11698 SW 125TH COURT-1 �i
t�
3
CERTIFICATE OF
CIWOFTIGA
IW �� OCCUPANCY
� G�k:RMI7 p, . . . . , . t MFrT90--0454
CITY OF( WARD
COMMUN9TY DEVELOPMENT Ddr4hTfk+ T 0R DATE 1S5UEDa 11/21/91
131251 SW Hall Blvd. P.O Hm 2339,',Tigard,Or%,cm 97713(15W)fin-4176
SI TE NDI) 1698 SW 1.25T'N U r' - - PARCEL t t8133DD-416500
SUBDIVISION. . . . t VILLAOL A1• SUMMLRLAKE ZONING.
BLOCK. . . . . . . . . . t LOT'. . . . . . . . . . . 1104
CLASS OF WORK. aNEW
TYPE OF USE:. . . xSF
OCCUPANCY GRP. tR3
OCCUPANCY LOAD2120 4
1'!�NAW NAME. . . x
Remarks a
Owr►ey't
DON MORISSETTE
PO BOX 19524
PORTLAND OR 00000- 0000
Phone M: 000 019 -i�000
Contractors
DON MORISSETTE: BLDE:R59 INC.
P 0 PDX 19524
PORTLAND OR 97219
Phone Nr 593-620-•7538
Reg M. . t 35533
Occupancy of the above ref(prenced building is he!rpby pitier►, and wertifiea
the crimplianco with the S)A1,ate Of Oregon Specialty Codes far the grump,
aectipancy, and urge under which the referenced permit w�,ls issued.
FIRE DEPARTMENT BUILDING NSPECTOR
/PUILDINO FFIC1 _._.. .-
AL
POST IN CONSPICUOUS PLACE:
i
- f
i
CITYOF
TWARD
PLAN ECK APPLICATION
(r', rnrw-een / PLnN CHECK IV '�•5A
COMMUN"DEVELOPMEITC DEPARTMENT / PERt1IT It /)1-5t
nmsw.w.SpA.sm��,�.ao...,a•�rm.cs�lc>:��T DATE: ISSUED
-;Ax rjAP/._oT
JOB AOR S:
)' C _ LAND USE:
SUB:
ALUATION: �2-''3� SPCCIAL NOTES
OWNER fyl�( IS _I 1 L REISSUE OF: BaP�'41;5.3u
NAME: LAST REISSUE:
ADDRESS: o(;_ nil Q 51_ �7� FLOOD PLAIN/
n- 12C
SENSITIVE LANO:
PtME: - ' APPIOVALS REQUIRED
i -
PLANNING:
CONTRACTOR ENGINEERING;: —
NAME: FIRE DEPT _ADDRESS: OT11ER:
----- I_TF11S_REQl1IRED
PHONE: _—.___ - — LIST/SUOOONTR ACTORS:
BUS TAX:
ARCH/ENGINEER
ME: T�I G I IJK-� C•ALUCALCULATIONS:NA
RUSS 01-TAILS:
AOORESS. PARKING PLAN:
~ - LANDSCAPE PLAN:
OTHER:
PHONE: -
PERMIT- N ACCT N DESCRIPTIONAMOUNT APIOUNT PD. BAT.. DUE
a,ySq 10-432 00 Building Permit Fees —
10-431 00 Plumbing Permit Fees
_
—� 10-431 Ol. Mechanical Permit Fees -
10-230 01 State Building Tax (5%) _ le
Building
Plumbing -� 3Y ✓
Mech / ✓ C)C' z c �A►
1033 00 Plans Check Fee, V 2 "/.'
Building /f ; 3V C"Ay,
Plumbing —
Mech _ = ✓ / U�i
cv -v 310 30-202 00 Sewer Connection
30. 444 00 Sewer Inspection _
7� 51-448 00 Street System Oev Charge (SOC) ✓ ^c c' cy
__•.�.-/ 52-419 00 Parks System Dew Charge (POC)
31-450 00 Storm Drainage Syst Oev Ct%rg (SSOC) 3
in-230 09 TRFO _
10-230 06 Washington County rirc al (95x) —
10-220 00 nmart/Wedgewood �� �
TU1'Al.
RCC If .
APPLICANT S1—
Deceived By: _ v_ (late Received:
INSPECTION NOTICE
City of Tigard Building Department f`
13125 BN Ball Blvd. Tigard, Oregon 97223
Inspection Line (nec-O-Phone)t639 A175 Business Phone: 639--4171
Inspection: _
Footing Plbg. Underelah Mech. Rough-in L Appy/BdMlk./
Found. Plbg. Top Out Gas Line PIBALt
Poat./Neam Strutt. San. Sewer Freminc -Bldg.
Post/Beam Mech. Fain Drain Insulation -Plumb.
Ping. Underfloor Water Line Gyp. Bd. -1tach.
Date Requesteds
Addraes:_��,•/ - ��J 1 �� _� Permit. 1t �� 9
Builder _._-.._ ✓-� __—_
THE FOLIkIWINC CORRECTIONS ARE REQUIRED:
1
Inspectors_ L-IjDates
APPROVEb DIBAP ROVBD APPROVED SUBJECT To ABOVE
Call Por Reinep.
■ ■
INSPECTION NOTSCE
city of Tigard Buildinq Department
t! 131.25 SW Ball Blvd. Tigard, Oregon 97223
Inspection Line (Rac-O-Pnone): 639-4175 Business shone: 839-4171
Inep-iction:�^_ --
Footing Plbg. Underelab Mech. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Gas Line FINAL:
Poet/Beam Struct. San. Sewer Framing _, Bldg. )
Poet/Beam Mech. Rain Drain Insulation -Plumb.
Plbg. Underfloor Water Line Gyp. Bd. -Mech.
Date Requestedt / Ti.me: AM �_P14
Address: I/[Dq Permit Lf_
Builders 120-1 . -
TAS FOLLOWING OORRECTIONS ARE REQUIRED:
61
tj
Inspantort ---- --------- nates
APPROVED niSAPPROVED AP:'ROVED SUBJECT TO ARWR
Call For Reinap.
INSPECTION NOTICE
City of Tigard Building Departsb'-nt
13125 SA Ball Blvd.. Tigard, Oreqon 97223
Tnepection Line (Rec-O-Phone): 639-4175 Bunineee Phone: 639-4171
Foot inq Plbg. Underelab Mer_h. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Gas Line PINALt
Post/Beam Struct. San. Sewer Framing -Bldg.
Poet/Beam Mech. Rain Drain Insulation L-P
u
Plbg. Underfloor Water Line / Gyp. Bd. -Koch.
Date Requestedt a/�i11 .//- /,v n !�% Timet
/
Addreeet / ` Permit
nuildert�tll /) I —
THE POLLOWING CORRECTIONS ARE REQUIRED:
1 11-713
Inspectors _ _ Dates to
APPROVED DISAPPROVID APPROVED SUBJRC.
T TO ABOVE
Call For Reinsp.
jNSPECTION NOTICE
City of Tigard Building Depart-went
13125 SN Hall Blvd. Tigard, Oregon 97223
Inspection Line Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspections -- — -- --
r
Footing /` Plbg. Underelab Mech. Rough-in Appr/Sdwlk
Found. ` Plbg. Top Out Gas Line FINAL:
Post/Beam Struct. San. Sewer Framing -Bldg.
Poet/Beam Mach. Rain Drain Insulation -Plumb.
Plbg. Underfloor Nater Line
�� Gyp. Bd. -Hoch.
Date Requested: // //�'% Ste_ T PH
Address:- 1L 'S Permit
Builder: yn
THE FOI.IOWING CORRECTIONS ARE REQUIRM
-;�lJ� S -T/I !�f "�l��/l'C v�i�•9 //V�/A Lc.s`r� i-'.?���,
tnepeatore ;� _, Dater
APPROVrO DISAPPROVEt',/>—C APPROVED SUBJECT TO ABOVE
Call i or Reinap.
INSPECTION NOTICE
City of Tigard Building Department
P O Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection --
Date Requester+11L—� r Time ------- A.M:,'44 P.M.
Address --I�lr—L ----.�ry ,� �- ---_.------ Permit
Owner .. - - _ —--- Lot —
Builder ----- l`—fir-- —-- —
The following Building Code deficiencies are required to be corrected:
Presented to (PApproved
Inspector / vU Diwpprovd
Date, . UU ®�-1✓ - ..-.._ __.
CALL FOR REWSPCC'TiON
❑ YES IPNO
s W
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223 l
Phone: 639-4175
Type of Inspection j-, ��-
Date Requested Time � A.M.--P.M.
Address G z J � Permit �,`> "
Owner Lot #
Builder
The following Building Code deficiencies are required to be corrected:
Presented to — � Rpproved
Inspector _ [] Disapproved
Date
CALL FOR REINSPECTION
YES 17 NO
W1W1W1 i "Off
HISTORY: VIEW UPDATE DELETE ESC
View comments for selected item
OAMASTER PERMITAAAAAAAAAAAAAAAAAAaAAaAaAAAAAAAAAAAAAAAAAAaAAAAAAAAAAAAAAaAASAaC
:MST90-0254: PROJECT:VILLAGE AT SUMMERLAE: STATUS:I : UPD:10/16/90: :JLH:
o PERMITTEE:DON MORISSETTE PRIM. . :MST90-0254: °
SITF ADDRESS:11698 SW 125TH CT
oA CASE HISTORY AAAAAAAAAAAAAAA666AAAAAAReq/SentASchd/DueAEnd/DoneAAByAStatA6AC
A705 Fout/found Insp 08/22/90 KS APP `
A707 Wtr Proofing Bsm't Walls / / Kg 4"14- °
A710 Post/Beam Structural 08/29/90 KS DIS °
A710 Post/Seam Structural 08/31/90 KS APP °
A713 Crawl Drain
A717 PLM/Underfloor 08/29/90 TLP PASS °
A718 Ftng Drain Bem't Walls
A720 Mechanical Insp
A722 Plumb Top Out 10/05/90 '3S FAIL °
A722 Plumb Top Out 10/09/90 MS PASS °
A725 Framing Insp 10/05/90 KS DIS °
A726 Framing <REINSP> 10/09/90 KS APP °
A730 Fireplace Insp 11/01/90 KS APP
A735 Gas Line Insp 10/12/90 KS APP °
A740 Insulation Insp 10/09/90 KS APP °
AAAAAAAAAAaAAAAAa.AAAAAAAAaASaAAAAAaAAaAaAAAAAaaA�5AAAAAAAAAAAAAAAAAAAAAAAAAASAi
HISTORY: VIEW UPDATE DELETE ESC
View comments for selected item
SAMASTER PERMITAAAaAAAAAAASAAAAAAAAAAAAAAAAAA�iaAAAAAaaAAAAAAAAAAAAAA<iAAAAAAAAAC
:MST90-0254: PROJECI':VILLAGE AT SUMMERLAE: STATUS:1 UPD:10/16/90: :JLH: °
PERMITTEE:DON MORISSETTE PRIM. . :MST90-0254: °
SITE ADDRESS:11698 SW 125TH CT "
bA CASE HISTORY AAAAAA.AAAASAAAA&SAAAAAAAReq/SentASchd/DueAEnd/DoneAAByAStatAAAt
° A745 Gyp Board Insp 10/16/90 KS DIS
A745 Gyp Board Insp 10/17/90 KS APP °
A755 Rain drain Insp
A760 %later Line Insp
A765 Appr/Sdwik Insp 10/18/90 CWV PASS
° A795 Mechanical Final H119 «O (4:51SNP °
A797 Plumb Final 11/19/90 MS PASS °
A799 Building Final
aAAAAAAAAAAAaAAAtibAAAAAAAAASbAAaAaAAAAAAAA#aaAAAAAAAAAAk5AAAAAAAAAAAAAAAaA5AAai
INSPECTION NOTICE ,
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection
Date Requested —4c>U _ Time_L5 A.M. P.M.
Addressff �T—��-j— l Permit WL2 —�.•�Sy
Owner. Lot #
Builder
The foilowing Building Code deficiencies are required to be corrected:
Presented to Approved
In.pector +red
Date
CALL FOR REINSPECTION
❑ YEa 0 NO
INSPECTION NOTICE
City of Tigard Building Department
P.O Box 23397
Tigard, Oregon 97223
Phone: 639-4175 A
Type of Inspection
Date Requested /� Tlme A.M._1L_P.M.
Address _,!1:1- ,. _ Permit 44
Owner _ Lot #
Builder
The following Building Code deficiencies are required to be corrected:
`'
sr t�✓cry�iz`
/ I "
i�F-y1Zr1 •-c=;f� A -
Presented to _ Approved
Inspector �, _ U Disapproved
Date
CALL. FOR RFUNSPFCTION
ED YES 0 NO
INSPECTION NOTICE
City of Tigard Building Department ��
P.O. Box 23397
Tigard, Oregon 97223
Phone 639-4175
Type of Inspection
Date Requested___.. ��/ Time A.M.___ P.M.
Address Permit� � --
Owner-.
Lot #
Builder ---..--
The following Building Coo deficiencies are required to be corrected:
Presented to r jKApproved
Inspector/,�C� Disapproved
Date
CALL FOR REINSPECTION
❑ YEs ❑ NO
i
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223 '
Phone: 639-4175
Type of Inspection
Data Requested �J 3 - �G Time15!'aZ&A.M. P.M.
Address �� �� Permit
Owner Lot #
Builder �7 9
The following Building Code deficiencies are required to be corrected:
Presented to _ / wtbproved
Inspector ❑ Disapproved
Date -�
CALL FOR REINSPECTION
❑ YES 0 NO
es s• w W ,■r M IN
INSPECTION NOTICE
City of Tigard Building Department
P.O. Bcx 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection Te-
Date Requested ' � Q Time ___ A.M. P.M.
Address v j� ---- — Permit
Owner— ----J ) _._._._ Lot # . --
Guilder —�--= 1 -- --- - — —
The following Building Code deficiencies are required to be corrected:
1
Presented to _____ _ Approved
i
Inspector __ FJ Disapproved
Date
CALL FO F'IMPFCTION
YES 1—J NO
S
IISIWQ !AmMW-BW-M
INSPECTION NOTICE
City of Tigard Building Department
P O Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection L E t_�
Date Requested O �� (�-- Mme/�—A.M.—P.M.
Address ��� /c-�S ~ Permit
Owner--_ _ Lot # -
7
Builder -
The following Building Code deficiencies are required to be corrected:
Presented to i _ Approved
sv
Inspector / Disapproved
Date
CALL FOR REINSPECTION
YES 0 NO
t �
I
INSPECTION NOTICE
City of Tigard Building Department ,�-
✓ P.O Box 23397
Tigard, Oregon 97223
C Phone: 639-4175
Type of Inspection ✓ y _.___
Date Requested_ Time A.M. 701zJ
Address /!� '7 / wl .� C _..__ Permit
Owner Lot #
Builder
The following Building Code deficiencies are required to be corrected:
Presented to %pproved
Inspector _ ❑ Diwpproved
Date
CALL POR REINSPECTION
0 YES Lu NO
CITYOFTIGARD ,SEWER RMNI*r T IOM �
1�'ERMIr
CITYOFTI6ARD FERM1T' ti. . . . . . . . SWR90-0.310
COMMUNITY DEVELOPMENT DEPARTMENT oReolc>N FRIM. C-'11 RMIT' T't. : MSI'90-.0254
13125 SW Hall Blvd. P.O.Box 23397,Tigard,Oregon 9722;'!(503)689.4175 D A T'E ISSUED: 08/17/90
��(:-rte-•a -- _ _ --- ---
S I T'E A1)I)R1-H.55. „ « , ,,r' 4 1a 2b1*1•4 c, 1 PARCEL.: 1 S 13 3D1)-•-0' 6'500
51.)BDIVIf:iIOM. . . . . VTL.11GE SUMI'1F RL(1KI.:* IONINGx
1+1...001/1. . . . . . . . . . . I...C)l . . . . . . . . ,
rl'I�IANT' NAME. . . . . :
USA NO. . A. . . . . . . . . . .. F"IX,TUI E� UNIT's. ,. . .
CLASS OFWORK. . . :NEW DWI:::L_I._1NG UNIT'S. . -.1
'rYFE OF USE-. . . . . .SF NCI. OF' BL1ILD:IMGS: 1.
I1,I5'FALL TYI''E . „ .. „ -J41JSWR 11711--'ERV SURFACE. . :
Rvniil-rk.,:
(J w rl a•r: ..._.__.._._.............._.__.._.._.__..._.........._..._......_....,.........................._...- _.._..... — - _._..............._ FEES
DOM MORISSET'T'E type <xn)nt.t)It by (i,xte •rec.,pt:
F'O BOX 19524 F'RI`i'r $ 1,`. 00. 00
1.N51=' $ :3Ei. 00
1::'01;T'L..AN1) OR 0 0 000 0000 I:''1•lYll $ 1,".53'5.00 J'I._M 08/1.7/'.0
I'�'11 c�1•l e N: pl El(%l-•H(�(d._.CSI H t•3(�
�.iMT'RAC;TC)R I4C1T ON F':I:I_I:_
r•,x.,11 a. . .
_...._.__..... REOU]'RE::D INSE'E.C;TION>
lh>.s Applicant agrees to comply with all the rules ant! regulations Sewer J..rl!:,pec t;j.c)n
of the Unified Sewage Agency. The permit expires 128 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
1='F�r lu i.t t c�e 5 i.l71•l�i•L-t.t r F�«
installer Lshall purchase
genciYsa "Tap and Side Sewer' Derma and theral
.
.._......... __...._...__....__...._ ._..... __._........_._.._._... _ . _..........
I:s;s;t.t Fe(I D I
Ctx 1]. -for 3.11 ipeet i c:lr1 t,'39 417`.;
19W-INUI
CITYOFTIFARD MO.S)T E R PERMIT
COMMUNITY DEVELOPMENT DEPARTMENT ITyOFTWARD PERMIT II. . . . . . . .. MST90, 0 2,5 4
omeooa PRIM. PERMIT #. - IIST90 0254
13125 SW Hall Blvd. P.O.Box 23397,Tigard,Oregon 97223(6046.R4.1.76 DATE'. ISSUED: 08/1 /-/90
S7:
TE (4 1)1)R L'S S. 44t" 5W I i2 b f H CT PARCEL: IS133DD-06500
SUBDIVISION. .. VILLAGE AT SUMMF*R L A K.E. ZONING:
BLOCK. . . . . . . . . . .. LOT. . . » » . . . . . . . . : .104
BUILDING
REISSUE:BUP892530 DWELLING UNITS.1 DASEMENI.. . . . . . . . :0 sf
CLASS OF' WORK. cNLW BEDRMS:3 FA OT[A S.2 GARAGE. . . . . . . . . . 9400 sf
'T'YK'E OF' U S E. . . :SF* FLOOR RE UUIRED SETBACK$---_.------._..-_..
TYPE: OF CONS*T. c51q V,I R 1:1)T. . « . : 1.789 sf LEFT. . : 10 ft RIGHT. :5 ft
OCCUPANCY GRP. .-R3 SLGOND. . . :0 sf F'RONT. :20 ft REAR. . :25 ft
STORIES. . — -. 1. 'THIRD. . . » :0 sf REQUIRE D
HE I GFIT. . . . .. . . . .20 ft TOTAL--------------. 1*789 sf SMOKE DETECTORS. IY
F`L.00R LOAD. 40 psf VALUE. . . . . $- 82338 F'A R K,1.N G SPACE:S. 0
Renia-(4rs a
PLUMBING
SINKS. . . . . . . . . . : 1. FLOOR DRAINS. . . . r0 rAA(..Kl:rl-.OW r-'REVN*T'R';. . 0
LAVATORIES. . . . . :2 WATER HEATERS,. . . .' J.
TUB/SHOWERS,, . . . '.G.'. LAUNDRY TRAYS. . . .0 CATCH BASINS. -.0
WATER CLUSETS. . :2 SEWER LINE (ft) . :0 GREASE
DISHWASHERS. . . . : 1 WATER LINE (ft) . -. 1.00 OTHER F-1 X T U R E S. .. . ,. ., atl
GARBAGE DISP. . . : 1 RAIN DRAIN (ft) . -.0
WASHING MACH. . . : l (:;1:: RAIN DRAINS. . : J.
MEC,'HANICAL FEES
FUEL TYPES-) UNIT HTRS. . 90 type amount by date reept
/GAS,/ VENTS . . . . . 10 PAYM $ 40.00 JLH 07/20/90 202950
MAX INPUT:0 P'T U VENT FANS. . 92 BPRT $ 382.00
FAIRN < 100K . . ol HOODS. . . . . . Il 14 P L 1, $ 40.00
TURN )-100K . . o@ WOC)DSTOVES. 10 B5PC $ 19. 10
FLOOR F*URN. . . . o@ CLO DRYERS. : I BPLC $ 30. 00
BOIL/CMP < 3HP10 OTHLER UNITS.-O STDG $ 600. 00
GAS OU*TLE.18: 1 SSDC $ 375. 00
Owner: P A R K $ 211750. 00
DON MC)RISSETTE. MPR T $ 33. 00
PO D 0 X 1.9524 11 P L C $ 8. 25
M5PC $ 1. 65
PORTLAND OR 00000--0000 PF-'RT- $ 117. 50
Phone "C 000-000---0000 P5 PC $ 5. 88
ContrAc.�tornn POYM $ 1822. 38 V"I L. 08/1'7/90
DON MORISSETTE BLDE.RS, INC.
P 0 PDX 19r.'j24
PORTLAND UR 9721.9
1:.Ih(-.)ne #c 503-620-7538
Reg #. . # 35533 .......
$ 1.862. 38 T_04 AL.
This permit is issued subject to the regulations contained in the REQUIRED INSPECTIONS
liqard Municipal Code, State of Ore. Specialty Codes and all other F'uot/1`0U11c1 Insp Meeh anical Insp
applicable laws. All W0Tk will be done in accordance with approved Wtr Proofing Bsm PIUMb Top OUt
plans. This permit will expire if work is not started wAhin log Plast/Beam StrLtUt F'-rAminq Insp
days of issuanco, or if work is suspino!d fAV days.. Plost/Eleani Mechan Fireplace Insp
Crawl. Drain Gas Line Insp
...... PlM/Undslab Insp Insulati.on Insp
PILM/Underfloor Gyp Board Insp
IssLted by -." Ftng drain Bsmlt Rain dran Insp
Ca1.1 for :inspection 639-4175
-
-TTY OF TICAPD PECEIPT OF PAYMENT RECEIPT NO, e 9(.:) D",3 061
CHE(*-'I,,* AMOUNT 5? 8
NAME x DOt,,l MOR ISSE'Up- CASH AMOUNT a c.).()(I
ADUPESS PO E,OX 195r.'i'N PAYMENT DATE' a (:)E);' 17/9(.:)
PORTLAND. OP 9 72 1P V AT SUMMER LAVE
F-URPOSE OF PAYMENT AMOUNT PAID PUPPOSE OF PAYMENT AMOUNT' PA 1.P
POILDINIS PEPH '02.f FLUMBIPili PERM 117.50,
IIF.CHAI,JicAi- rs c)(:,) ST. PLITLD PEP,26.6
PLAN CHIECI, FE 'e'25 SEWER UrA Of)
SEWER INSPECT ~M. 60 STREET SDC 6(.)(:,.Oct
PAP .;y SOC 2 5 STORM DRAIN SDC'
.1014L. AMO(jt,.JT F,Atb -,p
It 1w M OF rm
�,�An1nc�L:R()sloN Ct)N'1',tUl ,N,•�Jlin�n 1 1�1�
GENERAL CONTRACTOR NAME& ADDRESS:
CASEFILE NO.:
PERMIT NO.:—
I L ;. r" ` ;1 ' — APPLICANT NAME AND ADDRESS:
EXCAVATION CONTRACI-OR Lt Ldp• �;i -1, !
NAME& ADDRESS: ! i i i c ! < 1
tL � +;� 4 ` OWNER NAME AND ADDRESS:
TELEPHONE NUMBERS: PROPERTY DESCRIPTION:
APPLICANT - + 1 1` t t 1`
STREET A DRESS AND CROSS STREET/LOCATED
OWNER• `, .}� c 'lt 1 .t�Zt --
GENERAL CONTRACTOR: ,i a 1 %� �_c l i i I'`t ����,i�•l �r�
EXCAVATION CONTRACTOR:i
SITE/JOB LEGAL DESCRIPTION:
24 HR/AM- -R HOURS EMERGENCY TAX LOT 1/4 SECTION:NO.:_
CONTACT PERSON,TITLE,TELEPHONE: SITE SIZE,ACRES:_`7C'`•%?
DISTURBED/WORK AREA,ACRES:
LOCATION&ADDRESS WHERE SPOILS SITE RUNOFF:DRAINS TO: (CIRCLE ONE.)
LEAVING SITE WILL BE TAKEN CATCH-UKS'IN DITCH PIPE CREEK
(NOTE:PERMITS MAY BF.REQUIRED) h _
(CIRCLE ONE) PRIVATE PROPERTY_
OLIC RIGHT OF WAY
EROS IO NIS EDIMENTATI Iv_ (��r�1'ROl_ (ESC'1 MI:ASURE�
MINIMUM ESC REQUIREMENTS MINIMUM ESC REQUIREMENTS
DURING CONSTRUCITON: FOLLOWING CONSTRI ICTION:
SEDIMENTATION FACILITIES STABILIZE EXPOSED SURFACE
STABILIZED CONSTRUCTION ENTRANCE REMOVE AND RESTORE TEMPORARY ESC
PERIMETER RUNOFF CONTROL FACILITIES
CLEARING AND GRADING RESTRICTIONS CLEAN AND REMOVE ALL SILT AND DEBRIS
COVER PRACTICES ENSURE OPERATION OF PERMANT FACILiTIGS
CONSTRUCTION SEQUENCE OTHER
OTHER _ --
PLAN FOR EROSION CONTROL.PREPARED AND SUBMITTED IN ACCORDANCE WITH'TECHNICAL GUIDANCE HANDBOOK-.
EROSION CONTROL PLAN DRAWING,AS REQUIRED,HAS PLAN CONSTRUCTION NOTES COMPLETE,INCLUDING EMERGENCY
PHONE NUMBER, SCHEDULE/STAGING FOR INSTALLATION AND REMOVAL OF EROSION CONTROL MEASURES,AND
APPLICABLE STANDARD NOTES.
I HAVE READ AND WILL COMPLY WITH THE ABOVE AND WILL CONSTRUCT AND MAINTAIN ESC MEASURES AS NECESSARY
TO CONTAIN SEDIMENT ON TILE CONSTRUCTION SITE.
_�P—
OWNER SIGNATURE — APPLICANT SIGNATURE
• • • • • • • • • • • • • • • • • • • • • • • • • • •UITICIAL USI. ONLY. • • • • • • • • • • • • • • • • • • • • • • • • • • •
RECEIPT DATE ACCEPTED
FLT. NI_IM11ER RECEIVED BY
1
' P.O.Bax 19524
Portland,OR 97219
(503)244-9314
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