11340 SW VIEWMOUNT LANE 11340 SW VIEWMOUNT COURT
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BUILDING PERMIT APPLICATION 11 Y TIGARD Y°'�"7�-
n.',rE -- . i90
[HE UNDERSIGNED HEREBY APPLIES FOR A.PERMIT FOR THE WORK HEREIN INDICATED BUILDER PHONE 620--5460
OR AS SHOWN AND APPROVED IN THE ACCOMFANYINO PLANS AND SPECIFICATIONS. OWNERPHONF__
t LOT NO.
OWNER Bill AltlfJtr JOB ADDRESS i.' III '.I�,fA1J I'i'i..` �,ME IDDRESS
_T ARCHITECT
�r � ENGINEER
_BUILnER Terry I'Mars1 Mass � 7TDORL�a � _DESIGNER
STRUCTURE ❑NEW ❑REMODEL GALIDITION ❑REPAIR FJRENEWAL. ❑FIREDAMAOE ❑DEMOLITION
[3TESInENCE ❑COMM ❑EDUCATIONAL. ❑GOV'1 ❑RELIGIOUS❑PATIO-C'CARPORT ❑GARAGE ❑STORAGE❑SLAB ❑FENCE
❑BOND ❑MOVING ❑CONI,ITIONAL USE 0_DESIGN REVIEN LICOUNCIL APPROVED []SIGNS
OCCUr ANCY LAND USE ZONE__.BLDG.TYPE ___FIRE ZONE_ PLAN CHECK BY.
Connt. mcuonrary fire place and chi►mmay -all pqr code rff+qlt.tll>Cemebt -
LQADFLQOFjLOAAD ___HEIGHT I11S)�T9RW AREA _ NO,BEDROOMS __ VALU)< �'
BUILDING DEPARTMENT SETBACKS FRONT REAR LEFT SIDE RIGHT SIDE
Permit 1.•0 - - - ----THIS PERMIT IS ISSUED SUBJECT TO 1HE REGULATI:)NS CONTAINED IN THE BUILDING CODE. TONING
Plan Check REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES, AND IT IS HEREBY AGREED THAT THE
— '-- WORK WILL 4E DONE IN ACCORDANCE WITH THE PLANS A 4D SPECIFICATIONS AND IN COMPLIANI.E WITH
Sub-total ALL ArFLICABLE CODES AND ORDINANCES. THE ISSUANCE OF THIS PER".IT DOES NOT WAIVE
RESTRICTIVE COVENANTS. CONTRACTOR AND SUB CONTRAI;TORS TO HAVE CURRENT CITY BUSINESS
State Tax F, LICENSE. SEPARATE PERMITS RE.OUIFIED FON SEWER, PLUMBING AND HEATING.
TGtal
By _
-- —�- A$Rl ICANT OR AGENT -
Approved Recelp! No.
ADORFSS -PritSNE
DArE INSP. TYPE INSPECTION REMARKS PUIMBING DATE
Contractor
Permit No.
Rough-in -
Fixture
Final
HEATING
Contractor
Permit No.
Gas or Oil
Rough-in—
Final
SEWER
Final
DRIVEWAY
Final
Storm Mama
(Rain Drain) Final
Sidewalk
Curb&Street Final
--..,,,LULqach
BLDG DEPT. FINAL j TEMPORARY CERTIFICATE OCCUPANCY
CERTIFICATE OCCUPANCY Final
CLan, Iscaping
;,(-,iinq Final
CITY OF
9 212-
n_r ►rt ry �rTCA nN I DATE Q 8 I
J.i•...ali I �� 1.
RD
—S UNDERSIGNED HEREBY APPLIES FOR A PERMIT FOR THE WORK HEREIN INDICATED
OR AS SHOWN AND APPRGVED !N THE ACCOMI-ANYIN i PLANS AND SPE/CIF'CATIONS. OWNERPHONE
nwNF4
` ADDRESS l Z� n /•, ✓IF�.�- ER PHONE L � J tP
ENGINEER
DESIGNER
^ ^ac n+=� ADDITION []REPAIR L]RENEWAL []FIRE DAMAGE ❑DEMOLITION
;Tavr_-L'aE -'VEw — _'IAO__ ^
RESIOENCE_^_COMM ^=DUCA"ONAL []GOV-T []P.EUG:OUSnPATIO DCA.. PORT []GARAGE []STORAGEL.lSLAB ❑FENCE
^ r.
%IOV'NG
—CONDITIONAL USE n DESIGN REVIEW ❑COUNCIL APPROV ED G!S1GNS
T pG FIRE ZONE_— PLAN CHECK BY HEAT
OCCL'�=+��" '-AND USE ZONE 9L 7G_ Y
gill
17
OCC LOAD FLOORLOAD OAD HEIGHT NO.STORIES AHEA ...==== VALUE^C7V d
9'-'LO'NG OEOART'•, SET BACKS FRONT REAP LEFT SLOE RIGHT SIDE
' Permit
v
-� THIS PERMIT IS ISSUED SUBJECT TO THE nCGULATIONS CONTAINED IN THE `rU1L^viNG CODE, ZONING
Ptan Check REGULATIONS AND Al.L APPLICABLE CODES AND OPDI-NANCES, AND IT IS HEREBY AGREED THAT THE
r �* WORK WILL BE DONE IN ACCORDANCE WITH THE PLANS AND SPECIFICATIONS AND IN COMPLIANCE WITH
Recording ALL APPLICABLE CODES AND ORDINANCES THE !SS'+ANCE OF THIS PER1tiT DOES NOT WAIVE
�---- RESTRICTIVE COVENANTS. CO!'1T!tACTOR A it CONTRACTORS TO HAVE CURRENT CITY BUSINESS
6 State Q LICENSE.SEPARATE PERMITS REOUIREU FOk .ER, PLUMBING AND HEATING.
r----,
Tota!
APPLICAN
;tpprove eceipt No.
ADDRESS PHONE
./,i•l ��w1 ,µ� v,�A/}� L ��( wd�Y L�!G �� ���ali�' P"• ��`I� �^'��� iq 4�,L ,�ll�fi,
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CITY OF TIGARD
,rsa OREGON
7)) ;
Owner:....Columbia Custom.....................................Permit No......73-253.-... �
11340 S.W. V1•etdmount Ct. f'
Building Address........................................................................................................ ��� �► ,
I. r
Certificate is hereby given this......-13thday of......"�"e....................19. 75
4. that said building may be occupied and
that it complies with all requirements of ��,s
the Building Code for the City of Tigard,
as approved by the Tigard City Council.
-�
� -
Building Inspector
�4�F:XH119JT "H"
CITY OF TIGAfW
CERTIFICATE OF OCCUPANCY AND RELF:A.;X OF 1UzTHIcTION
The City of Tigard hezuby :ertifies that the occupancy of
the following described structure or premluen with reupect to which
a rentrictiun of occupancy was, on 1G_ , lye,
recorded in Rook Palp Deed Record of War•hington
County, Oregon, is hereby autluzrized and appruied.
1)EaCHI1'1'IUN OF I'RAi'ERTYS
lot 1' Vieumount
Tax Map 791 3dd
OW?4;j9: 1701umbis Custom Homes
RUILUING 1KRMIT NUMRFR. 73-253
BUILDING Al)DRE i:i:
This is to certify the said structure meets with the require-
meets of the Building Csxie of the City of Tigard and the above
referenced restriction ir. heret,y relensed rind terminated.
IN W;TNF:3S t,IIF.RF.UF, the under-.igned nuthurize.l officer of the
City of Tigard has: cn. 3ed thi-. certificate and release of restriction
to be executed this h day of lune 19 76,
A
Title:�
STATE OF ORAGON
County of Washington )as.
on this _13thr day of __?usru _, 1.9 7c,, personally
npptared before me the abcve named Doris Hs,r i , vhone
signature appears, hereon and who acknowledged to me that, he executed
the -,awe in his fftcal capacity on behalf of ttr. City of Tigard.
Hutary Pdblic of Gregon
My Cosmission expires:
E ,,i028 rti 42 4 p• ..__.. . y'%�'� tom,
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STATE OF OREOIL
OIv
N A
County of Weshrngtow I
1, hope, Thp 10" a of Records
and Elect, IM IIIAWk ' ecordsif of
Coovrrye fm mod cowft,r *try 4mf
my th wl n11 1 svriFifp
vAsr a -'� foeordL
!
No Mfr ►a._ :1 _.
A� of Nul OWtV, #-?$I,
!! / Witness YbWW&A&V$f�e.(,
vectof
,tea,sI►(�,rP
Domov
UJUBIT "B"
CITY OF TIGARD
(::Rxrin(,-ATE of Urt:UPANCY AND R}:1.F.ASz OF ItF:.TH1('I•IoN
The City of Ti n rd hereby certifies that the occupancy of
the folloving described structure or premlues vith respect to which
a rer.trlction of uccupency was, on 12-5 _, 19-2-2,
recorded in look 955 , hilp 425 — , Deed Record of Washington
County, Oregon, /.s hereby authorized and aaproved.
DFSCHIITION OF I'ROI'ERTY:
lot 11 Viowmount
Tax Map 251 add
OWNER: Columbia Custom Homes
BUIIDINO PERMIT NUMBER: 73-253
A 11.DING ADDPYM: i iawn g.
This is to certify the said structure meets with the require-
ments of the Building Code of the City of Tigard and the above
refer••nced regtrlct.lori l:, huirety .elewied and termlyal.ed.
IN WITNFiS WIFRFOF, the undersigned authorized officer of the
City of Tigar+l tins cnuced this certificate and relearce of ren:rictlon
to be executed this 13th day of _ June 19_7S
_ /cL Asti-• `z//� /c �,
Title:
STATS OF ORMON
County of Washington )ss.
On this 13th day of _ 1 _, 19_1;y, pernunelly
appeared before we the above named _ Doris Har 10 , whose
signature appears hereon aha who acknovledged to me that be executed
the saes in his official capacity on behalf of the City of Tigard.
J)
a' I)
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Notary of U
regon
Ky Comission expires: _
-—--L-�
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME '--�----,, PERMIT NO
DATE: DATE ISSUED:--Y--L
OWNERS NAME : z---
A D D R E S S :
C 0 N T R A C T 0 R :^-..--_- _-- --- -
TEST'. Air ❑, Water ❑ , Visual ❑ , Lahoratory p
RESULT: Approved , Disapproved 0 , Pending ❑
f SKETCH:
ilk
rt V
I —r P CTO DATE w
I
[NOTE : Attach supplemental test data hereto
CITY OF TIGARD MECHANICAL PERMIT
DATE 713 PERMITN0. _ 7 '/�� -rrn RECEIPT NO.BY .0 f� ( �_l.S r!'/YI /T TC FES 4,
1. Permit shall be obtained prior to cormencemetit of installation:
2. Permit shall be obtained for all appliances which & re to become
a fixture to the building.
3. Relocation, repincements, alterations, or changes to burners And
duct r,ork require permits.
4. All work to be concealed must be inspected before :c*,•cr up.
i New Install Tion Replace U location U Addition ❑ Alteration ❑
CONTR._ '/���1/ ' E r�A1� Crf f•� - ""� _
ADD 2E .� l • •�' �p' 'f� WORK ADDiLc5$ �' s u, '
0.C(1 � APPLICANT
TELEFHONE N0.
FURNACE - t•lANUFAC,'URER TELEPHUNS NO.
HEAT Tip ut ratin /� " t� Vent Size Flue Size
p 6 (Btu o Per----No Hour) �,L� Q �_.�--�--
FUEL OIL ❑ GAS N ELECT O OTHER ____ —•---------
TOTAL SQ. FT. Top FlOCT �-- � Main Floor �� basement
GENERAL
ITEM N0. FEB ' ITEM NO. FEE
For Issuance of Permit 3..0_x_ .oilers Over 50 Np z4�
New - Under�100�Oyu G. it NnndIJnA 1-01000 CF14 II
flew - Over lUo,OU fir.tangy n Over 10 000 CFM - •r
Vloor -Furnace � "'.vr. orc1t ve Cooler U
1=e --- ` oor -�ac� en e- �+.T er, inn
ns a men a 1 ens: e em
Repair - Heat�Goc nR .UO Hoo
Bo era n er e �i',n0 Domes e Incinerator � 5 0
Boilers to 15 H . '0 omm. nc .neraator 1U.0
' Nlere to H r_�10.00 e^ M-R—ed— w�T^ 7
I3cc lens o ^_ __LTS. _
INSPECTOR'S COMMENTS ..�-
I
APPROVED BY ---_ _ DATE 4 � ISSUED BY _ _ D T$
,v4/
Signature of Applicant
City of Tigard
INSPECTION REQUEST
for I
INSPECTION TIME: ., rMr PERMIT NO.. : ._
DATE: Z/ +- DATE ISSUED : I
OWNERS NAME
ADDRESS: S,G)
CONTRACTOR : _TEST : Air ❑, Water❑ , Visual , Laboratory ❑
RESULT: Approved 2.1 Disapproved ❑ , Pending ❑ I
SKETCH: ftv b.' 2 - 1 fir' to --74
I
INSPECTOR DATE
5NOTH: Attarh suPP1emental test data her Pt
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME Ef�`�'""---- DATEPERMIISSUED :_L-L--
GATE: . (1—1-� ( _
4-
OWNERS
OWNERS NAME : � U
ADDRESS: ✓ �l
C0NTRACTo R
TEST : Air ❑ , Water C] , visual G , Laboratory ❑
I
RESULT: Approvad Disapproved CJ Pending ❑ I
SKETCH: ,, „z o -IN
i
i
I
I
I
I
SPECTOR DA"rE
I
LN01E. Attach supplemental test data bs►etn,
�sl
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME: PERMIT NO.
DATE: DATE IuSUED
OWNERS NAME :
ADDRESS: L/_Zu ` cam vac: cvn ►,—t �y
CONTRACTOR .' —
TEST :
ONTRACTOR .'TEST : Ni( LJ, Water[] , visual* Laboratory O
RESULT : Apnroved _ Disapr.roved 0 Pendinv CJ
SKETCH:
751
INSPECTOR DATE
EOTE : Attach supplemental test data hereto
i
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME ' PERMIT NO. :
DATE : DATE ISSUED:_LJ
OWNERS NAME :
ADDRESS :
CONTRACTOR :__---Zt'! 's �-- � ✓. —
TEST*. A r ❑ , Water [1 , Visual O , Lal- ,ratory [1
RESULT : Approved ❑ , ()isuppro%ied,?).,,, Pendlnq,Q
SKETCH: 9;�S �M•, s -�s
Cs�r�vi.:. : cs�nrfe a�inrJ
A)
INSPECTOR DATE "
COTE : Attach supplemental test data heret:01
1
PLUMBING PERMIT APPLICATION
Jurisdiction of --
No. Type of Fixture Fee Permit No. _1,oe-e
Permit fee _ 3
_T Water Closets Toilets Permit Issue �-G-741
Bath Tubs Approved by
_ ft
Lavat.ory _ Wash Basin _f Building Perm -
_ Shower w Receipt No. - --0-La5
•�
_-METE Di shwashin
Sinks,_ Kitchen °
SinksOrdinaEy _-� Location of Buil.din .
Bar----- ---- — 1�3'` ' '� �� •"c� --
S i nk s, S101? _ _ ------- ----
/ Automatic is wasTT_er --
/ llis osal -- _ � �'
�-- Name dress of Owner
Laundry Trays.-— r--�� ---
Drains, Floor 1 � i�
Drains, Area _—.� siX�'
Draina, Refrigerator --
Rain Drains _ S.
Automatic Washer 4, Name & ddress of Plumer _
_ Fountains, Drinking --
Fountans,-Soda —_ Pi -
-� ^�
Hot Water Ta-n—Tt --Water Service Size3// -
Ur�npls Bui Old c New Alter, Re affair_ or
- Lj,D Sprinkler SystemF__ � ,__ ----- ------
--- Swimming-Pool _ Other
Sp r i nk 1 e r Sy s t e it____ ---- ----- -- --___-_ --�—This permit- becomes null and void if wor'c construction authorized is not
cornmenced within 60 days, or if constructs, or work is suspended or abandoned
for a period of 120 days at any time after woilr, is commenced.
All plumbing firms must be licensed by the City of Tigard and post a $1,000 bond
I hereby certify that I have r?ad nd examined this application and know the sam
to be true and correct. All provisions of laws and ordinances governing this ty
of work will be complied with whether specified herein. or not, the granting of a
permit does not presume to give authority to violate or cancel the provisions
of any other state or local law regulating construction or the performance of
construction.
Signature of Applicant
w ■
D
City of Tigard
INSPECTION REQUEST
for
INSPECTION i'IME: . 4,01- PERMIT NO. :
DATE: _J/. ZJ--0- ljk1 DATE ISSUED
0WNERS NAME : ---
ADDRESS:
C ON TR A CTO R :
TEST : Air 0, Water , Visual 0 , L.abar otory p
RESULT' Approved L] Disapproved ❑ Pending p
SKETCH.. &,C6,ii4
INSOtCTOR DATE
NOTE Attach suppiemenicl test data hereto
A
�w � wrrr-j ..���rrr.�.-�r.Wlw/Y.r •.IWr ..urr.w.u._..._.. ...�. ..
City of Tigard .
INSPECTION REQUEST
for
,
! INSPECTION TIME : PERMIT NO.:
DATE:
DATE ISSUED:_..L_L...
OWNERS NAME : L=�m-��� Ct.� .
ADDRESS : 113�a
CONTRACTOR : 2diiai _ -
TEST: Air ❑ , Water [3 , Visual ❑ , ,Laboratory ❑
RESULT: Approved Disapproved ❑ Pending []
SKETCH:
SPECTOR, ---- DATE
iNOTE : Altoeh suwamentol test da 'o herelol
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME: —m--_ PERMIT NO. :
DATE.' __�t_L 42Y DATE I S S U E D :_—.L1--
OWNERS NAME : _�- ,olsL n "`=_
ADDRESS:
CONTRACTOR -
TEST ' Air u , Water ❑ , Visjal ❑ , Laboratory (_]
RESULT : Apnroved X, Disl . proved ❑ Pending
SKETCH:
G''Sr
JL]jLf y f
�t z
INSPECTOR DATE
[OTE: Attoch supplemental test data bereto�
l /,00 0
1
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,
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UNIFIED SEWERAGE AGENCY NO. .______ 491_3
WASHINGTON COUNTY NATE _ztNIiNx-_ 11-13-73
CITY OF
i APPLICATION FOR SEWER CONNECTION PERMIT
OWNER:
Columbia Custom Homes
f , OWNER'S ADDRESS: 7 int-.--lafferson. Terrace
STREFi
_ Lake Oswego IIregon -
CITY S1ATE ZIP
BUILDING SITE: LOT 11__-__ BLOCK ADDITION Uiewmount
TAX LOT fd0. .___ TYPE OF OCCUPANCY Residence
I
ADDRESS ____11340 S.W. Viewmount Court
DWELLING UNITS _1 - - FIXTURE UNITS
SURCHARGE IF APPLICABLE -__SD--.L4-,Carry Dell
PERMIT FEE 450 INSPECTION FEE _26_ TOTAL DEPOSITED 476
Ti and
(NEW) (EXISTING) BUILDING SEWER SYSTEM _.��
The Applic,int agrees to comply with all rules and regulations of the Unified Sewerage Agency.
t
I APPLICANTQ� v 2v (z'C' i
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE `;EWER SYSTEM.
LINE SIZE Orr INSTALLER _
I
RECEIVED B Y. .c. .0 ---
I E G ITS AGENT)
COMMENTS, _� 3 �QG�Sr�1
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur,
CITY OF TIGARD
1;410 t w aa,.� a..«
iif3A"0 0x1 1004 ♦Y711
APPL*CATION FOR BUIWING PFPM I1.
E.Cy+ Construction r� Demolish 17 Addition Remodel Move
ZONING p..9
DATE ISSUED 11-1301.1— BUILDING PERMIT
DATE RECEIVED BUILDING PEE 8 114.00 No. 73_253
BY _ FLAN CHECK S K4.00 VALUATION S��405.0
_.__. .,_ _.._._. ,�TIIEtt S a.00
RECEIPT No. F.,1 3__
TOTAL s_-----��br*A
TWO SETTS OF PIANS AND PLOT P6ANS MUST BE FURNISHED WITH APPLICATION
LOT s 11 Vi8w410un1kAp 1--� _ CENSUS TRACT _ W-19 — JOB 1
Architect or Enginee r
Address --r--_ Phone—_r3F+-�4�+► —
_�.AL..._Sat lac anu.--Lksaar-.
Owner —Desmond Dans
Address ---- Phone "..'
Sul 1 der—t21W1g • Luatoo Names - -. ---------- ----`—--"-
Ad.lrear ___ r Phone
BUILDING USE Sin71e Res. x� Multi Res. l_J Comm. M Industrial
OCCUPANCY GROUP` No, of Stories 2— Total Height__261 Area of Lot
Type of Construction lKxyjtx �V#yx"ER V Floor Area B 273 11614 2 250
Set Racket Front_2W Back! L.Side_____71—_
Private Sewer Pipe Sise_-4" -_„_ So%+er_VSS_j,"Std6eptic Tank LJ
mater Service Pipe Site_- 3/40 Storm Sewer El Ditch Urywell `.J
Street and Curb Reojuirements_____jA,1,kj,1Qa _��______._._ —
Driveway Width_�liB” __No. of Parking Spaces
SEPARATF PERMITS REQUIRED FOR SEWER A!ID PLUMBING
SPECIAL INFORMATION
ADDRESS ASSIGNEDi- � 11340 S.W. Vieveount Court
FIELD CHECK BY
PERMIT APPROVED BY--� _
it is understood that all work will conform with applicable codes and ordinancom
of the State of Oregon and the City of Tigard, Oregon, and that the building will
not be occupied until a Certificate of occupancy has been issued by the City of
Tigard Building Inspector.
gna ure Of App scant
tXH19IT 'A'
CITY Of TMARO
Residential Structure Occupany R. r.ction
KNOW ALL AEN BY TNESf PRESENTS, that occupancy of residential
structure (s) on the following described lands prior to thn recording
of on occupancy permit releasing the restriction in the Deed Records
of Washington County, Oregon, is prohibited by the ordinance of
the City of Tigard, Oregon: (The City will Issue • 1610000
ss soon an a fleel lospectioii determine* that the construction
:s sst:•fsrtt)riiy completed)
DI,SCRIPT LO-4-0 11U_P_U TY:
Ir� 1/ �if� MQN,111
Ao0R(.55 0► PRO P'CRTE:__ ' �Jd��lr r '•Rt1'u,7 Lf�t .__
NAME Or_0W41 R tis j�( :y,�'i' •�cx �i -L-�:wau�s`
ADCHI55 OF OWNER: ��►j� 4'-�Y'x •�, 1�yra%s Ye uJ[ic�l��
IN WITNESS WHfREOE, the undersigned has caused this
restriction to be executed this 1, day of
OWNF R
res
Mrs—
r)AavRnvl :
R4 .
IF61 I d i nqOf f i c Fey
City of Tigard
STAY[ 0f Oshss -' 19 ? t
County
Washington
COUnty Of V•shingtOn
R�r nal y epee red before es the above nerved � r.
,T >rc«•� _ and acknowledged the foregoing
Instrument to he - �r. voluntary act and deed.
Cd
miry P,!Kjjc for Oregon ^^ -
Co '»fon Explrest
1
t
EXHIBIT *AN
CITY OF TIGARD
Residential Structure Occupsny Restriction
KNOW All MEN BY THESE PRESENTS, that occupancy of residentlel
structure (a) on the following described lands prior to the recording
of an occupancy permit releasing the restriction in the Deed Records
of Washington County, Oregon, is prohibited by the ordinance of
the City of Tigard, Oregon: (The City will Issue a release
as soon as a final inspection determines that the construction
is satisfactorily completed)
DESCRIPTION OF PROPERTY:
���' // Yjt►.�MOwil�
_�•il /11/f�ti i ��J1J f
ADDRESS Of PROPERTY:
NAME OF OWNi R t ��rt..Plit���eila.l�l raG�.�AlIe WA.lr; j.,& 1 tf.'A,s�,
ADDRESS OF OWNENi cYYr.SsJ.f 7rrrn _(II�.L CSa.'eT[
IN WITNESS WHEREOF, the undersigned hes caused Chie
restriction to bm executed this _s_3 day of Z), , 1977
nww R:
Name
APPROVED: T I n e
)!ullding OFFIcial
City of Tigard
STATE OF OREGON
County of Washington ; ss' 19
Pernal y sopsared before me the above nosed 1t.`6•'L( f /
' Ula bl- �- and acknowledged the foragning
instrument to be �I; ,r, voluntary act
�and
�deed,
Notary c or Oregon
Ay aemfssion Expireas
• M tied A M
.r�76N TIAL+'4ltLN No�wrre
arm 055 45
�2
@1
1 STATE of ORfr,(7N
Cauwr .A Welh"*f— p
iRnprr 1►r,w»gh f%gt/a 1 Rrc..A.
aq! [MCIiwM wd[.CNi.e 1a R�rd�. •I C,w.
wrasq M �n.d ta..Ir, do AwK+r c�+af�
dv1 IM Mrh�n IntM�1yM cA Mil,ro wog
Oct. N!f I�fIi1(�d r/1 bmA of
No
ul owd CN'Ir
1--d 0114 t*G' Offt-.d
R9r'•R0t TI-KWSSEN.
F rt odl • I&WI—W
e'(e'.'
r+v ry
Address„ 41 34L _. Permit No. � qC1 3
Permit charge
Owner s_ Connection fee
.....r...,...�....�.....»....._,
Paid b y
Type of building ���, , �. Date connected
9ery"�cm sate Inspection fes
Contractor _ „_.j„ t � Paid by JA-y2, date
Site of connection Amsssament paid
n ra.ar �r�w - au rrrwa.rw�.rrr