11775 SW 114TH PLACE-1 11775 SW 114TH PLACE
r �
m
cn ,e
d
O r
o rU
C r
O
cr I\
W �
H �
J
nl \\
Rol
r' to w cy c m w w
r
rn
tilt
r �
Ip
CL tr)
ANN rn H
• t
Ln
M ^
k
INSPECTION NOTICE
City of Tigard Building Department
P.O Box 23397
Tigard, Oregon 97223
Phone: 639-4175 v
WM
Type of Inspection ---- -
Date Requested /0 .r---- Time A.M. P.M.
Address 7 7-� l _. Permit #� _—
Owner CC[l( � "4 t' Lot # _
Builder,f',r(lC�'�, J4S -
The following Building Code deficiencies are required to be corrected:
Presented to - r i Approved
Inspector --.--_-- Disapproved
Date _—
CALL FOR REINSPECTION
0 YES [A NO
t
L;I I Y cal- I IUAHL ' MECHANICAL PERMIT =
Permit it s-
Description
Table 3A Mechanical Code
QTY PnICE AMT
City of Tigard 1) Permit Fee -0- ^0_ 10.00
13125 S.W. Hall Blvd. - ----
P.O. Box 23397 2) Supplemental Permit 3.00
Tigard, OR 97223 —
639-4175 1) Furnace to 100,000 BTU 6.00
incl.ducts&Wr nts
2) Furnace 10O,OOu BTU i 7.50
_incl.ducts&vents __---
Floor Furnace 6.00
Name of Development 3) incl.vent
Suspended heater,wall heater 6.00
Job Address _ 4) or floor mounted heater __-_..1
Address 1\l i I c-;` `_7l-'� \A ��-�L� Vent not incl.in
Tax l-ol Map No. 5) 3.00 —
_ __
Lot Block Subdivision appliance oorm,t
6.OU
_Repair of heating,refs ig.,
Name(or name of business) 6)
^— 11`` ,, ..kkcooling,absorption ung:
& t t,1:
Mailing Address P1OfQ 7) Boiler or comp to 3 HP 6.00
Owner (,-"2,C: absorp.unit to 100,000 BTU
�_,�. _ �1(< ._� ---- - -
Boiler or comp to 3 HP-15 HP 11.00
C
city/stele Zip 8) absorp,unit to 500,000 BTU -_
T kC�v�I� 7__Z___Z1 Boiler or comp 15-30 HP 15.00
Nacos 9) absorp.unit 1/2-1 million
r� ' Buller or comp to 3 J-50 HP 22.50
MaiYntt Address Phart• 10) absorp.unit 1-1.75 million
ContractorBoiler or rrr,t,to 5C HP $1.50
cnyrstafe
ZIP 11) absorp.unit 1,750,000 BTU -
i Bus rax W 12 Air handling unit to 4.50
c
Stale Registratkxl No h ) 10,000 CFM
13) Air handling unit 7.50
I hereby acknowllldge that I have rt-ed #w; a(1p11GIthy1 that the information(tIV11n 15 1 0,000 CFM + _-
cooed.that;am It*owner or a,at.wizod agent of the~w Rr,that plant,submitted art-In Non rtable
norry>lia ve with state I.ws,that I am registered with the State Hullers'FToard,that the 14) Ito 4.50
number given is acral (II exempt Iron+state regrstrat"'please give reawi below) — evaporate Cooler - -
-.v �,. - r L�__ 15) Vent tan connected 300
y- - to_a_single duct
-t 6) Ventilation system not 4.50
included in appliance permit _ _-
- Hand served by =4.50
1�)- mechanical exhaust
ne -
- lo1 A) Domea'IC type 7 50
incinerator
Describe work 17 addition ❑ alteration AZ repair [-I-residential-n
-
to be done residential noCommercial or industrial
non 19) 30.00
- -. _ _-- - - type Incinerator
Existing use at Other Le„woodstove,water - 4.50
building of properly- - 20) heater,solar,clothes dryers,etc. a
Proposed use of 2.00
building or property _-W -- --- 21) Gas wiping one to tali,outlets
Type of fuel- oil I ? natural gas 11 LPG F', rlertric Fl -
22) More than 4-per outlet
N_OTIr - SLiF1-1OTA1
THIS PERMIT BECOMES NULL AND VOID if WUiJK Uli ta_ll4 Iai7_5 n SURCHAaCESTRUCTION AUTHC IZED IS NOT COMMENCED WITHIN 180
DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR PLAN REVIEW 25%OF SUB-TOTAL
ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER TOTAI ,S
WORK IS COMMENCED. -- -
Special Conditions _-_�-
11NIr- is�urr<t t»
INSPECTION NOTICE
City of Tigard Building Department
12420 S.W. Main St.
Tigard, Oregon 97223
Phone 639-4171
Permit #
Type of Inspection ----- -�
The follcwing Building Code deficiencies are required to be corrected:-:Z
Presented to__---.. . - ---------.--—_-_--.— — Inspector ---
Date -----
GArL-�L FOR RE11VTECTION
W YE'.S ❑ NO
BUILDING PERMITAPPL,'CATION TIGARD DATE ' to
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT FOR THE WORK HEREIN INDICATED BUILDER PHONE
OR AS SHOWN AND APPROVED IN THE ACCOMPANYING PLANS AND SPECIFICATIONS. OWNER PHONE
OWNERBrian & Donna MOOJWADDRESS III il4th Place L.OTNO._9
._ —_— ARCHITECT - -
ENGINEER
BUILDER Cl aSsiC Hams Improv- ADDRESS12335 SU Ann Court DESIGNER
STRUCTURE ❑ NEW ❑ REMODEL ❑ ADDITION 0 REPAIR C RENEWAL ❑ FIRE DAMAGE E] DEMOLITION
a RESIDENCE ❑ COMM ❑ EDUCATIONAL ❑ GOV'T ❑ RELIGIOUS ❑ PATIO_❑ CARPORT i-' GAHAGE ❑ STORAGE ❑ SLAB❑ FE14CE
OCCUPANCY R LAND USE ZONE B"`7 BLDG.TYPE _Sn�FIREZUNE_ PLAN CHECK BY dWlt HEAT�_ 83__`
Cu trust family room & kitchen addition to existi_ngsingle family dueliing..
SEE C09RECTION SHEET ATTACHED,
SEWER PERMIT#
OCC.LOAD FLOOR LOAD 40 HEIGHT 1:3 NO.STORIES I AREA j 6 -1 NO.BEDROOMS --VALUE413,
BUILDING DEPARTMEN- SETBACKS FRONT _REAR _^LEFT SIDE'S% RIGHT SIDE 18
Permit x"68.00 THIS PERMIT IS ISSUED SUBJECT TO THE REGULATIONS CONTAINED IN THE BUILDING CODE, ZONING
REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES, AND IT IS HEREBY AGREED THAT THE
Plan Check 34,100 WORK WILL BE DONE IN ACCORDANCE WITH THE PLANS AND SPECIFICATIONS AND IN COMPLIANCE
C7 �0 WITH ALL APPLICABLE CODES AND ORDINANCES. THE ISSUANCE OF THIS PERMIT DOES NOT WAIVE
Subtotal • RESTRICTIVE COVENANT;. CONTRACTOR AND SUB CONTRACTORS rO HAVE CURRENT CITY BUSINESS
LICENSE.SEPARATE PERMITS REOUIRED FOR SEWER,PLU BING AND HEATING.
State Tax 4" 2..7?. f" • � ,
Total �104.72 SDC— f /
—� PDC# .44PPPLICANT OR A_GA
By al �~
A p . b'�S� /f`/-,;, � :- , c
Approved duh Receipt NoI i�:'��r'!/ ! 3 �_'• �_
A DRE 8 PHONE
DATE INSP. TYPE INSPECTION REMARKS I � .
_ PLUMBING DATE
I^fi\ -_�__� Contractor Own Q r—. f� rl r
Permit No.
27361 �.,�Z /D•3 -QU
—
'-/�
Fixture _ ----- -- -
-
Final
_ HEATING
Contractor
a _
Permit No.
Gas or Oil
Rough-in ——
Final �—
SEWER
Final —
DRIVEWAY
Final
-- Storm Drainage
(Rain Drain)Final
Sidewalk --
__ Curb&Street Final
Approach —
BLDG. DEPT. FINAL TEMPORARY C :RTIFICATE OCCUPANCY —
CERTIFICATE OCCUPANCY Final
Landscap{ng
Zoning Final
BUILDING PERMIT APPLICATION TIGARD DarE� �� t9�0
3113
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT FOR THE WORK HEREIN IN ICATED BUIMER PHONE
OR AS SHOWN AND APPROVED IN THE ACCOMPANYING PLANS AND SPECIFICATIONS. OWNER,
�Q raj 1, ' _�L _ LOT NO. �: --
E:''�^pty� / ' Db Ng,1�0 4 ADDRESS �I ' /,�j SK/ I I' I.
se) ARCHITECT
�� Qp v�� ___ lii .23��_ ENGINEER
BUILDEE(ak I' _ #ne�� ORESS Iy„ .� DESIGNER
STRUCTURE [] NELV ❑ REMODELAO __ ' -j REPAIR C1 RENEWAL 13 FIREDAMAGE C7 DEMOLITION
RESIDENCE C C0�11A ❑ EDUCATIONAL GOVT ❑ RELIGIOUS C1 PATIO 0 CARPORT 171 GARAGE ❑ STORAGE ❑ SLAEL) FENCE
O:.G:irANCY USE ZONE '+`BLDG.TYPE -. _-FIREZONE_- - PLAN CHECK BY HEAT_ _
--- �ls����1 �Qo�► -- -fit U'�'�� -��[ri"� . �k g `' � �,°1
SEWER PERMIT q ---
OCC.LOAC FLOOR LOAD / HEIGHT �,3 NO.STORIES V
__ _ / AREA 2W NO.BEDROOMS VA.LU"
^�BUIL01NG DEPARTMENT V SET BACKS FRONT REAR LEFT SICE
RIGHT SIDE /
Permit
- G�'d-_. THIS PERMIT IS ISSUED SUBJECT TO THE REGULATIONS CONTAINED IN THE BUILDING CODE,ZOWNC;
Plan Check REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES, AND IT IS HEREBY AGREED THAT THE
WORK WILL BE DONE IN ACCORDANCE WITH THE PLANS AND SPECIFICATIONS AND IN COMPLIANCt-
WITH ALL APPLICABLE CODES AND ORDINANCES. THE ISSUANCE OF THIS PERMIT DOES NOT WA V_
ISutYtatal X02. OO RESTRICTIVE COVENANTS. CONTRACTOR AND SUB CONTRACTORS TU HAVE CURRENT CITY BU3INESE
State Tax • 2 ,7 z LICENSE.SEPARATE PEt,MITS REQUIRED FOR SEWER,PLUMPING AND HEATING.
Total —
PDCM
By APPLICANT OR AGENT
Receipt Na.
Approved ADDRESS --
PHONE
0C —
DC — S �
Z9 x G = .2y7
EWER CONNECTION S 2 >< q = /e
EWER INSPECTION S 2GS 33.40 ; 25,0.3`/
EWER SURCHARGE S n14- 4f 6-yq
/
3,3'0 O
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME: PERMIT
DATE: . ./ i1221727 DATE ISSUED :-- Z
CWNERS NAME : /f•, .. .L•-�
.ADDRESS: ,// 7 7Jr S!y ;/�T•C �`�'!.
CONTRACTOR : — CLh e,,--
TEST :
,, -TEST : Air ❑ , Weter;7 , Visual Q , Laboratory ❑
RESULT: Approved C1 Disapproved LJ , Pending
r
SKETCH: �_7
- � �
26
I SPECTOR DATE I
COTE: Altooh 4upplemontnl test 0nigi
J
ADDRESS /1774i_ ti. f/,� V ��nc�c_ PERMIT NO. Ug7q
PERMIT CHARGE none
OWNER CLNNECTIGN FEE y�ib.o
PAID BY
TYPE OF BUILDING f�.a� t,-. DATE CONNECTED
SERVICE RATE INSPECTION FEE aS;ou
CONTRACTOR PAID BY Wvvt nawa z DATE
SI7.E OF CONNECTION tilt ASSESSMENT PAID
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME : PERMIT NO. :
DATE: 1-2-1 7 t! DATE ISSUED:
OWNERS NAME :
ADDRESS : &10(CONTRACTOR :
VIA-
TEST* Air O, Water ❑ , Vitiva Laboratory ❑
RESULT: Approved Disapproved ❑ , Pending ❑
SKETCH: l .
INSPECTOR DATE
[NOTE.: Attach supplemental test data horst,
CITY OF' TIGARD MECHANICAL PERMIT
DATE PERMIT N0. RECEIPT NO.
BY -- -- FEE
1. Permit shall be obtained prior to commencement of installation:
2. Permit shall be obtained for all appliances which are to become
a: fixture to the building.
3. Relocation, replacements, alterations, or changes to burners and
duct work require permits.
4. All work to be concealed must be inspected before cover vp.
New Insta lation Re lace ❑ Relocation ❑ Addition Alteration U
CONTR.,_._.&4 OIaNER_
ADDY ;SS ; �� LQ &
�,� 13
.t!t WORK ADDRESS
--P�J�:�LLjW,- �L!t-j.�_�/`�___� APPLICANT
FURNACE - DL4NUFACTURER TELEPHONE NO.
-g';�h - TELEPHONE NO.
HEAT Input rating (Btu Per,�Hour) reo ) Vent Size 'S_' Flue Size
FUEL OIL ❑ GAS L F LECT U OTHER
TOTAL SQ. FT. Top Floer Main Flou.• _1'�t n Basement
GENERAL
ITEM
NO. FEE ITEM NO. FEE
For Issuance of Permit _ .0 Boilers Over Hp
New - Under 100,000 Btu Air'_Randl t--'-E 000 CFM
New - Over 100.000 Btu _ -00— Air Randl.tng Over 10 U1 - CF
n _
Floor urace - .00 Evaporative Cooler' ..�:.0
Wall - Floor - Suspen-T d T 00 — Vent Fan ^' ""'"
Ins a 1 Vends �- D _Vend diem �0
fair - Heat & Cooling 4.00 Hood1 -
Boilers Under 3 H 4.00 -�Domest_c Inc HF-
p-offers 3 to 15-Hp __. _ 7-.;0 Cmm nerator J4 p
Boi ers 1 -"' .^Inc�nera�or �_'U.0
otoU Hsi 10.00~ Otj.CS
Doilers�JOo -50 Hp 3:570-0—
INSPECTOR'S
5.0 INSPECTOR'S COATIENTS
APPROVED BY DATE ISSUED BY _ DATE
Signature of A5Aicant
i
I
t
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME: �' PERMIT NO. :
DATE: n DATE ISSUED '.— 1. Z
OWNERS NAME : -
ADDRESS:
AME :ADDRESS: /cr 9
CONTRACTOR :
TEST '. Air Q, Water[] Visual�k-Laboratory [3
RESULT: Approved Disapproved 7 Pending L]
SKETCH.
INSPECTOR DATE
COTE: Attach supplemental test data Sarr']
/ I
City of Tigard v63s I
INSPECTION REQUEST
for -
-____
NSPECTION TIME: An -f PERMIT NO. :
DATE: 1,4DATE ISSUED :___1_L_
)INNERS NAME .'
ADDRESS: --_= ii z ,�t-��� ,E C4Lf-.
0NRACTOR : _u. _ ri,�
rE ST ' Air ❑, Water p , Wsua1 Leoratory ❑
RESULT: Approved ❑ Disapprovedle, Pending ❑
;KETCH. Y
I
� I
INSPECTOR DATE
Otff: Attach tupplomental test data beret a]
i
1
FILE COPY �
City of Tigard
INSPECTION REQUEST �
for-
s
----` cf' . PERMIT NO. ._ -- f 1
INSPECTION TI nAE.
DATE: DATE ISSUED :___1-1—..
OWNERS NAME .'
ADDR I
CONTRACTOR :TEST '. Air C., Water 0 , Visual P , I_ouoratory p I
RESULT: Approved G , Disapproved Pending
SKETCH: '�vT >f�t�,�'�• ; �064t CIA) I
!N Lpf�5C
° I
000;0600A f�Of
4 I
F.
INSPECTOR DA—E
I
FNOTV Attoch SUPP1OMN"01 test doto beret?' l
1
/
a
6' a
City of Ti g r
INSPECTION REQUEST
for
IINSPECTION TIME " PERMIT NO. '—
DATE'
O. : .DATE' I '%127 BATE ISSUED' 1_Z
OWNERS NAME '
I ADDRESS :CONTRACTOR :
It
TEST'. A r J , Water D , Ntisual La', ,ratory [I
RESULT. Apprnved 0 Disapproved _1 , Pending O
SKETCH'
I
I
I
I
I
INSPECTOR DATE
ICUTE : Attach supplemental test data heret]
1
City of Tigard
INSPECTION REQUEST
f o r
INSPECTION TIME : A-PL- PERMIT NO. . ..
DATE��. '�j ')ATE ISSLJED*---,-, J—
OWNERS NAME . --
ADDRESS ' 1-07-
TES I &-ter ,)<-rj Ln rr,
RESULT .- i,-xpprovs,4 n d
SKETCH:
An
INSPECTOR DATE
E:N-ITE Attach suppiementa I
W as W r s t
PLUMBING PERMIT APPLI ATION
Jurisdiction of !T e-4 tv-,
Cr
No. Type of Fixture Fee Permit No. �(�
Permit fee
'2— Water Closets Toilets -,� Permit Issued
Bath Tubs Approved by
t LavatoryWash Basin Building Permit. - 93
Shower Receipt No.
in s Dishwashing
SinksKitchen
SinKs, Ordinary Location of Building
Sinks Slop �-
Automatic DishwasFer
--- Disposal
Laundry Tri Name & A dr ss o er
Drains Floor
rains Area _
Drains, e r1�era or
Rain Drains
Automatic Wa,3her •d Na & Add ess f P1
oun ains Dri.n ntA
---t---
Fountains . oda
Hot Water Tank
_ Water Service Size Y4
Urinals I Building Old c.r New (Alter, Repair or
7'5 ,! -Bas ins -7—ar — Zns=a
Lawn Sprinkler ystem
.jw Lmmin (:'l 7 l
_�
S tnKler System ___ _This permit becomes null and vu.id if work +:r constructs Dn ,authorized is not
^ommenced within 60 rays, or if constructiorI or work .s suspended c:r abandoned
for a period of 120 days at any time after work is c .mmenced.
All plumbing firms must be licensed by the City of Tigard and post a $1,000 bond
I hereby certify that I have road and examined this application and k.nuw 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 cr 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.
6_'V�_-V-'A JAI
Signature of Applicant
l[uinIii,r? ��' .heating
AP . r. r'rn
155,15 S. f:. N1 11mam Dr.
i
I
i
of Tigard
INSPECTION REQUEST
for
lx-, G
INSPECTION TIME . ._t _/'Y _ PERM;-f NC
.)ATF ISSUED I
DATE.- -9--L'S-23 --OWN ERS AAME : ---
A D D R E S S: _ 8 --C�'---- - -------
!I O N.TRA rTOR --- ---------- —`
' EST ,4ter❑ c,1(. .�b ►ct �r; '.� (;
� , � �
d G
lRESUI-� _--� r',vec1 _ :uppt �. �•��idi`ir, u I�
SKETCH: I�
I
I
I
I
I
INSPECTOR DATE I
I
CNOTE. Attach suppiementai te®t uatu tieretul
1817
EXHIP.IT "A"
CITY OF TICARD
He!,Jdenttal Structure Occupancy Restriction
KNOW ALL Wlitl BY 71ME PRESENTS, That occupancy of residential
structure (a) on the following described lands prior to the recording
Of �n occupancy i,ermit releasing the restriction In tLe Deeu Record:;
of Washington Cuunty, Oregon, is prohibited by the ordinance of the
City of Tigard, Oregon:
DESCRIMION OF PRO;'ERTY:
I-6 9 aF 114 ?L4Lt
_a EL. 34 , T VS 'E.)w , w.Nr
ADDR].:,: OF YROPER'I'Y: //�7 �•., ¢ rA (ilG
NAME OF OWNER: Kl�wC—(_� S
ADD';t&;3 OF uWNEft: / 7c) �� t, 144 w7iy
IN WITNEuu WItMEOF, the undersigned has caused this restriction
to be executed this day of /`AUGUST 1y,74,
OWNER:
AI'PROVEU: No 0
Tule
By:
HuildinGUfflclal q-.p��'.._1�7e!�•�1� �pM
City of Turd q�r.LR lViOMRRU1.
Vto"'el ti.un'ds a t��.,+,,..•
OTATE OF OREGON
County of Wechington ) '_ /7 19_
Personaily appeared before me the above named
mid a:knowledged the foregoing instrument to be��
A. vollu .nract
and uetu.
t N,:tary,Fubllc 'fdr Oregon
Conn ,slop Expires:
Milk 045 mE76%
f
I
ago $� Cj
CITY OF "rIGARD
12420 & W. AWn shMf
TIGARD, OrBOON 1721
APPLICATION FOR BUILDING PERMIT
New Construction 11X Demolish Addition Remodel C] Move C7
ZONING R-7 UATE ISSUED___- -- BUILDING PERMIT
BUILDING FEE 5 n.QQ No. C.)
DATE RECEIVED_ -
tiY PLAN CHECK 5�,_
S '
----_ - -• OTHER 5 :,
_�.y°` c,. VALUATION
��l.. ----
TOTAL $ • ��Q 3-° RECEIPT No.
TWO SETS OF PLANS AND PLOT PLANS MUST BE FURNISHED WITH APPLICATION
LOT 1MAP I CENSUS TRACT y ly_- JOB 1
5L 4G➢__ -
Architect or Engineer` AO° mine
Address 85:1 S.M. Barbur Blvd. 4, - Phone_._
awn
Address Ione-_ _-
BUILDING USE Single Res. o� Multi Res. Comm. J Industrial
GCCUPANCY GROUPI _ No. of Stories_1 Total Height 15 Area of Lot#i,490_
Type of Construction V Floor Area B_____ 1_1364
Set Backs: Front 2U Back 25 _ L.Side_ __ R.Side` __1(6
Private Sewer Pipe Size 14" Sewer-usa Tigard Septic Tank I_J
water Service Pipe SizeStorm Sewer � Ditch ❑ UryweI ❑
Street and Curb Requirementsexisting
_-__ --
Driveway Width.- 18' - _No. of Parking Spaces
SEPARATE.' PERMITS REQUIRED FOR SEWER AND PLUMBING
SPECIAL INFORMATION
ADDRESS ASSIGNED!— 11775 A.Y. 114ULyyp<
FIELD CHECK BY� _ .�.+.. -__Y___- .__-DATE 8-113
PERMIT APPROVED BY
It is underRtood that all work will conform with applicable codes and ordinances
of the State of Oregon and the City of Tigard, Oregon, and that the building will
not be occupied until a Certificate of Occu c has b en issued by the City of
Tigard Building Inspector.
nature of pplic t: ¢���_
1`
1
UNIFIED SEWERAGE AGENCY NO 4879 t
WASHINGTON COUNTY DATE
clrY OF
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER atV --
OWNER'S ADDRESS `�0- _5, w__�vLC.__L✓!�_N�,�. .. .._.. --
STREIT
�.. r y ----- STATF <
BUILDING SITE: LOT � ...__.-_ BLOCK ADDITION
TAX LOT NO --- TYPE OF OCCUPANCY
75 �"
ADDRESS 11 7 S�_�. //"',' -pC'/GC'L-
DWELLING UNITS ------ _- FIXTURE IINITS _---
SURCHARGE IF APPLICABLE � --
�
PERMIT FEE q!50ec,
� INSPECTION FEE-95—!-TOTAL DEPOSITED
INEW) (EXISTING) BUILDING SEWER SYSTEM .us&_ �i6.r�i1l,
r
Thr! Applicant agree. to comply with all rules and7�-
of the Unifi+�r1 S w++eq+ Allem v
APPLICANT
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM
LINE SIZE 4W 4 -- INSTALLER - - - --
RECEIVED BY-_�r G� ribwrlt?9
UOENCV OR ITS AGENT+
COMMENTS
This Application and permit expires in ninety (90) days The amount nald will he forfeited
should expiration occu►.