Case File EROSION CONTROL:
1. PROVIDE & MAINTAIN 8' (min) THICK
GRAVEL PAD & DRIVE UNTIL PERMANENT
o CONCRETE DRIVE IS IN PLACE.
2. FROVIDE & MAINTAIN SOIL SEDIMENT
��- FENCE AS INDICATED.
tv
r Svv ' - NOTE' CENTERLINE C 0 N C E P i
�1 9 SWINYM WILL PIN ALL EXTERIOR
DRjV FOl�l1Im COMERS AND PROVIDE
� 'w' o � -9•$rR� �3
02.00, MORTGAGE SURVEY.
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GAARDE STREETS�SCALE r? RAVUING L®T 55 EAGLE POINTE
-�. S.W. 1 /4 SEC. 3�S.E. 1/4 SEC. 4, &
N.W. 1 4 SEC. 10,T.2S,R.1 W, W.M.
CITY OF 'TI GAR D
WASHINGTON COUNTY, OREGON
``�---- --- ...... OCTOBER 14, 199�
_ Centerline Cc3n cep is Inc .
--AN EIGHT FOOT PUBLIC u'nUTY EASEMENT -�- ~ -OR - MSG CHECKED BY: WGDIII
SHALL EXIST ALONG ALL STREET FRONTAGE. SCALE 1»=2O' ACCO
8�i--82v4-4Drive.. GLQd§ton�e, _Oregon 97027
M: M!I�PLAT EAGLEPO L55EP 503 650-0188 fax 503-b�50=018J-----
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13937 SW AERIE DRIVE
CITY OF TIGARD nsTrp
DEVELOPMENT SERVICES PERMIT #. . . . . . . : MST9704675
13125 SW Hall Blvd.,Tigard,OR 97223 11503)639-4171 nnTE7 ISSUED: 10/30/97
PnRCEL.: 2r3103Cc—(,4'300
`;TTJ; WDRES)S. . . : 13937 SW AEE Tl*- D'
'nD I Q T"i T 01\11. . . . -.Ei)01-17 POINTE" 7rt`!1N[, : 11 PD
'Oct,, . . . . I,..nT. . . . TIJP7�131=7 TON: TTr,
,.irks: SFD - Path I
—---------------------—----------------------------- BUILDING ------------------------------------------------------- ----------
T"'F: STORIES....... : FLOOR BASEMENT,,.; 0 sf REQUIRED SE7WXS-- REQUIRED-_
cc OF WORK,:NEW HEIGHT........: 17 FIRST....: 1748 sf GARAGE.....: 430 sF LEFT..........: 3 ME OETrCTr):
OF USE...:9F FLOOR LOAD....: 40 SECOND...., 609 sf FRONT......... : 20 PARKING SPACES:
-7 OF CONST.:9N DWELLING LNITS., I FINBSMENT: 0 sf RIGHT.........: 5
T*NCY GRP. :R3 BDRM: 3 8A'H- 3 TOTAL— 2"It7 sf VALUE..S; 165285 REAR..........: 37
-------------------------------------------------------------- PLUMBING -
I WATER CL"Nar.S. 3 WASHING iv4CH..: 1 LAbWDRY TRAYS.. I RAIN DRAIN ft: 100 TRAPS.........: e
''ITORIES.... 'i DISHWASHERS... I FLOOR D,AINS., 0 SEWER LINE ft: 100 SF RAIN DRAINS: I CATCH BASIS.: 0
'SHMP.S... 3 GARBAGE DISP..: 1 WATER HEATERS, 1 WATER -INE ft: 108 BCKFLW PRSYNTR: I GREASE TRAPS.. : 0
OTHER FIXTURES: 0
—
TYPES----------- PAN ( INK I BOIL/CMP ( 3HPt 0 VENT FANS..... : 4 CATHES DRYERS: I
FURIN )=I W .. I UNIT HEATERS... 0 HOODS.........: 1 OTHER 'PITS...: I
INP, 0 BTU FLOOR FURNACES: 0 VENTS.......... 0 WOODSTOVES.... 0 GAS OUTLETS...: I
ELECTRICAL - -------
C CIRCUITS--- ----MISCELLANEOUS---- --ADDL INSPECTIONS--
'.SlDENTTM UNIT— --SERVICE/FEEDER---- --TEMPSRVC/FEEDERS--
'�! SF 'L"'r 1 e - 200 amp..: 0 e, 200 83P.. 0 W/SVC OR FDR..: 0 PW, /IRRIGATION: t Pr.R IKSPECTJJN: ?
.17 L 'J' 4 211 - 488 amp..: 0 201 400 amp.. 0 1st W/O SVCIFDRt 0 SIGN/OUT LIN LT: I PER HOUR......: 0
'Er PS: ? 401 - 609 alp,.: I? 4e', - 600 amp.,; 0 EA ADDL PR CIR: 0 SIGNAL/DIEL...: 0 IN PLANT...... .
IOM/SVC/FDR: P 601 - to alp.,. 0 601+aeps-10 v: 0 MINOR LABEL -11: 1
10x0+ amp/volt.: 0 PLAN RNIEW SECTION
Reconnect only.; 0 )=4 RES UNITS..: SVC/FDR)=22'5 A.: GH V NOMINAL: CLS AREAISPC [a:
-------------------------_____ ELECTRICAL - RESTRICTED ENERGY
Ir RESIDENTIAL.----------.._..-------------- P. --MMERCIAL---------------------------------------------------------------------------
-:0 1 STEREO.: VACUUM SYSTEM— : .. t STEREO.: "TRE ALARM.....: INTERCOM/PAGING: 011MOOR LNDSC LT-
'7
-
LAR ALARM. 0TH: K:LER......... HVAC...........: 0NDSCAPE/I ARIS. PROTECTIVE SINL:7
IG"r 3WR..- '.LMT,........... INSTRUMENTATION: MEDICAL........: CNA:
...... DATA/TELE COMM.: NURSE CALLS....: TOTAL I SrTE4S: 2
,zr: -Contractor- TOTAL rEES-i 3269.45
AISSAKE CUSTOM HOMES RENAISSANCE DEVELOPMENT "his permit is subject to the regulations contained in the
%1
WILLAMETTE FALLS N 1672 SW W!LLAKTTE FALLS DR Tigard Municipal Code, State of Ore. Specialty Codes and al
LINK OF 97068 WEST LINN OR 9706A other applicable laws. All work will be done in accordance
witF approved' plans. This permit will, expire if work is
le 41 517-8008 Phone 4: '77-8880 rot started within IN days of issuance, or if the wr
Reg #..: 000499 suspended for more than IN days. ATTENTION: Oregon
---------- eqjires you to follow rules adopted by the Orhgon Utl,,.v
if icatior, Center. Those rules are sit forth in OAR 952-08I-0810 through OAP, 952-001-0088. You say obtain copies of these rjl?S 7
ict questions to ULINC by calling (583)246-1987.
.--_--------------------------------•------------------ REQUIRED INSPECTIONS ------------------—------------------- -------------
sion Control aw'.' Drain 17ectrical Rowh Gas Line Insp Water Line lisp
ting Irsp PLM/Underfloor Framing Insp Gas Fireplace Water Service Ir Bui:ding sinal
Idatior 'r;r Nevvical Irsp Shear Wall Irsp Insulation Insp Appr1Sdwlk Insp
Numb Top nut how Voltage Gyp Board Insp Electrical at
ear eplare lisp Rair drain Insp Me-hari
—
p r-m i t t e p 71 1 R j., t I.t t,e
i I I I I I I I I I I I I 1 .1 4 4.4 4 1-1 +4- f ++4,4- 1
7 4 t i ctrl rieeded the
CITY OF TIGARD
DEVELOPMENT SERVICES SEWER CONNECTION
13125 SW Hall Blvd.,Tigard,OR 97223 (503)6394PERMIT171 DERMIT #. . . . . . . : SWR97 0317'
DATES TOSUED. 10/350/97
6-,,nRC'E1_: r.2Sl03CC --04900
ITE OW AERIE DP
'USDIVIST[IN. r-r)GL.E POINTE ZONING: R-4. 5 !--'D
LOCK. . . . . . . . . . LOT. . . . . . . .. . . . . . :03 TURISDTICTION: TIC
E*NANT N(I- Mr. . . . . :RE1k1nTSSnNCr- CUTTO111 10M.P.,
ISA NO. . . . . . . . . . a. FTXTL)PE UNITS_ : 0
:L.',)SS or WORK. . . :NEW T)WrLLING 1JNTTS. . : 1.
Or tisr-. . .sr NO. OF BUILDINGS: I
NSTnL_l_ TYPE. zSLT)WP IMnERV rjURFACE: 0 f
(,M,A)-ks : !3rl`j PiAth 11
'caner,: ------ -_... ...-__v....--_._..._... . - --...--- - --- -------.- -- ,,- --------- - - FEES - --
rFNPI!71)()NjCr CH77nM
H(IME7, t,'I-p 'a M n 1.k n t by date ecpt
67,P, SW WILL-AMETTE 1)R PRMT $ 2200. 00 DRA 10/30/97 '97 0'15 37
IEST LINN OR 97068 INSP $ MOO DRP 10/30/9- 7 97
11une #.
'ENA IS:..)PNf7,r_- DEVELOPMENT
' 672 SW WTLLAMrTTE FALLS DR
!EST LINN nQ 1741C-,8
1ione #-. 021 TOTnl_
Pr7OLITRED TNSPEC-T7'l-
"his Applicant agrees to comply with all the rules and regulations Sewer- Inspection
' the Un.-,fiet Sewage Agpncy, The permit expires 180 days from
'le date issued. The total amount paid will be forfeited if the
,.eri't expires. 'he Agency does not guarantee the accuracy of the
Ide seller laterals, if the sewer is not located at the measurement
-,iyen, the irstaller Oa?': prospect 3 feef in all directions from
he distance given. !' --t so located, the installer shall pvchase
"Tap and Sidi Sewer" Permit and the Agency will install a lateral.
'.7ENTION- Oregon law requirps you to follow rulks adopted by the
,,egon Utili',y Notification Center. Those rules are sit forth in OAR
through OAR 92-01-MO, You may obtain copies of
hest rules or -stions to 1KX by calling (M)2461987.
r",m,mittec, -j I
4.4-+ I- It 4-+++++4 +-V4++ -1 1 '-++4+++++ +4+-1-4-+-+.4-4-.I-+4-4-h++.++++4.+4-+.+9-+.+++++++++4-+++4++-r i 4-1
Cia I I G 3 9 4.17 5 by 7 00 p. In for- va n inspect i o ri n e e d(-d t t i e next b t-t%i 1i e s s
+++{++++-1-++-1+4+•e•+4+4
Plan Check 0
ITY OF TIGARO Residential Building Permit Application Recd By i' 6_1
1125-S'W HALL BLVD. New Construction Additions or Alterations Date Recd c
IGARU, OR 97223 Single Family Detached or Attached (Duplex) Date to P E.
503-639-4171 Date to DST '
503-684-7297 Per mit 10 Y'1�' i. 7 ` ' 0
Print or Type callea, '=.`'
Incomplete or illegible applications will not be accepted � 4-- AG ;
Name of Project Name —"
Job Z.4'�-"Xz' ��>��t/;- A'�A� I�'1A-rC'ryp�
Address site Acidness ` Architect Mailing Address
-- w 7Sw� .,!11�'/ /J75 /�/�✓ /k '
Name _ CltyLq4ate Zip Phone
Owner Marling Address �y Name
G 'State zi Phone Engineer Marling Address
Name Crty/ ate Zip Phon_e
General <M'ic11y A6,' _S- Descrttle work Now 4/' Addition b AMeration O Repair O
Contractor Mailing Address to be done:
Additional Oescription of Work:
Crty'Slate Zip Phone
Qrrgon Const Cont.. Board Lic 0 Exp.Date.
Attach Copy of L --� ! / ' &s Al N
Current COT BusinessTax ar Metro M Q to , PROJECT
lieA
censes /.�r�, y � VALUATION
Name
Mechanical �,�'/ �.:,, ��.—�� ,��►���;�,�,�� NEW CONSTRUCTION ONLY:
Sub- Marling Address Sq. Ft. H Sq. Ft. Garage
ontractor i'j'�, % 5,'` '' 3.� 'l
'�`� j � Comer Lat YES Flag Lot LY�ESNv
C.ty',Stale Z;p Phgne
1 1.0*14%t„><c' < . ;� ; 5� (check one) (check one)
Oregon Const.Cont. Board LIC 0 Exp. Oto H Restricted Audio/Stereo Burglar
'ach Copy of 5 �,� �� S EnerT
� -Ic• �?� � 9Y S stem Alarm
Current CUT eusrnes:s Tax or Metro . a Installation
Licenses Garage Door HVAC
/ � , 1
Name -- Opener S stems
1 (checkall that Other.
r'It_ Ttbing rj�:. t'rr<-;J r f�" ' %'rt1 �'G apply)
Sub- Mailing Address Will the electrical subcontractor wire for all NO _
Contractor C?_� n'r;c�l � � restricted energy installations?
C-!YiState "Z p PNOne�-� Has the Sucdivislon Plat recorded? N/A NO
Oregon Canst. ConL Board L,c 0 Exp D to
", �� I , Reissue of 1S Solar Compliance ,{
Attach Ccpy of ("r, ( `
Curs nt PlurnOing Lic. p �- (Calculation Attached)
t_ic�nses f' /� •� ,'',, •'l ` I hearby acknowledge that I have read this aholication, that theRr�{
COT Business Tax or Metro sEillf Cate information given is correct,that I am the owner or authorized
',
agent of the owner, and that plans submitted are in compliance
Name with Oregon State laws.
Sgof
Electrical ' " ant Date
U
Sub- Mailing Address
ntact P n Na Phony. #
-ontractor r-� "cr' o �,.'� / -'.✓� ,�-8c=r�
CIt JFAta:e Zip Phone FOR OFFICE USE ONLY:
y� 5 P t#:
e� Ma�lTl-#:
ach Copy of
Cris Cont Board LicI E x (i�, c :11L
rcas __� Setbacks: /�t urrent c ecincar Lc. # o p j Y jong ", P,? �Y V'�
h �•.
Licenses .f_1'n b , �C� J /, r
COT Business Tar or Metro s Ex Dates '7 S^ �ineenng Approval: F!ah ing approval: IF
. Y ( yam' ✓/ / f F n
i:lsfapp 4oc Cast) 11977
P22-mit AccounS_2!�scriotion AmQuni Amt. Pd. Bal, Due
MST. Permit (BUILD) 5"f Y. w 'i8
Plumb. Permit (PLUMB)
Mech. Permit (MECH) *4 '' ✓ _ `�''
ELC/ELR Permit (ELPRMT) 2-5,v ���
State Tax (TAX)
Bldg: y 1,
Plumb:
Mech:
ELC/ELR:
Plan Check
MST: (BUPPLA) 3 �' l'' 5�' ' /.3,Y,
Plumb: (PLMPLN)
Mech: (MECPLN)
CDC Review (LANDUS) ..90U w L�
_5 /_L 37V Sewer Connection (SWUSA) ZZvu -- V .C,
Reimbursement District ( )
Sewer Inspection (SWINSP)- .i, 3,`
Parks Dev Charge (PKSDC) /(.JSu -V lv5'U
Residential TIF (TIF-R)
Mass Transit TIF (TIF-MT)
Water Quality (WQUAL) 10 V
Water Quantity (WQUANT) y
Erosion Control Permit (ERPRMT)
Erosion Planck/USA (ERPLAN)
Erosion PlancklCOT (EROSN)
Fire Life Safety (FLS) Ci
TOTALS: S`iv .� �� s� 5q, yr
hsfapp.doc (asc) lis?
SEE 35MM
ROLL# 22
FOR
LARGE
DOCUMENT
,LD T �
CITY OF TIGARD BUILDING INSPECTION DIVISION
24-Hour Inspection Linc: 6394175 Business Phone: 6394171
Date Requested: _��s}^ �= - A.M. P.M._- — MST: 7�
Terant: Suite:_—.—Bldg- MEC: _
Contactor:_-__ _—� -.y1 .d i Afi LC i Phone: 57-' -O _ PLM:
---Phone: ELC:
ELR: —
STI•:
BUILDING DG(so,0 UABI d1TEmmr'L� ECT'R SITE
Site b, earn Post/Beam I(fSVf3etTm- Cove'rl�ervrce Sewer/Storni
Footing Roof UndFI/Slab Rough-In Ceiling Water Line
Slab Framing Top(hit Gas line Rough-In U(i Sprinkler
Foundation Insulation Sewer Ilexxl/DUct Reconnect Vauil
Bsmt Damp Drywall Storm Furnace Temp Service MISC.
Masonry Ceiling Rain Drain A/C UG Slah
Shear/Sheath Fire Spklr/Alm Crawl/Found I)r I Icat Pump Low Volt __
Approv• < 93 Ap }up� Approved
Appr/Sdwlk Not Approved Not Approval Not Approved Not A xoved Not Approved
c'F'I1 �i II�AL FINAL
O Cali for reinspection O Reinspection fee of Srequired before next inspection O I Inable to irspect
n
Inspector Date "' 9 Page of
— r------ --- -- ----- — - -- ----
CITY OF TIGARD
DEVELOPMENT SERVICES
Ali, 13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171
CE::HTIFICATF" OF
OCCUPANCY
PERMIT 0. .
DATE I`:,GwD s Nti/05, 'qk
PARCEL a 2S 10 4C;C: 04900
1"E (-ll)DRCf]�a. . . 0 1313-1 SW RERIE DR
S1JI-AD IVISION. . . . t EAGLE POIN'rE: ZONINGrR-4. 5 F=BI?
BLOCK. . . . . . . . . . s L_C)1.. . . . . . . . . . . . . t035 .JURISDICTI ONtTIQ
:!_F'�e�iS OF WORK. s NEW
I ( IE OF USE. . . a OF
1 1'AE, OF C;(JNG T R t 5N
11CCUPANCY ORFS. t P3
JCCUPANCN LOAD ti'
R e m A r k s t WD - Path I
Owner^t ----._.._.w__.__.__.......__..,.....___. ____._._....__....._....
RF:NA I SSANCE CUSTOM HOMES
IES-;'Z :3W WIL.LAMETTE. FALLS DR
WF!J LINN OR 97068
Phone #3 5578000
Contr,;)ctora _....__._..._,_._...__.-___......__.._.�...._ _.......
RENAISciANCf DEVELOPMENT
167i? SW WILLAMETTE FALLS DR
14EST LINN OR 97068
Phone #1 537-8000
Rey #. . 1 000499
This Certificate grants occupancy of the aboye referenred building or portir
thereof and confirms that the hlailding hat been inspected for compliance wii ,
the State of Oregon Specin.lty Codvs for the group, occupancy, and use utide,-
which the referenced permit was insued.
I?l1IL ZIN `;I�Ef.'T� 9_ _ L/lN PE CT tIIV SUf EPVI1, -,
POST IN CONSP I C'UOUS
CITY' OF TIOARD
DEVELOPMENT SERVICES PLUMBING PERMIT
13125 SW Hall Blvd.,Tigard,OR 97223 (503)639-4171 PERMIT #. . . . . . . : P11-1198-0197
DATE ISSUED: 06/26/96
PARCEL: 2S103CC-04900
SITE ADDRESS. . . : 13937 SW AERIE DR
�AJBD I V I S I ON. . . . : EAGLE POINTE ZONING: R-4. 5 PD
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . :O55 JURISDICTION: TIG
....—----------------------------------------------------------
(-'I ASS OF WORK. . :ALT GARBAGE DISPOSALS. : 0 MOBILE HOME SPACES. 0
1 YPE OF USE. . . . :SF WASH NG MACH. . . . . . : 0 BACKFLOW PRE VNTRS. . 1
OCCUPANCY GRP. R3 FLOOR DRAINS. . . . . . . 0 TRAPIS. . . . . . . . . . . . 0
STORIES. . . . . . . . : 0 WATER HEATERS. . . . . : 0 CATCH BASINS. . . . . . . : 0
FIXTURES--- LAUNDRY TRAYS. . . . . : 0 SF PAIN DRAINS. . . . . : 0
5 1 NKS. . . . . . . . . : 0 URINALS. . . . . . . . . . . . 0 13REASE T RAFTS. . . . . . . 0
LAVATOR I ES. . . . : 0 OTHER FIXTURES. . . . : 0
FUB/SHOWERS. . . : 0 SEWER LINE (ft ) . . . : 0
WATER CLOSETS. : 0 WATER LINE (ft ) . . . 0
f)I SHWASHE RS. . . . : 0 RAIN DRAIN (ft ) . . . 0
Remarks :
Owner : FEES
RENAISSANCE CUSTOM HOMES type amot-trit by date reept
1672 SW WILLAMETTE FALLS DR PRMT $ 15. 00 JSD 06/26/98 98—.3,06863
W'FEST LINN OR '97068 5PCT $ 0. 75 JSD 06/26/98 98-306863
Phone #:
MOODY ENTERPRISE INC
1"� BOX 98
FSTPCPDA OR 97023
Phone 4t. $ 15. 75 TOTAL
Reg #. . : 000059
REPUIRED INSPECTIONS
This permit is issued sub)ect to the regulations contained in the RP/Backflow Prev
Tigard Municipal Code, State of Ore. Specialty Codes and all other Final Inspection
appiicable laws. All work will be done in accordarce with
approved plans. This permit will expire if work is not started
within 188 days of issuance, or it work is suspended for more
than 180 days. ATTENTION: Oregon lam requires you to follow rules
adopted by the Oregon Utility Notification Center. Those rules are
;Pt forth in DAR 952.-888I4*)8 through CAR 952 8881 8888. You may
obtain copies of these rules or direct questions to OUNC by ral'ing
�583)246-1967.
I sited By q1 "I re :Permittee
- g 0, r
r-'erm "L
+++++++4.+++++++++++++ ................. .........................................
Call 639-4175 by 7:00 p. m. for an inspection needed the next bi-tsiness dA-,)
............4........4-+,4-+4+-4 f-+4++++++++.......4.............................. ...4
CITY OF TIGARD Plumbing Application / !� Recd B�_-
^3125 SW HALL BLVD. Commerciai and Residential ` Date Recd
FIGARD, OR 97223 Date to P E.
503) 639-4171 Gate to DPermit r
Print or Type Related SWR r
Incomplete or illegible applications will not be accepted Called
Name of DeveionmenuProlect FIXTURES (Individual) QTY PRICE AMT
Job Sink 9.00
C Or � L�a �T Lavatory
Address street Adress Suite 9.00
f' L- Tub or TubiShower Comb, 9.00
B 9 siSlate Zip Shower Only 9.00
i " t ��"��- Water Closet 9.00
Nanta
Dishwasher 9.00
4 , 'c o i�OI-
Cwntar M&AN Address guile Garbage Disposal 9.00
r f Washing Machine 9.00
Cltymate Z1p Phone Floor Drain 2' 9.00
Wjj 7- Q >n`? i70 Y 9.00
Narita
/l./ 4- 9.00
Occupant Maitq Address Suite Water Heater 9.00
.3 54a.A xe. Laundry Room Tray 9,00
Ciylstate Zip Phone Unnal 9.00
r AJ- '� i� 3 Other Fixtures(Specify) 9.00
Na
0ol�TU"D.li.� G. 9.00
Contractor M 9 A dress-T_ Suite 9.00
Box 9 f 9.00
GtyrState Zip Phone
7"• .f f), .,3 4.3/- /,F -_ 9.00
Oregon Const Cont.Board Lic.s Exp. ate 9.00
AMselt Ca"of �- p
Current9-00
P►�sttbing Lie.r p.Dille Sewer 1 st 100' 30.00
t iceneea Sewer•each additional 100'
COT Business Tarr or Metro! Exp.Date 25.0u
3 Water Service-1st !00' 30.00
Name Water Serves•each additional 200' 25.00
Architect Storm a Rain Draw,• 1st 100' 30.00
I or I Madinq Address Si.;e Storm d Rain Drain.each additional 100' 25.00
Mobile Home Space 25.00
EngineRr C c yrltate Zip Phone Commercial Back Flow Prevention Device or Anti- 25.00
_ Pollution Cevtce
Describe work New Addition 0 Alteration 0 Reoair J Residential Backflow Prevention Device' 1500
It 3e done: Residential O von-residential 0 Any Trap or Waste Not Connected to a Fixture goo_
•w,"onal description of wort
Catch Basin 4.00
tnsp.of Existing Plumbing 4000
//
Der/hr
-- - Specialty Requested Inspections •x0.00
nso�q of ie fame __�_ oerihr
xrig of� �M-- Rain Crain.sin
9 y i lweilin
9 � 70.00 I
P,ope..ed use of Grease Traps g 00
bwkl.ng or pmperty.-- --- _
_ QUANTITY TOTAL
Are•ou upping rmnving or replacing any fixtures') Yes O No O isometric or neer simram a required t Cuanty Total is a 9
(If yes so*back of form) _ 'SUBTOTAL
+I hereby acknowledge'hat I ha.e read this acplicaUon,that the information
given m orrect. enat I jm;he owner Or authorized agent of the owner. and 5% SURCHARGE
7iat dans submitted are.n:omoliance with Oregon State Laws. _
PLAN REVIEW 25% OF SUBTOTAL
,iigna a EorlAgi�tt Data/ I l
�� 4eouxed only R'trture ity atal,s TOTAL >'
�_ _ t'
i Contact Ponan Name - Phone
n / 'Minimum permit No s S;15- 5%surcnarge.except Residential BaUcBow
Jl / ,v „/ l ' ( 3/ Prevention Cavite, which,s S15- 5%surcr,arge
i:14ststpimaop.doc 3196
it
?LEA,5E COMPLETAPPROPRIATE TO PROJECT:
T;
Fixtures to be capped, moved or replaced Qty
Sink
Lavatory _
I Tub or Tub/Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain
3"
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE: