Permit t
C ITY OF TIGARD BUILDING PERMIT
PERMIT #: BUP2006 -00129
DEVELOPMENT SERVICES DATE ISSUED: 8/8/2006
' • J I I 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2 S 104 D B - 04700
SITE ADDRESS: 13222 SW ROCKINGHAM DR ZONING: R -4.5
SUBDIVISION: AMESBURY HEIGHTS LOT: 047 JURISDICTION: TIG
Project Description: 400 sq ft deck
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: OTR FIRST: sf N: S: E: W:
TYPE OF USE: SF SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 5N sf N: S: E: W:
OCCUPANCY GRP: R3 TOTAL AREA: 0 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED:
STOR: HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED
FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET:
DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC:
BEDRMS: BATHS: IMP SURFACE: PRO COR R: PARKING:
VALUE: $ 6,640.00
Owner: Contractor:
CHRIS DUFFIN LMC, INC
16842 SW GLAGSTONE DR 4915 SW GRIFFITH DR #301
BEAVERTON, OR 97007 BEAVERTON, OR 97005
Phone: 503 - 998 -6434 Contact #: PM 503- 646 -0521
FAX 503- 646 -6823
Reg #: LIC 161282
. FEES
Description Date Amount REQUIRED ITEMS AND REPORTS
[BUILD] Permit Fee 8/8/2006 $110.50
[TAX] 8% State Surcha 8/8/2006 $8.84
[BUPPLN] Pln Rv 8/8/2006 $71.83
[CDCPLN] CDC Pin Re 8/8/2006 $43.00
(additional fees not listed here) EXPIRED D
Total $240.17
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 than 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy
of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued By:�� _ ( p o ' Permittee Signature: 41111r, l dIIIIVIP - A gilliIW "Ill Illr
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that bus -ss day.
This permit card shall be kept in a conspicuous place on the job site until corn • - • • • e project.
Approved plans are required on the job site at the time of each inspection.
Building Permit Application FOR OFFICE USE ()NIA
City of Tigard ��y. — 9 **DID1i19
Received /N D� I Permit No.: u / �Y/Ot�
11 4 I ° 13125 SW Hall Blvd., Tigard, OR 97223 / 4 4
Phone: 503.639.4171 Fax: 503.598.1960 Date/By.. Plan Review y / /��D 1e Other Permit:
f I G n It D Inspection Line: 503.639.4175 Date Ready/By: / i l l , / Juris: ® See Attached Checidist for
Internet: www.tigard- or.gov Not /M - '7 G�/ a/! f ( ,, Supplemental Information
• `� -( wccq/ - / . ! / -
TYPE OF WORK REQUIRED DATA - AND 2- FAMILY D / LING
L! Neyw construction ❑ Demolition Permit fees' are based on the value of the work performed. .
Indicate the value (rounded to the nearest dollar) of all
At dition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit r the
CATEGORY OF CONSTRUCTION work indicated on this application. � /. •
l -and 2- family dwelling ❑ Commercial/industrial
Valuation: $ W f
❑ Accessory building ❑ Multi - family - Number of bedrooms: 0) W°
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 1 ' Z �� S Li e GitAV% 5` 4,,%, . J ✓ • New dwelling area: square feet
City / State/ZIP: — 1 - 1 - 6 (An j j Garage /carport area: square feet
Suite/bldg. /apt. no.: I Project name: Covered porch area: square feet
Cross street/directions to job site: ' �--1_, ° $ (2,0 L I:, h q Liar" Deck area: (4 0 O square feet
J Other structure area: square feet
•
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: A, ,,,..L, vY y 14...4./1 14 i I Lot no.: U ( -1 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
DESCRIPTION OF WORK work indicated on this application.
Valuation: $
Existing building area: square feet
New building area: square feet
PR PEATY OWNER I 0 TENANT Number of stories:
Name:
,1,4/.t ∎ S D U t Type of construction:
Address: I 6, d y L S Cv ' ,, J c) V Occupancy groups:
City /State/ZIP: � + �,,,��� .. G Existing:
Phone: (sa 9 E''6 ({ 3 C Fax: ( .) • New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name: under ORS 701 and maybe required to be licensed in the
Address: jurisdiction in which work is being performed. If the •
City / State/ZIP: applicant is exempt from licensing, the following reasons •
ap
Phone: ( ) I Fax:: ( )
&mail:
CONTRACTOR
Business name: L L 1 — I; in L ■ BUILDING PERMIT FEES*
Address: l.' 9 1 S- s i ,. £ r7 4/, S r r *k3°) (Please refer to fee schedule)
City/State/ZIP: y � U Q Structural plan review fee (or deposit):
Phone: ( '') 6o �/ 6 _ O c Z I Fax: ( ; ) ( Li (p -- 6 7.3 S plan review fee (if applicable):
l Total fees due upon application:
CCB lic.: t Co L - -r...,, gn ature: , a i�� !� Amount received: r
Authorized si t'
�i
/I. This permit application expires if a permit is not obtained
Print name: q . - y .- D 4' i 4 • d 4 within 180 days after it has been accepted as complete.
[iY� go • Fee methodology set by Tri -County Building Industry
Service Board.
I:\ Building1Permits \BUP- RES- PermitApp.doc 03/21/06 440-46 13T(1 1/02/C064/WEB)
l ltt+ t
One- and Two - Family Dwelling
.,Building Permit Application Checklist FOR OFFICE: 1 S1.1 ()NIA'
,i•
. ,
City of Tigard ; Received
Permit No.:
As
U 13125 SW Hall Blvd., Tigard, OR 97223 Associated
° ' Phone: 503.639.4171 Fax: 503.598.1960 Assodated permits:
24 -Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
TIGAILD
Internet: www.tigard- or.gov ❑ Other.
FOLLO\•ING ITEMS ARE RREQUIREI) Foiz PLAN REVI w le; No Nip
I Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ •
2 ...Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑
. 3 Verification of approved plat/lot. ❑ ❑ ❑ .
4 Fire district approval required. Name of district: . ❑ ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity ❑ ❑ ❑
6 Sewer permit. . ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.
11 Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑.. ❑ ❑
there is more than a 4-ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements
•
and driveway; footprint of structure (including decks); location of wells /septic systems; utility locations; direction
indicator; lot area; building coverage area; percentage of coverage; impervious area; existing structures on site; and
surface drainage.
12 Foundation plan. Show dimensions, anchor bolts, any ho)d -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑
and location. -
. 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑ •
furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc. •
14 Cross section(s) and details. Show all framing - member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑
floor, wall construction, roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings
and foundation, stairs, fireplace construction, thermal insulation, etc.
15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. ❑ ❑ . ❑
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full -size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing (prescriptive path) and /or lateral analysis plans. Must indicate details and locations; for non- ❑ ❑ ❑
prescriptive path analysis provide specifications and calculations to engineering standards. _
17 Floor /roof framing. Provide plans for all floors/roof assemblies, indicating member sizing, spacing, and'bearing ❑ ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑ .
. systems, see item 22, "Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑
over 10 feet long and/or any beam/joist carrying a non - uniform load.
20 Manufactured floor /roof truss design details. ❑ ❑ ❑
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑
for four or more appliances.
22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or ❑ ❑ ❑
architect licensed in Ore on and shall be shown to be licable to the ro'ect under review. •
23 Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17".
24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. ❑ ❑ ❑
26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document. ❑ ❑ ❑ •
27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑
28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑
Street Tree List.
29 Site plan to include tree protection measures as required by conditions of approval. ❑ ❑ ❑
30 A Clean Water Services' Sensitive Area Pre- Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
I:\ Building \Pamits\BUP.RES- PamitApp.doc 0321/06
RETURN RECORDED DOCUMENT TO:
CITY HALL RECORDS DEPARTMENT 11E(;1:71k/Ff's:
CITY OF TIGARD
13125 SW HALL BLVD.
TIGARD, OR 97223
JUL 1 8 2006
INDIVIDUAL
Ll 1 jug
. • T TTT fm r. r� TNToN
File No. MST2004 -00200 and BUP2006 -00129
Space above reserved for Washington County Recording Information
EASEMENT AGREEMENT/ ENCROACHMENT (REVOCABLE PERMIT)
THIS AGREEMENT is entered into on June g ' `2006, between the CITY OF TIGARD
• (the "City ") and CHRISTOPHER J. DUFFIN ( "Property Owner ").
RECITALS
•
A. Property Owner owns the property located at 13222 SW Rockingham Drive, Tigard, •
•
Oregon 97223, more particularly described as Lot 47 Amesbury Heights Subdivision, in
• the City of Tigard, Washington County, Oregon (the "underlying property").
B. The City owns an easement for sanitary sewer and storm sewer purposes over the
underlying property. The description of the easement is: The southerly 20 feet of Lot
47, Amesbury Heights Plat, as recorded in Plat Book 110, page 10 of plats, Washington
County Records (the "easement ").
C. A deck has been constructed within the easement (the "encroachment" ).
•
•
• D. The City believes that the encroachment may be maintained in place without
significantly interfering with the City's facilities in the easement, and is willing to allow
the encroachment to remain, subject to removal only if needed to allow full use of the
• easement rights.
E. The City therefore agrees to permit the encroachment to remain in place, subject to the
• City's right to revoke that permission.
TERMS OF AGREEMENT
•
Property Owner, on behalf of Property Owner and all future owners of the underlying
property, agrees:
•
1. To forego any and all claims that Property Owner might have at any time against the
City arising from work performed in the easement pursuant to the City's easement right
due to the encroachment on the easement, including, but not limited to, damage to or •
•
removal of the encroachment;
2. To reimburse the City for all repair or installation expense that exceeds the expense that
would have been incurred if there had not been an encroachment;
•
• Page 1of3
c' f
•
•
3. To reimburse the City for the total repair expense if the repair work is necessitated by
damage caused by the encroachment. The cause of damage shall be established by the
•
written opinion of an independent registered engineer selected by the City;
•
4. The City may determine, in its sole discretion, the materials, means, and methods to be
used in performing work within the easement. Expenses for work within the easement
are deemed reasonable when based upon competitive bids obtained by the City or upon
the written opinion of costs by an independent registered engineer selected by the City;
and
5. On demand of the City, to remove the encroachment, or such part of it as needed to
• allow the City to exercise full use of its easement rights. If Property Owner does not
remove the encroachment as directed by the City, the City may remove the
encroachment at Property Owner's expense.
In the event that the City determines that continued occupation of the easement by the
encroachment is inconsistent with the City's right to use the easement for sanitary and storm
sewer purposes, the City may revoke this agreement. Any such revocation shall be
communicated to Property Owner or successor in interest at least 30 days in advance, unless an
emergency situation does not allow the full notice period.
• It is covenanted and agreed between the parties hereto that all the covenants and agreements
above expressed shall be held to run with and bind the property described herein, and shall
extend to and include their heirs, assigns, devisees, lessees, and holders of any kind of and
under Property Owner. This paragraph does not limit the City's unilateral right to terminate
this agreement as provided above.
This agreement allows the encroachment as built to remain, but does not allow any expansion
of the encroachment within the easement. If the City undertakes any work that requires
removal of the encroachment, the City will allow the encroachment to be reconstructed
without expansion, if consistent with continued operation of the City's facilities in the
easement All rights and privileges granted herein by the City shall terminate upon the non-
conformance to the plot plan or discontinuance of such use.
WITNESS our hand this P`' fay of June, 2006.
Prop .... Owner 'vr ature Property Owner's Signature
Property Address Mailing Address (if different)
Page 2 of 3
0
•
STATE OF OREGON )
) ss.
County of Washington )
•
This instrument was acknowledged before me on :_ , 2006 by: Christopher J.
• Duffin.
• l) = = == TAMMERA L J I ON- REITER r
NOTARY P'UBUC-OREGON
() •'� COMMISSION NO. 404046 )
( MY COMMISSION EXPIRES APRIL 23, 2010 0 o ry s Signature----
•
My Commi x ires) P ,111 3 2.c)
City of Tigard AA-14
• 13125 S.W. Hall Blvd. City Maer •
• Tigard, OR 97223
• STATE OF OREGON )
) ss.
County of Washington )
• This instrument was acknowledged before me oig-/(/"t le , 2006 by: Craig Prosser as
City Manager of the City of Tigard.
•
( OFFICIAL SEAL
• J BENGTSON D A/J l� r
NOTARY PUBLIC- OREGON • w \� l \!
•
( ) COMMISSION NO. 368086 0
MY COMMISSION EXPIRES APR. 27, 2007 tary s Signature / I r n'
My Commission Expires i i r
•
•
•
•
•
I✓
•
•
Page3of3
.
at fa ?oily i/4/4 4
CITY OF TIGARD
• Tuesday, July 18, 2006 OREGON
Chris Duffin
13222 SW Rockingham Dr.
Tigard, OR 97224
RE: STATUS AND NEXT STEPS: House and Deck Permits, MST2004 -00200 and BUP2006-
0, and Easement /Encroachment Agreement.
Dear Chris,
This confirms that:
1. The Easement /Encroachment Agreement between you and the City of Tigard is now
in effect, both parties having executed it and the time for public comment having
elapsed, and the Building Division has received a copy.
2. Your application for permit BUP2006 -00129 for construction of a deck that will
encroach into the City's Public Utility Easement at 13222 SW Rockingham Dr.,
Tigard, has, with receipt of the Easement /Encroachment Agreement, been approved
and is ready to be issued to you upon payment of the permit fees of $240.17.
3. Now that the Agreement has become effective and as soon as the deck permit is
issued, Final Plumbing and Building Inspections may be scheduled for your permit
MST2004 -00200 for construction of your home. Upon your receiving final
inspection approval we will issue a permanent Certificate of Occupancy (CofO) (as
opposed to the Temporary and Conditional CofO previously issued.)
4. Upon issuance of the permanent CofO we will ask the Municipal Court to dismiss
citation 89645 issued 5/26/06 for Occupancy Without Final Inspection Approval.
I have enclosed a copy of the Agreement and a copy of our 4/17/06 inspection report
under permit MST2004 -00200 which shows the few corrections that were still required.
Obviously, items 3 and 4, pertaining to the deck permit and Agreement will be satisfied as
soon as the deck permit is issued. Please call for Final Plumbing and Building Inspections as
soon as items 1 (downspouts) and 2 (street trees) are completed.
Congratulations on resolving the encroachment issues that have delayed completion of the
deck and of your home. Thank you for the willing cooperation you have demonstrated
throughout the process. Please call if you have any questions.
My best -
, ert '' ds
Building Codes Enforcement Officer, Housing Inspector
cc: Property File, Municipal Court, Hap Watkins.
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 TDD (503) 684 -2772
CITY OF TIGARD - SITE PLAN REVIEW r -__.
BUILDING PERMIT NO.: uP CQ--�[ l �
PLANNING DIVISION: r - _ -- -
Required Setbacks: BrApproved.. ❑ Not Approved v o
RECEIVED 8 Z
' Side: < Street Side:
Front. /'� . Garage: Rear: I S 3 i.:. a 0 '2;..'
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• ®a�a r ❑/Approved ❑Not Approved APR 14 2006 O . ,74 < a, Q 0 cal
Maximum Building Height' 3 � feet ARE =8667 S VIan i BRE SC14 L2<j Au ti v o Z
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tj'. . ice Provider Letter Required: 0 Yes 1)TiI�INt. CovERA �T aR I� 2646 NW Overton Z Street >7- Z r
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it �,;•;;;.;.:',.:. , . Tigar Oregon
t 6f-IZ3 I
••.'• ••;.. \� Lot 47, Amesbury Rockingham Heigh ts
" Plat Book 110 Page 10
` i..: `_ %,- *
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/ , / / )4E 'i \ \ \\ �\ \ � `� \ �� � � )SEWER Owner: 4915 Griffith Drive
� 'Y i I .1 „• \���� -� _ , �� \ - , ' • e ;' • I Beaverton, OR 97005 '
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CITY OF TIGARD .. , .
i l BUILDING DIVISION PERMIT #: BUP200&.00129
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 8/8/2006
Phone: (503) 639 -4171 AM:k
1 Inspection Requests (24 Hrs.): (503) 639 -4175 ?I L
INSPECTION WORKSHEET FOR DATE: 8/9//2006 TIME: 7:04AM PAGE: 57
SITE ADDRESS: 13222 SW ROCKINGHAM DR CLASS OF WORK:
SUBDIVISION: AMESBURY HEIGHTS LOT #: Q47 TYPE OF USE:
PROJECT NAME: AMESBURY HEIGHTS
DESCRIPTION: 400 sq ft deck
OWNER: DUFFIN, CHRIS PHONE #: 503 -998 -6434
CONTRACTOR: LING, INC PHONE #: 503 - 646 -0521
Inspection Request Scheduled For: Date: 8/9/2006 Pour Time: 11 :00
Code # Inspection Description Confirm # Contact # Message
205 Footing 034640 -01 503. 998.6434 N
Corrections/Comments/Instructions:
D i aO • a- -, - V GZ-aiS
O`1 0.7! SY 'Fr • oyi
gA/ / ene.--- 114 ed i
r I P -7 ' : c - -- ' i ir e
PliDipriD
❑ PASS ❑ P RTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
AIL MICA FOR I ION Li 2 ? i >: DDITIO (503) 718 '177-)
a _ Y .
CITY OF TIGARD
BUILDING DIVISION PERMIT #: BUP2006-00129
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 8/812006
Phone: (503) 639 -4171 101,¢r
Inspection Requests (24 Hrs.): (503) 639 -4175 I t ..
INSPECTION WORKSHEET FOR DATE: 8/9/2006 TIME: 7:04AM PAGE: 51
SITE ADDRESS: 13222 SW ROCKINGHAM DR CLASS OF WORK:
SUBDIVISION: AMESBURY HEIGHTS LOT #: 047 TYPE OF USE:
PROJECT NAME: AMESBURY HEIGHTS
DESCRIPTION: 400 sq ft deck
OWNER: DUFFIN, CHRIS PHONE #: 503.998.6434
CONTRACTOR: LMC, INC PHONE #: 503. 646.0521
Inspection Request Scheduled For: Date: 8/9/2006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
275 Framing 034640-02 503-998-6434 N
Corrections /Comments/ Instructions:
.Z /t &✓, p 7 oY( 7 / AL aw-
'XPIRF'n
•
❑ PASS ❑ PARTIAL APPROVAL XANCEL ❑ NO ACCESS
❑ FAIL A FOR INSP TIOk DITION . L FEES ASSESSED
Inspector: A' �� D ate: • i t Phone #: (503) 718- `
•
CITY OF TIGARD
BUILDING DIVISION PERMIT #:
BUP2006-00923
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 8/8 /n006
Phone: (503) 639 -4171 4
Inspection Requests (24 Hrs.): (503) 639 -4175 I I..
INSPECTION WORKSHEET FOR DATE: 8/9/2006 TIME: 7:04AM PAGE: 50
SITE ADDRESS: 13222 SW ROCKINGHAM DR CLASS OF WORK: •
SUBDIVISION: AMESBURY HEIGHTS LOT #: 047 YPE OF USE:
PROJECT NAME: AMESBURY HEIGHTS
DESCRIPTION: 400 sq ft deck
OWNER: DUFFIN, CHRIS PHONE #: 503.998 - 6434
CONTRACTOR: LMC, INC PHONE #: 503 - 646.0521
Inspection Request Scheduled For: Date: 8/9/2006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
299 Final inspection 034640 -03 503- 998 -6434 Y
Corrections /Comments /Instructions:
j .
❑ PASS ❑I '• RTIAL APPROVAL CANCEL ❑ NO ACCESS
❑ FAIL ,% C • e ■ ,A • N Ili ADDITIONAL. FEES SSESSED _ N e
Inspector: Date: Phone #: (503) 718 -2