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City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME:: PERMIT NO. :
DATE. DATE ISSUED :- i /
OWNERS NAME
ADDRESS:
CONTRACTOR
TEST : Air p, Water visual Q , Laboratory p
RESULT: Approved Disupprcved ❑ Pending p
SKETCH:
INSPE TOR DATE
EN07 E : Attach supplemental test data bereto�
CITY OF -T-IGARQ
12110 5. N
W. Main Strw
TIGARD, OREGON 97217
APPLICATION FOR BUILDING PERMIT
New Construction ❑ Demolish ❑ Addition ❑ Remodel ❑ Move
t 70NING C-3 to H-7 DATE ISSUED 7"1)-73 BUILDING PERMIT
DATE RECEIVbD
r, BUILDING FEE $ No. ,73 . 166
BY PLAN CHECK $
VALUATIVALUATION $
OTHER $
TOTAL $ ').Ou RECEIPT NO.
TWO F--S OF PLANS AND PLOT PTANS MUST BE FURNISHED WITH APPLICATION
LOT N _ MAP M CENSUS TRACT JOB N
Architect or Engineer
Address Phone
Owner_ XXKKIM dwi,beiic:al UhiTch
Address - Phone—
Builder_ E
AddressRoute i b-;x ,c., Mt. AnLie1, UaegOn >+"(3b2
— -, Phone
BUILDING USE Single Res. ❑ Multi Res. ❑ Comm. ❑ Induetrial
OCCUPANCY GROUP`-_ No. of Stories Tutal Heigh . — Area of Lot
Type of Construction kO0dCb006jjKX)&X V Floor Area d� 1-- 2`
Set Backal Front _ Back �L.Side— R.Side_
Private Sewer ipe Size Sewe' 'Septic Tank ❑ �.
Water Service Pipe ize_ Storm+Sye ems❑ Ditch ❑ Drywell❑\'�
Street and Curb Require is
\ — ----
Driveway Width_ No. of Parking Spaces
SEPARATE PERMITS REQUIRED FOR SEWER AND PLUMBING
SPECIAL INFORMATION
ADDRESS ASSIGNED lU IU S.M. ld-ILt Ave.
FIELD CHECK BY _ i _ _-_- --`- _DATE.—
PERMIT APPROVED BY ez Y- .7
i
It is understood that all work will conform with applicabl code: d ordinances
of the State of Oregon and the City of Tigard, Oregon, and that t building wil:
not be occupied until a Certificate of Occupancy has been i ed by the City of
Tigard Building Inspector.
Sia ure of App cant