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Address Permit No.
Permit charge )C y?
DWner �h� �.� _ Connection fee �`cc
�t
Paid by --
Type of building ,oJ Date connnctt.d
Service rate � _ Inspection fet
Contractor —..
Paid by _ d a'.e
Assessment Paid
;iza of connection 9/ ��� _,
rw WyeWWI
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City of Tigard
INSPECTION REOUE�T
for
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ft
i INSPECTION TIME '. �' PERMIT NO. : _
I DATE:C—L ;' . DATE ISSUEJ:._./
OWNERS NANrIE �� ----- -
ADDFSESS '// ..SL I-Lkel LZ—
I CONTRACTOR : — --- ---
f TEST. Air ❑, Water G , Visual [] , Lobcratory ❑
RESULT: Approved , Disapproved 0 Per,dln9 Ll
I SKETCH: —
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IN8 ECTOR DATE
ILVOT!_ Attach supplomentol last data heretj
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City Of Tigard
IN �110" REQUEST)
for
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lOA SO:
CONTRACTOR1 1 �{..w.�+�w.���r.rw�.�.•
TEST:Wr a►.W..o, , lwM 0, Lobere ,►
RESULT: Appmed '� oiswp,.ow• El P"dime 17
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IN301ECTOR 04TE
Matt: attach supci.moftl.l test dots berete�
UNIFIED SEWERAGE AGENCY N0.
WASHINGTON COUNTY DATE
CITY
APPLICATION FOR SEWER CCNNECTION I?EhIVIIT
OWNER:
T."1_..
OWNER'S ADDRESS: ----___STREET
_,cITY PDDITION
BUILDING SITE: LOT--.-- BLOCK ------- residence
'TAX LOT NO. - - TYPE OF OCCUPANCY
11555 SW Haze1woo_d_.L00P_
ADDRESS -
1
DWELLING UNITS-_
FIXTURE UNITS__
S S
URCH,,),RGE IF APPLICABLE
600.
PERMIT F EE INSPECTION rEE TO I AL DLpOSITED
(N-c-W) (EXISTING) BU!1..DING
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANT
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
.. INSTALLER
LINE SITE
RFCEIVED
R'y
(AGENCY OR ITS AGENT)
COMMENTS- eldg. -0,315
This ApplicatThe aion and permit expires in one hutidld red and twenty (120) days.
mount paid will be forteiipd shouexpiration occur.
1
CITY '1 IGARD 9
BUILDING PERMIT APPLICATION of DA,E- __.____, 1
'THE UNDERSIGNED HEREBY APPI-IES FOR APERM T FOR THE WORK HEREIN INDICATED BUILDERPHONF
JOR AS SHOWN AND APPROVED IN THE ACCOMPPNYING PLANS AND SPECIFICATIONS. OWNER LPHr�NE_
:J7 NO._____—
O }'IU1.+.� `H0"ME:ADDRt:55
T^• ° ori ADDRESS WNER — '—' ARCHITECT ._-_
_�
5:71.'L entu I`�(I. ENGINEER
ADDRESS DESIGNER
BUILDER
ll REMODEL 1REPAIR
STRUCTURE NEW t_ ❑ADDITION ❑ C7RF.NE`NAL ❑FIREDAMAGE DEMOLITION
rr-J
_RESIDENCE ❑COMM ❑EDUCATIONAL ❑GOV'T ❑RELIGIOUS❑PATIO ❑CAR PORT ❑GARAGE ❑STORAGE❑SL.AB ❑FENCE
❑BOND ❑MOVING ❑CONDITIONAL USE ❑DESIGN REVIF�� [:](OUNCIL APPH—OBD_ J ❑SIGN
OCCUPANCY LAND USE ZONE BLDG.TYPE. IRE ZONE. PLAN CHECK BY�__�
HEAT
conK;t;. sinylre fami.Ly dualling W attaChed gGrOgs 3 bedrou bath
ge>rago 462 eq. ft. - - --- ---
S VALUE
a�DROOM
OCC.LOAD FLUOR LQAr HEIQH7 _. NO�TORIE-- SxT.;s AREA NO �r� —
BUILDING DEPARTMENT SET BACKS
FRONT REAR LEFT SIDE P.IGHT SIDE
Permit
THIS PERMIT' IS ISSUED SUBJECT TO THE REGULATIONS CONTAINED IN TOE BUILDING CODE, 7.ONING
Plan Check « REGULATIONS AND ALL APPLICABLE rODES AND ORDINANCES, AND IT IS FEREBY AGREED THAT THE
WORK WILL BE DONE IN ACCORDANCE. WITH THE PLANS AND SPECIFICAT IONS AND IN COMPLIANCE WITH
Subtotal v ALL APPLICABLE CODES P.ND ORDINA?4CF.S. THE ISSUANCE OF THIS PERMIT DOES NOT WAIVE
RFSTRICTIVE COVENANTS. CONTRACTOR AND SUB CONTRACTORS TO HAVE CURRENTCITY BUSINESS
State Tax 7 07 13 1 I LICENSE. SEPARATE PERMITS REQUIRED FOR SEWER, PLUMBING AND HEATING.
Total --II
By NF —':ANT OR AGENT
Approved T Receipt No. -
-� PHONE v
UATE JINSP.1 TYPE INSPECTION REMARKS PLUMBING DATE
:2n1ractor
Contractor
No.
e-7 R20Auh-in
Fixture
,4 Final
HEATING
Contractor
Permit No. -77
Gas or Oil
C B2-41
Final
SEWER
Final
DRIVEWAY
Final
Sy.orm Drainage
(Rain Drain) Final
Sidewalk
Curb&Street Final
A roach
BLDG DEPT.FINAL TEMPORARY CERTIFICATE OCCUPANCY Final
CERTIFICATE OCCUPANCY
Landscaping
Zoning
oning Final
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