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Permit ip q CITY ®F - r��7� MASTER PERMIT P a'. COMMUNITY DEVELOPMENT Permit #: MST2010 -00002 T1G 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 02/02/2010 A RD Parcel: 2S112CC20700 Jurisdiction: Tigard Site address: 15610 SW 81ST AVE Subdivision: GAGE FOREST Lot: 14 Project: Gage Forest Project Description: New SF BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 4 First: 902 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 24 Bathrooms: 3 Second: 1350 sf Garage: 403 sf Front: 20 Smoke Dwelling Units: 1 Third: 0 sf Right: 5 Detectors: Yes Total: sf Value: $246,445.68 Rear: 15 PLUMBING Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 1 Rain Drain: 1 Catch Basins: 0 Lavatories: 4 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Other Fixtures: 0 Tubs /Showers: 3 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Drains: 0 Bckflw Prevntr: 0 MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 4 Clothes Dryers: 1 Natural Gas Heat Pump: N Hoods: 1 Other Units: 0 Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4 Furn > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits 1000 sf or less: 1 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0 Ea add! 500 sf: 4 20 1 -400 amp: 0 201 -400 amp: 0 1st W/O Svc /Fdr: Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add'I Br Cir: 601 -1000 amp: 0 601 +amp- 1000v: 0 1000 +amp /volt: 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All asin Y Other: N Other Description: Ecom p 9 BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: Owner: Contractor: Required Items and Reports (Conditions) J T ROTH CONSTRUCTION INC J T ROTH CONSTRUCTION 1 MST Ersn Cntrl 503 681 - 4444 12600 SW 72ND AVE 12600 SW 72ND AVE #200 TIGARD, OR 97223 TIGARD, OR 97223 PHONE: 503- 639 -2639 PHONE: 503 - 639 -2639 FAX: 503 - 624 -0239 Total Fees: $15,217.06 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. pp Issued By: C� X P ermittee Signatu, JP - %° gip "'Bufllcking Permit A pig. cation Residential �J 7E:1771 � �� � r-jr )„ , . T , � r ,. ��1 w , ,.� r , ��Jl tl �11! v I „ 1 O lt ()I 1 IC l 115 O \t \ f City of Tigard Received i.f Permit No (^'' hi a �J g Date /By: I S i� �" J2 -XV /O fob'e0 i 13125 SW Hall Blvd., Tigard, OR 9 0 5 2 O � O Plan Review '101. .4/ „ t 3 Other Perm Phone: 503.639.4171 Fax: 5 03 . 598 . 1960 Date/By , �� I O � /Q -0000 r � " Inspection Line: 503.639.4175 D ate Read . er 1°ris H See Page 2 for r CITY O F TIGARD y ' g Pl , L G A, t .? Internet: www.tigard or.gov Notified/Method:- �f a- i i /� Supplemental Information BUILDING DIVISION • TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING ® New construction ❑ Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all ❑ Addition/alteration /replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. ® 1- and 2- family dwelling ❑ Commercial /industrial Valuation: $250,000.00 ❑ Accessory building ❑ Multi - family Number of bedrooms: 3 ❑ Master builder ❑ Other: Number of bathrooms: 2.5 JOB SITE INFORMATION AND LOCATION Total number of floors: 2 Job site address: 15610 SW 8e. New dwelling area: 2252 square feet City /State /ZIP: Tigard OR 97224 Garage /carport area: 403 square feet. ., 1J'?, i s�'j Suite/bldg. /apt. no.: Project name: Covered porch area: 45 square feet Cross street/directions to job site: Hall Blvd. to Langtree then to 81 Deck area: 0 square feet 2 ,q c .. Other structure area: 0 square feet 2 4,,ss REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: Gage Forest I Lot no.: 14 Permit fees* are based on the value of the work performed. Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. Construction of new single family resisdence Valuation: $ Existing building area: square feet New building area: square feet ® PROPERTY OWNER ❑ TENANT Number of stories: Name: J.T. Roth Construction Inc. Type of construction: Address: 12600 SW 72 Occupancy groups: ' City /State /ZIP: Tigard OR, 97223 Existing: Phone: (503)639 -2639 Fax: (503)624-0239 New: ❑ APPLICANT El CONTACT PERSON NOTICE Business name: J.T. Roth Construction Inc. All contractors and subcontractors are required to be Contact name: David Jensen licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: 12600 SW 72". jurisdiction in which work is being performed. If the City /State /ZIP: Tigard OR, 97223 applicant is exempt from licensing, the following reasons apply: Phone: (503) 806 -0602 I Fax: : (503) 624 -0239 LOO W— i)0 E -mail: davidj @jtrothinc.com / 1 / r( , tQ ,1 CONTRACTOR �i lN�l (. ✓RT/V Business name: J.T. Roth Construction Inc. - BUILDING PERMIT FEES* Address: 12600 SW 72 °d. (Please refer rofee schedule) City/State/ZIP: Tigard OR, 97223 Structural plan review fee (or deposit): 75 r el Phone: (503) 639 -2639 Fax: (503) 624 -0239 FLS plan review fee (if applicable): CCB lic.: 31700 Total fees due upon application: 2 5"o O r et Amount received: s� li Authorized signal l��r This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: David Jensen 12121109 * Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\BUP -RES Perm' pp.doc 10/01/09 440- 4613T(1 l /02 /COM/WEB) • } Md 1Ry2Iad 'N.LQL M r y (341 VUllad Jo %V) aa"wptnc win NM A illat a JO WO w 1 wW os"ZLS : ;ltu70tlauun!a!L _ .fir tE1 ME Zo•s Mil , „ 4;0 MI 4C9S 11.111 Amt MIMI Salatd ety M 2!0 “. ZO EM NM Isola aamm I PM uad JeAtoyH /tD.KU4st4R1 NM p 2 - SZ = Odetat Igelod) anon /tips NMI ZO ko!tnIUlm agp,wS 1111111111=11 (le!anauaoo) rump poll IIIIMIIIIIEIMIIIIIII t D ried mud ( — $ :"PA) Ha la !PMT! ZO'SZ IIIM dell a seaa;!'luaydaonpul MR IS'i:I =taw all ZO SZ 4I9 14 - Z° .CZ Ell l !P a®uQ.rsp Zi SZ (R OMs s inag/utgap'aoll ME t0 SZ — du►aafSl 5 "r - u!utunc) - u 1 >I4441 ZO 6Z 11.. cyk�I� �Lien *OA .01 fleas 11111111111EMIMIll = MEM t °Meld IIIIII (J :V .maw! 'au) a3laaas zesm (re : a Aeult 'nu) mend aim MN t 01f; uaaatl'ou) Lj!aec. 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N 1 nulsNaz X40 AzoOra.v laowoolatitai/uop lemomppb' ❑ +uowlouna Q W&0133n44103 n611■1 3 MOM' 40 14&L 91) Nvr 1 Jo uoq* ggay minruadllano � ,w r e' rhki d d Ma i, t ,. L P Y '^I i. = echan 1Ca1 Permit Application i �� � /7 pp a • � �tit,�o� FOR OI I I(I liSl O \I:1 f" �� JL \SJ�YJH Y � L p :v s.�, _,alrk9'41, riti i,dln 1 ' ..I . ..r.. �t'. City o Ti gar d Received ` ' �9 `, Date/By: / - f / Permit No",-/ s O K V�� �?) Ot z ih rr i , i_.a Y ° 13125 SW Hall Blvd., Tigard, OR 97223 Revi °? Phone: 503.639.4171 Fax: 503.598.1960 JAN 0 5 201 Plan Date/By: Re: Other Permit: hl I A It I); Inspection Line: 503.639 Date Ready /By: Juris: ® See Page 2 for ,, ntw °' T-, <, r't Internet: www.tigard - or.gov CITY OF TIGARD Notified/Method: Supplemental Information BUILDING DIVISIO TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST ® New construction ❑ Addition /alteration/replacement Mechanical permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit. CATEGORY OF CONSTRUCTION Value: $ RESIDENTIAL EQUIPMENT / SYSTEMS FEES* ® 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist. ❑ Multi- family ❑ Master builder ❑ Other: Description Qty. Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling Job site address: 15610 SW 81s`. Air conditioning (requires site plan showing placement) 46.75 City /State /ZIP: Tigard OR, 97224 Furnace 100,000 BTU (ducts/vents) 1 46.75 46.75 Furnace 100,000+ BTU (ducts/vents) 54.91 Suite/bldg. /apt. no.: Project name: Heat pump 61.06 Cross street/directions to job site: Hall Blvd. to Langtree turn onto 81 Duct work 23.32 Hydronic hot water system 23.32 Residential boiler (radiator or hydronic) 23.32 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 46.75 Subdivision: Cage Forest Lot no.: 14 Flue /vent for any of above 23.32 Other: 23.32 Tax map /parcel no.: Other fuel appliances DESCRIPTION OF WORK Water heater 1 23.32 23.32 Gas fireplace 1 33.39 33.39 HVAC installation for new single family residence Flue vent for water heater or gas fireplace 23.32 Log lighter (gas) 23.32 Wood/pellet stove 33.39 Wood fireplace /insert 23.32 ® PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32 Other: 23.32 Name: J.T. Roth Construction Inc. Environmental exhaust and ventilation Address: 12600 SW 72 "d. Range hood/other kitchen equipment 1 33.39 33.39 City /State /ZIP: Tigard OR, 97223 Clothes dryer exhaust 1 33.39 33.39 Single -duct exhaust (bathrooms, Phone: (503)639 -2639 Fax: (503)624 -0239 toilet compartments, utility rooms) 4 23.32 93.28 ❑ APPLICANT ® CONTACT PERSON Attic /crawlspace fans 23.32 Other: 23.32 Business name: J.T. Roth Construction Inc. Fuel tin P g Contact name: David Jensen $14.15 for first four; $4.03 for each additional Address: 12600 SW 72 "d. Furnace, etc. Gas heat pump City /State /ZIP: Tigard OR, 97223 Wall /suspended/unit heater Phone: (503) 806-0602 Fax: : (503) 624 -0239 Water heater Fireplace E- mail: davidj @jtrothinc.com Range CONTRACTOR Barbecue Business name: B & M Heating Clothes dryer (gas) Other: Address: PO Box 1111 MECHANICAL PERMIT FEES* City /State/ZIP: Boring OR, 97009 Subtotal Z(7. ( Minimum permit fee ($90.00) Phone: (503) 637 -3489 Fax: (503) 637 -5244 Plan review (25% of permit fee) CCB lic.: 124757 State surcharge (12% of permit fee) Z3. %3Z TOTAL PERMIT FEE 3 0.9' 9 Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: Bruce White Date: 12/22/09 * Fee methodology set by Tri-County Building Industry Service Board I:\ Building \Permits\MEC- PermitApp.doc 10/01/09 440-4617T (11 /02/COM/WEB) ' Electrica1 Permit Application cEi V ED � , � } , 11 0l2'O I,IC I litil ONI 1 '' `1. C of Tigard Received 1 �� Permit No `J g Date /By: / . () io yS/ozcV© ' - 1J04'6 . rf q 13125 SW Hall Blvd., Tigard, OR 97223 JAN 0 5 2010 Plan Revie • 9 Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit. I I V n R lit Inspection Line: 503.639.4175 Date Ready /By: Juris: ® See Page 2 for .v Internet: www.tigard - or.gov CITY OF TIGARD Notified/Method: Supplemental Information TYPE OF W ELDING DIVISIO PLAN REVIEW ® New construction ❑ Addition /alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below): ❑ Service or feeder 400 amps or more ❑ Building over three stories. ❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. • less to ground, or exceeds 14,000 ❑ Commercial -use agricultural ® I- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "I -3 ", Job no.: Job site address: 15610 SW 81't. I00HP or more. occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State /ZIP: Tigard OR 97224 ❑ Health -care facilities. ❑ Supply voltage for more than ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Hall Blvd. to Langtree turn onto 81s Description 1 Qt.. 1 Fee. 1 Total New residential single- or multi - family dwelling unit. Includes attached garage. Subdivision: Gage Forest Lot no.: 14 1,000 sq. ft. or less I 168.54 168.54 1 4 ' Ea. add'l 500 sq. ft. or portion 4- 33.92 1 Le,l Tax map /parcel no.: Limited energy, residential 1 67.84 67.84 2 DESCRIPTION OF WORK (with above sq. 11.) of New Single Family Residence Limited energy, multi- family Wiring g Y residential (with above sq. 0.) 67.84 2 Services or feeders installation, alteration, and/or relocation 200 amps or less 100.70 2 ® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2 Name: J.T. Roth Construction Inc. 401 amps to 600 amps 200.34 2 601 amps to 1,000 amps 301.04 2 Address: 12600 SW 72nd. Over 1,000 amps or volts 552.26 2 City/State /ZIP: Tigard OR, 97223 Temporary services or feeders installation, alteration, and /or relocation Phone: (503 )639 -2639 Fax: (503)624 -0239 200 amps or less 59.36 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2 Branch circuits - new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with ❑ APPLICANT ® CONTACT PERSON above service or feeder fee, each branch circuit 7.42 2 Business name: J.T. Roth Construction Inc. B. Fee for branch circuits Contact name: David Jensen without service or feeder fee 56.18 2 first branch circuit Address: 12600 SW 72 "d. Each add'I branch circuit 7.42 2 Miscellaneous (service or feeder not included) City /State /ZIP: Tigard OR, 97223 Each manufactured or modular 67.84 2 503 806 -0602 Fax: (503) 624 -0239 Reconnect t on y and/or feeder Phone: ( ) ( ) Reconnect only 67.84 2 E -mail: davidj @jtrothinc.com Pump or irrigation circle 67.84 2 CONTRACTOR • Sign or outline lighting 67.84 2 Business name: Grizzly Electric Signal circuit(s) or limited - energy panel, alteration, or Address: 8002 NE Hwy. 99 Suite #401 extension. Describe: Page 2 2 City/State /ZIP: Vancouver WA 98665 Each additional inspection over allowable in any of the above Per inspection 66.25 Phone: (360) 909 -4080 Fax: (360) 694 -8939 Investigation per hour (1 hr min) 66.25 CCB Lic.: 186218 Electrical Lic.: 37446 -C Suprv. Lic.: 2643 -S Industrial plant per hour 78.18 ELECTRICAL PERMIT FEES _ Suprv. Electrician signature, required: '- . .__ , ...- , Subtotal: �7z . Print name: Ron Nelson Date: 12/22/09 Plan review (25% of permit fee): State surcharge (12 %ofpermit fee): 44, (e, . Authorized signature: o j %� TOTAL PERMIT FEE: , i b , ` 7 � This permit application expires if a permit is not obtained within 180 Print name: A14, //94,73- Date: days after it has been accepted as complete. /� • Number of inspections allowed per permit. 1:\ Building\Permits\ELC- PermitApp.doc 10/01/09 440-4615T(t l /05 /COM/WEB 1 1 II 1 RECEIVED *..,\... , JAN 0 5 2010 MARK STEWART HOME DESIGN CITY OF TIGARD BUILDING DIVISION )))�' 8137 S.W. SENECA — I Tualatin, Oregon 97062 I I 1 CfiJabl, / I 1 1 i (503) 885.8377 P �_ 1 L 1 i ,� O 0. (503) 579.4132 F 0 % ' i � ��� / - / ' I p I www.markstewart . com O 1 1 D 'L�' , -�T -- L6 - - -- -° I' ° °_ °° ° -� ' A� or N3 S O s ' ' - f - 1 . 96 ' -- - - -- --- - - - --j z z� � � i19 f a l. - AI % ' ; . ... y l ------)ii( /s , I + f a 0 �� 13/5, ; / eE ea�c a Ir 1 / 7/ I, A t = = =: 13A -GfR QI a r� I w I �1 ( . = RE QI ° �Q II imit SETB I r' i MAIN FLOOR • 1009' 0 �.i r' z s v) m u Z . , I Cs4RAGE • • IMO' ■ �' !'� Cr' r: F- ` I ' • �'..II 6 O °C ! r it f -M. i I �t 1 2 2 -� � Ly,. ? . J C� 0 — - -- - -- - - -H i - ` • 1^ lb. 9 8138 - -� -° _ Stock Home Plans �� ' t it e, Custom Design I Cr) I B Q m m z Builder Marketing I r� I , - Interior Design Since 1982 CITY OF TIGARD - SITE PLAN REVIEW . Thom • BUILDING PERMIT NO.: / "ri 000a, Y "m 1 d .r F•°er pa PLANNING DIVISION: a �"` 5bi@° SG�rart lark O . Ste t 61. MNO Required Setb .cks: el Approved, ❑ Not Approved Important Disclosure _ ...... i s 1 (: i ii A fOr If S ide: `� Street Side: ( � Pisan R.O From. !� G rage: C) Rear: )5 , �.. r7 Is " Y� � O N home . only. Visual Clearance: Apr e ❑ Not Approved bold m frown ' mos without �..rl ocasent from e pima Maximum Building Height feet +ed and n b a violation a F.d.d bad eo ,ep,aaae p� CWS Service Provide L Required: ❑ Yes ❑ No `�` ` r .o MI ) around. Amy Ytlatlm a w (Z FI c. .t—1 dr and w Mtl�ert�d k b r n tha h t b ❑ Received tb1�lFIF1 e. nw egabSl l(yd aontootdr to mat i a han. °even° hoed% on any parebuQ alto By: m Date: t Ls--7 lv a eMhb �r� of the aovom►w GINEERI 1%Approved EPARTMENT: b y myca • ds Y pi= to MY - ad x MY aaeAia ®� , FORES A tual lop : ❑ Not Approved area site Pt Approved ❑ 'of pproved .I.r. ROTE CONSTRUCTION SCALE: 1" - 16' -0" . By: Dater / 5 10 . RAN AO? f14- 11_R8YL£2 Notes: C p4 .. 4 ____ i +1� GAGE FOREST o /MIMI DEC. 18, 2008 ' E PAST SITE Oregon Residential Specialty Code N1107. HIGH - EFFICIENCY INTERIOR LIGHTING SYSTEMS Permit No.: fl 0/0 _ oz - Jurisdiction: Site Address: /cl / Subdivision/Lot #: 27 and /or Map and Tax Lot #: By my signature below, I certify that a minimum of fifty (50) percent of the permanently installed lighting fixtures in the above mentioned building have been installed with compact or linear fluorescent, or a lighting source that has a minimum efficacy of 40 lumens per input watt. (Oregon Residential Specialty Code N1107.2) Signature: �' ��� _ Date: d /6 Owner / eneral Cons : ctor • uthorized Agent Print Name: ��. ORSC Section N1107.2. High - efficiency interior lighting systems. A minimum of fifty (50) percent o the permanently installed lighting fixtures shall be installed with compact or linear fluorescent, or a Lighting source that has a minimum efficacy of 40 lumens per input watt. Screw -in compact fluorescent lamps comply with this requirement. The building official shall be notified in writing at the final inspection that a minimum of fifty percent of the permanently installed lighting fixtures are compact or linear fluorescent, or a minimum efficacy of 40 lumens per input watt. I:\Building\ Forms \RES- HighEfficiencyLighting.doc 07/01/08 Oregon Residential Specialty Code R318.2 MOISTURE CONTENT ACKNOWLEDGEMENT FORM I, /j /�/� , am the general contractor or the owner - builder at the following address: Site Address: � % �;�j� � � City: �'V J / Permit #: f7 2-O /,-- 000 • Subdivision/Lot #: 57 207/7 and /or Map and Tax Lot #: To conform with the 2008 Oregon Residential Specialty Code (ORSC), Section R318.2 and OAR 918- 480 -0140, I am notifying the building official that I am aware of the moisture content Requirement of ORSC Section R318.2 and have taken steps to meet this code requirement. [Section R318.2 is provided for reference]. R318.2 Moisture Content: Prior to the installation of interior finishes, the building official shall be notified in writing by the general contractor that all moisture - sensitive wood framing members used in construction have a moisture content of not more than 19 percent by dry weight of dry framing members. Signature: Date: / Date: 3 General ContraEtor or ►. • er- Builder I:\ Building\ Form \RES- MoistureSensitiveWood.doc 09/25/08 .. STREET TREE CERTIFICATION „ . „ ":, ,,,,, ,77, , „ ,, ,,, , , „ .. „ , „, ,,, , _:„ , -„,..,..„.„,,, , „.,:.,„,„,,,,.„.„, Win.:". -_!° tom:: " a A S, r* r milk fi led , i,-?1,V*- ,'tAltIt'-4-4: t 1: % , :' j, Aifn s ," , S;: , ''':::::' 1 ;''- ' i q'ttak -f a*:41=1 ------' ,! I �G %� 6721:///5,1111941, , Ow >r gent,for , �.'�' C��S� //l-',. , (PLEASE PRINT) i (PERMIT HOLDER) l •:, p' ' k ,k 1 k, 4w. dt + '�- , ,„1 s, k P , ,1' , �.. Do hereby t t he foll ow�n location meets a • City of Tig ,gu a d d ev e lo r p i r e nt standards fo str tr l n 3 'v4 fi r- :� ] 4' l r t ,` � 1 ? 'z rr i y ) � '�^ } 't' q 4 y, r :t .1.9t"; a 3 n, ' r 'k .;,5 2 ADDRESS: /5 / J 7/ 4b g ��5 - i6/0 0002 -- _ SUBDIVISION: _j1l� / 1 2 V LOT: 1' SIGNATURE: ,.: ��� DATE: g �- 2d/(Y pirNEK /AGENT) RECF,IVED BY: DATE: (C111 OF TIGARD) I: \Building \Forms \StreetTreeCertificate 01/19/07