12452 SW KING GEORGE DR r
BUILDING PERMIT APPLICATION c oF TIGARD DATE , 19 NA
THE UNDERSIGNED HEREBY APPLIES FOR APERMIT FOR THE WORK HEREIN INDICATED BUILDER PHONF -
OF AS SHOWN AND APPROVED IN THE ACCOMPANYING PLANS AND SPECIFICATIONS. OWNER PHONF
LOT NO
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4 - 0 ��f _ ..!I "'B ADDRESS / A, _ ' 7, . • - 0 ❑DRESS
ARCHITECT
/� �� ENGINEER
?EEO _ a, _i� il�i�ii y ADDRESS _Ii _ / 2 • 0 /�:' . ,m,- DESIGNER
_ICTURE ONEW / D R ODEL El ADDITION REPAIR ❑R :f EWAL OFIRE DAMAGE ['DEMOLITION
IDFNCE DCOMM ❑EDUCATIONAL ❑GOV'T DRELIGIOUS❑PATIO ❑CARPORT ❑GARAGE DSTORAGEDSLAB ❑FENCE
‘:FOND ❑ MOVING DCONDITIONAL USE 0 DESIGN REVIEW DCOUNCIL APPROVED DSIGNS
: ".CUPANCY._- -_LAND USE ZONE_ BLDG. TYPE FIRE ZONE_ PLAN CHECK BY HEAT
L • .I' i / . . / / .rs /i i / . _ / . / ,t ' �
`:C LOAD FLOOR LOAD HEIGHT NO STORIES AREA NO. BEDROOMS VALUE �0 o(r2,1".4.644
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BUILDING DEPARTMENT SET BACKS FRONT REAR LEFT SIDE RIGHT SIDE
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IC - -
- --- THIS PERMIT IS ISSUED SUBJECT TO THE REGULATIONS CONTAINED IN THE BUILDING CODE, ZONING
Plan Check REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES, AND IT IS HEREBY AGREED THAT THE
t WORK WILL BE DONE IN ACCORDANCE WITH THE PLANS AND SPECIFICATIONS AND IN COMPLIANCE WITH
I Sub - total ALL APPLICABLE CODES AND ORDINANCES. THE ISSUANCE OF THIS PERMIT DOES NOT WAIVE
L. — RESTRICTIVE COVENANTS. CONTRACTOR AND SUB CONTRACTORS TO HAVE CURRENT CITY BUSINESS
`;tale Tax • AI LICENSE. SEPARATE PERMITS REOUIRED FOR SEWER, PLUMBING AND HEATING.
- Total $ /4. G
B I < ,c r�l .6 p) ,ZV e ..-e- / Am. T OR AG
Approved Receipt No.
ADDRESS PRONE
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- `CIT'S - -ST,RUGTURAL CHANGE- .. REQIEST
Member ‘ "7 Date ,a i/— ' 7
Address /.2.q.,112.., 4 DI.) 4.. , Phone 639'.r„2 O y
TYPE OF CHANGE
(Patio Cover, Room, Fence, etc.)
PLAN:_ DIMENSIONAL AND MATERIAL DETAILS,
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Note:
1) Adjacent property owners will be informed of the requested change.
2) If there is an objection, the objection, but not the name of the objector, will
be given to the member asking for the change.
3) The Board of Directors of the Civic Association will review the plans and property
for approval or disapproval and compliance with the stated restrictions.
4) A building permit must be obtained from the city for all improvements costing over
$500.00
Date Notified KCCA Board of Directors
President
Date to be Completed Approved Vice-President
Final Inspection Disallowed (Reasons) •
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