Permit o
` CITY OF TIGARD MASTER PERMIT
• n
- ,': COMMUNITY DEVELOPMENT Permit #: MST2009-00159
13125 SW H Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/28/2009
Tl fir�ARL Parcel: 1 S 125DB02901
Jurisdiction: Tigard
Site address: 9280 SW 74TH AVE
Subdivision: BOULEVARD HEIGHTS Lot: 5
Project: Brown
Project Description: Add 500 sq ft to rear of home.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 500 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Yes
Total: sf Value: $50,975.00 Rear: 0
PLUMBING
Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 1 Rain Drain: 0 Catch Basins: 0
Lavatories: 2 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0
Tubs /Showers: 2 Garbage Disp: 1 Water Heaters: 0 Water Lines: 0
Drains: 0
Bckflw Prevntr: 0
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 3 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Furn <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp SrvclFeeders Branch Circuits
1000 sf or less: 0 0 -200 amp: 1 0 -200 amp: 0 W/ Svc or Fdr: 10
Ea add'I 500 sf: 0 20 1 -400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr:
Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add'I Br Cir:
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +amp /volt: 0
ELECTRICAL - RESTRICTED ENERGY
SF Residential
Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
Owner: Contractor: Required Items and Reports (Conditions)
BROWN, HARRY L & TRACY J OLTEAN ENTERPRISES 1 MST Ersn Cntrl 503 - 681 - 4444
9280 SW 74TH AVE 14325 NE AIRPORT VW STE 103
TIGARD, OR 97223 Portland, OR 97230
PHONE: PHONE: 503- 255 -6310
FAX: 503 - 255 -6313
Total Fees: $2,093.94
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in O
952 -001 -' r through • • - 952-8! 4100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.3 2.2344. t
/
Issued B'. _ i■ Permittee Signature:
B,uildb g Permit A,nplication
, : ,
Residential FOR OFFICE USE ONLY
City of Tigard CEi d E� !iepermit No.: 111 v 13125 SW Hall BlvdTigard, OR 9 722 w
/ Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Permit:
TIGARD Inspection Line: 503.639.4175 JUL 2 2 2009 Date Ready /By: „...,044 furis: ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: GO ' �5' V ( 15, Supplemental Information
CITY OF TIGARD 7�
,",'.t. 'i�''��s "'C TYKE " -,j0 T, A S'Y IiJti4 -$ .t r �..,.,:.::,.� ;� f8 r r.»',. s s,..., :.: �, ,;
?'d �..__, , �s....W . .W t- _ � ; *K10. CI D r 11, , . . � REQUIREI).DATA I S AND 2 FAMII Y�DWELLING W '
_��r ,,ate .�,� >. .. - tee. e .
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
A Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
- a , za OA Pr work indicated on this application. rTS-
� r CATEGOO RY UF CONSTRUCTION , , . ! 1 y /
X I- and 2- family dwelling 12 Commercial /industrial Valuation: $
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms: 3' 2
' JOB SITE If TI6 AND LOCATIp
,. .�.u. V " max. Total number of floors: ,..
Job site address: gsbo SVV / I,{ 14 port, New dwelling area: 5D0 square feet
City/State /ZIP: "r1 ( jam ok 97 2"3 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: 6'ROW Covered porch area: square feet
Cross street/directions to job site: GW CO CP ! 1 6 ���I Deck area: square feet
l v Other structure area: square feet
t- REQUIRED DATAGON MERCIAI TJSE'CHECKLIST
Subdivision: Lot no.: 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, '� ` " a fibl _ �' a n „ t' � o work indicated thi�slapplicationead, and the profit for the
t , ".r., �a. .,, .iw DESCR OF W ORK � ' . , p .,, application.
. Acn1)I NG S 10 x 59 P=T ADD1 t 10 � Valuation: $
e 1 V C�IfT Q n c I ,�' 5 .- 11 6 - i o t 7 c OF �, Existing building area: square feet
New building area: square feet
❑ PROPERTY• OWNER 9 ®TENANT N Number of stories:
Name: 1 tp, \I 4- ' IZ -c' / sg Type of construction:
Address: q' 0 sv) '1(.4 .,T A "4r Occupancy groups:
City/State /ZIP: T1& 0 o f., Oil 223 Existing:
Phone: (563) ZLIy 200/°7 Fax ( ) New:
❑ APPLICANT t
r . CONTACT TPERSON V3 y
u , , ; „1'x:7., , , 0� , ".,..T,.,�,„ »..:40;�s:ee , ¢...,...* " � 4 1 - . NOS L
,- ar , ,. � . ,.- � � ,.- .��� Ana.., s
Business name: 01_,T,■ i N ` I.p3P 15 1 S All contractors and subcontractors are required to be
Contact name: Srf1lzl,��S licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 04 3 Z,5 I A P(j�t - LT — t A-\1 jurisdiction in which work is being performed. If the
City/State /ZIP: x' 1 ') / o R or-7 23
applicant is exempt from licensing, the following reasons
Q apply:
Phone: 6 gee i .. I 2.3q Fax:: ( ��3) �•�5 _ t✓ 3 i 3
W 1
E-mail: Shdpr -o wwb cot n e� -
a ..,,; `c F > °P.44 gai CO l �RAcTOR . ;A,.. . ' ,... ”. to ..
Business name: Q - fr Stv' Z 64,17 BUILDINGjPERMIT F ,
pp`� a . r i p r P (Pl ase,rejer tofee lath l) ,x i� r ..
Address: 1 "t i. N I `L pi R�T' w p� j 4 I o 2 c. s i
�T �` ``�� lJa Structural plan review fee (or deposit):
City/State /ZIP: D _ b °i - 7 2 3 0
�^�° . 1 FLS plan review fee (if applicable):
Phone: (gO3) z7 - to 3 i 0 Fax: (03) 2.55 'f 4 13 3
s 0 , ,, Total fees due upon application:
CCB lic.: l 6 9 t 1
i / } Amount received:
Authorized signature: /- , / This permit application expires if a permit is not obtained
+ within 180 days after it has been accepted as complete.
Print name: kV ��V1 O t 1F •e\ Date: 7- ZO - 0 * Fee methodology set by Tri-County Building Industry
/ Service Board.
I: \Building\Permits\BUP -RES PermitApp.doc 11/6/07 440 4613T(11/02 /COM/WEB)
'Mechai ical Permit Application FOR OFFICE US ONLY
City W Tigard , S Received Permit �p
13125 SW Hall Blvd., Tigard, O' Date /By: 7 a � t N
G � �eJT�9 G1DlJ /
- Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 � Date /By: Other Permit:
T IGARD Inspection Line: 503.639.4175 JUL 2 2 2009 Date Ready /By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplementallnformation
G1TX OF TIGARD
f
t �x TYP DyISIUN COMIYIEKCIAL�FEE *SCHED[JLE �US H
ECECKI:IST
�
❑ New construction °Addition/alteration/replacement Mechanical permit fees* are based on the value of the work
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
RESIDENTIAL EQUIPMENT/ SXSTEMSgF�ES *'''
1 and 2 family dwelling ❑ Commercial /industrial ❑ Accessory building" e
For special information use checklist.
❑ Multi - family ❑ Master builder ❑ Other:
Description Qty. Ea. Total
JOBSI INF AND LOCAT ON` Heating /cooling
Job site address:" 9 Z. 8 0 ' Vj 9 { ' if1� Air conditioning or heat pump
_ 1 1 � l_ (requires site plan showing placement) 14.00
City/State /ZIP: 'l (,-f 1 _b O2.... a T .z.1 Furnace 100,000 BTU (ducts /vents) 14.00
� r � ^I Furnace 100,000+ BTU (ducts /vents) 17.90
Suite /bldg. /apt. no.: Project name: �lJ vY Gas heat pump 14.00
Cross street/directions to job site: 5J L cjI j Duct work 10.00
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 14.00
Flue/vent for any of above 6.80
Subdivision: Lot no.:
Other: 1 0.00
Tax map /parcel no.: Other fuel appliances
DESCRIPTION WORK .., d t � _. - ;� Water heater 10.00
Gas fireplace 10.00
k V J 1-L j#'i l l -S [IJ k Dt to O c) Flue vent for water heater or gas
fireplace 10.00
Log lighter (gas) 10.00
Wood/pellet stove 10.00
Wood fireplace /insert 10.00
- Chimney /liner /flue /vent 10.00
w PROPERTY R OWNE � TEN
...,,.,. �. � � P . - -_ '�, ANT „5, Other: 10.00
Name: ftfR`/ d .•tC'/ f?j24f3\4J Environmental exhaust and ventilation
Address: (t'Lt)t S� r7 L(T* J Range hood /other kitchen
equipment 1 0.00
City /State /ZIP: 'ri & 0 R "!1 2.23' Clothes dryer exhaust ( 10.00
� Single -duct exhaust (bathrooms,
Phone: (503 ) j4LI - 2. q� Fax: ( ) toilet compartments, utility rooms) 0 I 6.80
” APPLICANT �� CONTACT PER$
�t�� � ON� r Attic /crawlspace fans 10.00
� „ „r >r, >.�,,� �,;..,, sit» ,., ,,.
ne , b i T iJ C L J l t $
Other:
ueI piping 10.00
Business name:
P g _
Contact name: J3(� f+1 � �qS l4 L.D C, , o � $5.40 for first four; $1.00 for each additional
Address: t' t
3 ' � R t O R•1— V , J r ` l Gas heat e P um P
City/State /ZIP: 1 T \ N 1) , G ' 7''Z Wall /suspended/unit heater
Phone: ( 503) 3 ��1y Z 3C1 Fax: (Fj03)l�255_,3 Wateaceater
E-mail: s kd p r: � l ii1 eL C�GP5+' f+ Range
?.
�" CONTRACR - r wJ Barbecue
a a�. � TO ✓.rf.'� .�a
Business name:
V ����� Clothes dryer (gas)
�` �
Other
Address: .' �MECHAN1CAPERMIT FEES*
City/State /ZIP: O . q7 Subtotal
I r Minimum permit fee ($72.50) 7Z' Phone: ('O3 1, 5-- 3 l Fax: (5Q3) 2 57 b 3 1 3 Plan review (25% of permit fee)
CCB tic.: ( (, U (, State surcharge (12% of permit fee) .7 0
TOTAL PERMIT FEE w'
/ This permit application expires if a permlt is not obtained within 180
Authorized signature: i days after it has been accepted as complete.
Print name:
�f Q Date: - - Z 0 — c 9 * Fee methodology set by Tri- County Building Industry Service Board
electrical Permit Application FOR OFFI USE ONLY
F21
City of Tigard i � ��� � Received .y q P No.: e �, �+ l
1 Date/By: / a4- O / ��GXJT"� J
13125 SW Hall Blvd., Tigard, OR 972 Plan Review
Other Permit: •
IMMI Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Inspection Line: 503.639.4175 JUL 2 2 2009 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF W(c { I Y OFTI PLAN REVIEW
❑ New construction Addition /alto atibtt/t'e la PAnj ISION Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1 - and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 - ", "1 - ",
Job no.: Job site address: 9 a B ei Sv 7-174 V 4- 100HP or more. occupancy.
❑
0 Six or more residential units. Recreational vehicle parks.
City /State /ZIP: T 1 P''D OR ( 7 2�' ❑ Health -care facilities. ❑ Supply voltage for more than
' ` ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: B tv ❑ Service or feeder 600 amps or more.
_ FEE SCHEDULE
Cross street/directions to job site: S v A Ccb, es Q .. g tee ( Description 1 Qty. 1 Fee. 1 Total 1 "
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Ea. add'l 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family 75.00 2
residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
200 amps or less It 80.30 3C 2
kr PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 0.,Aggj/ d- TRAcy BD‘A) 0 401 amps to 600 amps 160.60 2 -
` a g O s tJU .7 y V t_ Over am ps to 1,000 amps 240.60 2
"
Address: Over 1,000 0 amps or volts 454.65 2
City/State /ZIP: &„ ft-R / 0 R a 1 D.D. 3 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (C,o3 ) Z .LI L. - 20q -7 Fax: ( ) 200 amps or Tess 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT CONTACT PERSON above service or feeder fee, /0 6.65 2
01 � x 1�7 1 Keg each branch circuit
Business name: l� 'f Fee b
B. Fee for branch ch cia rcuits
Contact name: J 0 it t\1 s ' Lb S firs branch service or feeder fee, 46.85 2
first branch circuit
Address: ( L a 5 Ni 9, p Vv Each add'I branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City/State/ZIP: ?OtikT1, D Q 01 -7 a30 Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: (5 301_ 1;a Fax: :(66 ) a /r 55« o3 (3 Reconnect only 66.85 2
E -mail: 5hd pv' t ec- e. Conn a,S4 n of Pump or irrigation circle 53.40 2
�J CONTRACTOR Sign or outline lighting 53.40 2
Business name: L v" N C G C - ,.. ( / L c Signal circuit(s) or limited-
` Y v energy panel, alteration, or
Address: 2.2 Sr
dock! extension. Describe: Page 2 2
7 $t City/State /ZIP: £ q Each additional inspection over allowable in any of the above
fiK1 1 G IAN' Per inspection 62.50
Phone: ( - Q , Pax: ( 60 Investigation per hour (1 hr min) 62.50
CCB Lic.: /67 /C4 Electrical Lic.: C — f QG6e Suprv. Lic.: gd30 Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: • Subtotal: KC, ,e)
. Print name: c,1 .. i u e U , : fi Date:07 _-2,0 Plan review (25% of permit fee):
f.� State surcharge (12% of permit fee): V , G
Authorized signature: TOTAL PERMIT FEE: ( Cy 4 4_-2--
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\ Building \Permits\ELC -PermitApp.doc 05/23/06 440- 4615T(11/05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
n Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
❑ Instrumentation
•
Fl Intercom and Paging Systems
❑ Landscape Irrigation Control*
n Medical
n Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\BuildingPermits\ELC- PermitApp.doc 03/23/06
Plumbing Permit Application
Building Fixtures FOR OFFICE USE ONLY
N , City of Tigard RECEIVED Received /� ^ Permit No.:
ill SW Hall Blvd., Tigard, OR 97223 Date /By: 7 a P al (iaf'Tapp - QD /,
Phone: 503.639.4171 Fax: 503.598.1960 JU 2 2 2009 Plan Review
DateBy: Other Permit No.:
Inspection Line: 503.639.4175 Date Ready/By: g g Notified /Method: Supplemental uris: El See Page 2 for
TIGARD Internet: www.ti and - or. ov CITY OF TIGARD y. g
lnformation
' W 44441-'s TYPE i OIOTLD, NGt} �� O N u H ' 'x;. r. �; F HED .s
F-- ,- aa..r,. v �, � _'t':i x .. d Y Y».,a„„,".J !• ..(e. ,, 1 . 4
❑ New construction ❑ Demolition For special information use checklist.
Description 1 Qty. 1 Ea. 1 Total
%Addition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 R. for each utility connection)
17,1,71' ATE 01fi' OF CONST UCTION�' � Y_ SFR (1) bath 249.20
�, fri'X'iR, >S� ,,. '05,
X 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
s =,� - _ Fire sprinkler (_ sq. ft.) Page 2
1 y „ JOB SITE NFORMAT,ION AND LOCATION r ''
_....ax �x, u� .;, �. ,�<r . - �.: «�aa` � Site utilities
Job site address: 12, f,0 G, / Li - i ei._, Catch basin or area drain 16.60
City/State /ZIP: -r 1 G-prA[) o e, °I L'2 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: $g_ Footing drain (no. linear R.: _) Page 2
SW C f ciZ gli c Manufactured home utilities 1 10.00
Cross street/directions to job site: L
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: (OD) Page 2 5 ,ex)
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no
Absorption valve 16.60
r ttDESCRIPTIOPT OF WORK ry. `'
,,, , .,, r,� _ ...., ..mow :v��, , „ -, _ _ -� , „- �, a3-.,__A. ,: , B preventer Page 2
AM I t;7" 1 .' MI-1" j 4 II\0v l is & Backwater valve 16.60
(C.UrCi i IJ 5I O lc cj i_ 1 t Pb Ey IN A - D D i °, 0 J Clothes washer ( 16.60 16n , 70
N Dishwasher ( 16.60 I (e ,.
Drinking fountain 16.60 I
t
•
PR OPERT OWNER �I r TENANT M ,. s Ejectors /sump 16.60
.. „-.•a� rear ,.�, r, _x
Name: 1l -Rk'/ e.. , 1 R 7 i s mm Expansion tank 16.60
Address: QI S. , z, 0 5 vi ( Lt 0 A-1h, Fixture /sewer cap 16.60
City/State /ZIP: ii (r&1&J) I O 11 223 Floor drain /floor sink /hub 16.60
Phone: (!,1)3) 2.1. L. 20C17 Fax ( ) Garbage disposal 1 16.60 16 , C.p
l A PP L CAN a _ _ .i t t " q ",CONTACT PER SON Hose bib ' 16.60 ((c+,1
,"a, ~_ .. „ . e.,,,,,„ _ _ _. � Ice maker 16.60
Business name: 0 J,i PrKI, c ic RP R ($ f S Interceptor /grease trap 16.60
Contact name: TO O I f i 1 51 t L'S Medical gas (value: $ ) Page 2
Address: 14 32.6 N A gplsKir vJpol Primer 16.60
City/State /ZIP: r <rua l J D OK Q r1 .- 3® Roof drain (commercial) 16.60 MO
Phone: (03) 391 . - I 3
/ Fax: : (5-D 255 -i,3 SiSink/basin/lavatory ( Q® ti 16.60
5h� `eG-+� z e�'lm-S�s, Q� Tub /shower /shower pan 16.60 j;Z
E-mail Urinal 16 60
if, 3 t .. 't' ° CONTRACTOR x � ' � �
r 5 4 1
Y. ,, i F .. _, „„ ,,m,,_ t y,. , ,, Water closet 16.60
Business name: , MiRR I fit (l{-N pL,Ltm 9 ( 0 ` Water heater 16.60
Address: Po Box / 41, 0 Other:
a fp } I r k vo Subtotal
City/State /ZIP: O� �(
1?
j M inimum permit fee: $72.50
Phone: (,31 0 0 - g f e , 31 Fax: ( 3/„ Op q r - 5 Residential backflow minimum permit fee: $36.25 270.80
CCB Lic.: 15,33 L 0 1t. y • • Plumbing Lic. no.: :vi � �� il+r [�/ Plan review (25% of permit fee)
��- -2-3P2 State surcharge (12% of permit fee) 9 j�. 7e_.+
• Authorized signature: `` -? 1 11 TOTAL PERMIT FEE 1:3(M.
Print name: 4. d I i 0 40wker�v-N Date:'? - 20 -0/ This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
1:\ Bui lding \ Permits \PLMF - PcrmitApp.doc 12/27/06 440- 4616T(10/02/COM /WEB)
CITY OF TIGARD �_s"7'- s-- -:�Z -- S T ?_ a0,9
BUILDING DIVISION PERMIT #:
13125 SW Hall Blvd., Tigard, OR 97223 DATE
Phone: (503) 639 -4171 A. ,�� t l\
Inspection Requests (24 Hrs.): (503) 639 -4175 �...i `'I � ! INSPECTION WORKSHEET FOR DATE: TIM .
SITE ADDRESS: '?i-9 7 '7 Z CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION: 1
OWNER: PHONE #: 36 / 239
CONTRACTOR: W PHONE #:
Inspection Request Scheduled For: Date: Po ur Time:
Goy' 3 >- o / C--cat /
Code # Inspection Description onfirm ? Contact # Message
-g 6,_..,....s
-- - o ' L,_.. „‘L/
Corrections/ omments /Instructions:
f
I ''
' ,I
/
i ' ' / 1 5 . ' - II y 5 . 4 1 - . . ; s )
Ay j ti ti
❑ PASS n PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
n FAIL CALL FOR INSPECTION n ADDITIONAL FEES ASSESSED
Inspector: Date: Phone #: (503) 718-