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City of Tigard
iNSPECTION REQUEST
for
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1N5PECTION TIME: PERMIT ND—
DATE :/! �;P - UATE ISSUED ..___I
OWNERS NAME : -2&-ate_ . 41w A &t4– q---.
A D D R E SS 3 ti's _ C , 3�►.zrrse�► .._ i
CONTRACTOR :
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TE 3T ' Air Q, Water C) , visual L3 , Laboratory ❑
RESULT: Approve Disapproved O Pending []
SKETCH. _
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NSPEC T'OR DATE
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BUILDING PERMIT APPLICATION TIGARD LATE- N° 0496
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT FOR THE WORK HEREIN INDICATED
OR AS SHOWN AND APPROVED IN THE ACCOMPANYING PLANS AND SPECIFICATIONS. OWNER PHONE —
WNER_ —460' ' r ��` 'r ° ADDRESS ' a f BUI LDER r ')(')E
ENGINEER
BUILDERrte_ ARCHITEJ _ DESIGNER
U _
STRUCTURE NEW ❑REMODEL _ ❑ADDITION OREPAIR ❑RENEWAL ❑FIRE DAMAGE r�--11 ❑DEMOLITION_
❑ RESIDENCE ❑COMM ❑EUUCATIONAL ❑GOV'T ❑RELIGIOUS❑PA?10 ❑CA9 PORT ❑GARAGE LJxSTORAGE OSLAB ❑FENCE
❑BOND ❑MOVING ❑CONDITIONAL USE []DESIGN REVIEW ❑COUNCIL APPROVED ❑SIGNS
OCCUPANCY—L—LAND USE ZONE_ BLDG.TYPE FIRE ZONE_ PLAN CHF.X BY HEAT
-- /
OCC, LOAD FLOOR LOAD HEIGHT NO.STORIES AREA VALUE J T
BUILDING DEP RTMENT SET BACKS FRONT REAR LEFT SIDE RIGHT SIDE
Permit �, —� - --.---- ------- -.—.
THIS PERMIT IS ISSUED SUBJECT TO THE REGULATIONS CONTAINED IN THE BUILDING CODE, ZONING
Plan Check REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES AND IT IS HEREBY AGREED THAT THE
WORK WILL BE DONE IN ACCORDANCE WITH THE PLANS AND SPE,.IFIC1%TIONS AND IN COMPLIANCE WITH
Recording ALL APPLICABLE CODES AND ORDINANCES THE ISSUANCE OF THIS PERMIT DOES NOT WAIVE
RESTRICTIVE COVENANTS, CONTRACTOR AND SUB CGNTRACTO,.s TO HAVE CURRENT CITY BUSINESS
)%State f 1 LICENSE. SEPARATE PERMITS REOUIRED FOR SEWER, PI !MBING AND HEATING.
Total
By
APPLICANT OR AGENT �y
Approved Re(�r,I�t No
ADDRESS PHONE
DATE INSP. TYPE INSPECTION REMARKS PLUMBING DATE
Contractor _
Permit No.
Rough-in
Fixture
_ r anal_ _
&ATING
Contractor
Permit No.
Gas or Oil
Rough-in
Final
SEWER
_ Final
~ DRIVEWAY
Final
Storm Drainage
(Rain Drain) Final
Sidewalk
Curb&Street Final
Approach _
SLOG. DEFT.'!NIAL TEMPORA9f CERTIFI(.ATE OCCUPANCY
CERTIFICATE OCLIJPANCY Final
-7 , Landscaping
Zoning Final
f
.. .. I WO
A(Id.r.esS /3 �'�;" 5; ��, L��=.t.�x. Fl Permit No.
Permit chargeY
Owner` �,.rcC�r. � JY Connection fee_,
Paid by
Type of building _ k'A Date connected__v? 15- 11
Service rate Inspection fee_��75��'
Contractor Paid by Date
Size of connection Assessment Paid
1�
PERMIT TO %".'ON IECT
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Tigard Sanitary District
PERMIT N? 1 4578 DATE �..7 ` 2 " 7 C .
PERMIT 1S GIVEN TO �+_� r�.5✓�'� _/}__
OF
TO CONNECT A
TO THE SvSTEM OF TIGARD SANITART DISTRICT
Al
THIS PERMIT MUST BE POSTED ON THE DRSCRIBED PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTION OF CONNECTION HAS BEEN COM-
PLETED.
PERMI -"EE PAID 6...3.24-:7.L.aTIGARD SANITART DISTRICT
or
CONNF C 110N D SPECTED AND APPIt0VF11
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