Permit „-/
.CITY OF T MASTER PERMIT
PERMIT # • MST96 -0370
COMMUNITY DEVELOPMENT DEPARTMENT DATE ISSUED: 07/30/96
13125 SW Hall Blvd. Tigard, Oregon 97223.8199 (503) 839 -4171
PARCEL: 2S104DD -02000
SITE ADDRESS...: 12876 SW RIDGEFIELD LN
SUBDIVISION • MOUNTAIN HIGHLANDS ZONING: R -4.5 PD
BLOCK LOT -017
Remarks: Path 1
-- --
____________________________________ BUILDING _____________________
REISSUE: STORIES • 2 FLOOR AREAS- - BASEMENT...: 432 sf REQUIRED SETBACKS - -- REQUIRED
CLASS OF WORK.:NEW HEIGHT • 26 FIRST • 1143 sf GARAGE • 492 sf LEFT • 41 SMOKE DETECTRS: Y
TYPE OF USE...:SF FLOOR LOAD • 40 SECOND...: 1322 sf FRONT • 23 PARKING SPACES: 1
TYPE OF CONST.:5N DWELLING UNITS: 1 FINBSMENT: 0 sf RIGHT : 16
OCCUPANCY 6RP. :R3 BDRM: 3 BATH: 3 TOTAL - - - -: 2465 sf VALUE..$: 174626 REAR • 15
--- - -- ------ - - - - -- PLUMBING ------------- -- - - -- - -
SINKS • 1 WATER CLOSETS.: 3 WASHING MACH..: 1 LAUNDRY TRAYS.: 1 RAIN DRAIN ft: 0 TRAPS • 0
LAVATORIES : 4 DISHWASHERS...: 1 FLOOR DRAINS..: 0 SEWER LINE ft: 0 SF RAIN DRAINS: 1 CATCH BASINS..: 0
TUB /SHOWERS...: 3 GARBAGE DISP..: 1 WATER HEATERS.: 1 WATER LINE ft: 1% BCKFLW PREVNTR: 1 GREASE TRAPS..: 0
OTHER FIXTURES: 0
--- - - - - -- MECHRNICAL -------- - - - - -- ----=-------------- - - - - --
FUEL TYPES - --- FURN ( 100K ..: 0 BOIL /ChB ( 3HP: 0 VENT FANS • 4 CLOTHES DRYERS: 1
/GAA /S / / FURN ) =100K ..: 1 UNIT HEATERS..: 0 HOODS • 1 OTHER UNITS...: 1
MAX INP.: 0 BTU FLOOR FURNACES: 0 VENTS • 0 WOODSTOVES....: 0 GAS OUTLETS...: 1
ELECTRICAL ------ - ----- ------ - - - - -- - - - -
— RESIDENTIAL UNIT -- — SERVICE /FEEDER - -- —TEMP SRVC /FEEDERS -- -- BRANCH CIRCUITS -- — MISCELLANEOUS -- — ADD'L INSPECTIONS- -
1000 SF OR LESS: 1 0 - 2•' alp..: 0 0 - 200 alp..: 0 W /SVC OR FDR..: 0 PUMP /IRRIGATION: 0 PER INSPECTION: 0
EA ADD'L 500SF.: 5 201 - 400 alp..: 0 201 - 400 amp..: 0 1st W/O SVC /FDR: 0 SIGN /OUT LIN LT: 0 PER HOUR • 0
LIMITED ENERGY.: 0 401 - 6'.' amp..: 0 401 - 600 amp..: 0 EA ADDL BR CIR: 0 SIGNAL /PANEL...: 0 IN PLANT • 0
MANF HN /SVC /FDR: 0 601 - 1''Y amp.: 0 601 +amps- lw v: 0 MINOR LABEL -10: 0
1000+ amp /volt.: 0 ----------------------------------- PLAN REVIEW SECTION -------------- — __—
Reconnect only.: 0 )=4 RES UNITS..: SVC /FDR) =225 A.: ) 6% V NOMINAL: CLS AREA /SPC OCC:
-------------------------------------- ELECTRICAL - RESTRICTED ENERGY ---------- - - - - -- - -
A. SF RESIDENTIAL----- - - ---- --- B. COMMERCIAL------ - - - - -- — _— _-- _- -_ - - --
AUDIO 8 STEREO.: VACUUM SYSTEM..: AUDIO 8 STEREO.: FIRE ALARM INTERCOM /PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM..: 0TH: :: X BOILER HVAC LANDSCAPE /IRRI6: PROTECTIVE SIGNL:
GARAGE OPENER..: CLOCK • INSTRUMENTATION: MEDICAL OTHR: ..
HVAC • DATA /TELE COMM.: NURSE CALLS • TOTAL # SYSTEMS: 0
Owner: ---- - - - - -- -- Contractor: -------------- - - - - -- TOTAL FEES:$ 4763.96
DAVID SCHWERDT OWNER
9407 SW MAPLEWOOD DR #17138
TIGARD OR 97223
Phone #: 620 -5404 Phone #:
Reg #..: 13125
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Specialty Codes and all other
applicable laws. 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.
------------------------------- - - - - -- REQUIRED INSPECTIONS ------- - - - - -- - - - -
Footing Insp PLM /Underfloor Framing Insp Insulation Insp Electrical Final
Foundation Insp Mechanical Insp Shear Wall Insp Gyp Board Insp Mechanical Final
Post /Beam Struct Plumb Top Out Low Voltage Rain drain lnsp Plumb Final
Post /Beam Mechan Electrical Servi Gas Line Insp Water Line Insp Building Final
Crawl Drain Electrical Rough as F Appr /Sdwlk Insp Erosion Control
Permittee Signature” AF /0. / Issued `''fit v
Call for inspection — 639 -4175
• Plan Check # c;
:;ITY OF TIGARD Residential Building Permit Application Rec'd By �
;3125 SW HALL BLVD. New Construction Additions or Alterations Date Recd °.-° s
1GARD, OR 97223 Single Family Detached or Attached Date to P.E. / -4 3 - 9 10
iO3) 639 -4171 Date to DST 7 - 2 4 1 - 9 6
Print or Type Permit # Wily- 0'310
Called ; ( I /toa
Incomplete or illegible applications will not be accepted '0,,
Name of Subdivision Pvfaseh f.2 :a..waa � Lot # a e
M
Job a )074x' t4(L,rla.4Mos (7 Architect Mailing Address
Address Site Address ID
r tai A
1.22 1.22 (.�. al oc*sFrJaLa l..0 13aS N Yrt
Cj i /State „pp Phone
!pave y, dam at . li�q 229 Q I lv l
A Yi, Y p I S C th)tEfL» " "
Owner ?Oiling Address ame
9 4.07 Lam j " 't lla. I 1 �3S Engineer Mailing Address
¶
C /State ,..Zip Phone g
� 6 aP Z G • { 7223 (o2) S 4 * City/State Zip Phone
Name �'�v
General , 'i f Describe work new 0 addition 0 alteration O repair O
Contractor Mailing Address to be done:
Additional Description of Work:
City/State Zip Phone
Oregon Const. Cont. Board Lic.# Exp. Date
` Attach Copy of Project • 0
Current COT Business Tax or Metro # Exp. Date Valuation 17 4 4 i-1 ,
Licenses r
N me NEW CONSTRUCTION ONLY:
Mechanical cad.- RD Sq.Ft. House: _ ♦4 3V' L Sq.Ft.Garage:
Sub Mailing Address f) r3^ �" X12
Contractor pp , .A2.2" Corner Lot Yes No iFlag Lot Y No
City/State Zip - Phone (check one) (/ (check one)
14( uSec22002- j',2) [o4-0 wool a f ' Restricted Audio /Stereo Burglar
Oregon grist. Cont. Board Lic.# Exp. Date z -0- /J Energy System X Alarm
Attach Copy of O03 c.m 2 a 7 1 4. a
Current COT Business Tax or Metro # Exp. Date Installation Gara Door HVAC
Licenses (1? t - ( -9 (, X Opener K Systems
Name (check all that Other.
Plumbing 0nc..cosa- RV t16/t3v CrAt7r apply) K \Mc
Sub- Mailing Address Will the electrical subcontractor wire for all Yes N
restricted energy installations?
Contractor Pb 00.i.; 20v'i Has the Subdivision Plat recorded? N/A Ye v
o
City/State Zip Phone
62a 04.1703D LAO 17g
Oregon Const. Cont. Board Lic.# Exp. Date Reissue of MST# Solar Compliance
Attach Copy of 023 Vol tv lt`(l9 7 f (Calculation Attached
Current Plumbing Lic. # Exp. Date ✓ I hereby acknowledge that I have read this application, that the
Licenses 2 (o - 2 p S T $ SS / 3 S� c)lo information given is correct, that I am the -owner or authorized agent of
COT Business Tax or Metro # Exp. Dat the owner, and that plans submitted are in compliance with Oregon
cj 0 O.$ I State laws.
Name Sig• -ture of a ner /Agent / Date
AI i�'L lJ/ k !u i A. .../ 7- -
Electrical F/�Q 6 (..a.c a ics. Co tact Pers n • me Phone •
Sub- Mailing Address g k
vii ..)ACior 6 6.2 (02o S - 4
1 Contractor -74-o2 I,JR . t ( Z € Th iLa. FOR OFFICE USE ONLY:
Y:
Vg City/State /State Phon Plat # Ma /TL #:
s)co=i+ia 2� A "FL - '3 1 a° 2 LU].Z p may,
Oregon Const. Cont. Board Lic.# Exp. Date 1 h - yg I Z5 Li DD —2iZ 7
Attach Copy of oV) 3 0 to /2. /7/ Setbacks Zone: Solar:
� - ��
Current Electrical Lic. # Exp. Date e .....
Licenses 37 - 271 G (0 1 �t (. ✓ ��� T Y,
C T Busines Tax or Metro # Exp. Date Engineering Approval: Planning Approval: TIF:
Re ACID / � Y � V n l B o
- \dsts\mstapp.doc 4/) r 7.2 N A /0 •
Permit # Account Description Amount Amt. Pd. Bal. Due
tis,96- 0370 MST. Permit (BUILD) ‘070,s7) , '57)
Plumb. Permit (PLUMB) 22 e ) ; (-9
Mech. Permit (MECH) dV ��: cti
ELC /ELR Permit (ELPRMT) 0 2 75
State Tax (TAX) Se. Z( S f, t r
Bldg: 31,0 3
Plumb: /1' 2
Mech: , 2 ;-
ELC /ELR: 1.3. 1 (
Plan Check
MST: - 't` (BUPPLN) 3 , 3 3 C� / 3
A/ S3, 3
Plumb: (PLMPLN)
Mech: (MECPLN) //, 2 //. 2
CDC Review (LANDUS) -VU Li 0
54,040 3Sa Sewer Connection (SWUSA) r .2„), U v ?)-oU
Sewer Inspection (SWINSP) 3 .)` 3 j
Parks Dev Charge (PKSDC) /05 v / OS o
Residential TIF (TIF -R) /5 / 3 76
Mass Transit TIF (TIF -MT) / 2-e / 2j
Water Quality (WQUAL)
Water Quantity (WQUANT) / UL) / by
Erosion Control Permit (ERPRMT) 6 $ C y
Erosion Planck/USA (ERPLAN) c2e
Erosion Planck/COT (EROSN) 2v
Fire Life Safety (FLS)
TOTALS: 203,..4-0(-6--
0 3,.. - 0( 6-- 7'dr• ��
i:\dsts\rnstapp.doc
Rev. 7/96
Solar Balance Point Standard Worksheet
Address
Box A calculations: North -South dimension for the lot. Box A:
This dimension is determined by finding the midpoint of the North lot line and drawing
an intersecting line perpendicular to that point.
First, determine which property line is the North lot line. The North lot line is the line
with the smallest angle from a line drawn east -west and intersecting the northern most
point of the lot.
45' —•
t
IO NO A 6 4 !
NORTHERN
N North -South
Dimension for Lot:
Measure the distance from the midpoint of the North lot line to the South lot line along
the described line. '72. feet
• •
_
NOR415OUIH DOAET6gN
Box B calculations: Shade point height for your residence. Box B•
1. Determine whether measurements will be based on the peak or eave of your Which describes
structure. The orientation of the ridge is also important your residence?
MCI
1a: If the roof line runs North - South, measurements will 'N
f� (circle one)
• i�
be based on the peak of the roof. o 0 o c
mu Lin
Nami 1A 1B
1 b: If the roof line runs East -West and the roof pitch is
less than 5/12, measurements will be based on the
eave.
SHADE POINT EAVE
•
lc: If the roof line runs East -West and the roof pitch is
5/12 or steeper, measurements will be based on the - o QZI�,
peak.
swnE PJM RDGE
•
Box B. continued Box B:
2. Measure change in elevation from front property line to finished floor elevation. If
the lot slopes up from the front lot line to the foundation, the figure is positive. If ft
the lot slopes down from the front lot line to the foundation, the figure is negative.
3. Measure distance from finished floor elevation to the affected peak/eave. + 33 2. .. ft
4. If the roof line runs North - South, deduct three feet. If the roof line runs East -West, - ft
deduct nothing.
5. Subtract one foot for each foot of difference in elevation from the front property
line to the rear property line, if the lot slopes up from the front to the rear. If the
lot has no slope or slopes up from the rear to the front, deduct nothing. - ft
6. Total figure for box B: -' i( . 3o. 's ft
Box C. Distance to the shade reduction line. Box C:
1. Measure the distance from the North property line to the foundation near the a3. O ft
affected peak/eave.
2. Measure the distance from the foundation to the affected peak or eave. + I t',P , () ft
3. Total figure for box C: 35 r c7 ft
It is most useful to draw a vertical line to represent the appropriate figure found in box "A" and a horizontal line to represent the
appropriate figure found in box "C ". The intersection of the vertical and horizontal lines determines the value found in box "D ". The value
in box "D" should be compared to the value in box "B "; if the value in box "B" is less than or equal to the value found in box "D ", then
the building is in compliance with the solar balance code. If you have any questions, please contact us at 639 -4171, x304 or at the
Community Development Counter.
MAXIMUM PERMITTED SHADE POINT HEIGHT (In Feet)
Distance to North -south lot dimension (in feet)
shade 100+ 95 90 85 80 7 70 65 60 55 50 45 40
reduction line
from northern •
70 40 40 40 41 42 g 44
65 38 38 38 39 40 • 42 43
60 36 36 36 37 38 3: 40 41 42
55 34 34 34 35 36 38 39 40 41
50 32 32 32 33 34 3. 36 37 38 39 40
45 30 30 30 31 32 3; 34 35 36 37 38 39
_ _ t 33 34 35 36 37 38
35 26 26 26 27 28 2: 30 31 32 33 34 35 36
30 24 24 24 25 26 2' 28 29 30 31 32 33 34
25 22 22 22 23 24 2, 26 27 28 29 30 31 32
20 20 20 20 21 22 2'; 24 25 26 27 28 29 30 '
15 18 18 18 19 20 2h 22 23 24 25 26 27 28
10 16 16 16 17 18 1d 20 21 22 23 24 25 26
5 14 14 14 15 16 1 18 19 20 21 22 23 24
I Box D. Maximum allowed shade point height: Cal L.,025 3 .3 feet
h:Wocs\nancy\ventura\solar.chp
Revised 2/26/96
WATER METER FIXTURE UNIT WORKSHEET
Contractor Name 04 1101 (romt C#etIOtt.2 OQ -
Billing Address l4O7 APLa t.J�ra O2. j j I ( '-S $ T( 972z
Site Address of New Meter \ 2 $710 S ( R t, ut,ag t (
`p ,
Lot # Subdivision { OUP ;`1:4 0 7 t(PA •- .O6JOS P °Z
Please fill in the number of each fixture as detailed on the plans, then multiply quantity by the point value given to arrive at
the point total. Add all point totals together for total fixture unit points.
Fixture Unit Quantity Point Value Point Total
Hose Bibs X 3 = (a
Toilets 3 X 3 = q
Bath Tubs Z X 2 =
Shower Stalls t X 2 = 2.
Lavatories 4 X 1 =
Kitchen Sink � X 2 = 2
Laundry Sink ( X 2 = 2.
Bar Sink X 2 =
Clothes Washer I X 2 = Z,
Sprinkler Heads X 1 =
TOTAL FIXTURE UNIT POINTS
Meter Size: Meter Cost:
5/8" x 3/4" 1"
Total Fixture Unit Points 32 = 5/8" x 3/4" meter Bull Mountain Area $1,325 $2,435
Total Fixture Unit Points 33 = I" meter Lower Elevation $1,170 $2,125
FOR OFFICE USE ONLY
Fixture Count Verified with Plumbing Permit
-
Meter #
Receipt #
Emp. Name
7/96
Page No. 1 CASE HISTORY FOR CASE NO.: MST96 -0370
DAVID SCHWERDT
12876 SW RIDGEFIELD LN
12/03/97
Action Description Reg/ Schd/ End/ Action Notes Disp By Update Upd
Code Sent Done Done Date By
MSTA005 Application received / / / / 07/05/96 PASS JD 07/24/96 BT2
MSTA008 Permit Created / / / / 07/23/96 PASS BON 07/24/96 BT2
MSTA010 Check for prcl. restrict. / / / / 07/23/96 PASS BON 07/24/96 BT2
MSTA012 Plans routed to Plans Examiner / / / / 07/23/96 PASS BON 07/24/96 BT2
MSTA026 Plans approved by Plans Exmr / / / / 07/24/96 PASS RT 07/24/96 BT2
MSTA030 Reviewed plans routed to DSTS / / / / 07/24/96 PASS AT 07/24/96 BT2
MSTA080 (F) Ready to issue / / / / 07/30/96 PASS CJS 07/30/96 CJS
MSTA092 (F) Issue combination permit / / / / 07/30/96 PASS JSD 07/30/96 JD
MSTA097 Issue plumbing signature form / / / / 07/30/96 RECD JT 08/21/97 JT
MSTA098 Issue electric signature form / / / / 07/30/96 RECD JT 08/21/97 JT
MSTA705 Footing Inep / / / / 08/21/96 seismic restraint; ufer tagged PASS RB 08/22/96 RB
MSTA706 Foundation inep / / / / 08/28/96 N/R KS 08/30/96 KBS
MSTA706 Foundation Inep / / / / 08/29/96 # - isolated piers not included this A/N KS 08/30/96 IBS
inspection.
piers located on upper level needs to
be lowered
will pour with basement slab
MSTA710 Post /Beam Structural / / / / 12/04/96 APP KS 12/04/96 KBS
MSTA711 Post /Beam Mechanical / / / / 12/04/96 APP KS 12/04/96 KBS
MSTA713 Crawl Drain / / / / / / 07/23/96 BON
MSTA717 PLM /Underfloor / / / / 10/30/96 fernco not intended to be used as a FAIL MS 10/31/96 MRS
repair coupling
MSTA720 Mechanical Insp / / / / 12/02/96 #-1- see correction n otes DIS KS 12/03/96 KBS
MSTA720 Mechanical Inep / / / / 12/05/96 # -1- support SST gas tubing at crawl A/N KS 12/05/96 KBS
space four ft o/c
# -2- provide light and receptacle
adjacent to furnace
located in crawl.
MSTA722 Plumb Top Out / / / / 11/26/96 PASS MS 11/26/96 MRS
MSTA723 Electrical Service / / / / 11/25/96 PASS TLP 12/19/96 TLP
MSTA724 Electrical Rough In - / / / / 11/25/96 PASS TLP 12/19/96 TLP
MSTA725 Framing Insp / / / / 12/02/96 # -1- see corrections notes DIS KS 12/04/96 KBS
MSTA725 Framing Insp / / / / 12/04/96 APP KS 12/04/96 IBS
MSTA726 Shear Wall Inep / / / / 12/03/96 • APP KS 12/03/96 KBS
MSTA735 Gas Line Inep / / / / 12/05/96 # -1- Gas test 60 PSI for thirty minutes= A/N KS 12/05/96 KBS
two lbs supply piping sized
from two lbs table as installer
indicated
•
MSTA740 Insulation Inep / / / / 12/09/96 • APP KS 12/09/96 KBS
MSTA745 Gyp Board Inep / / / / 12/13/96 APP KS 12/13/96'KBS
Page No. 2 CASE HISTORY FOR CASE NO.: MST96 -0370
DAVID SCHWERDT
12876 SW RIDGEFIELD LN
12/03/97
Action Description Req/ Schd/ End/ Action Notes Disp By Update Upd
Code Sent Done Done Date By
---- --- -- ---- -- - --
MSTA755 Rain drain Insp / / / / 09/05/96 PASS MS 09/06/96 MRS
MSTA760 Water Line Insp / / / / 09/10/96 PASS MS 09/11/96 MRS
MSTA765 Appr /Sdwlk Insp / / / / 04/04/97 FINAL. PASS PI 04/07/97 RB
MSTA770 Misc. Inspection / / / / 09/11/96 # -1- slab on grade basement insulate DIS KS 09/12/96 KBS
total perimeter
of slab also need vapor barrier
MSTA770 Misc. Inspection / / / / 09/12/96 # -1- slab on grade/ basement fl APP KS 09/12/96 KBS
MSTA770 Misc. Inspection - / / / / 01/28/97 #-1- slab on grade= garage fl APP KS 01/29/97 KBS
MSTA790 Electrical Final / / / / 04/01/97 strap service conduit DIS MJR 04/03/97 MJR
' to -volt installation not complete
protect conductor to furnace
no rear grade level plug
MSTA790 Electrical Final / / / / 04/03/97 prey elec corr appr APP GS 04/03/97 GES
MSTA795 Mechanical Final / / / / 07/23/97 No one available, couldn't make FAIL KS 07/23/97 J *H
inspection. Please reschedule.
MSTA795 Mechanical Final / / / / 07/29/ 3)Wea MS3118TCHa DaV8e N15t40 99i PASS KS 08/20/97 J *H
MSTA797 Plumb Final / / / / 04/03/97 needs hot water FAIL MS 04/04/97 MRS
MSTA797 Plumb Final / / / / 04/04/97 PASS MS 04/07/97 MRS
MSTA799 Building Final / / / / 04/04/97 # -1- need final erosion control app DIS KS 04/07/97 KBS
# -2- need plumbing finaled
# -3- provide deck at man door fem /rm
# -4- support gas piping at kitchen range
# -5- insulate door jambs at upper
storage
#- 6- provide landing at patio door
# -7- seal line from a/c unit condensing
unit not install
# -8- slope finish grade away from
structure
# -9- post insulation cert
MSTA799 Building Final / / / / 07/23/97 Please reschedule, no one available at PASS KS 07/23/97 J*H
11:00 on site.
•
•
Page No. 3 CASE HISTORY FOR CASE NO.: MST96 -0370
DAVID SCHWHRDT
12876 SW RIDGEFIELD IN
12/03/97
Action Description Req/ Schd/ End/ Action Notes Disp By Update Upd
Code Sent Done Done Date By
MSTA799 Building Final / / / / 07/29/97 1. Slope finish grade away from PASS KS 08/20/97 J +H
structure.
2. Homeowner will construct retaining
wall at both sides of property (or slope
finish grade).
MSTA960 (F) Issue Cert. of Occupancy / / / / 07/29/97 mailed 12 -3 -97 12/03/97 S*W
. MSTB708 Erosion Control / / / / / / 04/07/97 KBS
•
•
1
CITY OF TIGARD BUILDING INSPECTION DIVISION
24 -Hour Inspection Line: 639 -4175 Business Phone: 639 -4171
Date Requested: '7 - , 9' - A.M. - _ P.M. `' MST: % — 6 70
1
Location: r 74, 4%, f e re. CL-4 r/ 7) BUP:
Tenant: , / Suite: Bldg: MEC:
■ ° ' Contractor: _�t�_ L >` � I /�i _ . Phone: S �� g
�t 7 PLM:
Owner: I Phone: ELC:
"ttf< j-ifrt ELR:
SIT:
BUILDING con't) PLUMBING MECHANICAL ELECTRICAL SITE
Site •ost/Beam Post/Beam Post/Beam Cover /Service Sewer /Storm
Footing Roof UndFl/Slab Rough -In Ceiling Water Line
Slab Framing Top Out Gas Line Rough -In UG Sprinkler
Foundation Insulation Sewer Hood/Duct Reconnect Vault
Bsmt Damp Drywall Storm Furnace Temp Service MISC.
Masonry Ceiling Rain Drain A/C UG Slab
Shear /Sheath • Fire Spklr /Alm Crawl/Found Dr Heat Pump Low Volt
—
I Approved Approved Approved Approved Approved
Appr /Sdw . • . oved Not Approved Not Approved Not Approved Not Approved
I AL FINAL FINAL FINAL FINAL
- _ • OGv.c e� t,�y Zii__ r'�.�57'S2uC� '721...5774-4 u [o LO,
•tom✓ A-L. i., @ a rz 5" 6.0 '` -1 7
c®fL Ste,, d.r !,l C;'y24�,..7 'l/
•
D Call for reinspec on O Reinspection fee of $ req • ed before next inspection O Unable to inspect
Inspector: Date: *7 Page of