10540 SW 121ST AVENUE 10540 SW 121ST AVENUE
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FIRE PREVENTION BUREAU
OF('ICc OF FIRE MARSHAL_
55�' ^ �,
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HNSPECTION NOTICE
OWNER^ � n p C/ BATE �� r
OCCUPANT Y
OCCUPANCY %d(r A
YO�Jr ATTENTION IS CALLRD TO THE FOI.'t OWING FIRE SAFET EFtC1ENC1ESt
-~♦ FAILURE TO CORRECT THE ABOVE. CONCI rIONS WITHIN GAYS WILL WAVE Y100 L!ApJ1:E:'e O EC ION. 11H2OULO F RE
RESULT FROM SUC1+ CONDITI ON9 YOU MAY BE LIABLE kOR DAMAGF.,Q TO PE4110(-1S 0R rR0- FIT QRR P"VIDIO OF
ORS ATY 100 �Y� J I 'r 4
WASHINGTON COUNTY FIRE DISTRICT N1 T FIRE MARSHAL. %
17880 S. W. BLANTON STREET
ALOHA, OREGON Y7005 649-8577 PRESERtIED TO � rl
FORM 000-40
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UNIFIED SEWERAGE AGENCY No. 11047WASHINGTON COUNTY CGUNTY DATE i..10-77--
CITY
, a-??--CIT Y OF-------- ---- T i g a r d -
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER: Robar Randall Co.
OWNER'S ADDRESS: - -- -- ----
STREET
-- CITY - STATF -- ZIP ----
BUILDING SITE: LOT.____ BLOCK - __ ADDITION
TAX 1_01' N0. __— TYPE OF OCCUPANCY _... commercial _
ADDRESS 10540 SW _1219t Ave.
DWELLING UNITS 6 - --- FIXTURE UNITS
SURCHARGE IF APPLICABLE -----
PERMIT FEE __4450_-- __ INSPECTION FEE 35•-- TOTAL DEPOSITED 3435.
LUEM (EXISTING) BUII-DING SEWER SYSTEM __J'4nno_Creek.
The Ahnlirant agrees to comply with all rules and regulations of the Unified Sewerage Age icy.
l
SEWER PCRMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE _-__ _. INSTALLER __-�- - ------ ----, -
RECEIVED BY.� ----- - -
tnGENCV OR i AGENT)
cOMMENTS: Bldg. #1237
This Application and permit expires in one hundred and twenty (120) days.
The amount paid will be forfeited should expiration occur.
POBUILDING PERMIT APPLICATION CITY TIGARDI DATES-77 1717
OF
THE UNDERSIGNED HEREBY APPLIES FOR APERMIT FOR rHE WORK HEREIN INDICATED BUILDER PHONE_
OR AS SHOWN AND APPROVED IN THE ACCOMPANYING PLANS AND SPECIFICATIONS. OWNERPHONF
LOT NO.._ _
OWNER !OB ADDRESS HOP IE ADDRESS
ARCHITECT
BUILDER ENGINEER
ADDRESS DESIGNER
STRUCTURE �[:❑NEW 13 REMODEL ❑ADDITION ❑REPAIR ORENEWAL ❑FIRE DAMAGE ❑DEMOLITION
C3 RESIDENCE 'LIt:OMM ❑EDUCATIONAL ❑GOV'T ❑RELIGIOUS❑PATIO ❑CAR PORT ❑GARAGE ❑STORAGE❑SLAB ❑FENCE
❑BUND ❑MOVING ❑CONDITIONAL USE_ ❑DESIGN REV-EW ❑COUNCIL APPROVER [-]SIGNS
OCCUPANCY tl LAND USE ZONE PQ BLDG.TYPE _FIRE ZONE PLAN PLAN CHECK BY__, HEAT
dLclq. d Lovett.. multifamily apt u/Ullt e: 11 , �.., _ —_
_ ,.
PeL s Shoats 1 thru ;i7 C; Unite Inrludel-q all Sita aeiew.l.. ,:,a, ;s F,vin,, la;,l.x_r b;
�.,,.��: 1
lei
QAC .LOAD _-_F149gLQADL--- `_EIGHT l _�Q,�e`TQB► ;?. AR��^. _—_ NQ.A ?AQ(2(Yl5 VALUE 10820.l .
BUILDING DEPARTMENT SET BACKS FRONT_ REAR LEFT SIDE RIGHT SIDE
Permit 1(1 7.1](? - -_-THIS PERMIT IS ISSUED SUBJECT TO THE REGULATIONS CONTAINED IN THE BUILDING CODE, ZONING
Plan Check Pp 'j,, aici REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES, AND Ir IS HEREBY AGREED THAT THE
WORK WILL BE DONE IN ACCORDANCE WITH THE PLANS AND SPECIFICATIONS AND IN COMPLIANCE WITH
Sub-total ALL APPLICABLE CODES AND ORDINANCES. THE ISSUANCE OF THIS PERMIT DOES NOT WAIVE
RESTRICTIVE COVENANTS. CONTRACTOR AND SUB CONTRACTORS TO HAVE CURRENT CITY BUSINESS
State Tax 0�Qi LICENSE. SEPARATE PERMITS REOUIRED FOR SEWER, PLUMBING AND HEATING.
Total . 01
1
BY
---- — APPI ICANT Oq AOEN1 - - - -- -- --- - _--
Approved Receipt No.
DATE INSP. TYPE INSPECTION REMARKS PLUMBING GATE
(.contractor
Permit No. Q Y, f z Cl
Rough-in
Fixture
anal
HEATING
Contractor
Permit No.
Gas or Oil
Rough in
Final
SEWER
Final
DRIVEWAY
-- Final
Storm Drai lege
(Rain Drain) Final
--- Sidewalk Y
Curb&Street Final
Annrtiarh
BLDG DEPT. FINAL TEMPORARY CERTIFICATE OCCUPANCY
CERTIFICATE OCCUPANCY Final
Landscaping
C
Zoning Final
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Address / 5'0 ,�/moi f�� Permit No. ,/iC 5/7—
Permit- charge
/7—
Permit- charge _22-0I e-
Owner ��-t�'a,�f � � Connection fee
Paid by
Type of building _ (gin . Date connected
Service rate � � Inspecti-)n fee 3
Contractor Paid by Date
Size of connection Assessment paid
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