Permit Building Division
°°1T1' Applicant Request for Permit Action
City of Tigard
TO: CITY OF TIGARD, BUILDING OFFICIAL
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.639.4171 Fax: 503.598.1960
FROM: Applicant Name:
Mailing Address:
70 .- LE�v
,^r& City /State /Zip:
V 0 1 D Phone No.:
Fax No.:
V2-011
PLEASE TAKE ACTION CHECKED (✓) FOR THE FOLLOWING PERMIT:
AK CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES.
Permit No.: MST2005 -00128
Type of Permit:
Site Address: 7190 SW SANDBURG ST
Subdivision:
Lot No.:
EXPLANATION: CREATED IN ERROR, SHOULD HAVE BEEN BUP.
FEES CF) ti- y-Era 4JEiC T29-NS,c 7a
eao0A - D0/4 (- /6 3
4/18/05
Signature: � Date:
DODIE ROSSETTI
Print Name:
FOR OFFICE USE ONLY
Route to Admin.: Date: By: '
Permit Canceled: Date: y/ s /s By: 4
Refund Processed: _ Date: /Z < /d_5 .- By: di
i:\Building\Forms\ReqPerrnitAction.doc
. 7/yo Sc') Sandhyr.
fI c t ■ I 4 4 0 1 r
IV Building Permit Application FOR OFFICE USE ONLY
.City of Tigard C E I V E D D ed _ / F ( ,d Permit No.' gu^ p�`00 I6,�,
?' 13125 SW Hall Blvd., Tigard, 0 Plan Review
Phone: 503.639.4171 Fax: 503.598.196 p 4*4 Date/By: Other Permit:
Inspection Line: 503.639.4175 AN 0 O 20 -! - °' Date Ready/By: Jars: ® See Attached Checklist for
I Internet: www.ci.tigard.or.us Notified/Method: 1 — Ir. Supplemental Information
CITY O�FT�I�GAHu
BUE1Fl 1 A I W Y - REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ Ne onstruction ❑ 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 equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application. A
❑ 1- and 2- family dwelling mmercial/industrial Valuation: $ (\�,r
❑ Accessory building ❑ Multi- family Number of bedrooms: V r` < 4.
❑ Master builder ❑ Other: Number of bathrooms: U
AND LOCATION Total number of • • •. • • L V e
JOB SITE INFORMATION ND LOCATIO f fl 8.. 0 �
Job site address: '1190 . de--,b. New dwelling area: \ \�� quare feet
/State/ZIP
Ci Garage/carport area: square feet
City/State/ZIP: : r ( ` IgQX' � , . � O � . � ��
Suite/bldg. /apt. no.: d I Project name: � r7 Z CCDYa ti�ti4 J P . Covered porch area: square feet
Cross street/directions to job site: . (�) • 12I . Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: I 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, materials, labor, over and the profit for the
DESCRIPTION OF WORK work indicated on this applicati 99
.5�1 ',� , ,• A _ � f�• 1 r y c ,` ,k� cv . o � e l. Valuation: $ snl.
`�'"`�"� Tc0.pl�L uvV► Existing building area: 14 1 042 s feet ,�,� 10
New building area: 1, 1 448 square feet \ i '
PROPERTY OWNER I ❑ TENANT Number of stories: I .(. PT
Name: ' t taccarlA ► Type of construction: V
Address: - 11,90 r . 4:‘,AA,A,..to 9Jt . Occupancy groups: is, 4 < j
City/State/ZIP: 'i * _t GM . 4 97 Existing: .e, 4 5
Phone: (r/)C . i — Zr:190 Fax: ( ) Cer&9 — 4 New: 'Qj
a APPLICANT ❑ CONTACT PERSON NOTICE
Business name: ji IN fxWa.4 442414 ITISCT All contractors and subcontractors are required to be
Contact name: /2A.V1a VoDA. licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: AP ) � I , ( ) • mocAD RA 4 (op jurisdiction in which work is being performed. If the
City/State/ZIP: 14 (Jc7 OM . ' ' applicant s exempt from licensing, the following reasons
' / apply:
Phone: ) '2.4 -ten(o I Fax: : (G 1..4 =Tico
E -mail: 7 rcv (,O AvaAA .C
CONTRACTOR
Business name: premo laccazolielt 'pQ 4 IC.
BUILDING PERMIT FEES*
Address: '-) ( C7C) t ijD . (Oto(1� .
J Please refer to fee schedule.
City/State/ZIP: er rive.. � , 23
1 Fees due upon application A Phone: (*Mg, ^ 209c)
I Fax: FJ ) & � 4'�,
CCB hc.:
1 43 A 7 �
•k 1. ' l
g �0 Amount received
Date received: Y_ z) I
Authorized signature: a i , co This permit application expires if a permit is not obtained
jjj��JJ� I within 180 days after it has been accepted as complete.
I Print name: id \e I Date: 4, .. . I , p, I * Fee methodology set by Tri- County Building Industry
Service Board.
i:\ Building \Permits\BUP- PermitApp.doc 12/03 440- 4613T(IIN2/COM/wEB)