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LIABILITY, The City of Tigard, Oregon, or it's
�.--'. er� loyees, shall not he r :sponsit�le for
2� � _`�'� '-- -- 10," ____�'_-{ discrepar,cys which -ma a ear. hereon
250 '' Y pp
S o u.T t L L C)N G) \tJ 4 LL..
APPROVED FOR CCNSTRUCT1101 --
s T u s �'' x � ' �� ;N D ► __ _ CITY OF TIOAPD _ -
calE ria ��, __ - PERi1,11T NO. sfgi =o3-93
5 /2 1 .�.._ � SITE- ADDRESS I3-�.�-b
DATE 3 -04
I I i l l l I ' I � I I I I I I I I I I I I I I I I I I I I I I _I 1 1J.tj
NOTICE- IF THE PRINT OR TYPE ON ANY I { I I I I II I I I { { I { I I I III 111 111 11111111111 I ! I 111 III f 11 111 l I l i 11 l 1 1 III i � I 1111 111 ! 1 11 ! I III 11111 11 III III 1 1 111 11
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IMAGE IS NOT AS CLEAR AS THIS NOTICE, 9 10� 11 12
ITIS DUE TO THE QUALITY OF THE
ORIGINAL COCUMENT IIE 6� 9 717
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_ 13530 SW ASCENSION DRIVE ,�
CITY OF TIGARD BUILDING INSPECTION DIVISION MST,
24-Hour Inspection Line: 639-4175 Business Line: 639-4171
BUP
Date Requested_ AM PMBLD _
Location "7-)1�7 7;'C; Suite _ MEC r
Contact Person _
Ph PLM l�
Conti actor _ _._ Ph _ SWR
UILDI_ Tenant/Owner _ _— ELC
Retaining Wall ELR _--
Footing Ar- - FPS
Foundation -- - -
Fig Drain NOT REQUESTED sGN
------..._------
Slab Crawl Drain Ir FOUND DURING RESEARCH SIT
Post& Beam NO INSPECTION('.) FOUND IN FILE
Ext Sheath/Shear --.---------
Int Sheath/Shear
Framing -- ---
insulation ��
Drywall Nailing J - -- --._. - - --
Firewall
Fire Sprinkler -
Fire Alarm
Susp'd Ceiling - - --
Roof
Misc. --- - —
� din l�---
PASS PART FAIL - -- -- --
81NG _---
Post& Beam —
Under Slab
Top Out
Water Service ---
Sanitary Sewer
Rain Drains -- - -- -- ----------- -------- ---
Final
PASS PART FAIL
MECHANICAL -
P est&Beam --- ---- �_.._ ------ - - - ----------
Rough In.
GasLine ---_ -- ----- _.�_ -- --.__. - -------- -----------------__ -
SmOKe Damper,,
Final _..___----------------_ - _.._ _- ----------- --- ----------- ---
PASS PART FAIL
ELECTRICAL
Service
Rough In --_.---------_..- --- ----
UG/Slab -------
Low Voltage
Fire Alarm ---- --- ------ - - - —---- _
Final
PASS PART FAIL - --------- --------- - ---....- - - --SITE
Backfill/Grading ------------------------ -._-._�___— ----- -- -----
Sanitary Sewer
Storm Drain ( )Reinspection fee of$_ required'.efore next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin Unable to inspect- no access
Fire Supply Line ( J Please call for reinspection RE: — — ( ) P
ADA C
Approach/Sidewalk 1 ";` L- 'C
Other
_ Date Inspector _ Ext
Final _
PASS PART GAIL DO NOT REMOVE this inspection record from the job site.
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CITY CSF TIGARD
DEVELOPMENT SERVICES MASTER PER11IT
13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171 PERMIT #. . . . . . . : 11ST56--04r4DATE I SSLIED: 11/04/96
PARCEI-: 2S 1.04CC-HW:794
SITE ADDRESS— : 13530 SW ASCENSION DR
SUBDIVISION. . . . : H I L-L.SH I RE WOODS ZONING: R-7 PD
BI-OC:K. . . . . . . . . . . L-OT. . . . . . . . . . . . . :094
Remarks: Path 1
-----------------------------------•--------------------------- BUILDING --------------------------------------------------------------
REISSUE: STORIES.......: 1 FLGOR AREAS---------- BASEMENT...: 0 sf REQUIRED SETBACKS---- REQUIRED--------
CLASS OF WORK.:NEW HEIGHT........: 16 FIRST....: 2075 sf GARAGE.....: 857 sf LEFT..........: 5 SMOKE DETECTRS: i
TYPE OF USE...:SF FLOOR LOAD....: 40 SECOND...: 0 sf FRONT.........: 20 PARKiNG SPACES:
TYPE OF CONST.:SN DWELLING UNITS: 1 FINBSMENT: 0 sf RIGHT.........: 5
OCCUPANCY GRP.:R3 BORN: 2 BATH: 2 TOTAL------: 2075 sf VALUE..l: 153970 REAP..........: 99
---------------------------------------------------------------- PLUMBING ---------------------- - --
- - -------------------------------------
SINKS.........: 1 WATER CLOSETS.: 2 WASHING MACH..: 1 LAUNDRY TRAYS.: 1 RAIN DRAIN ft: 0 TRAPS.........: P
LAVATORIES....: 3 DISHWASHERS...: I FLOOR DRAINS..: 0 SEWER LINE ft: 0 SF RAIN DRAINS: 1 CATCH BASINS..: 't,
TUB/SHOWERS...: 3 GARBAGE DISP..: 1 WATER HEATERS.: 1 WATER LINE ft: 100 BCKFLW PREVNTR: 1 GREASE TRAPS., : 0
OTHER FIXTURES: 0
L - -------------------------------------------------------- ---- MECHANICAL ---------------------------•---------_ --------
cUEL TYPES------------ FURN ( 100K ..; 0 BOIL/CMP ( 3HP: 0 VENT FANS....,: 4 CLOTHES DRYERS: 1
/GAS/ / / FURN )=100K .,: l UNIT HEATERS..: 0 HOODS.........: 1 OTHER UNITS...: l
MAX INP.: 0 BTU FLOOR FURNACES: 0 VENTS.........: 0 WOODSTOVES....: 0 GAS OUTLETS...: I
- - -- --------------- - -- ---—------------------------- ELECTRiCAL ----------------------- --- -- - -
--RESIDENTIAL_ UNIT--- ---SERVICE/FEEDER---- --TEMP SRVC/FEEDERS-- ---BRANCH CIRCUITS--- ----MISCELLANEOUS---- --ADD'L INSPECTION"..
1000 SF OR LESS: 1 0 - 200 amp..: 0 0 - 200 amp.. : 0 W/SVC OR FDR..: 0 PUMP/IRRIGATION: 0 PER INSPECTION: P
EA ADD'1. 500SF.: 4 201 - 400 amp..: 0 201 - 400 amp..: 0 Ist W/O SVC/FDR: 0 SIGN/OUT LIN LT: 8 PER HOUR......: 0
LIMITED ENER&Y.: Q 401 - 680 amp..: 0 401 - 600 alp.. : 0 EA ADDL BR CIR: 0 SIGNAL/PANEL...: 0 IN PLANT......: V
MANF HM/SVC/FDR: 0 681 - 1000 amp.: 0 601+amps-1008 v: 0 MINOR LABEL -18: 0
1088+ asap/volt.: 8 ------------ ----- ---- PIAN REVIEW SECTION ------------------------
Reconnect only.: 8 )=4 RES UNITS..: SVC/FDR)=225 A.: ) 600 V NOMINAL: CLS AREA/SPC OCC:
-------------------------------------------- -----
ELECTRICAL - RESTRICTED ENERGY ------------------------------------------------ ---
A. 5F RESIDENTIAL-- ------------------- S. COMMERCIAL------------------------------------------------------------------------------
AUDIO 6 STEREG.: VACUUM SYSTEM..: AUDIO X STEREO.: FIRE ALARM.....: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM..: 0TH: :: X BOILER.........: HVAC...........: LANDSCAPE/IRRIG: PROTECTIVE MR.:
GARAGE OPENER..: CLOCK..........: INSTRUMENTATION: MEDICAL......... OTHR:
HVAC...........: DATA/TELE COMM.: NURSE CALLS....: TOTAL 1 SYSTEMS: 0
Owner: ------------------—---------------Contractor: ------------------------------ TOTAL FEES:$ 4476.95
SHELBURNE DEVELOPMENT SHELBURNE DEVELOPMENT
7006 SW NYBERG RD 7008 SW N'YBERG RD
TUALATIN OR 97062 TUALATIN OR 97062
Phone 1: 692--6383 phone 1: 694-6383
Reg 1..: 42388
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Specialty Codes and all other
applicable laws. All work will be done in accordance with ouq.,nved plans. This permit will expire if work is not started within 188
jays of issuance, or if work is suspended for more than 18, days.
------------------- --_-----------------._M._M REQUIRED INSPECTIONS --•--------------•-------------- -- ---- ------------
Footing Insp PLM/Underfloor Framing Insp Gas Fireplace Water Service In Building Final
Foundation Insp Mechanical Insp Shear Wall Nip Insulation Insp Appr/Sdwlk Insp Erosion Control
Post/Beam Struct Plumb Top Out Low Voltage Gyp Board Insp Electrical Final _
Post/Beam Meehan Electrical 5ervi, @place In Rain drain Insp Mechanical Final
Crawl Drain Electrical as Line - Water Line InspP Final
c-Ier•mittee Signatl..ir ISS1_1ed By :
("aI l or- inspection - 639-4175
CITY O F TI C A R D SEWER CONNECTION
DEVELOPMENT SERVICES PERMIr
Anzatm 13125 SW Hall Blvd., Tigard,OR 97223 (5PERMIT #. . . . . . . : SWR96045A03)639-4171 DATE ISSUED: 11 /04/96
STE ADDRESS. . . : 13530 SW PF7ENSION DR PARCEL: 2SI04CC--HWO94
I
SUBD I V I S I ON. . . . : H I LLSH I RF WOODS ZONING: R-7 PD
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . :094
TENANT NAME. . . . . :SHELBURNE DEVELOPMENI*
USA NO. . . . . . . . . . : FIXTURE UNITS. . . 0
CLASF:') OF WORT',. . . :NEW DWELI-ING UNITS. . I
TYPE OF USE. . . . . :SF NO. OF BUILDINGS: I
INSTALL. TYPE. . . . :13USWR IMPERV SURFACE: 0 s
Remar-ks : PAth 1.
Owner-: FEES
f:)HELBURNE DEVELOPMENT type amoi-tnt by date
7
7008 SW NYBERG RD PRMT $ r, 11/04/96 96- 8604
TUALATIN OR 97062 TNSP $ 35. 00 B I 1/0/1/96 96-286042
F11-ione #: 692-6383
Corltv-actnt-.-
CONTRACTOR NOT (IN FILE
Phone fi -. $ 2235. 00 TOTAI_
Reg
REOUIRED INSPECTIONS
This Applicant agrees to cooply with all the rules and regulations -Sewer- Inspection
of the Unified Seway- Agency. The permit expires IN dayi frog
the date issued. The total asount paid will he forfeited if the
per@it expires. The Agency does rut guarantee the accuracy of the
side sewer laterals, If the sewer is not located at the mpasureeent
given, the installer shall prospect 3 feet in all directions from
the distance given. If not so located, the inst5per shall urch e
a "Tap
and SiSJe Sewer' Pervit and tii P-66 11 inst'alal a a lateral.
I-Im-mittee Si. n at 1_1 I'
Tssi-ted By . 41
Cal. 1 for inshect i 0 6-39-4175
Plan Check#
ITY OF TIGARD Residential Building Permit Application Recd By
3125 SW HALL. BLVD. New Construction Additions or Alterations Date Recd�} ��
1GARD, OR 97223 Single Family Detached or Attached Date to P.E.f-Z
-,03) 639-4171 Date
Print or Type Permit#
Incomplete or illegible applications will not,,be accepted Ar
. 0U"AeO
ash- .r
r Name of Subdivision Lot N V Name
,fob Ilillshire Woods ray' LA 'r"jI�/__W
Address Site Address _ Architect Mailing Address
/� Sw /YETfQ G
Name City/State 7 l I Phone
Shelburne Development _ r-/Zv02 q?AG ?Z-
Owner Mailing Address Name
r
Ciat J Zi Phone Engineer Mailing Address
�- rivalatin 9062 692-6383 7 c✓ T 4 11tdr� 11,Q _
Name City/State Zip I Phone
General Slielburne Development revy C'Q '�G? 6 1 -,5--99/
p Describe work new addition o alteration O repair O
Contractor Meiling Address to be done:
7008 S.W. N be r c Rd. Additional Description of Work:
City/State Zip Phone
Tualatin 97062 692-6383
Oregon Const.Cont. Board Lir..# Exp. Date _ _
Attach Copy of 042388 11-8-96 Project -
Current COT Business Tax or Metro# Exp. Date Valuation
_ Licenses 00003412 7 1 9 7 zz _
Name NEW CONS RUCTION ONLY:
Mechanical Oregon Comfort Pleating Sq.1=t, House: Sq.Ft.Gara e: �--
Sub- Mailing Address
Contractor P.O. Box 355 Corner Lot_ Yes No Flag Lot Yes No
City/state Zip — Phone (check one) (check one) IX -
Eagle Creek 97022 G55-0221 Restricted Audio/Stereo Burglar
Oregon Consl. Cont. Board Lic# Exp. Date X
Attach copy of 042519 2-24-97 Energy _ System X Alarm
Current COT Business Tax or Metro# Ex ppa Installation Garage Door HVAC:
Licenses 00001313 3p%l f 7 X Opener X Systems
Nome (check all that Other:
Plumbing C & K Contracting, Inc. a IPy) K _central vacuum
Sub- Mailing Address Will the electrical subcontractor wire for all Yes No
Contractor 1- 36 N.E. 63rd restricted energy installations? X
City/Slate zi Pty Has the Subdivision Plat recorded? N/A Yes No
Salem 97T01 311-3539 X
Attach C Oregon Cost. Cont Board Lic# Exp Dale Reissue of MST# Solar Compliance T
Copy of r_
y OG�U1� 3-1� 9 _
- .�__ _. 7 (Calculation Attached)
Current Plumbin Li # xp ate I hereby acknowledge that I have read this application, that the
Licenses 7..4-199 PB -3q-
97
_ _ information given is correct, that I am the owner or authorized agent of
COT Business Tax or Metro# Ex Date the owner, pd that plan submitted are in compliance with Oregon
00 5-2 � l- 97 state //
Name SI a e of Owner 'go Date
Electrical Dryer & Sons Electric
i -- - intact Pers Name Phone
Sub- Mailing Address
Contractor 5536 SE Woodstock01,A4 ,,"y
FOR OFFICE USE ONLY:ME 2Zo -7� F
7
City/State tip Phone Plet# p
Portland 97206 774-1606 n lTLN:
Oregon Const.Cont. Board Lic.# Exp Date ( ' Z l' i 2L 1 - S c ,A I'
Attach Copy of 00111.4 11-23-96 Setbacks Zone: Solar: �.
Current Electrical Lic.# Exp. Date
Llcenses 26-43C '}-� 10-1-96/A- � I e, I
P:1
COT Business Tax or Metro# Exp.pale Enginooring Approval: Planning Approval: TIF:
000030_46 12-1-96 .,4 ryr:4,CVV-01, T_
i
Ntsvnstapp doc r ,ir D 11 r 1
'I t ��„_I��-25 1f� �1-A►.:� Dt<°a<7� rI' crc_ -w` I�..r Al l:V �1'r'•� C_�'�i•[jPT-I��.
Permits Account Description Amvit Arrit, pd. BaL D-=
MST. Permit (BUILD)
Plumb. Permit (PLUMB)
Mech. Permit (MECH) t=-
ELC/ELR Permit (ELPRMT) U $ U,
State Tax (TAX) „i;�2, • 1�
Bldg: ✓a1 b', y 0
Plumb: ✓ �. 7�
Mech: Z a
' r
ELC/ELR:
Plan Check
MST: (BUPPLN) 2,a
Plumb: (PLMPLN)
Mech: (MECPLN)
CDC Review (LANDUS) ✓�U. �� �� , r
a_ Sewer Connection (SWUSA) /',,:2o 6)
Sewer Inspection (SWINSP) ,/ 3.)' 35—
Parks
SParks Dev Charge (PKSDC) t/ /U S7J /O,S D
Residential TIF (TIF-R) /S 7y
Mass Transit TIF (TIF-MT) J 7 V
Water Quality (WQUAL)
Water Quantity (WQUANT) //tr-V law
Erosion Control Permit (ERFRMT)
Erosion Planck/USA (ERPLAN)
Erosion Planck/COT (EROSN) �v•,
Fire Life Safety (FLS)
TOTALS- (9
\. r
i\dstsVnstaDP dor.
Rev 7/96 444 llllll
,. �,. ... 1 -. .. ._...1.-1.-...r.r�.....�...t ...t
A 7
C
141 �►
-- 5700
I
r
� s76
u r
i
�e Lor 25 la4(a..o7sm
Con ST�1.T�GPr' EN�"R�C`c
13rso sc.J�o�Ksfd,RvLL .zlt fgOSIO/v G�nT,ecL
-o
$ ,oG G92- 6$ FT
Lp/rA,7 3u'��►+� CpNG
41A[.K
1
May 3, 1996
I ill Aldrich
City of Tigard
1:3125 SW Hall Blvd
Tigard. OR 9722:3
Dear Ms Aldrich
Re: Solar Balance Point - Lots 93 & 94, Hillshire Woods
Shelburne Development is the owner of both Lots 93 & 94 in Hillshire Woods. The home
on Lot 93 Hillshire Woods will not have any windows in the garage on the side facing'-ot 94
Hillshire Woods. This should resolve any potential solar balance point issue with respect to
these lots
Sincerely.
SHELBURNE DEVELOPMENT
Greg H einze
President
CITY OF TIGARD
DEVELOPMENT SERVICES
13125 SW Hall Blvd., Tigaid,OR 97223 (503)639-4171 FIL E Copy
CERTIFICATE OF
OCCUPANCY
PERMIT #. . . . . . . : MST96-045[-
DATE ISSUED: 04/03/97
PARCEL: 2SI04CC-HWO94
�i ) L ADDRE.Ijf3. . . : 13530 SW ASCENSION DR
SUBDIVISION. . . . c HILLSHIRE WOODS ZONING:R--7 PD
BLOCK. . . . . . . . . . .. L01.. . . . . . . . . . . . . :094 JURISDICTION:TIG
-----------------------------------------------------------------------------------------
GLASS OF WORK. :NEW
TYPE OF USE. . . :SF
TYPE OF COhJSTR:5N
OCCUPANCY 1jRP. :R3
OCCUPANCY LOAD: 1
i+emarksi Path I
Owner.
SHELBURNE DEVELOPMENT
7008 F)W NYBERG RD
TUALATIN OR 97062
Phone #: 692-6383
C=ontractor:
SHELBURNE DEVELOPMENT
7008 SW NYBERG RD
IUALATIN OR 97062
Dhone #.- 692-6383
Reg #. . : 000423
Fhis Certificate grants occupancy of the above referenced building or portion
thereof and confirms that thr building has been inspected for compliance with
the State o Qregon Specialt / Codes for the group, occupancy, and use under
which the r f renced permit was issued.
BUILDING IINSPECTOR BUILIAhG OFFICIAL
POST' IN CONSPICUOUS PLACE
CITY OF TIGARD
DEVELOPMENT SERVICES PI...UMBING PERMIT
13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171 PERMIT #. . . . . . . : PI_M9 7--1710135
DATE ISSUED: 03/19/97
(:')ITE ADDRESS. . . : 13530 SW ASCENSION DR PARCEL: .?S i-O4CC•-HWO94
SUBDIVISION. . . . : HII._I...SHIRE WOODS ZONING: R-7 PD
BLOCK. . . . . . . . . . . LOT. . . . .. . . . . . . . . ..O94
rl_ISS OF WORK. . :AI_T rARBAGE DISPOSALS. : 0 MOBILE HOME SPACES. • '0�—
TYp'F: OF USE. . . . :SF WASHING MACH. . . . . . : 0 BACKFLOW PREVNTRS. . : 1
OCCUPANCY GRP. . :R3 FLOOR DRAINS. . . . . . . 0 TRAPS. . . . . . . . . . . „ . . 0
(!TORIES. . . . . . . . : 0 WATER HEATERS. . . . . : 0 CATCH BASINS. . . . . . . : 0
f-TXTURES-•----•- ------- -- LAUNDRY TPAYS„ . . . . : 0 SF RAIN DRAINS— _ : 0
fNKS. . . . . . . . . . .. 0 URINALS. . . . . . . . .. . . . 0 CREASE TRAPS. . . . . . . . rn
I .AVATORIES. . . . . : 0 OTHER FIXTURES. . . . : it
TUB/SHOWERS. . . . : 0 SEWER LINE= (ft) . . . : 0
WATER CLOSETS. . : 0 WATER LINE= (ft ) . . . : 0
DISHWASHERS. . . . : 0 RAIN DRAIN (ft) . . . : 0
Remar^I.(s : TnstAl l residential bacl.(flow prevention device
Ownfit': FEES
(',HEL.BURNE= DEVELOPMFNT type amoi.(nt by date recpt
7008 SW NYBERC RD PRMT $ 1.5. 00 JSD 03/19/97 97—r91.92ri
TIJAI..AT T N OR 97062. SPCT $ 0. 75 JSD 03/19/97 97-291920
r-'hone #: E9P-4,383
MASTER' S TOUCH SERVICES INC
DONALD BURTON
`?02 SW MICHAEL DR
',JEST I_TNN OR 97008 _ __..__....._._______--.--_. __________.___--•--_._..
1-11-ione #: 555-6436 15. 75 TOTAL_
rA.1 #. . : 11909
RFl7l.l I RED T NSPECT I ONS
'his permit is issued subject to the regulations contained in the 4P/Backflow Pr-ev
Tigard Municipal Code, State of Ore. Specialty Codes and all other Final Inspect ion
Applicable laws. All work Mill be done in accordance with
approved plans, This permit Mill expire if work is not started --- --� ---
within 180 days of issuance. or if work is suspended for more
`han IN days.
permittee S _...__.__ __ __ �__._ _.._�_-----
�n 'e : _
� SS1aed � --
Call for inspection - 639--4175
;T-Y-OF ?'IGARD Plumbing Application Recd
3125 SW HALL BLVD. Commercial and Residential DateRec'd D— ► yr f
"IGARD, OR 97223 Date to P E.
.503) 639.4171 Date to DST
Permit isc�
Print or Type Related SWR 2
Incomplete or illec,ible applications will not be accepted called_ <<
Name of Devetopment/ProlectFIXTURES (individual) QTY PRICE AMT
� Sink
Jobl/i�E900
—_
Address X111 1d7Suite Lavatory
7 Tub or Tub/Shower Comb. 9.00
Sc rW-4�,f* 11 �C/� 9.00
Bldg t CityiS'ate Zip Shower Only -- 9.00
_ZWater Closet 9.00
N me
-1 L j— Dishwasher _ 900
Owner Mailktq Address Suite Garbane Disposal _ 9.00
Washing Machine g 00
City/State ,TJp Phone Floor Dram 2' 9.00
NWM --- 3' 9.00
a� 9.00 —
Occupant 0%1&^9 Address Suite Water Heater —�� — 9.00
Laundry Room Tray 9.00
l;ity/State —Zip Phone Unnal 9,0o
--— --
Name Other Fixtures(Specify) '— g 00
ft 9.00
Contractor Ma
2202 S.W.Michael Drive
-- 9.00
C ty/Stafe ne
9.00
Oregon Const.Cont.Board Lic.0 Exp.Date --- 900
Adeck copy of / d 9 (4-30 9 — 9.0o
carrel rltaribing Lic-s Erp Date Sewer•1st 100' —
L30.00
icsesss Sewer-each additional 100' 25 00
COT Business Tax or metro t Ex � to Water Service-1st 100' 30.00
Name -- Water Schnee•each additional 200' S5.00 �
Architect Storm 6 Rain Drain-1st 100' — 3000 .�
or I Mailing Address St.:0 Storm b Rain Drain•each additional 100' ^ — 25 00
Mobile Home Space 2500 i
Engineer I utyrSlate — - Zip-- Phone Commercial Back Flow Prevention Device or Anti- 2500
Pollution Device
ncri a wan Herr O Addition O AMeration O Repair O Residential Backflow Prevention Device' 15.00
r be dons: lesidennal O yon-residential O Any Trap or Waste Not Connected to a Fixture 900
.ddrbonow description of worn Catch Bann I 9.00
insp.of Existing Plumbing a0 00
per/hr
-- — — — ----
a.ixiq use of Specialty Requested Inspections t0.00
o'enhr
aaarq or� y ---- — ----- Rain Crain,singie family riweiling — I 30.0(j
,oposed use of Grease Traps g.0p
•idding or property_ — — —
_ QUANTITY TOTAL
ire ycu :,appmg. n:ovvlg or replacing any fixtures? Yes C) No,C] Isometric x neer Diagram a recut"d cuaney total is >9
(H yes see back of fnnn)_ *SUBTOTAL
erebw acknowledge that I ha.e read this application,that the information
,een.s - rect.tnat I am the cwner or authorized agent of the owner.and 5% SURCHARGE
'at s bmitted are n comoliance with Oregon State Laws _ _ _ _ _ f I '
l nature f 036111Date —PLAN REVIEW 2S% OF SUBTOTAL
/ 4ecuW only d tbnue city, ictal,s>3
0 'f 7 � TOTAL � /r
:ontact Parson Name Phone
'Minimum permit fess S75-5%sure^,arge,except Residential Backflow
/� �� �, _— (�5 y y�b P•evennon Cevice,which is S 15- 5%surcharge
1 i.ldststptmapp.dcc 9/96
I
Fixtures to be capped, rr; ved or replaced Qty
Sink _
Lavatory
Tub or Tub/Shower Combination
Shower Only
_Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain Y 2"
4„ -
_Water Heater _
Laundry Room Tray _
Urinal r.
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE: