone: 1 Fax: 1E-mail:
Type of construction
Occupancy group(s): Existing:
CCB no.: New:
City /metro lic. no.: Notice: All contractors and subcontractors are required to be
ARCI IITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
City: 'State: ZIP: exempt from licensing, the following reason applies:
Contact person: 'Plan no.:
Phone: Fax: E -mail:
Name: Contact person: Fees due upon application $ 75.7/
Address: Date received:
City: State: ]ZIP: Amount received $
Phone: 'Fax: 1E-mail: Please refer to fee schedule.
I hereby certif I have - • • and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached chec ist. • Arovisions of laws and ordinances governing this 0 Visa 0 MasterCard
work will be • pli • , hether specified herein or not. Credit card number: Expires
/
r
Authorized sign • /, /. , Date: Name of cardholder as shown on credit card
Print name: Cardholder signature $ Amount
_.
Notice: This petmi . ppli cation expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (6A10/COM)
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