Permit P
,
Building Permit Application
7 Datereceived: /8111 N
Yr
Permitno.: i P ,/ fps \
°r- �y� . � City of Tigard
"= Project/appl. no.: . Expire date:
City of Address: 13125 SW Hall Blvd, Tigard, OR 97223
Phone: (503) 639 -4171 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
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ New construction ❑ Demolition
)(Addition/alteration/replacement ❑ Tenant improvement ❑ Fire sprinkler /alarm ❑ Other:
• `,, JOB SITE INFORMATION •
Job address: f (rf 'm4) • Co • , e. , :L� ' P - Bldg. no.: Suite no.: _ A.
Lot: Block: Subdivision: Tax map /tax lot/account no.:
Project name: - L , K.. 4 )
Description and l�ocjtion of work on premises/special coyditions: f4C J do S7 J» ? Pty hay-c- l.�rf3 -C_ ,QC LO-c4 -r
Vf NaJ —SlItX547• 'l-- �.C,J M I Cz) ,er4Z) GL ASS = — iZ 7V = 10 r /i�N
O�VNER . FOR SPECIAL INFORMATION, USE CHECKLIST
(Floodplain, septic capacity, solar, etc.)
Mailing address: , 1 r c.& ►/t I t - 1 & 2 family dwelling: , '
_ � EM' ZIP: r f l Co Valuation of work $
Phone: 91(. 9 .b Fax: • 9 >/ MEr. No. of bedrooms/baths
-- O" • - _ • , .. - *qv v - O ► I.: _ -1, -- - _ -- -Total-number-of-floors -. . -. :.--------_,' r--
---- - - - _, ,
- Phone: Fax: E -mail: New dwelling area (sq. ft.) ....
APPLICANT Garage/carpo area (sq. ft.) .... r'
Name: ,44 ` 4a. .. - c - r6LA<T' S Covered porch -. a (sq. ft.) . ..,„t'
Mailing address: 43 Za M 4 .?( - Dec F • (sq. i,)\,..., .... , ` ...t:
Eal State ZIP: 91Z2o Other a cture to s;; ` i, _
Phone $s3'Z 1 • 33 E -mail: :,* MP -/ .: '' '' t ? k 4 1 t "-Y'-
CONTRACTOR Valuati 'I of work S
Business name: /V 6 4z t Cs iNi----p�}L"��S Existing ilx g. area(s ' ,... a....�
Address: _•, Zoo / S7 - New bldg.: • . (sq. ft.) ;r ... .,,,a .
City:.',:, ,- 1-t�t.O StateD2 ZIP: 912-, Numbe o ns t, ,ribs y v..:...
Phone: Fax: Email Type of co ... op .... .... .
CCB no.: & Z r 3 Occupancy gro�,: (s): sting:
i New:
City /metro lic. no.: Notice: All con .._,4 ors and subcontractors are required to be
ARCHITECT/DESIGNER licensed with 4 Oregon Construction Contractors Board under
0 , , _ provisions of .c! S 701 and may be required to be licensed in the
Address: •2_/. Z � , _ 2 jurisdiction where work is being performed. If the applicant is
EMM ZIP: S. , _ exempt from licensing, the following reason applies:
Contact person: ! Los. Plan no.:
Phone: (,12;j, ( Fax: 3 rD• E- mail:00ZfLo}rf5
ENGINEER
Name: Contact person: Fees due upon application $
Address: ' - Date received:
City: State: ZIP: Amount received $
Phone: Fax: E -mail: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for mote information.
attached checklist. All provisions of laws and ordinances governing this ❑ Visa ❑ MasterCard
work will be complied with, whether specified herein or not. Credit card number: / /
Expires
Authorized signatur : P- Date: V. I . Name of cardholder as shown on credit card
Print name: J 1 Cardholder signature $ Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (6/00/COM)
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