12111 SW 125TH AVENUE I1L11 SW 125TH AVENUE
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City of Tigard
INSPECTION REO U E ST
for
INS?EC TION TIME :-- PERMIT NO.
I DATE: i1111Z,� DATE ISSUED: .—L-,
OWNERS NAME :
ADDRESS : �rti
ICONTRACTOR :— ' t 1
TEST: Air CI , Water [] , Visual �, &-aboratory p
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RESU!T: Approved t'sapproved L7 , Pending [j
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INSPECTOR DATE
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City of Tigard
INSPECTION REQUEST
for
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INSPECTiON TIME: aUte PERMIT NO. :
DATE: /,.?VI-2 ✓ DATE ISSUED :--L-/--
OWNERS NAME : - _ __ I
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ADDRESS: lel 11
CONTRACTOR " -
TEST '
ONTRACTOR : _TEST : Air (,, W rater Q , Visual , Laboratory p I
RESULT. Approved Disapproved CJ Pending p
SKETCH:
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INSPECTOR DATE I
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Chfy of Tigard
INSPECTION REQUEST
for
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INSPECTION TIME. PERMIT NO. :
DATE: f-� DATE ISSUED :—/
OWNERS NAME : k/ a- Ss ev .
ADDRESS: /.2//) S ck-J S1
CONTRACTOR : c, _74ft 11(f0 SS ea--
113
TEST : Air Q, Water 0 , Visual D , Laboratory ❑
RESULT: Approve , Disapproved EJ , Pending ❑
SKETCH.
INSPECTOR DATE
L01E Attach supplemental test data hc►eta]
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City of Tigard
INSPECTION REQUEST
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for
INSPECTION TIME: PERMIT NO. :.
DATE: . Im_'ZrY DATE ISSUED '. _ I
OWNERS NAME :
ADDRESS: ,.,CONTRACTOR : _
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TEST Air p, Wa;wr[] , Visual p , Laboratory p
RESULT: Approved Cl Disapprovsd 11 Pending p
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SPSPECT0R DATE
LNO1E Attach suppiememfol teal dot,, hareto,
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City of Tigard
INSPECTION RE �
G?��ST �
for
INSPECTION TIME: �� °p PERMIT NO. :--.--
DATE:
O. :__. _DATE: DAT ISSUED : Z i
OWNERS NAME : e�-c! SsEyC . I
ADDRESS:
CONTRACTOR :
TEST . Air p, Watery , Vlsual j�', Laboratory 0
RESULT. Approved Disapproved O Pending p
SKETCH.� I
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INSPECTOR DATE I
CNOTF. Attach suppletnentat test data bereloi I
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ADDRESS PERMIT N0.
PERMIT CHARGE
OWNER C`Si �K�\fir ila�o
CONNECTION FEE 45-0
PAID BY --
TYPE OF BUILDING DATE CONNECTED
SLRVICE RATE pc,c� _ �____T INSPECTION FEE S
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CONTRACTOR PAID BY DATE
. .. ��.. -_ ---- _
SIZE OF CONNECTION 'u�� ASSESSMENT �r PAID _
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City of Tigard
INSPECTION REOUEST
for
INSPECTION TIME : PERMIT NO. :
DATE: DATE ISSUED:—/
OWNERS NAME : .�.1a
ADDRESS :
CONTRACTOR : , - -.---
TEST: Air O, Water 0 , Visual l , Laboratory []
RESULT: Approved Disapproved U Pending L]
SKETCH: /o'�c �•'� �- ' "'
INSPECTOR DATE
LNOTE : Attach supplemental test dato horst]
City of Tigard
INSPECTION REQUEST
for
_
iNSr'ECTION TIME : '• �' ��uyDATE I ISSUED:__.t'_
DATE* �`_L----
IWNERS NAME : Q Al r
t4ADDRESS : zLl
CONTRACTOR :-----
- —
TEST. Air 0, Wafer Q , Visual ❑ , Laboratory ❑
RESULT: Approved Disapproved 0 , Pending p _
SKETCH:
NSkCTOR DATE
CN01E Attach eupplementol tett dato heret]
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Cit of Tigard
City g d
INSPECTION REQUEST �
for
INSPECTION TIME: =/,
PERMIT N0. :
DATE. _ "1'112 DATE ISSUED :__._—L_L_
OWNERS NAME : � � V�p
ADDRESS: _1
CONTRACTOR .-
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TEST ' Air O, 'sYnter O , Visual O Laboratory p I
RESULT: Approved* , Disapproved O Pending p
SKETCH.
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INSPECTOR UAT E
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City of Tigard
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INSPECTION REQUEST
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for
NSPECTiON TIMPERMIT PERMIT NO. : —_
DATE: 3.LlQZ$j DATE ISSUED :__1..1_._ I
)wIINERS NAME : -- --- - I
ADDRESS: -5 � --
:ONTRACTC R : r�•�E' t1j` r� ____ I
rE ST : Air 0, Woter^ , V` al Laboratory [] I
RESULT ' Approved Disapproved 0 , Pending p
K E'r C N.
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INSPECTOR DATE
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Cify of Tigard
INSPECTION REQUEST
for
INSPECTION TIME : _ PERMIT NO.:
DATE: ,3 -' / DATE ISSUED:_1�
OWNERS NAME ' - �ARQ104 /I�i 3ic
ADDRESS :
CONTRACTOR : __ _
TEST: AirO, Water �C VieualX, Laboratory ❑
RESULT: Approved) , Disapproved ❑ , Pending L]
SKETCH:
INSPECTOR DATE
[OTE : Attach supplemental tett data hest]
CITY OF TIGARD
P. O. Box 23557
12420 S W. Main
Tigard,Oregon 97223
noromber 28, 1 l7 i
Mr. Peter Klym
Route 3 box 113
Cornelius, Oregon
RE: SEWER PERMIT NO. A887
On August 29, 1973 the UnifieJ Sewerage Agency issued
you the referred permit and according to our records no action
has been taken on your behalf to use the permit. According
to the regulations of the Agency, all permits expire 9n
days from the date of issue with the fees being forfeited.
This requirement is also a part of the regulAtions of the State
Department of Environmental Quality as incurpereted In the
Agency's waste discharge permit.
The Agenr..y has been lenient in not forfeiting chis permit
prior to this time; therefore, unless you tak[ positiv3
action to use the permit within the following 30 days said
forFeil.ure will be made without further notice.
If we ran provide any information concerning this matter,
please du not. hesitate to rontact us.
Sincerely,
1 �
James Brien
Acting Building Official
J8/fs
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70 /V0
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UNIFIED SEWERAGE AGENCY NO.
WASHINGTON COUNTY DATE
C I T Y O F---LL–ALD —_ - -
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER: — TL 1�"r ALM
" .ET
-
OWNER'S ADDRESS: SSI,... /o�''S ��y.�- _ --------- ---
aTRF ,t3
�+ —%6
ITV 6TATE
BUILDING S11 E: LOT BLOCK__..___---- ADDITION
jEc�+Cwr+
TAX LOT N0. -" - —
TYPE OF OCCUPANCY .
Idlll �",v �-
ADDRESS__ .�Zl--�r- ______
DWELLING UNITS--
-_. FIXTURE UNITS
O$
—r.0-
SURCHARGE IF APPLICABLE
Ov 11—cl
PERMIT FEE -4��Q--- INSPECTION FEE-91K
TOTAL DEPOSITED � � 4
(NEW) (EXISTING) BUILDING SEWER SYST01
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The Applicant agrees to comPly with all rules and regulations of the Unified Sewerage Agency.
APPLICANT
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SEWER PERMIT
THIS PERM11 AUTHORIZES CONNECTION TO THE SEWrR SYSTEM,
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LINE SIZE , 4 ` ._____
_. INSTALLER -_.-- - -- __ - -----.—.--
RECEIVED 8Y (AGFNef opt ITS A61NT1
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COMMENTS. '{
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This Application and permit expires in ninety (90) days. The amount paid will h� tot eihtd
should expiration occur.
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1819
EXHIBIT "A"
CITY OF TIGARD
Residential Structure Occupancy Restriction
KNOW ALL MEN BY THESE PRESENTS, That occupancy of residential
structure (s) on the following described lands prior to the recording
of an occupancy permit releasing the restriction in the Dee" Records
of Washington Cuunty, OreEon, is prohibited by the ordinance of the
City of Tigara, Oregon:
DESCRIPTION OF PROPERTY:
=nT V `t3zoar V.�,by
ADDRESS OF PROPERTY: laIll
NAME OF OWNER: l't>Tic� KLYM
ADDR&I,S OF OWNER: r%?1. .3 /3eh //i C' ,�.J i ,,•<, UeE ._ q111?
IN WITNESS WHEREOF, the undersigned has caused this restriction
to be executed this day of U., lye,
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OWNER:
:lime
APPROVED: By:
T.tle
Byt 11�c �:u,. . 1 o IQ ?t4'4 k.�4M PM
h0tilding Official D-1,11 ..-m.
City of Tigard
STATE OF OREGON ) as.
County of Washington
' , 191
Personals,, appeared before me the above riameedd �
C._._. and acknowledged the foregoing instrument to be
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vol ;.ary act and deed.
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Notary P 11u for Oregon.
Aly Co'^m'ssion Expires:
Bn 945 [ALE770
Uz8 ! _
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60 % I�
$! c ■9um
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CITY 4F TIGARD
17420 S. W. Main Skeet
TIGARD, ORRGON WM,
APPLICATION FOR BUILDING PERMIT
New Construction El Demolish LJ Addition Remodel l� Move
ZONING R-7 DATE ISSUED --i-23-73 BUILDING PERMIT
DATE RECEIVED XA 9, 1973 BUILDING FEE $__�6 .00 No. 7+3.104
BY_ FS --- PLAN CHECK $ VALUATION $ 24,050
- OTHER $ 10.00
TOTAL $ 99.00 RECEIPT No.
TWO SETS OF PLANS AND PLOT PLANS MUST BE FURNISHED WITH APPLICATION
LOT M A s MAP M231 3BB CENSUS TRACT W-i9 JOB N
Architect or Engineer _Doaald Brim.
Address 5930 State St., 561. L_Pa _JPhone _
Address 9.W. 125th 1ve. Phone—
Builder
---
Builder r,.,�
(leroeliue ,,j lf./ ,� Phone
Address _ --- --
BUILDING USE Single Res. 0 Multi Res. Comm. D Industrial
OCCUPANCY GROUP I No. of Stories 1 Total Height_ 14' Area of Lot 8,000_
Type of Construction V Floor Area B_ —_ 1 16 � 2
Set Backs: Front 20' _ Back 45' L.Side_- 51 --. R.Side 8�1
Private Sewer Pipe Size 411 Sewe rues ! ij Septic Tank
Water Service Pipe Size_ �� Storm SewerllC_I Ditch ❑ brywe11 ❑
Street and Curb Requirements_- Weting�
r)riveway Width 18 _ __ No. of Parking Spaces 2
SEPARATE PERMITS REQUIRED FOR SEWER AND PLUMBING
SPECIAL INFORMATION
Q
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ADDRESS ASSIGNED 40M B.W. 1251h Ays.
FIELD CHECK BY IC DATE. 5-23-73
PERMIT APPROVED BYE,�,.�,� ✓.� ____
It is understood that all work will conform with applicable codes and ordinances
of the State of Oregon and the City of Tigard, Oregon, and that the buildi,ig will
not be occupied until a Certificate of Occupancy has been issued by the City of
Tigard Building Inspector.
5 qi natuir_ of A p icant -
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