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CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rer,O Phone): 639-411-15 Business Phone: 639-4171 J'
tr,ya*, Inspection:
x �
Footing Susp. Ceiling Sprink. Rough-in Appr/Sd%,iik'
>r ' ,, r� Foundation Plbg. Underslab Mach. Rough in FireF,ace
19' �FS ,f1 Post/Beam Struct. Plbg. Top Out Eloc. Rough in
_MTx , tai i
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Post/Beam Mech. San. Sewer Gas Line -Bldg.
Plbg. Under.bor 9air Drain Framing -Plumb. O
Alwm Water Line Insulation
Underflr. Insul. Shear Wall Gyp. 6d. I •Elect.
Date Requested:
Address:
Builder: Permit #Aife_ 00 A.
THE FOLLOWING CORRECTIONS ARE REQUIRED:
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i s q 4L—AP41igOVED _DISAPPROVED _APPROVED SUBJECT TO ABOVE
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- CITY OF T ..
MECHANICAL
CAL
COMMUNITY DEVELOPMENT DEPARTMENTl 1?Ir.
13125 SW NII Blvd.Tigard,Oregon 97223.8199 (503)839-4171 PERMIT #. . . . . . .
DATE ISSUED: 02!0t_- 1/ �
PARCEL: 26102CC02200 a
ITE ADDRESS. . . . 10135 SW HILL VIEW ST os
SUBDIVISION. . . . : FRELEON HEtIGHTS NO. 2 ZONING: R 5 •
3LOCK. . . . . . . . . . . L.01.. . . . . . . . . . . . . :25
CLASS OF WORK. . :ALT FLOOR r URN. . 0 EVAP COOLERS 0 y
TYPE OF USE. . . ,. .-SF- LIN I T HEATERS. . : 0 VENT FANS. . . : 0 •
OCCUPANCY GRP. . :A1 VENTS W/O AE"PL: it) VENT SYSTEMS: 0
STORIES. . . . . . . . . 0 BOILERS/COMPRESSORS MOODS. . . . . . . : 0
'UEL TYPES_....._._____.... .__m. _ 0_.3 HP. . . . : 0 DOMES. INCIN: 0
/GAS/ / / ,,:,-•15 HP. . . . : 0 CGMML. INCIN: 0
r1AX INPUT: 100 I+TU 15-3,70 IIP. . . . . 0 RLPAIR UN1TS: 0
I RE DAMPERS?. . : 30-5171 HP. . 0 WOODSTOVES. . : 0 1
=; AE PREaSURE. . . . SO HP. . . . 0 CLC? DR'YF_RS. . : 0
OF LJN I TS-- - -- -- - AIR HANDLING UNITS OTHER UN I t5. : 0
i=URN ( 1001; BTU. 1 100110 cfm : 0 GAS OUT! 77 1
1. i"URN > =1'?1121K BTU: 0 > 10000 c:f m : 0
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•.ema•rks: Install. gas f1_rr-nar.-e to 1001: BTU and gas piping orre to four, ol.lt l et
FEES
STEVE FOLTZ type amol-Ent by .late r-er_pt I
10135 SW ItILLVIEW t~'RMT 4 18. 00 CJS 02/08/96 95-275767
`;r'CT 9 0. 90. CJ's V12108/96 95-275767
TIGARD OR 97,":231
Phone #:
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..ontr-actor^: -___--._-_._._________________-.-
1CASGALE P & T GAS SERVICE, INC.
6528 SW 190TH AVENUE
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-EHVLRTON GR 97007
I r o„^ #s 642-724;3 18. 90 TOTAL
g #. . 91 .104
REQUIRED INSPECTIONS;
This perait is issued subject to the regulations contained in +he Uar.• Line Insp _
Tigard Municipal Code, State of Ore. Specialty Codes and all other Mectianic:al Insp
applicable laws. All work will be done in accordance with Final I n s p E ct i o n
approved plans. This perait will expire if work is not started --------- ------__
within 180 days of issuance, or J work is suspended for more
than 188 days. .._...._.-_._. � -���'i'-' •
P e v,m i.t t e e
f a s .r a cJ Dy: J1 4LI. C
Ca 11 for, inspect i Lm 639--4175
RIM
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City of Tigard MEOHANICAL PERMIT
13125 SW Hall Blvd. APPLICATION Permit #
Tigard, OR 97223 •
(503) 639-4171
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�:�«+ Description I
Table 3A Medunical CfA% CITY PRICE MAT
Job 1. ,� �.
i) PemrAt Fes -0- -0- 10.00
Address W
2) Supplementai r'ermit 3.00
U-1 W wa-WR Fumaoe to 1756.000 BTU
1) ind-duds 4 vents 6.00 c r
i00, +
Owner ��_�� -�� l)W 2) incl.d.,ds h vof" 7.50
n ,"Furnatwe
3) ind.vent 6.00 �r
his ra�w >F aaWr
4) or boor mounv,d heater 6.00
.p w T wr1�a r1
Occupant 6) appliance Permit 3.00
- —" par c i 1m n
6) cooling,absorption unit 6.00
uu L icy_, er or comp,heat pump,air co O—
��j T 7) to 3 HP absorp unit to 100K BTU 6.00
.« der or oonyl,heat pump,aim
)/"F . 8) 3-15 HP absorp unit In 500K BTU 11.00 —_
Contractor E" or comp,beat pump,aY cord.
-)00 9) 15-30 HP absorp unit.5-1 mil BTU 15.00
er or oomp,heat pump,air cord.
9udq ('e' 10) 3050 HP absorp unit 1-1.75 mil BTU 22-50
ire y ac aw ga at have re r,application, t e do er oreeat pump,air co
information given is carred,that I am the owner or autlaotized agont 11) >50 HP absmp unit 1.75 nvI BTU 31.50
of the owner,that plans submitted are in compliance with Stara W handing udd to
laws,that I am registered with the Construclion Cont-adlDes Bowl, 12) 10,000 CFM 4.5U
that tt,e number given is collect. (II exempt born State registration AUr handling un
please give reason below.) 13) 10,000 CTFA+ 7.50
--- on i;WW—)Fe---_
14) evaporate 000ler 4.50
:} Vent-fa
__.
15) to a single dud 3.00
en abon system not
16) included in appliance pwmit _�-^ 4.50
« vwwwl by
17) medunicai exhaust 4.50
-Nscribo work new a on a lterabon mpar unr CZ ror xtnal
to be done residential Q ran-residential Q 18) type incinerator 30.00
Existing use of Other tie.,wxxiswo.water
building or property 19! heater,solar,do0ves dryers,etc_ 4.50
Proposed use of 20) Gas piping one to lar outlets , 2.00 .u
building or prop"
Type
—� _--- --
Type of fuel -ob 0 natural gas O LPG O electric Q 21) Moro Man 4 pxx outlet
NOTICE-- -
- Minim $25.00 SUBTOTAL j,t
PERMITS BECOME VOID IF WORK OR CONSTRUCTION -=--: "` -
AUT1iORtZED i;',NOT COMMENCED WITHIN 180 DAYS,OR 5%SURCHARGE
IF CONSTRUCTION OR WORK IS SUSPENDED OR —
ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME PLAN REVIEW 25%OF SUBTOTAL
AFTER WORK IS COMMENCED. -
TOTAL L i<
Special Condtions
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NAME 014OUIV I 1
ADI)RE Sli ,(.) 1++ ' 111 AVI 1-1"YMI.N1 I)1-111:: c
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CITY OF TIGARD BUILDING INSPECTION NC.rICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639 1
Inspection:__ -�:� �
Footing Susp. Ceiling Spink. Rough-in Appr/Sdwlk
Foundation Plbg, Underslab
Le
.QaAough-in Fireplace
Post/Baam Struct. Plbg. Top Out Elec. Rough-in `
Post/Beam Mech. San. Sewer ,s Line -Bldg.
Plbg. Underfloor Rain Drain Framing -Plumb.
Alarm Water Line Insulation �M
O
Underflr. Insul. Shear Wall Gyp. Bd. -Elect.
Date Requested: 2-'Z `� (R Time:__�kAM PM
Address:
Builder: Permit tt:alitfc-_1 G U U 2-(0
THE FOI.LOwiiMG CORRECTIONS ARE REQUIRED:
4
4
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j - t7 ;k}ALL�It
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I pec to Date:_
PROVED _DISAPPROVED _APPROVED SUBJECT TO ABOVE
_Call For Reinsp. i
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AM-
CITY OF TIGARD MECHANICAL m •
(COMMUNITY DEVELOPMENT DEPARTMENT PERMIT #. . .PERMIT. . . . . MEC96-
13125SW Hall Blvd.Tigard,Oregon 97223.8199 (503)839-4171 D()TE ISSUED; 02101 111. 6
•
"` •'' PARCEL : 2S102CC 1)2200
;LITE ADDRESS. . . : 101;:,5 SW HILL VIEW ST
SUBDIVISION. . . . . FRLLEON HEIGHT'S NO. 2' ZONING: R--w. 5
77 LOCK. . . . . . . . . . . . . . . . . . . . . . . 5,
LOT. :.... �
VA
CLASS OF WORK. ALT FLOOR TURN. . . . . 171 EVAP COOLERS: 0
TYPE: OF USE. . . . :SF UNIT HEATERS. . : 0 VENT FANS. . . : 0 �
OCCUP(INCY GRP. R3 VI:_NTS W/O ()PPL: t0 VENT SYSTEMS: 0
S'f0:.IES. . . . . . . . .. 0 BOILERS/COMPRESExORS MOODS. . . . . . . : 0
F=UEL TYPES------._ _.___.-_,.__ li'r- 3 HP. . . . : N DOMES. INCI1,1. Vi
:/GAS,, f / 2-15 HFA. . . . : O COMML. INC 1.N: 0 �
MAX INPUT: ZI DTU 1C-30 HP. 0 REPAIR UNITS.,, 0
"'IRE DAMPERS''. . : 30--s0 HP. . . . : til WOODSTOVES. . : 0
' GAS PREIiSURF. . . : ail+ lir'. . . . : 1) CLO DRYG:RS. . r?1 1
' . NO. OF AIR HANDLING UN I Ta OTHER UNITS. : 1
FRJ1.'21\1 ! 1001' BTU: ID ( 1012 0141 c_f In : 0 GAS OUTLETS. : 1
TURN > -100K. BTU: 0 ) 10000 cfm: 0
Rernart.<s : INSTALL GAS FIREPLACE INGERT
OwriE": __.__.._._ __._.,_..____..__.__.____..__.____W._..._..._.__.___.__..____.__-.•..___..._.._._.._ FEES ---
STEVE FOLT7_ & JAN type amol.tnt 1)y date v-ecpt
10135 SW HILL VIEW PRMT $ 25. 00 J5D 02/01/96 96--275588
1-IGARD OR 9722;3 5PCT $ 1. 25 JSD 0,`/01/96 96--27`;53n
Phone #: 503--639--7746
Contr•ac:tar: ____.._...._...__....._....._.__.____._._.___.__._ ._._._ ._.__..
TE:ASDALE: B & T GAS SERVICE., INC. §;
82J28 SW 190Th AVENUE z
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�1EAVERTON OR 97007
Oh o n e #; 642-7i243 '26. a5 TOTAL
.._
Reel #. , : 91104
REQUIRED INSPECTIONS
This permit is issued subject to the regulations contained in the Me&ianical In,,p _
Tigard Municipal Zode, State of Ore. Specialty Codes and all other Mi sc. Inspect: on
applicable laws. All work will be done in accnrdanre with Final Inspectiun
approved plans. This permit will expire if work is nct started
within 160 :iays of issuance, or if work is suspended for more
than 180 days,
T s la e d Dirt-
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Call -For inspection - 639-4175
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City of Tigard M EOHAN ICAL PERMIT Planck/Rec. #
13125 sw Hao Blvd. APPLICATION Permit # 1411e-G )c"'
Tigard, OR 97223
(503) 639-4171 -Do scription
Table 3A Madumucal Coda CITY PRICE AMT
Job 1kj hitlu.. , 1) Permit Fee -0- -0- 10.00
Address - —
2) Supplemental Permit 3.00
�.,r to Fmiam to 100.006 d t�
('.tie S
uM t �_ 1) Ind.duds ut,vents 6.00
umwe 100,000
Owner lvl? 5.,) 147Nu.i,' ')I . (c� 2) Ind.duds d vanes 750
urnarwe
.ti V_ 1 ZZ .5 3) ind.vent 6.00 �
�+» SuspeZ2 heato(.wall heater
4) or floor mounted heater 6.00
Occupant . ant eX in
P 6) ar4Aanco Permit 3.00
XP pair of hauling, ng.
6) cooling,absorption unit 6.00
_ naer or comp-Fat pump,air
L.i4- 7) to 3 HP absorp irnA to 100K BTU 6.00
MMV .n -soder or camp, at pump,au
015)_d S� )yu'-'L Ave C7'/L 11413 6) 3-15 HP absW unit to 500K BTU 11.00
Contractor
yer or cony%liow pump,au co .
g 7Up -7 9) 1530 HP absorp unit.5-1 mil BTU 15.00
� _ Cow T.N. Fojer o;comp,foal pump, u cond..
10) 30-50 HP absorp unit 1.1.75 mil BTU 2250
7 horoby a low ge-iatT Eave read this application,d at_ie goiw or oomp,twat pump,air W
inlormation given is o((Ted,that I am tea owns(or authorized argent 11) >50 I-M absorp unit 1.75 mil BTU 31.50
of the owner that plans submitted are in compliance with State Air liandliN emit lo ---- i
laws,dial I am registered with tlw Construction Contract'or's Board, 12) 1-.,000 CFM 4.50
that the number given is comruct. (If exempt kam State registration, X
please give reason below.) 13) 10,000 CTM. 7.50
N in portable
14) evaporate cooler 4.50
Vent fan RWv_v�—
15) to a single dud 3.00
1 _ en aeon system not
16) inc,ludnd in appkvxe ponnit _ 4.50
bg •"-fe N-M Hood served by
17) mechanical exhaust 4.50
carbo w�raw ei tiw .) alteration Commercial or �
to be done m6tidenttal Q non-residential Q 18) type incinerator 30.00
Existing use of Odier te_woodstm,water
building or property r__ 19) heater,solar,clothes dryers,el.: 4.50
Proposed use of 20) Gas ptpmng one b tarn outlets / 200 1. J
building or property
T of fuel-o4 21) More than 4-per outlet
ype Q nature'gas C LPG Q electric Q
NOTICE_—
~� Min• um Fee$25.00 SUBTOTAL
PERMITS BECOME VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS PICT COMMENCED WITHIN 180 DAYS,OR 6%SURCHARGE
IF CONSTRUCTION OR WORK IS SUSPF.NVED OR --
ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME PLAN REVIEW 25%Of SUBTOTAL
AFTER WORK IS COMMENCED. 4-11
J l ' / TOTAL
mdi2�aZc
Special Clions �-I(rE�l)[I. ��L .?f'� I ,r- ..".
Date issued �^W by _
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INS_PEi'.T_ION NOTICE. -17
City of Tigard Building Departaent
13125 SR Ball Blvd. Tigard, Oregon 97223
Inapection Line (Rec-O- hone): )39-4175 Bueined+ Phone: 639-4171
Inspection:__ // --- •
Footing Plbg. Underslab / Mach. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Gag Li:.e
Poet/Beam Struck. San. Sewer Framing -Bldg.
Poet/Beam Mech. Rain Drain Insula,ion umiak .
Plbg. Underfloor. Water Line G, Gyp. Bd. -Mech.
Date Requested: / / —Time: An PM
Address: I LSI —7 7! T t (C� Permit 1:121
�Bu414art 6o 3 /�/ / / ()
i
THE FOIJOWING CORRECTIONS ARE REQUIRED:
rr�
Inspector, �/ /� "`/ - T_ Date:_ 1"�
APPROVED - DISAPPROVED APPROVED SUBJECT TO ABOVE
_Call For Rainsp.
CITY OF TIGARD►
COMMUNITY DEVELOPMENT DEPARTMENT
13125 SW Hall Blvd.Tigard,Oregon 17223*8199 (503,639-4171
PLUMbING PERMIT
PERMIT i#.. , , . . • . : F-11-1194-0236
639-4.171 DATE ISSUED: 10/13/94
Pf:+RCEL: 2SI02CC-02200
SITE ADDRESS. . . : 10133 SW HILL VIEW SJ
SUBDIVISION. . . . : FRELEON HEIGHTS NO. L ZON'ING: --3. r
R
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vl .. . . . . . . . . . : LO I.. . . . . . . . . . . . . :25
CLASS OF WORK. . :NEW GARBAGE D I SPOSALS. MOBILE HOME SPACES.
TYPE OF USE. . . . -SF WASHING MACH. BACKFLOW PREVNTRS. . .1
OCCUPANCY GHP. . :A I FLOOR DRAINS. . . . . . . . TRAPS. . . . . . . . . . . . . .
ST'ORIE'S. . . . . . . . . WATER HEATERS. . . . . . : CATCH BASINS. . . . . . .
JX
F I X LAUNDRY TRAYS. . . . . . : SF RAIN DRAINS. . . . .
'
..
SINKS. . . . . . . . . . s URINALS GREASE TRAF:`S. .
-1V(-41-,-.)r4IES. . . . . .. OTHER FIXTURES. . . . . . . . . .
TUB/SHOWERS. . . . SEWER LINE (ft ) . . . .
WATER —,LOSETS. WATER LINE (ft ) .
DIGHW4'3HERS. . . . . RAIN DRAIN (ft ) . . . . :
Remarks . INSTALLING UNDERGROUND SPRINKLER SYSTLM.
Uwner: FEES
STEVE FULTZ type amount by date recpt
10135 SW HILL VIEW P RMT $ 15. 1110 PLL 10/13/94
:.=PL 1 $ 0. 75 PLL 10/13/94
T I G A R D OR 97;_' _3
Phone
COTltraCtOl-':
Phone IS. -7c!; TOTAL
Peg
REQUIRED INSPECTIONS
This persit is issued subject to the reyulations contained in the Top—o1-it Insp ?"A
Tigard Municipal Lode. State of Ore. Specialty Codes and all other Final Inspection
applicable laws. All work will be done in accordance with
approved plans. This pewit will expire if work is not started
within 180 day- of issuance, or if work is suspended for sore
than ?80 days.
Pf3t-M i t t V P !:i I q n at LWe
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Call for inspection 639-4175
VIM
w�! 1'�as^'ei:nl�n��t
Permit#•
Address: 12
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Issued by: � Date: ZQ
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Statement: Information Notice to property Owners
About Construction Responsiblilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the :
following s,.itement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 3B:
51 1 1 own. reside in, or will reside in the completed structure.
2. I understand that I must regiNter as a construction contractor if the structure is sold or offered for sale
before or upon completion.
❑ 3A My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
j
OR
3B. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
j 1 hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
f (Signatu of permit applicant) (Date —'�-
(White copy to issuing cn,,..ncy permitfile,
pink copy to applicant)
information Notice to Property Owners
Abort Construction Responsibilities •
Note: This Information Notice to Property Owners about Construction R sponsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5). e♦
If you ace acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent many problems by being aware of the following responsibilities and areas of concern. -
EMPLOYER RESPONSIBiLITIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement of a residential structure,you will, in most instances,be ruled to be an employer and the people
you hire will be employees. As the employer,you must comply with the fo!lowing:
Oregon's withholding tax law: As an employer,you must withhold income taxes from employee wages at the time employees
are paid. You will be liable for the tax payments even if you don't actually withhold the Glx from your employees. For more
information,call the Oregon Dept.of Revenue at 945-8091.
Unemployment insurance tax: As an employer,you are required to pay a tax for unemployment insurance purposes on the
,cages of all employees. For more information,call the Oregon Employment Division at the Department of Human Resources
at 378-3524.
Yorkers'compensation insurance: As an employer, you are subject to the Oregon Workers'Compensation Law,and must
obtain workers'compensation insurance for your employees. If you fail to obtain workers'compensation insurance,you may
be subject to penalties and will be liable for all claim costs if one of your employees is injured on the job. For more information,
call the Workers'Compensation Division at the Department of Consumer and Business Services at 945-7888. «
U.S.Internal Revenue Servi m: As an employer,you mus'withhold federal income tax from employees'wages. You will be
liable for the tax payment even if you didn't actually withhold the tax. For more information,call the Internal Revenue Service
at 1-800-829-1040.
r
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the perm,t holder for this project,you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections.
Liability and property damage Inst,.ante: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools,paint overspray,water damage from pipe punctures,fire,or work that must be
re-done.
Time to supers ise employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor,to coordinate the work of rough-in and finish
trades,and to notify building officials at the appropriate times so they can perform the required inspections. f
if you have additional questions,write or call the Construction Contractors Bi yard(PO Box 14140, Salem,OR 97309-5052,
503/378-41521). The Board is located at 700 Summer St. NE Suite 300,in S,tlem.
prop-riwn.pm4
1/94
City of Tigard PLUMBING PERMIT APPLiCATION Planck/Rec. # °
13125 SW Hall Blvd. Permit #
Tigard, OR 97223 I
(503) 639-4171 •
MINIMUM $25.00 PERMIT FEE + ST. SURCHARGE
•w o.rrwM.n ✓ New Single Fames Residences OnlyI
F01 TH HOUSE$140.00 CJ 2 BATH HOUSE£195.00 +
Job �� s j �f- ❑ 3 BATH HOUSE$225.00 I
Address Well. Fee includes all plumbing fixtures In the dwelling and the first 100 feet
Ila ii f-,7;Z,3 of water service, sanitary sewer and storm sewer. See fees below. r i
M nw.raw� j FIXTURES CITY PRICE AMT
f� ✓[� 4 Jan �-( 7th-- Sink 9.00
M"N�+� - Ph- Lavatory 9.00 '
Owner �`Zhih Tub or Tub/Shower Comb. �►
ctwsar. xa Shower Only 9.00
Water Closet 9.00
N.- ^•-•f b • ) Dishw:,sher _ 9.00
Garbage Disposal 9.00
Occupant M..,Ad&.- / - Ph" Washing Machine 9.00
Floor Drain 9.00
cxylm•ft �� � Water Heater 9.00
Laundry Room Tray 9.00
Nam Urinal � 9.00
Other Fixtures (Specify) 9.00
M.i.,o wtr Ph � -_ 9.00
C ontr9ctor �. -.
9.00
^Iryi�s. Ln
9.00
Sever 1st 100' 30.00 I
u..a.u..ab.N. -" ur e.. T..rM Sewer-ea. Addit. 100' 25.00
Water Service 1st 100' 30.00
I hereby acknowledge that I have read this application, that the Water Service ea. Addit. 200' 25.00 !
informatior, given is correct, that I am the owner or authorized agent of
the mvner, that plans submitted are in compliance with State laws, that Storm &Rain Or tat 100' 30.00
l�rn registerNd with the l:agstruction-L:enfraster s Beerd;-that-" Storm &Rain Drain Addit. 100' 25.00
dumber given is correct. (If exempt from State registration. please ---
give reason below.) Mobile Home Space 25.00
Back Flow Prevention
" Device or Anti-Pollution Device Q.00
'b"•'w "'a'"'i ��_�L °ie Any Trap or Waste Not
Connected to a Fixture 900
Describe work new addition Q alteration.. repair Q Catch Basin 9.00
to be done residential I_ non-residential Q Insp. of Exist. Plumbing 40.00/hr
Specialty Requested Inspections 49.00/hr
Existing use of ,� /,-
building or property iltL LC���- Rain Drain, single family dwelling 30.013
Residential backflow prevention
devices 15.00 � �Q
Proposed use of / - /
building or property fl.5ion *fly
'(Except residential backflow
prevention devices)
NOTICE *Minimum Fee $25.00 SUBTOTAL
PERMITS BECOME VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 1b0 DAYS, OR IF 5%SURCHARGE
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED --FOR A.PERIOD OF 180 GAYS AT ANY TIME AFTER WORK IS
COMMENCED. KLAN REVIEW 25^/e OF SUBTOTAL
i
TOTAL sj5
Special Conditions 1���! t2�� r ,r^
�� S T
l by
Date issued
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City CIF T'I OARD — REC.:L::I1-'f' CSF' PAYMK'N I F2F_I:F:1 I'I' N(j1 e94--P57789
I:;NF•I.:IS AMOUN 1 e 1`i. P5
NAMEC !'1]L TZ, STEVE ;��'^ � GASH AMC.1l.IN'f a 0. 00
ADDRESS a 101351 SW N!L_L. VIEW f3T' I::'(4YMF:NI DOTE a 10/13/94
1:31JBD I V 19.1 ON e
PURT'L_OND, OR 9 721"''3--
y.
"URP(.19F OF PAYMENT AMCIL.INI PAID PLlfzl=LISP OF PAYMEN.1 AMOUNT PA 11.)
i�I...LIMPIN(ii F.im Frl.h194 -v':3E+ 15. 00 1:�HLIII.:G �'f::Ft 0. 75
I NU TAI_L.A f I ISN UIQ AN I.INCIF.NLiHOI)ND L.-P H I Nlr LL H G r t-i 11'.1*1
It..!TAL_ AMOUNT Pt,lU _. _ > 1"5. !`:,
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