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' RR11
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection _ _� , ��-z� o
Date Rt.quested___ _C Sim'0 Time A.M. -P.M.
Address ._'_ `_L --_-_ �7 �A �►'� Permit
Owner Lot
Builder _ ---
The following Building Code-deficiencies are required to be corrected:
i
P n 'hUY- 031? O 7 ---
_ Tk C az Z.
Presented to r —�— A-Approved
Inspector (] Difepproved
Date
CALL FOR REINSPECTION
yes �.__] rio
INSPECTION NOI ICE P
City of T igard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection -------
Date. Requested J— 1-1
— LI Time A.M._ V P.M.
``Y �^
Address _( l �� ILI-? � Y\_ Permit
Owner __ Lot # - _
Builder 7)c IILO)ncc_i --� I
the following Building Code deficiencies are required to be corrected:
Presented to _ ❑7i Approved
ImPeot�ir �J bisapproved
Date tz --
CALL FOR WUNSPECTION
l" YES I-1 NO
INSPECTION NOTICE
City of Tigard Building Department n ,(�
P.O. Box 23397 I V\
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection
NIP Requested
Time A.M, P.M.
Address 1 _/ �C 1�"C�t Permit # /5�U
i
Owner- l ' Lot #
Builder
y o -----
The following Building Code deficiencies are required to be corrected: `
Presented to _-
Approved
Inspector _
Disapproved
Date
CALL FOR REI_MVECTION
YES 0 NO
FW w
INSPECTION_NOTICE
City of Tigard Building Department
P O. Box 23397
Tigard, Oregon 9722.3
Phone: 639-4117755
Type of Inspection W("' -----
Date Requested'/ b Time A.M. P.M.
//
Address 1LX�� `�J L,1 1 C'-C L� — Permit
Owner Lot #_
Builder --'4,e- r Yl l l d�� O J�
The following Building Code deficiencies are required to be corrected:
Presented to pproved
Inspector ❑ Disapproved
Date
CALL FOR REINSPECTION
0 YEs ❑ NO
INSPECTION NOTICE
City of Tigard Building Department
P.O Box 23397 C
Tigard, Oregon 9722.3
Phone: 639-4175
Tvoe of Inspection
c
Dat: Req tested Lf � ' `J nTime A.M. P.M.
Address ��x ' ( � <1y7� J ___ Permit 0 2
Owner_ Lot
B iilder ' .nl('6�lnc "t C)
The following Building Code deficiencies ere required to be corrected:
9�-%����— --�•+.� ail a��( Lv 1 r P S�,�t��'�___�_
r�
Presented to _. I[-�tt-/tjiproved
InspaccL_1
or �_ _� —. Disapproved
Date
CALL FOR REINSPECTION
0 YES ❑ NO
INSPECTION NOTICE ✓
Gity of Tigard Building Department 7�
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type if Inspection
Da;e Requested Time---A•M. P.M.
Permit
Address 1 L LL
Owner ,__
Lot M
Builder 'r,o t 't J
The following Building Code deficiencies are required to be corrected:
Presented to �l►proved
Inspector i Disa-peoved
Date.– --- —.-1 — --
CALL FOR REINSPECTION
[] YES 0 NO
ADDRESS ASSIGNMENT REQU;ST
Please help me inform the proper parties for address assignments by giving, me
the following information:
o Site to be assigned an address (Tax Map and Lot Number)
f7
AV—1A6 U 5 �e.^ of I ✓ 1'
/ M04-
; ���
o Former address at site (if applicable) y � OS Lt) �/� Coil
o Type of unit (single family dwelling, multi-family dwelling, commercial. unit ,
office shell with suites. . . )
'C�
o Number ofuun'IIts (i .e. , apartments). Please indicate where I may find a site
plan for reference.
o Comments:
o Property owner or developer to confirmaddress with
Name: WA4 tom-%UF
Add ress:
o Name and address of other parties In receive address confirmation letter.
n Planning file number to receive copy of address confirmation letter.
fit:/72881)
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CITY ®F' T'IGA RD crryL BUILDING PEPM11
J�Llw I
COMMUNITY DEVELOPMENT DEPARTMENT 04100" PE:AMII NO. ; BLA.391.5,,21
13125 S.W.Hall Blvd.,P O.Box 23397JIgard,0irqon97223,(503)639-4l75
PA4 I.
PRI I PMT' ,N0 . 861!521
.JOB ADDRESS : *211l5 SW LINCOLN AVIii.
TAX MAP/l..O*T* 2511. RAB 100 5t*1 : LT . "I<
1. AND USE: 471 . :9
1-1.111, SIZE : V61.AJAI I ON: tb ,".ilk'-710 5 E T'HAC'K S
FPUN r : E'4 14EAR : t?T
WORK (71-ASti : NEW DWELL .UNI I'S I I EF1*: 10 PIGI+r : 1.9
USE 'TYPE : SINCM-A' FAMILY NO. BEDROOMS . 3 EXT .WALL.. CUNSI* .
C'ONS'T' 'VYIDE: VN NO . BA TIA S 2 N ; 5 : E W
UCCIUP . (:-341 . : 1:4,3 PPOI* .C)PENINGS :
OCCXJP . LOAD N: 5 : E: W:
1*OTA1 APEKO : 1266
NO . S*TOPIES : 1. 1.S'T : 1268 ROOF CONS'T : (I. IX IRE" PEL-1-
HE,3:(:•H'T :1.13 E?.ND: AREA SEPAP7 RA*I,E-,.:[):
HASE.MEJ41*7 31417: O(N::t.1P . 5F'PAA7 14AT*ED :
MEZZONINF.".7 BASUM' 'T
FLOC)n IA*)AD : 10 GAPACVEH: 41."1 FIPE SPAKI P7 ALARM,?
II 1-0W 11 GPM I Effijffff rf -YF4-
T,yl:*,E..: : GAS HIXI.P AC1(111*_.SC31? (70API7
11-111.-AN (:,14F*.'.CK E.4Y : rlt
RE'MAIUS :
I-In mole. Tir.moto c.,hall-ge-1cl 1-caplakc-'].fig exilliting PEA'SSUE OF NO.
"11— r TIft-
0
IN
N 11 at In CP P11H.".11.4m7: T, $310 00
E
PLAN PEV11-:61 llliPO 1.
FIRIE. DEPT
5*1 A'T'F I'AX 4, 11 'i '50
C 01 HEI
0
N ELE'
VEOPMNI C,1IARGF_-:% :
T GODWIN WX 1_1 I AM SEK",( S'1`00M)
R
A I-1-KPINIWOOD I)E*-*V . :INC' SOC(SPEE*
*1` T")
C 9110 SW MAI`4A.-_*1_1-_-.AF S'T* PIX11#11. 11
T .
0 T'IGAnD C)p 97P.P.3 PREPAID < 41.1.00 . 00
la i
PHONE*. ( 50-.1) 245--96-11
EA'.1.5 f. 216 TC)1*AL 7 . 0
This permit is issued subject to the regulations contained in Title 14
of the
G. State of Oregon Specialty Codes. zoning regulations PE(,.,F.*T.Pt NO.
And all other applicable codes and ordinances, and it is hereby
Agreed that the work will be done in accordance with the plans diid 1Et4UTPEr) INSPEC-TIONS
des and FOCNO SEWE44
specifications end in compliance with all applicable co
ordinances The issuance of this permit does not waive restrictive 1::*OI[
:*OI[JN0A'TION WALL PAIN DPAINS
covenanA. Contractor and subcontractors shall have current city
husiness tax permits. This permit will expire and become null and PC)S*T & BEAM WATLP LINE
void If work is not started within 180 days.or it work is suspended or PPB .UN0F.-*_P!5LAB CIIY APPPI17H/SW
ASI
,abandoned for a period of 180 days any time after work has
commenced. It shall he the responsibility of the permittee to assure _A8 FINAL
P1.S . 'TO POLI T*
;ill required injections are requested and approved
F11 A Ill 1.NO
F I PF PLACE
GAS I_]:NF
PertINSIA A'TI ONnittee Signature GYP ROAR()
Issued By!
SEPARATE PERMITS REQUIRED'fb� *ftle-&AHVIU4 ft'S4tA1`8ED ABOVE
E ISSUIEKO : a/12/B8
C11YOFT11FARD DA'T*Ewm:"r NO.
O. : mr--
CITYOFTWARD
OProoN COMMUNITY DEVELOPMENT DEPARTMENT F)RIM . VIMT .NO. 801.521
13125 S.W. ''Blvd.tP.O.Box 23397.Tigard,Oregon 97223.(503)639-4175
s 1145 C:w I TNI-J]1 N nuv
fAX MAF)11-cyr :?Si 1. PAH 4-1100 SULI : L'T: SK :
I AND USE' : P1q . 15
Lal* SIZE: :
11%M: NO- NO:
I40WK CLASS : NEW 1.11MACE" (3.001( :11 AIP I-IANIA..P (3.0
USE *T*Y1---1E'. : SINGLIL'. 1::'AMT.1 Y F:'UPNA(",I--: 1001<4- AIR HANDI.-P 101(
VN FLOOP F:*Ul4NA(.;!:* EVAP.GOOLIEP
occup .Gpp. : 11. 3 HEA'TF-P VP.:N'T FAN 3
V E.N I VIEW' . SYSTE'li'll
01-1411MIOMP <31-4p HOOD 1.
NO. S1 011:43,FS : 1. DI P/COMP 3 3.311-4p 1 IN C,I Nf.-.-.P A T Of 4(1IOM
DWEL.L . LJN1 i,S : t OLP/COMP 15--.3011-11P XNCINE-'.PA (COM
r--.L ,1,y P E.: GAS ULWCOMP 30--50HP PEVAIP UNIT'S
MAX . INPUT 81.44/COMP 30+1-41-1 0 THE:11
IL :ML DIVIPPL.v f GAS PIPING OU-11-LIFJ5 1.
1-11UPH V"PE'SSI?
L-Ow P14F*S%11
neer
GODWIN WILL IAM V,F-PMI T $1.0 . 00
0 01.10 t-M MAPLEN.-EAF S-T 1:-I-1-)N Pl---V:EF-W $10 . 13
W 11.('.."A P D OR 9.72P.3 1: 1 X I'Ll PES5 $30 150
N PHONF-.: 11 50:!,) 245-96*71 STAT E: FAX $2 . 03
E
R O'T I IF..'P
— 14E'11 T N W-110 CW I
C I-IFA)IN' S 1-11li-A'TING
0
N 134::5 NW 231ST*
T hi T.1!a t)ci r-t.i LI r• 971P3
R
A PHONE (50'3)
C NO IfTIP11 'TO1'AI 1111115P . 65
T
0
RI RECEIPT N0.
This permit Is issued subject to the regulations contained in Title 14 PE.'QUIPEM INSPEX T T(INS
of the TMC, State of Oregon Specialty Codes,zoning regulations GAS L.,:LNF-'
and all other applicable codes and ordinances, and it is hereby POST* 6 BF.-,:Am
agreed that the work will be done in accordance with the plans and POUGM I N
specifications and In compliance with all applicable codes and F,'1 NAL
ordinances The issuance of this permit does not waive restrictive
covenants Contractor and subcontractors shall have current city
business tax permits This permit will expire and become null and
void if work is not started within 180 days,or it work is suspended or
abandoned for a period of 180 days any time after work has
commenced It shall be the responsibility of the permittee to assure
all required inspVctIons are requested and approved.
JJXUVVt- A-
Pprmittee Siginatm,
oii I. F:m4 rNSPEC-TION 639-411.75
Issued By
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE
PLUMBING IoEWMIT
CITY OF TI17A RD PE RMI'T NO .. KSI. f3Eg1 ?'3f3
airoF nc,4Rn
COMMUNITY DEVELOPMENT DEPARTMENT OREGON DATE: IS!S1JM:1101 : 8/12/B(3
13125 S.W.Hall Blvd.,P.O.Box 23397,Tigard.Omgon 97223.(503)839-4175 PRIM PM'T . NO . (381321.
,.JOB ADDPESS : 12145 SW L.IN(.:01 N AVE:
TAX MAP/1-01 i?S 1 RAS 400 SUB: 1.,.'T : UK :
LAND USE: : PA . 5
I-01, SIZE: :
ITEM NO : NO:
WORK CLASS : NEW WA'T'ER CLOSE'.T c? TRAP
USE: 'TYPE. : SX NGL..E 1=AMII...Y UPINAL. BKF'I...OW PNVN*rP
CONST . 'T'YPE: VN L.AV(:)RA'TC)FTY 2 TRAP PRIME::R �
0(:CLIP. GPP. : R:3 Tl.1H SHOWER i::'. ("aRIMAS(i. TRAI:"i
D1!:iHWASHER 1.
I:yAMF.irrG",k D:I:SPOSAL. 1
NO. S1'OPIE:S : 1 WASIA I:N(:, MAGHT.NEi 1
DWELL. .(JNI'T'!5 : 1 L.Al.1NUPY PRAY 131-01G.I)NAIN MIA
F1..00P L)RA:I:N
!SINK 1. SEWER (F'T)
WA'T'ER HLME,R 1. S'T'ORM/PAT N (F-'T 1
RE::MAPKS :
nc.�brl•1 c^al•tt,r•In.c^t,ar I•tttmla�.xl�
F E:F,.!.) ,
0 GODWIN WILLIAM 14-:421MIT X1.1. 7 . 50
W 81.1.0 SW MAPl... A.E:AF !ST �
E 'T':igat.r(l Or 9,71k?P-3 F'TXTURE:!5
R PHONE (".103) 2A5 96'71. !S'TA'TE- 'TAX IM5 .60
O'THE:CZ
C GUL)W:I:N WTI_L.IAM
OF L7F:V IN(*,
N
T 01.10 SW MAPI._EI...E:AF Cil
R
A TIC,AI'�D OR 97c?P-3
C F-11-10NE (503) ;245-9671-
T 71.
O RE„G1:45T'RA'T10N NO. A 276I 'TOTAL. : *Ie3 .30
R
RECw'IP'T NO. /r)0�� �'
__..__...................._.........
_.__
This permit is issued subject to the regulations contained in Title 14
of the TMC, State of Oregon Specialty Codes.zoning regulations GE-W(J:LRED INSi EZI TONS
and all other applicable codes and ordinances, and it is hereby 131-I3 .(.1NDE DS1_AB
agreed that the work will be done in accordance with r„e plans and POS1 s BE.AM
specifications and in compliance with all applicable codes and WA T'IT L..INr
ordinance. The issuance of this permit does not waive restrictive
covenants. Contractor and subcontractors shall have current city PL F.1 'TOPC1l.1'T
business tax permits This permit will expire and become null and RAIN DPAtNS
void f work is not started within 180 days.or if work is suspended or 1F.T NAI_,
abandoned for a period of 180 days any time after work has
commenced. It shall be the responsibility of the permittee to assure
all required inspections are rerluested and approved
Permittee Signature �
Issued By 1. Vit- CALL FOR INSPE'C'TION 639-417,'.)
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE
1
BUILDING PERMIT
13E:RMI'T NO. : BUS81520
CITYof TIG cl Or�T�xim
OtrFOUN DATE ISSUED . £a/ 4/88COMMUNITY DEVELOPMENT DEPARTMENT
13125 S.W.Hall Blvd..P.O.Box 23397,Tigard,Oregon 97223.(503)6394175 !� 1-1,11:11 M . 1'aM I .NO . (381520
.JOi•) A1:)0RL-'::SS: 12145 SW LINCOLN AVE:
TAX MAP/1_.(:)T' r S 1 2AB 400 SUB: L..T' : BK
LAND usr :
L_(:)T SIZE : VAL.(JAIION:
Ff'ONTREAR
WORK DE:MCIL.I'T 1.014 OWEI_.I.. ,UNITS : L_FT'T" . RIGHT
I JSE: TYPE : !.i'Mil'aL.Ei: FAMILY NO . F,1k::1 DOOMS : fx T . Wl11..1.. C:(lN!:i r
DONS T . T'YPE:: NO . BA'THS : N 1:1 ; 1— W
OC.:C'UP . GRP. : PRO T . OPENINGS :
(:)('CUP .1...OAD IA : S: I::: . W
TOTAL.. ARk-A
NO. S'TI[JIRTFIS : IST : P(:)(:)1 CONST : F:.PE: PEA"?
HFA'.('BHT : 2ND : AI"1E::A 5FPA1'2'? RATED.
BA SE::MITN'T'r 3RD : 0(:(::tJN . `EPAR•7 RAT 1=D
MEQ: ZANINE7 DASEM''T
I''I._00A LOAD: GARAGIZ : F:CP1:= SI"al'21<I...F77. AL.AF2M'f
F.I...0W((•;P ) DETECT 7
1-IEA'T' T'YPE: HDCP .AC,Cki 9 S'? (:;(7RR'r
PI-AN C3.1ECK 9Y:
Rt.:MAPKS :
i,eiriUV4R all dobr:i.tit PEESS(JE OF NO.
inow Rr' tat.tatt 1:)e c--mppod and :i.ritapi.,.r.tied I..A!;iT' 1='w.:C(iiSLIE:
rEE.:!i
O GODWIN WII...I...IAM PE.RMI T 1111.9 00
W :i38,111 !:iW :1 7011••1 PLAN PEEVIEW
N talohat tar F 111E DEPT
E
R STA I*r--. T'AX $ 7!'i
OTHER
L)E:t)F.::f._OPME_NT' CI
aARCyE:5 :
C GODW:I:N 141:1_L.:I:AM SOC:(STOPM)
N r'E:RNWOOD DEV . 'ING !M',(S'T'REE.1 1
T ;J;3(35 SW 170TH PDC.:11# 1
R
A in.11a11tit, or 7006 PREPAID < >
C PW(]NE:: (503) 6AP-7502
T
O GTis(' 1:r�.I.ITFIT NO AIPP'1 TOTAL OT'AI_: $1"5.'19
R
RE(-.F.IIST NO.
This permit is issaed subject to the regulations contained in Title 14
of the TMC, State of Oregon Specialty Codes.zoning regulations REQUIRED INS3PE•C T.T.ON!5
and all other applicable codes and ordinances, and it is hereby SEWER
agreed that the work will be done in accordance with the plans and
specifications and in compliance with all applicable codes and
ordinances. The Issuance of this permit does not waive restrictive
covenant; Contractor and subcontractors shall have current city
business tax permits. This permit wi'I expire and tecome null and
void if work is not started within 180 days,or if work is suspended or
abandoned for a period of 180 days any time titer work has
commenced.1;shall be the responsibility of the permittee to assure
all require inspections are requested and approved.
��w _ -
Permittee Signatu
Issued By
C.:AL I_ FIJI: :I.NSPEC:TION 639-417!:')
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE
CITYOFTIGRRD �,- li �, PLAN CHECK A� PPLICATI
COMMUN" DEVELOPMENT DEPARTMENT GFTYOFT* RD PLAN CHECK 0
13126awwnewd v.o.FkW 23397, PERMIT
fid.a.yo„972x31503)6394»&
DATE ISSUED
JOB ADDRESS: � Z 14� Sv,/ 6 /NCQL,�I TAX MAP/LOT _
SUB• — LOT: 2 5 - 2A13 *L 00 LAND USE:
VALUATION: /;7, ( s c tW� -
OWNER SPECIAL NOTES
NAME: _ ( pOD ?WEY. //,"c' , REISSUE OF:
ADDRESS: IQJ�E� LAST REISSUE_ _
2 — FLOOD PLAIN/
PHONE:-� SENSITIVE LAND:
CONTRACTOR APPROVALS REQUIRED
NAME:
woo PLANNING:
,�7f/ / PLANNING: _
AUDRtSS: — ENGINEERING.
FIRE DEPT _
- OTHER: _
PHONE: X45- -7/ ITEMS REQUIRED
ARCH ENGINEER LIST/SUBCONTRACTORS: _
NAME: BUS TAX:
--�� OLg! CALCULATIONS:
ADDRESS : TRUSS DETAILS:
PARKING PLAN: _
PHONE: _ LANDSCAPE PLAN:
OTHER:
COMMENTS-
PERMIT # ACGT N �
DESCRIPTION AMOUNT AMOUNT PD. BAL. DUE
5-) 10-432 00 Building Permit Fees
' �` J ' 10-431 00 Plumbing Permit Fees GV
10-431 01 Mechanical Permit Fees
10-230 01 State Building Tax (5X)
Building /S•gZ, 3� / -max y
('lumbing
Mech _ ' , 4,3
10--433 00 Plans Check Fee C5G'
Building -
Plumbing _ --
Mech %C , ; T --
.a 3U-2.0?_ O0 Sewer Connection
30-444 00 Sewer Inspection —
51-448 00 Street System Dev Charge (SDC) `-
52--449 01 Parks I System Dev Charge (PDC)
52--449 02 Parks 11 System Dev Charge (PDC) -
31-450 00 Storm Drainage Syst Dev Chry (SSDC)
10--230 09 TRFD _ ._...�
10-230 06 Washington County Fire H1
10-220 00 Amart-/Wedgewood
W Ary) TOTAL - �'U•Ub " .O`I
APPI TCANT S1GNn
Received By: -
_._--- l / _---.-- ---_— Date Received
ht/3507P/18P
r
CT.I*Y OF "I'lUARD RFCFIFT OF PAYMENT
mAllE- F"1. I-:M-JQOD DEVELOPMENT FVLCE*-APT NO: 001001!5/1
JIDPES's t 8130 qW MAPLFLEAF ST REFT PAYMENT 1:),-)IEt 08-0:1--8b
TISARD, OR 9122'� FAM:', NO/ADDR%
12145 SW LINCOLN
OF P(MIENT AMOUNT PAI U PURPOS'E' OF PAYMENT AMOLIN V K411)
CIALTA.:', FEE
I-AEJ
I I 'l ANY T I IIE.
TOTAI- 0110LIN't Lft)
i
i
I
Address
_071S1= G.dL '� Permit No.
i I
Name of Occupant _ �_ Permit charge
Paid
Date connected.
Type of Building /wi-P.f�,Lt11�. Inspection fee
Service Rate__2 _ paid by
Contractor __.__—__.-_._.- Assessment_ Paid___
Size of connection
CITYOFTIFA- RD PLAN CHECK APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT COO RD PLAN CHECK N
""'$WH.n8t0& P.O.eonnW.Tqwd.o,egm arm(600)GN 4176 oN PERMIT M
DATE ISSUED -
JOB ADDRESS: -moi_ (_ l ! l C'�' I Y �-11 TAX tiAP/LOT
SUB: L) LOT: LAND USE:
VALUATION:
OWNER
� SPECIAL NOTES
NAME: - REISSUE OF:
ADDRESS:- LAST REISSUE: —
^� FLOOD PLAIN/ —
PHONE:
_ SENSITIVE LAND:
CONTRACTOR APPROVALS REQUIRED
PLANNING: _
NAME.
ADDRESS; ENGINEERING:
FIRE DEPT
01HER: _
PHONE: Y
ITLMS REQUIRED
ARCH/ENGINEER LIST/SUBCONTRACTORS:
NAME:
BUS TAX: --
ADDRESS: CALCULATIONS:
-- - TRUSS DETAILS:
PARKING PLAN:
PHONE:
LANDSCAPE PLAN
OTHER:
COMM(-NTS: 7 ; ;
71
PERMIT // ACCT N DESCkIPTION AMOUNT AMOUNT PD. BAL. DUE
10-432 00 Building Permit Fees
10-431 00 Plumbing Permit Fees ---
10-431 01 Mechanical Permit Fees '- --- ----
10-230 01 State Building Tax (5X) - -- -—
Building _ ---_-.
Plumbing _-
Meeh _
10-433 00 Plans Check Fee
Building - —_ — ---- _
Plumbing
Mech
30--2.02 00 Sewer Connection _
30--444 00 Sewer Inspection —_— — -
51-448 00 Street System Dev Charge (SDC) �-
52--449 01 Parks I System Dev Charge (PDC) _ -
52-449 02 Parks II System Dev Charge (PDC)
31-450 00 Storm Drainage Syst Dev Chrx3 (SSDC) i
10--230 09 TRFD - — —
10-230 06 Washington County Fire N1
10-220 00 Amart/Wedgewood -
TOTAL ---
REC y ------
(1f'f'l ICAN7 SIGNATOR;
Received fly : ,^— Date Received:
ht/3587P/18P - --- . __ - -- — —