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Case File 4. � � ,� �.�f- 41� �/o r;� rv'�"�I P,�rr' f`/�Q,r� .1�)Q�,,.✓�"" kr � NOTE: CENTERLINE CONCEPTS, � y s SURV`EMRS.WILL PIH E)(TERIOR FOUNDATION CORNEM AND PROVIDE SUBSEQUENT VORMAGE SURVEY. EROSION CONT L: e• �° .�S� �/ 1. PROVIDE 8 MAINTAIN r(min)THICK 91 GRAVEL PAD 8 DRIVE UNTIL PERMANENT o° CONCRETE DRIVE IS IN PLACE \, 2 PROVIDE&MAINTAIN SOIL SEDIMENT FENCE AS INDICATED. CIO ^'o,• / ' 9 w 14 X7--Z4r : S �C->36�C L Ll mac^ so, �O/V*7 q C r ..90;10;7 INV � \ J �s.o. S •ly Soo• 1 • Colo, c, SCALE DRAWING LOT 53 EAGLE POINTE S.W. 1 4 SEC. 3,S.E. 1 4 SEC. 4, & � N.W. 1 4 SEC. 10,T.2S,R.1 W, W.M. TY OF 11GARD �r CITY /7 WASHINGTON COUNTY, OREGON AUGUST 6, 1997 Centerline Concepts Inc . DRAWN BY: MSG CHECKED BY: WGDIII --AN EIGHT FOOT PUBLIC UTILITY EASEMENT SCALE 1"=20' ACCOUNT # 115 S640 82nd Drive Gladstone, Oregon 97027 HALL EXIST ALONG ALL STREET FRONTAGE. M: MLl�PAL EAGLEPO L53EP 503 650-0188 fax 503 650-0189 NOTICE: IF THE PRINT OR TYPE ON ANY r� 1111r� I I I f 1 . I 1 ( ` _ . C lIiIII � s � � � � � IIIII � � IIIl- ---I � r � I [ II ► � ► I . ► � 1 ' � � � 111 � � f � i11FJ -rlirTi � irlrII � ffrli � i ( � I11i111 � 111I C 1 � f I 1 � I ---- . 1 2 3 4 5 6 7 8 9 - 0 11 12 IMAGE IS NOT AS CLEAR AS THIS NOTICE, _ -- ---__._--- .^ _ _ _ -- ----_-_-- IT IS DUE TO THE QUALITY OF THE ` ORIGINAL DOCUMENT N_38 �_�.��.,.,...• E 6Z 8Z LZ ��►� �� i�� 119�� Z 111'1 'n- � Z litfi 'll1 ]111Z 111, Holl Z1111 1161, I 8I1111 11L11 �1�� 9T �' i fiI ET ZT iT � 6 8 L 8 4 � £ - Z Ta► w � i W <O N . t0 �C C m Fn- 13929 13929 SW AFRIE DRIVE CERTIFICATE OF OCCUPANCY CITY OF T i G A R D PERMIT#: MST97-00346 DEVELOPMENT SERVICES DATE ISSUED: 8/28/97 13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 PARCEL: 2S103CC-04700 ZONING: R-4.5 JURISDICTION: TIG SITE ADDRESS: 13929 SW AERIE DR SUBDIVISION: EAGLE POINTE BLOCK: LOT:053 CLASS OF WORK:. NEW TYPE OF USE: SF I YPE OF CONSTR: 5N OCCUPANCY GRP: R3 TENANT NAME: REMARKS: SF - Path 1 Final Inspection Approved 7/23/98 by George Steele. Building Inspector Owner: JOHN BURNS 13929 SW AERIE DR Phone: Contractor: RENAISSANCE DEVELOPMENT 1672 SW WILLAMETTE FAILS DR WEST LINN, OR 97068 Phone: 557-8000 Reg #: This Certificate grants occupancy of the above referenced building or portion thereof and confirms that the building has been inspected for compliance with the State of Orvyoii Specialty Codes 'Far the group, occupancy, and use under which the referenced permit was issued. ,} BOLDING INSPtCTO9 BUILDING OFFICIAL POST IN CONSPICUOUS PLACE J CITY OF TIGARD BUILDING INSPECTION DIVISION I MST 70--3 24-Hour Inspection Line: 639-4175 Business Line: 639-4171 SUP _ Date Requested AM PM -- BLD _ Location ��,�' (��(� Suite MEC y Contact Person _ — Ph PLM Contractor Ph SWR BUILDING Tenant/Owner ELC — Retaining Wal! ELR Footing Access: Foundation FPS Ftg Drain Crawl Drain Inspection Notes: SIGN Slab --------- — -- ------- ._ - 3IT Post& Beam --' -- Ext Sheath/Shear Int Sheath/Shear Framing — Insulation -----_.—__—_--------- - Drywall Nailing _ Firewall Fire Sprinkler Fire Alarm --------- --------.—__-------- Susp'd Ceiling _-._-...__.- ------------------ ---_--- Roof Misc ----- - - -- ----- PA 1 PART FAIL -- --}--- — PL SING I Post& Beam -- — - Under Slab Top Out - ------------- -- - Water Service Sanitary Sewer Rain Drains �--P—AS—S-1 PART FAIL MECHANICAL I'o,a 1 Bean-i -- ---- — _— Rough In Smoke Dampers PAS,. > PART FAIL ELECTRICAL -- Service Rough In -- ------ -- -------- UG/,lab Low Voltage C'LIAlarm LPK pAS PART FAIL ____ ------__--- --- SITE Backfill/Grading - -- ------ ------ ------ --- Sanitary Sewer Storm Drain ( i Reinspection fee of$— -required before next inspection. Pay at City Hall, 1.3125 SW H�-' Blvd Catch Basin f ] Please call for reinspection RF — ( j Unable to inspect- no access Fire Supply Line ----- - ADA Approach/Sidewalk Other Date /' 7 . ` 9 Inspector -G _ — Ext _ Final PASS PART FAIL DO NOT REMOVE this hispection record from the .job site. CITY OF TIGARD MASTER PIERMIT DEVELOPMENT SERVICES PIERMIT #. . . . . . . : PIST97-0346 13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171 DATE ISSUED; 08/28/97 VIARCEL: 2S103CC-04700 SITE: ADDRESS. . . : 13929 SW AERIE DR SURD I V I S I ON. . . . :EAGLE PIO I NE ZONING: R--4. 5 PID BLOCI'. . . . . . . . . . LOT. . . . . . . . . . . . . :�� JURISDICTION: TIG Remarks: SF - Path 1 ---------------------------------------------------------------- BUILDING ----------------------------- REISSUE: STORIES.......: 2 FLOOR AREAS---------- Bf15EMENT...: 0 sf REQUIRED SETBACKS---- REQUIRED------------- CLASS OF WORK..-NEW HEIGHT........: 20 FIP'ST....: 1811 sf GARAGE..... 440 sf LEFT..........: 5 SMOKE DETECTRS: Y TYPE OF USE...:SF FLOOR LOAD....: 40 SECOND...: 975 sf FRONT.........: 20 PARKING SPACES: 2 TYPE OF CONST.:SN DWELLING UNITS: 1 FINBSMENT: 0 st RIGHT.........: 5 OCCUPANCY G"P.:R3 BDRM: 3 BATH: 3 TOTAL------: 2786 sf VALUE—$: 194162 REAR..........: 4a ---------- __------- - -------------------------- -------- PLUMBING ---- ---- ------------------------------------------------ SINKS.........: I WATEP CLOSETS.: 3 WASHING MACH..: 1 LAUNDRY TRAYS.: 1 RAIN DRAIN ft: 100 TRAPS.........: 0 LAVATORIES....: 5 DISHWASHERS...: 1 FLOOR DRAINS..: 0 SEWER LINE ft: 100 SF RAIN DRAINS: 1 CATCH BASINS..: 0 TUB/SHOWERS...: 3 GARBAGE DISP..: 1 WATER HEATERS.: 1 WATER LINE ft: 100 BCKFLW PREVNTR: I GREASE TRAPS..: 0 OTHER FIXTURES: 0 - ------------------------------------------------------------ MECHANICAL ------------------------------------------- -------------------- FUEL TYPES----------- FURN ( 100K ..: 0 BUIL/CMP ( 3HP: 0 VENT FANS.....: 4 CLOTHES DRYERS: i 6A5 FURN )=100K ..: 1 UNIT HEATERS..: 0 HOODS.........: 1 OTHER UNITS...: I MAX INP.: 0 BTU FLOOR FURNACES: 0 VENTS.........: 0 WOODSTOVES....: 0 GAS OUTLETS...: 1 -- ---------------------------------------------------------- ELFCTRTrAL - ------------------ __ -RESIDENTIAL UNIT--- ---SERVICE/FEEDER------ --TEMP SRVC/FEFDERS--- ---BRANGI CIRCUITS--- ----MISCELLANEOUS---- --ADD'L INSPECTIONS-- 1000 SF OR LESS: 1 0 - 200 amp..: 0 0 - 200 amp..: 0 W/SVC OR FDR..: 0 PUMP/IRRIGATION: 0 PER INSPECTION: 0 FA ADDIL 500SF.: 5 201 - 400 amp..: 0 201 - 400 alp..: 0 lst W/O SVC/FUR: 0 SIGN/OUT LIN LT: 0 PER HOUR...... . 0 LIMITED ENERGY.: 0 401 - 600 amp..: 0 401 - 600 amp..: 0 EA ADDL BR CiR: 0 SIGNAL/PANEL...: 0 IN PLANT......: 0 MW HM/SVC/FDR: 0 601 -- 1000 amp.: 0 601+amps-1000 y: 0 MINOR LABEL. --L0: 0 1000+ amp/volt.: 8 ---------- ---------------- PLAN REVIEW SECTION ---------------------------------- Reronnect only.: 0 )=4 RES UNITS..: SVC/FDR)=225 A.: 1 600 V NOMINAL: CLS AREA/SPC (ICC: ------------------------------------------- --- ELECTRICAL - RESTRICTED ENERGY ---------- -A. SF ",ESI DENT --------------------- B. COMMERCIAL--—--------—-------------- -------------------__ ---- AUDIO 6 STEREO.: VACUUM SYSTEM..: AUDIO 9 STEREO.: FIRE AL.ARM.....: INTERCOM/°AGING: OUTDOOR LNDSC LT: BURGLAR ALARM..: 0TH: :: X POILEP.........: HVAC...........: LANDSCAPE/IRR1G: PROTECTIVE SiGNL: GARAGE OPENER..: CLOCK..........: 1NSTRIINENTATION: MEDI(:AL........: OTHR: HVAC...........: DATA/TELE COMM.: NURSE CALLS....: TOTAL t SYSTEMS: 0 Owner: -----------------------------------Contractor: ----------------------------- TOTAL FEESO 4603.36 RENAISSANCE CUSTOM MKS RENAISSANCE DEVELOPMENT This permit is subject to the regulations contained in the 1672 WILLAMETTE FALLS DR 1672 SW WILLAMETTE FALLS DR Tigard Municipal Code, State of Ore. Specialty Codes and all WEST LINN OR 9706A WEST LINN OR 9706A other applica5le laws. All work will be done in accordance with approved plans. This permit will expire if work is Phone 1: 557-NO Phone 0: 557-8000 not started within. 180 days of issuance, or if the work is Reg A..s 000499 suspended for more than 180 days. ATTENTION: Oregon law ------------------ - ---- requires you to follow rules adnpted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0080. You say obtain copies of these rules v direct questions to OUNC by calling 1503)246-1987. ------ REQUIRED INSPECTIONS ----------------------------------------------------------- Erosion Control Underfloor insul Plumb Top Out Low Voltage Rain drain Insp Plumb Final Footing Insp Crawl Drain Electrical Servi Gas Line Insp Water Line Insp Final inspection Foundation Insp Footing/Foundati Electrical Rough Gas Fireplace Appr/Sdwlk Insp Building Final Post/Beam Stro PLM/Underf1oor Framing Insp Insulation Insp Electrical Final Post/Beam M an anical 1 Shear Wall Insp Gyp Board Insp Nechanicat Final IssoaedI y : d4u Plermittee Signa':.1.tt- +i t++-F+i- 4-+++4 +++4++1.....+.i-+ r+++++-1 4 t++ttt... ....44-+T-+ ++++ ++ +'++# tti Call 639-4175 by 6:00 p. m. for an inspection needed the next- bIASi�ess day CITY OF TIGARD DEVELOPMENT SERVICES SEWER CONNECTION 13125 SW Hall Blvd., Tiga,u' OR 97223 (50)639-4171 PERMIT #PERMIT PERM . : SWR37-0329 DATE ISSUED: 08/28/97 UARCEL: 2SI03CC---04700 SITE ADDRESS. . . : 13929 SW AERIE DR SUBDIVISION. . . . :EAGLE POINE ZONING: R--4. 5 FID BLOCK., . . . . . . . . . LOT. . . . . . . . . . . . . :O53 JURISDICTION: TIG --------------------------------- TENANT NAME. . . . . : RENAISSANCE CUSTOM HOMES USA NO. . . . . . . . . . : FIXTURE UNITS. . . . 0 CLASS OF WORI-11. . . :NEW DWELLING IJNITS. . : I TYPE 01:7 USE. . . . . :SF NO. OF BUILDINGS- I INSTALL TYPE. . . . :BUSWR IMPERV SURFACE: 0 sf Remarks : SF — Path I Owner: FEES RENAISSANCE type Amol-tnt by date r-c-cpt 1672 WILLAMETTE FALLS DR QUL $ 0. 00 DRA 08/28/97 97-298741 WFi"r LINN OR 970r-,8 DUN $ 290. 00 DRA 08/28/97 97-298741 PRMT $ 2200. 00 DRA 08/28/97 97-298741 Phone #: INSP $ 35. 00 DRA 08/28/97 97-298741 EROS $ 64. 00 DRA 08/28/97 97—i,98741 Contract $ 20. 80 DRA 08/28/97 97-298741 OWNER ERPC $ 20. 80 DRA 08/28/97 97--298741 ---- ----------------------------------------- Phone 2840. 60 TOTAL Reg #. . : --------I REQUIRED INSPECTIONS This Applicant agrees to comply with all the rules and regulations Sewer- Inspection of the Unified Sewage Agency. The p�reit expires 180 days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-MI-90I0 through OAR 952-MI-M. You may obtain copies of these rules or dire0_411ist ions io OUNC by calling (503)246--1967. Issued y Permittee Signati-ir-e : 4 4.......4-+++4................. ......................4......................f+++++ Cal. 1 639-41.75 by 6:00 p. m. for- an inspection needed the next bt.1siness day 4 4 4 4+++-4-+++-#............f+++4........4-+4-+++4-4........f.........4 .................1-+++ IT OF IIGARD Residential Building Permit Application Rleed Bye 3125 SW HALL BLVD. New Construction Additions or Alterations Date Rec'a = c� IGARD, OR 97723 Single Family Detached or Attached (Duplex) Date to P I:. ' SQ: 6394171 Oat@ to DST 21- 503-684-7297 Permit# Print or Type Called Incomplete or illegible applications will not be accepted Name of Protect Name Address site Address Architect Mailing Address Name C tale Zi Phone ��/t'/9�S/�i�►�Crz-- • i>•1,�/t Cir c�a,�� Owner Mailing Address I ame C�tyrStale Zi Phone Engineer Mailing Address `� rF' ' f�rrt �- /cJ : '✓� Aim Name — City, to 3 Z `' rp Phone General , 'ir%�iu, 'r c�d�" �7 fearsr��avr' G� , ✓`/ �.r'Jr Describe work New O Addition 0 Alteration O Repair O COntrartor Mailing Ar ress to be done: - i` Additional Oescriphon of Work. + CityrState Zip Phone Oregon Const Cont. Board Lie I Exp.Date. //�'��J✓ �`� / '� j/�j>,;/ ntUch copy or C�:L ,Da r &� Current COT Business Tax or Metro N ate . PROJECT y u Ucenses f.T'C'(; / j' VALUATION Name 'Aerhanical Tit'/ �;..,,rl-y ,— ��,y ,� NEW CONSTRUCTION ONLY: Sub- Mailing Address — Sq. FC House: .t S Ft. Gara e / C t q , C.tyBtate Zip Phone Comer of YES NO, Flag Lot YES O C, !k.ri„%�s4� r i: s/� (check one; L� (check one) Oregon Corist.Cont. Board Lie# Exp, v to Restricted Audio/Stereo Burglar t, 'oPY cic ,��, Energy System Alarm Current COT Business Tax or Metro# y HVAC Installation Garage Door HVAC L.JcensM � �+ _ N Opener Systems (check all that Other. i7 lurnbing I��%rt?/ _., .F',C[ SCJ;;416 apply) i Sub_ Mailing Address Will the electrical subcontractor wire for all YEN Contractor (7�g restricted energy installations? C, ,State Zip Phone / Has the Sucdivlslon Plat recorded? N/A gT? NO Oregon Const.Cont_Board Lie.# F�rp. pate Reissue of MST# Solar Compliance Arach Copy of (^.�C� ;� r I -:- Current Plumbing Lie. - 3 E C , —_ (Calculation Attached) Licensest ,�,��- I ✓}! ,f i' I hearby acknowledge that I have read this arplication, that the COT Business Tax or Metro# Date information given is correct, that I am the owner or authorized (?c )C' 'r �- ;; ager,;er ti a own;;r• and that plans submitted are in compliance Name with Ore_go i State taws. c lectrical Signature r(Ow pF/ gent �, r -- Date Sub- Mailing Address _.. Contact Person Name Phone 0 contractor ✓ cr' X” /try �- ��' C ty/5ta:e Zip Phone FOR OFFICE U5E ONLY: / Plat tY: Ma /TLA#: PY of Oregon Ocnst Cant. Board Lc#-!ach Co2 r - Solar ectcat c. tCurrent Zone: l_icensea , COT 9usiness Tax or Metro a Ex Dam Engineering Approval: P!anning Approval: TIF: ' Y I. s'fapp doc(dst) 1/97 1 t ePID�iL Acecunt Descri p AmoWn Amt. Pd. Bal- Due , 1-U.3 G MST. Permit (BUILD) Plumb. Permit (PLUMB) C Mech. Permit (MECH) � y, i ELC/ELR Permit (ELPRMT) State Tax (TAX) �0• �'' �� Bldg: 33, S 3 Plumb: //• ��. Mech: 2� ' i E:LC/EL.R: Plan Check MST: (BUPPLN) � S t r- o"?J ' Plumb: (PLMPLN) Mech: (MECPLN) I CDC Review (LANDUS) ov ' r o3Z Sewer Connection (SWUSA) 0 U r _ Reimbursement District ( ) i Sewer Inspection (SWINSP) Parks Dev Charge (PKSDC) r. Residential TIF (TIF-R) _ Mass Transit TIF CT T) _ Water duality (WOUAL) _.�1.- _ Water (Quantity (WOUANT) �� r C'' Erosion Control Permit (ERPRMT) Erosion Planck/USA (ERPLAN) Erosion Planck/COT (EROSN) Fire Life Safety (FLS) ` 4 R TCTALS: i:ursoo.doc t(d$t)!;1;J9? f ' 40 `1v SEE 35MM ROLL# 22 � FOR LARGE DOCUMENT CITY OF TIGARD DEVELOPMENT SERVICES PLUMBING PERMIT 13125 SW Hall Blvd., Tigard,OR 97225 (503)639-4171 PERMIT #. . . . . . . : RLM96-0206 DATE ISSUED: 06/26/98 PARCEL-.- 2SI0ZEC-04700 SITE ADDRESS. . . : 13929 SW AERIE DP SUBDIVISION. . . . EAGLE POINTE ZONING: R-4. 5 PD BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . :053 JURISDICTION: TIG CLASS—OF WORK. . :AI-T GARBAUE DISPOSALS. : 0 MOBILE HOME SPACES. : 0 TYPE OF U;E. . . . :51 WASHING MACH. . . . . . : 0 BACKFLOW PREVNTRS. . : 1 OCCUPANCNi GRP. . :R23 FLOOR DRAINS. . . . . . . 0 TRAPS. . . . . . . . . . . . . . . 0 STORIES. . . . . . . . : 0 WATER HFf4TERS. . . . . : 0 CATCH BASINS_ . . . . . : 0 FIXTURES-------- - — — LAUNDRY TRAYS. . . . . : 0 SF RAIN DRAINS. . . . . : 0 SINKS. . . . . . . . . : 0 URINALS. . . . . . . . . . . . 0 GREASE TR.')PS. . . . . . . : 0 LAVATORIES. . . . : 0 OTHER FIXTURES. . . . : 0 I UB/SHC1WERS. . , : 0 SEWER LINE. (ft ) . . . : WATER CLOSETS. : CA WATER I.-INE (ft ) . . . : DISHWASHERS. . . . 0 RAIN DRAIN (ft ) . . . : 0 Remarks : Re-,idential backflow preventer Owner: FEES RENAISS'ONCE type amoi-int by date t-eept 1.672 WILLAMETTE FALLS DR PRMT $ 15. 00 JD 06/26/98 98-306863 WEST LINN OR 97068 5PCT $ 0. 75 JD 06/26/98 98-306863 Phone #: MCJODY ENTERPRISE INC P0 BOX 98 ESTACADA OR 97023 Phone #: $ 15. 75 TOTAL Reg #. . : 000059 REDUIRFD INSPECT IONS -------- This permit is issued subject to the regulations contained in the RP/Backflow Prev Tigard Municipal Cnde, State of Ore. Specialty Codes and all other Final Inspection applicable laws. All vork will he done in accordance with approved plans. This permit will expire if work is not started within IN days of issuance, or if work is suspended for more than 180 dayt. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center, Those rules are get forth in OAR 952-MI-010 through OAR You may obtain copies of these rules or direct questions to ODIC by calling (9@3)246-1987. I S S fAed By: Mid e t-in i t t e e LS i g n a t 1-i t-P ...............4.........4•......4..............I.................4................ + Call 639-4175 by 7:00 p. m. for an insper-tion needed the next bi-isiness Jay .........*...................................................4......+++++4+4++++-+++ �1A. i.ITY OF TIGARD Plumbing Application Recd By- 13125 SW HALL BLVD. Commercial and Residential Date Recd ("? ic-1 7 Z-7 TIGARD, OR 97223 Dale to P E.Dale;0 0 '503) 639-4171 Permit! 1 Print or Type Related SWR! Incomplete or illegible applications will not be accepted call-. Name of CevelopmentiProlect �, FIXTURES (individual) QTY PRICE AMT _ Sink 900 Job �� / � T s lavatory _ Address Street dr£,ss Suile 9.00 �1 c i ( Tub or Tub/Shower Comb 9 06 ldg! 1 G rStal) Zip Shower Only 9.00 Water Closet 9.00 Na Water y / f Dishwasher — 9.00 I Owner M�^ail-�CV Address S6110C� Garbage Oisposai I 9.00 1G?A 41•/14^e tit F//S Washing Machine r—9.00 Ctfy/state Zip Phone f=loor Dram 2' 9.00 9.00 tarn. _ 4' 9.00 Occupant Me"A6dmss t� suite Water Heater 9.00 /3 S!�/.�C.CiC rr Laundry Room Tray 9.00 CitVistate Zip Phone Unnal 9.00 —rj— 9 '2'1 Other Fixtures(Specify) 9.00 Na /t1oo1� 9.00 Contractor Mailkgdre-u 'Suite 9.GO ra 0. do X le -- 900 Cltyrstale Zip Phone T4C� A 0 �� 6.3/-••-I/X 9.00 Oregon Const. ont.Board Lic.! Exp. ale 900 A*bch copy of /-;A- 30_ 6 ,� _ 9.00 Cu TW" PAwnbirg Lie.! p. to Sewer-1st 100' --- 30.00 LkAtesete Sewer-each additional 100' _ I 25.00 COT Business Tax or Metro! Exp.Date Water Service-1 st 100' 30.00 Name Water Service-eacn additional 200' 25.00 Architect Storm&Rain Oram-1st 100' 30.00 Marling Address St.,:e Storm R Rain Drain-each additional 100' 25 00 i I Or Mobile Home Space I i 25.00 i Engin eferrC.tyrState Zip Phone Commercial Dack Flow Preve;iuon Device or Ants- 25.00 _ II I oulluoon Cev+re — Descs Mara New A,,dition O Alteration O Repair 0 Residential Backflow Prevention Device' 15 00 b be dour 7esidenhal 0 Non-residential O — _ try Trap or Waste Not Connected to a Fixture 900 I Addoxnal desc inion of work si J S Catch Basin I 9.00 I nsp of Emsting P!umomg i I 4000 Derihr Sceaaly Requested Inspections ��penhr Rain Cram.single family dwelling 3000 Proposed use of Grease Traps I 900 building orNLiOMyv _ QUANTITY TOTAL _1 Ara yap capping. moving or replacing any fixtures? Yes C7 No❑ lsorretnc or riser diagram u enured if Cusney Total is >9 _ ('f yes see ba:k of form) _ _ 'SUBTOTAL I here!,acxruwledge that I hate read this apolication that the informal on t givens wrrec:.;nal I am the owner or authorized agent of the owner.and 5°/. SURCHARGE — liat clans sut-iitted are n comollance with Oregon State taws. Signatu OIf Gw ejiV►yent Dat PLAN REVIEW 25% OF SUBTOTAL l / secured only I lic ure vy !&Am s>3 __ 1--- �/ y. 1, _ I h Z S y7 TOTAL I — Contact Person Name Phone 'Minimum permit fees S25• 5%surcharge.9 xcept Residential Backflow P•evertion Ce•r,ce.which ,s S15- 5%surchar e Wsts,,pimacp dor-31go PLEASE COMELETE AS APPROPRIATE TO PROJECT: Fixtures to be capped, moved or replaced I Qty Sink Lavatory Tub or Tub/Shower Combination Shower Only _ Water Closet Dishwasher Garbage Disposal Washing Machine Floor Drain 2" 3" Water Heater Laundry Room Tray Urinal _ Other Fixtures (Specify) ,"OMMENTS REGARDING ABOVE: