Permit CITY OF TIGARD BUILDING PERMIT
7 e PERMIT #: BUP2008 -00103
COMMUNITY DEVELOPMENT DATE ISSUED: 4/23/2008
_ TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171
PARCEL: 1 S136AD -06504
SITE ADDRESS: 11462 SW PACIFIC HWY ZONING: C -G
SUBDIVISION: AMERICAS TIRE COMPANY LOT: 003 JURISDICTION: TIG
PROJECT: DISCOUNT TIRE COMPANY
Project Description: Fire sprinkler system.
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
. CLASS OF WORK: FPS FIRST: 8,817 sf N: S: E: W:
TYPE OF USE: COM SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 5N sf N: S: E: W:
OCCUPANCY GRP: M TOTAL AREA: 8,817 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: 73 BASEMENT: sf AREA SEP. RATED:
STOR: 1 HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT ?: MEZZ ?: Y REQD SETBACKS REQUIRED
FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: Y SMOK DET:
DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : Y HNDICP ACC:
BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING:
VALUE: $ 32,000.00
Owner: Contractor:
HALLE PROPERTIES LLC WESTERN STATES FIRE PROTECTION
20225 N SCOTTSDALE RD 13896 FIR ST STE B
SCOTTSDALE, AZ 85225 OREGON CITY, OR 97045
Phone:
Contact #: PRI 503 - 657 - 5155
FAX 503 - 657 -5182
Reg #: LIC 104570
FEES
REQUIRED ITEMS AND REPORTS
Description Date Amount
[BUILD] Permit Fee 4/4/2008 $266.08
[TAX] 12% State Surcha 4/4/2008 $31.93
[FLS] FLS Pin Rv 4/4/2008 $106.43
Total $404.44
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 than 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 these rules or direct questions to OUNC by
calling 50 . J..•.99or 1.800.332.2344.
Iss - d By: Permittee Signatu . , // ( 1
Call 503.639.4175 ; by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
t--(16Q
Fire Protection System
Building Permit Application USE ONLY
roR :
�����r'
City of Tigard Received OFFICE �� Date/B : t l / 9 Qg B PermitNo.: 4, Pam — OC)/Q
13125 SW Hall Blvd., Tigard, OR 97223 ee�� p Plan Revue •.-
• Phone: 503.639.4171 Fax: 503.598.1960 APR ¢➢ 2008 Date/B : i�: tom' Other Permit:
TI n 1t D Inspection Line: 503.639.4175 Date ReadyBy:_ fa See Page 2 for
Internet: www.tigard -or.gov CITY TIGARD Notified/Method: / A Supplemental Information
BUIL !N( 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: $
❑ Accessory building ❑ Multi- family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 11462 SW Pacific Hwy. New dwelling area: square feet
City/State/ZIP: Tigard, OR 97223 Garage/carport area: square feet
Suite/bldg. /apt. no.: Project name: America's Tire Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: 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.
• new NFPA 13 fire sprinkler system - ESFR at roof, in -rack fire sprinklers Valuation: $$32,000.00
Existing building area: square feet
New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City/State/ZIP: Existing:
Phone: ( ) Fax: ( ) New:
® APPLICANT ® CONTACT PERSON
NOTICE
Business name: Western States Fire Protection Co. All contractors and subcontractors are required to be
Contact name: Darrell Fluit licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 13896 Fir Street, Suite B jurisdiction in which work is being performed. If the
City/State/ZIP: Oregon City, OR 97045 applicant is exempt from licensing, the following reasons
apply:
Phone: (503) 657 -5155 Fax: : (503) 657 -5182
E -mail: darrell.fiuit@wsfp.us
CONTRACTOR BUILDING PERMIT FEES*
(Please refer to fee schedule
Business name: Western States Fire Protection Co. ` U
Permit fee:
Address: 13896 Fir Street, Suite B
State surcharge (8% of permit fee): I Q 3
City/State/ZIP: Oregon City, OR 97045 FLS plan review (40% of permit fee):
Phone: (503) 657 -5155 'Fax: (503) 657 -5182 (Due upon application)
t I XQ • L f 3
CCB lic.: 104570 Total permit fees:
xe 4 Authorized signature:
Amount received:
This permit application expires if a permit is not obtain d
Print name: Darrell F uit Date: 02/13/08 within 180 days after it has been accepted as complete.
■ • Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits \FPS- PermitApp.doc 03 /23/06 440.4613T(II /02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist .
Page 2 - Supplemental Information
Describe work to be done:
1.) ® New 2.) Modification to sprinkler heads only:
❑ Addition ❑ 1 -10 heads: No plan review required.
❑ Alteration ® 11+ heads: Plan review required.
❑ Repair
Number of sprinkler heads: 133
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
® Wet ❑ Dry
Additional Standpipes
Information: Hazard Group rubber tires
Density N/A
Design Area # of spr.
K. Factor 25.2
Sprinkler Project Valuation: $ $32,000
• B.) Type I - Hood Fire Suppression System
Hood Project Valuation: I $
J t
� I C.) Fire Alarm
Submittal shall Battery Calculations ❑ Yes
include: Individual Component ❑ Yes
Cut Sheets •
Fire Alarm Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $187.50
2,001 to 3,600 $232.50 •
3,601 to 7,200 $292.50
7,201 and greater $381.50
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $ 32,000.00
•
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (8% of permit fee): $
FLS Plan Review (40% of permit fee): $
TOTAL: $ 404.44
Plan review requires a completed application and 2 sets of plans at submittal. Plan review fees are required at submittal.
"New" fire protection systems require that plans bear the original seal of an Oregon licensed fire suppression
engineer, or NICET level "3" technicians.
C: \My Data \ Drawings \L00016 - AMERICAN TIRE \City of Tigard permit applicationloc
07/30/2008 08:46 5036575182 WSFP PAGE 02/03
0Pa00 ? - 6 0 63
_ CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR A BOVEGROUND PIPING
PROCEDURE
Upon completion of work, Inspection and tests sha0 be made by The contractors representative and witnessed by an owners representative. All defects shall be corrected and system left le service
before contractors personnel finely leave the job.
A certificate shell be filled out and signed by both representatives. Copies shall be prepared for approving authorities. mars, and contractor. It Is understood the owners representative's
signature In no way prejudices any calm against contractor for faulty materiel, poor woncmanehip, or failure to comply with approving authority's requirements or local ordinances.
PROPERTY NAME Date
America's Tire . re
•
. 7
•
PROPERTY ADDRESS
11462 SW Pacific Hwy., Tigard, OR 97223
ACCEPTED BY APPROVING AUTHORITY('S) NAMES Cify of Tigard
ADDRESS 13125 SW Hag Blvd.
Huard. OR S7223
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS El YES ❑ ND
EQUIPMENT USED IS APPROVED ® YES ❑ NO
IF NO, EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION ® YES 0 NO
OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT?
IF NO, EXPLAIN
INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON NE PREMISES:
1. SYSTEM COMPONENTS INSTRUCTIONS IEl YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS ® YES ❑ NO
3. NFPA 13A ® Y ES [I NO
LOCATION SUPPLIES BUILDING: WET SYSTEM
OF SYSTEM _ _
YEAR OF ORIFICE TEMPERATURE
MAKE MODE, MANUFACTURE SIZE QUANTITY RATING
RELIABLE Fl Upright - 2008 'A" 64 286 °F
RELIABLE Fl Uptight 2008 ' 'A" 26 155 °F
SPRINKLERS RELIABLE Fl Upright 2008 '�4" 12 200 °F
RELIABLE FIFA Ree aced Pendent 2008 'A" 20 155 °F
RELIABLE Fl Horizontal Sidewall 2008 ',4" 6 212 °F
•
PIPE AND Type of Pipe, Sehodule Schedule - 40
FITTINGS Type of Fgtings: Caat wow 125 #, grooved, CFVC fitting
MAXIMUM TIME TO OPERATE
ALARM DEVICE THRU TEST, CONNECTION .
ALARM VALVE TYPE MAKE MODEL MN. SEG
OR FLOW Flow Indhcntor POTTER VSR 0 ...tli
INDICATOR J
DRY VALVE CAD.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP TRIP POINT TIME WATER ALARM
THRU TEST WATER PRESSURE AIR PRESSURE AIR REACHED OPERATED
CONNECTION' PRESSURE TEST OUTLET' PROPERLY
DRY PIPE MM. SEC. PSI PSI PSI MIN, SEC, YES NO
OPERATING Without ❑ ❑
TEST O.O.D.
WI4i 0 ❑
0.0.13,
IF NO, EXPLAIN:
'MEASURED FROM TIME INSPECTOR'S TEST CONNECTION OPENED. (OVER)
•
07/30/2008 08:46 5036575182 WSFP PAGE 03/03
OPERATION
❑ PNEUMATIC ELE CTRIC HY DRAULIC
•
PIPING SUPERVISED ❑ YES ❑ NO DETECTING MEDIA SUPERVISED YES NO
DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS ❑ YES NI NO
16 THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO, evud
DELUGE &
PREACTION 0 YES ❑ NO
VALVES
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT OPERATE VALVE MAXIMUM TIME TO
MAKE MODEL SUPERVISION LOSS ALARM? RELEASE? OPERATE RELEASE
YES ND NO MIN. SEC
in o CI
HYDROSTATIC; kyr/rastetns tests shall be made at not lees then 200 951(13,5 bars) for two hours or 59 p51(3.4 bras) abate shalt pressute in excess tr1150 pal (10.2 bars) Ter two hours.
TEST Differential ary.plpe valve clappers shall be left open durin0 teel t0 prevent damage. MI aboveground OIDIMA leakage Shah be slopped.
DESCRIPTION PNEUMATIC: Establish 40 ps1(27 bats) air pressure ltd measure drop which shall net exceed 1 -1 f2 051(0.1 bars) In 24 hours. Test pressure hale at ,aural water level and air pressure and
measure atpreaswe drop whldt shall not exceed 1.12 psi (0.1 bars) In 24 hours.
ALL PIPING PNEUMATICALLY TESTED AT 40 PSI FOR 24_ HRS. IF NO, STATE REASON:
DRY PIPING PNEUMATICALLY TESTED ❑ YES ❑ NC
EQUIPMENT OPERATES PROPERLY D YES 0 NO
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM 6IUCATE OR DERIVATIVES Of SODIUM SILICATE, BRINE. OR
OTHER CORROSIVE CHEMICALS WERE NOT USE) FOR TESTING SYSTEMS OR STOPPING LEAKS?
TESTS ❑ YES D NO
DRAIN READING OF GAGE LOCATED NEAR WATER SUPPLY TEST RESIDUAL PRE WITH VALVE IN TEST
TEST _ [ CONNECTION: Q P SI CONNECTION OPEN WIDE L 1 PSI
UNDERGROUND MAIN AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING
OTHER EXPLAIN
VERIFIED BY COPY OF THE U FORM NO.85B ❑ YES Q NO
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING 0 YES ❑ NO
BLANK NUMBER USED LOCATIONS: NUMBER REMOVED
TESTING
GASKETS -
WELDED PIPING ® YES 0 NO
IF YES...
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY
WITH THE REQUIREMENTS OF AT LEAST AWS 010.9, LEVEL AR-37 ® YES D NO
DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUAUFI IN
WELDING COMPLIANCE WITHTNE REQUIREMENTS OF AT LEASTAWS D10.9, LEVELAR.3? ® YES ❑ NO
DO YOU CERTIFY THAT WELDING WAS CARRI OUT IN COMPLIANCE tam A DOCUMENTED
QUALM/ CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS
IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED AND THAT
THE INTERNAL DIAPAETERS OF PIPING ARE NOT PENETRATED? ® YES 0 NO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT. ALL
r S CUTOUTS (DISCS) ARE RETRIEVED? Ca YEs 0 No
HYDRAUUC NAME PLATE PROVIDED IF NO, EXPLAIN;
DATA
NAMEPLATE 12I YES ❑ NO
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS
NAME OF SPRINKLER CONTRA • Western States Fire Protection Com'an
TESTS WITH® BY
FOR PROPERTY OWNS K t ' = TITLE �!}' I � ��- DATE �
SATURES -'S r,: � 7 /4fT
r r i ,, , : GO' OR (SIGNED) DATE ��p-
� ty� � � PAZ/ r-Ad — I — 7 ' "f►
f�� • L FIRE MARSH ( ED) TITLE DATE
� ® �1 ... OYES i51 TITLE DATE
fl -C 1 Al z `
DATE
I I
ADDITIONAL EXPLANATION AND NOTES (BACK)
•
CITY OF TIGARD
BUILDING DIVISION PERMIT #: B UP2008 -00103
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/23/2008
Phone: (503) 639 -4171 x;ii4,,� .� ill
Inspection Requests (24 Hrs.): (503) 639 -4175 ''__..
INSPECTION WORKSHEET FOR DATE: 7/31/2008 TIME 7:00AM PAGE: 52
SITE ADDRESS: 11462 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: AMERICAS TIRE COMPANY LOT #: 003 TYPE OF USE:
PROJECT NAME: DISCOUNT TIRE COMPANY
DESCRIPTION: Fire sprinkler system.
OWNER: HALLE PROPERTIES LLC, PHONE #:
CONTRACTOR: WESTERN STATES FIRE PROTECTION PHONE #: 503.657 -5155
Inspection Request Scheduled For: Date: 7/31/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
999 Sprinkler final 073485-01 971 - 409 -3248
Corrections /Comments /Instructions:
%j PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL • CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: _ / Date: 7 / Phone #: (503) 718-
CITY OF TIGARD
BUILDING DIVISION PERMIT #: BUP200B -00103
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/23/2008
Phone: (503) 639 -4171 ! to
Inspection Requests (24 Hrs.): (503) 639 -4175 ..L. P_
INSPECTION WORKSHEET FOR DATE: 7/22/2008 TIME: 7 :01AM PAGE: 61
SITE ADDRESS: 11462 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: AMERICAS TIRE COMPANY LOT #: 003 TYPE OF USE:
PROJECT NAME: DISCOUNT TIRE COMPANY
DESCRIPTION: Fire sprinkler system.
OWNER: HALLE PROPERTIES LLC, PHONE #:
CONTRACTOR: WESTERN STATES FIRE PROTECTION PHONE #: 503-657 -5155
Inspection Request Scheduled For: Date: 7/22/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
dir tyl!D_
909 Sprinf3er final 072982-01 971-409-3144
Corrections/Comments/Instructions: AAA
` 444 C� Z- � `r�l'�f z s�7�c ,u (i ' O r�
Z� i ? Po / I ( AI P i•-) l_W0 �� N F l'
D
❑ PASS PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
4 ` CALL FOR INSPECTION [1] ADDITIONAL FEES ASSESSED
Inspector: Date: 7 zazg_ Phone #: (503) 718- _2_12_,X
CITY OF TIGARD •
BUILDING DIVISION I PERMIT #: BUP2008 -00 1 03
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/23/2001'!
Phone: (503) 639 -4171 1
Inspection Requests (24 Hrs.): (503) 639 -4175 1. °TI � ..
INSPECTION WORKSHEET FOR DATE: 7/17/2008 TIME: 7:00AM PAGE: 46
SITE ADDRESS: 11462 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: AMERICAS - TI RE COMPANY LOT #: 003 TYPE OF USE:
PROJECT NAME: DIf3COUNT TIRE COMPANY
DESCRIPTION: Fire sprinlder system.
OWNER: HALLE PROPERTIES LLC, PHONE #:
CONTRACTOR: WESTERN STATES FIRE PROTECTION PHONE #: 503 - 657 -5155
Inspection Request Scheduled For: Date: 7/17/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
910 Sprinkler rough -in /test 072790-01 971 - 409-3144 Y
Corrections /Comments /Instructions:
(---- / , _ .,
(. /A ,7f PARTIAL APPROVAL ❑ CANCEL El NO ACCESS
❑ FAIL CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: ? / Voi5 Phone #: (503) 718-
CITY OF TIGARD
BUILDING DIVISION PERMIT #: BUP2008•00 iO3
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/23/20013
Phone: (503) 639- 4171i p tall
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 7/10/2008 TIME: 7:00AM PAGE: 26
SITE ADDRESS: 11462 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: AMERICAS TIRE COMPANY LOT #: 003 TYPE OF USE:
PROJECT NAME: DISCOUNT TIRE COMPANY
DESCRIPTION: Fire sprinkler system.
OWNER: HALLE PROPERTIES LLC, PHONE #:
CONTRACTOR: WESTERN STATES FIRE PROTECTION PHONE #: 503-G57- 5156
Inspection Request Scheduled For: Date: 7/10/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
991-7 Misc. inspection 072431 -01 503 -657 -5155 N
Corrections /Comments /Instructions:
/11 a.4 fe_.--er
l �`v l 1-7 C/ ? Al 4 — 7 i1 tr l L 4
C_ • 4 PPS e_*/( , .. -at--- PI_A ) v )
❑ PASS I PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
41191 ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
/ ---z----
7/
Inspector. Date: / D 6 Z 6 Phone #: (503) 718- V
1
CITY OF TIGARD
BUILDING DIVISION PERMIT #: BUP2008.00103
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/23/2008
Phone: (503) 639 -4171 Arti Inspection Requests (24 Hrs.): (503) 639 -4175 . _..
INSPECTION WORKSHEET FOR DATE: 7/8/2008 TIME: 7:00AM PAGE: 14
SITE ADDRESS: 11462 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: AMERICAS TIRE COMPANY LOT #: 003 TYPE OF USE:
PROJECT NAME: DISCOUNT TIRE COMPANY
DESCRIPTION: Fire sprinkler system.
OWNER: HALLE PROPERTIES LLC, PHONE #:
CONTRACTOR: WESTERN STATES FIRE PROTECTION PHONE #: 503 -657 -5155
Inspection Request Scheduled For: Date: 7/8/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
995 Misc. inspection 072327 -01 971-409-3150 Y
Corrections /Comments/ Instructions:
'w. itko - ezor to co/t4etki
fi 4/CC�l1 -A--
Im11�Ji\IL�ill
4: & I
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❑ P'S ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL pl CALL FOR INSPECTION 0 ADDITI NA FEES ASSESSED
Inspector: / z Date. lJ�= ? Phone #: (503) 71 4
IPP
CITY OF TIGARD
BUILDING DIVISION PERMIT #:'fit' zm ( cc,/ a 3
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 +�
Inspection Requests (24 Hrs.): (503) 639 -4175 !i L.
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: 1iy6Z s►../ P - c_ Nwy CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: 17tsco‘,r+r T rZcz c_,r- ccoA- ,.so.f
DESCRIPTION: ciQE S �2INK syscP -1
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: Pour Time:
Code # Inspection Description Confirm # Contact # Message
5PiziN+( IZ. g_c ?(om 1 Z 971- -L/ y_ '
Corrections/Comments/Instructions:
l ui , -/ L. ° � /l.)
❑ PASS /i 'ARTIAL A � ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
_625_ Inspector: , / Date: _ O Phone #: (503) 718- 26 g