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City of Tigard
INSPECTION REQUEST
for
IINSPECTION TIME : PERMIT NO.:
DATE: -Y DATE ISSUED:_..1�
OWNERS NAME .* - _
ADDRESS : _ ' L30 � � �'�
�
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CONTRACTOR :
ITEST:Air ❑, Water ❑ , Visual ❑ , Laboratory ❑
RESULT. Approved ❑ , Disapproved ❑ , Pending ❑
SKETCH:
IV/
i
IN-SPECTOR DATE
COTE Attach supplemental fast data horst]
.cam;,_._. _ � . _: �._->r��--�-��-•-• =-
CITY OF TIGARD
12420 S. W. Main Street
TIGARD, OREGON 97223
APPL:�-A. LON FOR BUILDING PERMIT
New Construction ❑ Demolish ❑ Addition ❑ Remodel \a Move ❑
ZONING DATE ISSUED �/�s1�9� BUILDING PERMIT
BUILDING FEE $'�L! . ,'?pNo. �
DATE RECEIVED -�• -7(4
BY PLAN CHECK $ --
OTHER $ VALUATION
TOTAL $ RECEIPT No.-9-7-
TWO SETS OF PLANS AND PLOT PLANS MUST BE FURNISHED WITH APPLICATION
LOT # MAP # CENSUS TRACT - JOB #
Architect or Engineer
Address_ / 3Q, _ /O Sr 7Phone__.-_-
Owner_ ___ �_ _.! ''^ �._,-•� n'-1
Address_ _3 (c 3��-_ _._ 14 j0j L.d _ /9-.f . Phone _
Builder •-- -- ----- --- -----
Address -.---Phone---
BUILDING
_-Phone_ -BUILDING USE Single Res. ❑- Multi Res. ❑- Comm. industrial❑
OCCUPANCY GROUP No. of Stories^ Total Height--m.
ei j/m.t _ Area of Lot
Type of Construction I II III IV V Flo/or,Atea B _ l - _ _- 2` -W-
Set Backs: FrontBack _ f..S LS R.Side` _
Private Sewer Pipe Size ewer Septic Tank ❑
Water Service Pipe Size Storm Sewer ❑+ Ditch ❑ Drywell❑
Street and Curb Requ rements
Driveway Width_ _ --_ No. of Parking Spaces__________
SEPARATE PERMITS REQUIRED FOR SEWER AND PLUMBING
SPECIAL INFORMATION
ADDRESS ASSIGNED - 13O _ •_!i!/•-.� S- �Y_ _II`fi.��c.s Cc l/�-�_-r.
FIELD CHECK BY _-�---� �_ ------ --`-_-DAT£---- -
i
PERMIT APPROVED BY
It is understood that all work will conform with appl4cabie c4
es and ordinances
of the State of Oregon and the City of. Tigard. Oregon, and that the building will
not be occupied until a Certificate• of O pancy has been issued by the City of
Tigard Building Inspector.
Signa r oAp 1l can
I
PER141 T TO CONNECT
Tigard Sanitary District
PERMIT NO 9)8 DATE _
7
PERMIT IS GIVEN TO
OF
TO CONNECT A
TO THE SYSTEM OF TIGARD SANITARY DISTRICT
AT�_,
THIS PERMIT MUST BE POSTED ON THE DESCRIBED PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTION OF CONNEC'T'ION HAS BEEN COM-
PLETED.
PERMIT FEE PAID 5.... .:,...!. .................TIGARD SANITARY DISTRICT
BY
CONNECTION INSPECTED AND APPROVSD
— Date Buperintendent
Addresi/#/.3oSV_ lg�,5-44 ' Permit No.9`�R —
Name of Occut)ant Permit charge
Connection
Paid
Date co:nected
Type of Building i ��� .�. C_ -___ Inspection fee-
Service
ee_Service Rate-- ---------.- ._-_—_ Paid by Date--_----___--
Gout,actor.... - - _-- - - --_ Assessment-- -_ Paid
Size of connection __