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—43228 SW HILLSHIRE DRIVE —
- -
CITY OF TIGARD
DEVELOPMENT SERVICES
zo 13125 SW Hall Blvd., Tigard,OR 97223 (503)639-4171
CERTIFICAIr OF
OCCUPANt,Y
PERMIT #. . . . . . IMST96
DATE ISSUED1 0,4/ 10/97
PARCEL 2S1Q14CA---06-,k
ADDRESS. . . a 13220 SW HILLSHIRE DR
UBD I V I S'I ON. . . . c HILLSHIPt- 'ONINGsR--7 PO
BLOCK. . . . . . . . . . : LOT.. . . . . . . . . . . . . a QtbwJURISD" ICTION0"IG
CLASG OF WORK. iNEW
TYr-,E OF USE. . . s9
IYPk." OF CON!7TR:5N
fRXUPANCY GRP. -R3
1(A--U1-'1ANCY LOAD: I
c-marks I PATH I
i-YLLP X DEBBIE LARSEN
3')04 SW SHORE' PVLD.
1-PKF OSWECL30 OR 9'103!;
V,honp #1 699-90301
I-untractort
CORNE REj TONE' VIOME BUILDERS INC
16015 r';E TAYLOR
v,owrt AND OR 978c'13
Phunp #s
RV9
This Cert ificate grants occupancy of the Above referenced building or portion
thwreof anti (:onfit-mq that the building has been i,--.p*,:ted for compiianc,e
the St,Jf- of Orp4on gppci.Alty Codes for the VOUPy lr-cupmli , r ar-1 use under
iqhJc:h the referenced permit was jss,.A&(j
Kii,cDfNC INSPECTOR BUI(WING OFF DIAL
POST IN CONSPIWOUS PLACE
Page No. 1 CASE HISTORY FOR CASE NO.: MST96-033?
TYLER & DEBBIE LARSEN
13228 SW HILLSHIRE DR
07/22/97
Action Description Req/ Schdi End/ Action Notes Disp By Update Upd
Code Sent Done Done Date By
MSTA005 Application teLeived / / / / 06/20/96 PASS BON 06/28/96 BT2
MS"A008 Permit Created / / / / 06/28/96 PASS RT 06/28/96 BT2
P.bTA010 Check for prcl. restrict. / / / / 06/27/96 PASS JD 06/28/96 BT2
MSTA012 Plans routed to Plans Examiner / / / / 06/27/96 PASS JD 06i28/96 BT2
MSTA026 Plans approved by Plans Exmr / / / / 06/28/96 PASS RT 06/28/96 BT2
MSTAO'SO Reviewed plans routed to DSTS / / / / 07/08/96 PASS RT 07/08/96 BT2
MSTAO80 (F) Ready to issue / / / / 07/09/91, PASS CJS 07/09/96 CJS
MSTA092 (F, Issue combination permit / / / / 07/24/96 PAID JMH 07/24/96 J*H
MSTA097 Isste pturrAting signature form / / / / 07/24/96 PAID JMH 07/24/96 J*ll
MSTA098 Issue etectric signature form / / / / 07/24/96 PAID JMH 07/24/96 J*H
MSTA705 Footing Insp / / i / 6//31/96 N/R KS 08103!96 KBS
MSTA705 Footing Insp 08/01/96 / / 08/01/96 APPROVED ON CONDITION THAT BAR(SEE APPR RS 08/08/96 BT2
DETAIL) IS INSTALLED WORE POURING
FOOTING
MSTA706 Foundation Insp / / / / 08/19/c,6 PASS TLP U8/20/96 TLP
MSTA710 Post/Beam Structural / / / / U9/12/96 #-1- provide engineering for ;�ispenM i Ni" C?,12196 KBS
garage fl
MSTA710 Post/Beam Structural / / / ! 09/17/96 MOVE TRIPLE 2X6 POST AT SO END AWAY FROM PART GS 09/17/96 GFS
CONC; NAIL ',WBLEl JOISTS 2411 OC; DOUBLE
STUDS AT HOLDDOWN!;
P&B UNDER GAw NOT 'ET IN
MSTA710 Post/Beam Structural / / / / 12/15/96 garage- lateral brace pasting; submit PART RB 12/17/96 RB
revised engineering for garage floor
",!stem- w/ledger;
MSTA710 Post/Beam Structural ! / 1 / 12/19/96 garsge fl engineering showed a 2x'2 PART GS 031OF,9t MRS
scabbed to side of beams nailed 811.c 2
rows staggered
nailing wrong f. dis app 1
MSTA7'11 Post/Beam 'Aechanical / / / / 12/16/96 PASS RB 12/17/96 RB
MSTA717 PLM/Underfloor / / / / 03/06/97 PASS MS 03,'06/97 MRS
MSTA720 Mechanical Insp / / / / 12/16/96 exhaust venting disconnected; b-vent F":L RB 12/17,96 RB
sleeve w/in attic; seal joints of flue
at L.R. fireplace & basement fireplace;
chase return air durt at main bathroom;
chase duct in op;age.
Page Nu. ? CASE HISTORY FOR CASE NO.: MST96-0332
TYLER 8 DEBBIE LARSEN
13228 SW HILLSHIRE DR
07/22/9?
Action Description Req/ Schd/ End/ A tion Notes Disp By Update Upd
Code Sent Done Done Date By
r1STA720 Mechanical Insp / / / / 12/20/96 gas line failure; chase flue in garage; FAIL RB 12/20/96 RB
chase duct Win main bethrm; exhaust fan
disconnected at bei !nt; heat duct
disconnected at nor n end basement;
protect b-vent w/in attic in garage;
fireplace instal. instr. need to be
v i ewes;.
MSTA720 Mechanical Insp / / / / 12/23/96 incompleted issues FAIL RB 12/23/96 RB
MSTA720 Mechanical Insp / / / / 12/24/96 pending- .seal joints of fireplaces as PEND RB 12/2'/96 RB
per specs;
MSTA720 Mechanical Insp / / / / 12/26/96 flue piping Wil needs to be sealed at S 15 RB 12/30/96 RB
joints of bath ti-eplaces.
$15.00 charged
waived fees 12-27-?6- contractor was
caught up in the ice :storm
MSTA720 Mechanical Insp / / / / 12/27/96 PASS RB 12127/96 RB
MSTA722 Plumb Top Out / / ! / 12/23/96 PASS MS 12!26/96 MRS
MSTA723 Electrical Service / / / ! 12/23/96 need ground rods - to be noted on final PASS MJR 12/2.4/96 RB
need smoke alarm at basement
fan box in m. bedroom
MS(A724 Electrical Rough In / / / / 12/23/96 scc :;ervice PASS MJR 12/24/96 RB
MSTA725 Framing nsp / / ! / 12/24/16 m+r,. issue; ranger- rafter :aii^ in FAIL RB 12/24/96 RB
darbge; strap plates where off-set <48"
in garage; tempered glazing req'd at
jacuzzi; metal plate protect plumbing at
baseme,it at hose bib; notched floor
joists need errrectin0; draft stop wells
at basement.
MSTA725 Fr ing Insp / / / / 12/26/96 meth issue still perri,ng- no inspection FAIL RB 12/26/96 KAS
made!
MSTA725 framing Insp I / / / 12/27/96 pending- blocking for notched floor PEND RB 12/30/96 R8
joists inedegaute- provide blocking
closer to notched locations.
drypack sower line at foundation wall
MSTA725 F-aming Insp / / / / 12/30/96 PASS RB 12/30/96 RB
Page No. 3 CASE HISTORY FOR CASE NO.: MST96-0332
TYLER & DEBBIE LARSEN
13228 SW HILLSHIRE DR
07.22/97
Action Description Req/ Schd/ End/ Action Notes Disp By Update Upd
Code Sent Done Dnne Date By
------- ------------------------------ -------- -------- -------- --------------------------------------- ---- --- -------- ---
MSTA726 Shear Wal; Insp / / / / 11/05/96 #-1-inromplete at this time N/R KS 11/05/96 KBS
MSTA726 Shear Wall Insp / / / / 11/07/96 #-1- msts straps missing at lower level DIS KS 11108/96 KBS
MSTA726 Shear Wall Insp i / / / 11/08/96 #-1- this inspection does not include PART KS 11/13/96 KBS
interior shear
walls
MSiA726 Shear Wall Insp / / / / 12/20/96 pending- garage gyp shear req'mts as per PASS RB 12/20/96 RB
blocking if .joints occur.
MSTA727 low Voltage / / / / 02/20/97 need c;vers PASS MJR 02/21/97 MJR
MSTA735 Gas Line Insp / / / / 12!20/96 dropped pressure from 18-1/4# to 150 FAIL RB 12/20/96 RB
MSIA735 Gas Line Insp / / / / 12/23/96 #173996 PASS RB 12/23/96 RB
MSTA740 Insulation Insp / / / / 12/30,96 PASS RB 12/30/96 RB
MSTA745 Gyp Board Insp / / / / 01/06/97 where is jet tub pump access; backing; APP GS 01/06/97 GES
needed in bsmt bthrm ceil
MSTA755 Rain drain Insp / / / / 10/01/96 partial around house PASS MS 10/02/96 MRS
neat' underfloor crawl drain
MSTA760 Water Lir— Insp / / / / 11/20/96 PASS MS 11/21/96 MRS
MSTA765 Appr/Sdwlk Insp / ! / % 02/19/97 OK PASS PI 02/21/97 RB
MSTA770 Misc. Inspection / / / / 12/16/96 foundation drain- ok PASS RB 12/17/96 RB
MSTA770 Misc. Inspection / / / / 02/12/97 showy- ok PASS MS 07/12/97 MRS
MSTA790 Flectrical Final / / / / 02/20/97 grounding approved PASS MJR 02/21/97 MJR
Lo-volt boxes nerd covers
MSIA795 Mechanical Final / / / / 03/06/97 see building final this date FAIL RB 03/06/97 RB
MS'iA795 Mechanical Final / / / / 04/10/97 PASS RB 04/10/97 RB
MSTA797 Plumb Final / / / / 03/04/97 home occupied FAIL MS 03/04/97 MRS
not sure if anyone was home^
MSTA797 Pltmb Final / / / / 03/06/97 REO. 1 FOOT COVERAGE OVER RD AND SEWER PART MS 03/06/97 MRS
WATER HEATER RELIEF needs to go out
seperntely
MSTA797 Plumb Fina! / / / / 03/19/97 PASS MS 03/19/97 MRS
Page No. 4 CASE HISTORY FOR CASE NO.: MST96-0332
TYLER 8 DEBBIE LARSEN
13223 SW HI'-LSHINE DR
7/22/97
Action Descr;ition Req/ Schd/ End/ Action Notes Disp By Update Upd
Code Sent Done Done Date By
------- ------------------------------ -------- -------- -------- - -----------------.------------------- --- --- -------- ---
MSTA799 Building Final / / / / 03/06/97 Dwelling being occupied?????? FAIL RB 03/06/97 R8
Fi ml grade/slope; cover rain drain;
lateral brace deck(s); deck incomplete
at lower level- post/beam splices need
gussets; tighten HD's and anchor bolts
at sill under-floor; remove wood debris;
A/C unit not installed; seal wall thru
penetrations w/in garage; caulk/grout
tile where lacking, ie. bathrooms,
kitchen counter R fireplace; handrail
req'd at stairs; firestop thru
penerations in furnace room; provide 11,
8-vent clearance- furnace room- add
collar; electrical covers missed; master
bedrm smoke detector not inner
connected.
MSTA799 Building Final / / / / 04/10/97 PASS RB 04/10/97 RB
MSTA960 (F) issue Cert. of Occupancy / / / / 04/10/97 mailed 7-22-97 07/22/97 S*W
MSTA970 Cape Finaled / / / / 04/10/97 PASS RB 04/10/97 RB
MST8708 Erosion Control / / / / 02/21/97 PASS USA 03/06/97 RB
MASTER 171ERMI1*
r',ERII T MT9
CITY OF TIGARD Df-ITEI ISSUED: 07/c-14196(-
COMMUNITY DEVELOPMENT DEPARTMENT
13125 SW Hall Blvd.Tigard,Oregon 97223*8199 (503)639-4171 PIARCEL" 2Sl04CVA06J_,00
SITE ADDRLS35. . . : 13,228 SW IdILLIGIAIIRE. DR
SUBDIVISION. . . . : HILLSHIRE ZONING: R7 V'r)
BI_O('K. . . . . . . . LOT. . . . . . . . . . . . . lb 6 2!
Remarks: PATH I
--------------------------------------------------------------------- BUILDING -----------------------------------------------------------------------
REISSUE: STORIES.......: I FLOOR AREAS----------- BASEMENT...: 1095 sf REQUIRED SETBACKS---- REQUIRED--
CLASS OF WORK.:NEW HEIGHT......... 19 FIRST.,..; 1733 sf GARAGE.....: 497 sf LEFT..........: 8 SMOKE DETECTRS: Y
TYPE OF USE...:SF FLOOR LOAD....: 40 SECOND...: 0 sf FRONT..........: 21 PARKING SPACES: I
TYPE OF CONSI.:5N DWELLING UNITS- I F I NBSMENT: a sf RIGHT.......... 8
OCCUPANCY GRP.:R3 5DRM: 9 BATH: 4 1733 sf VALUE—$: 191357 REAR..,........: 41
------------------------------------------------------------____ PLUMBING __---------------------------------------------------------
Slw5......... 1 WATER CLOSETS.: 4 WASHING MACH.,: I LAUNDRY TRAYS.: I RAIN DRAIN ft: 0 TRAPS.........: 0
LAVATORIES....: 4 DISHWASHERS...: I FLOOR DRPINS...- I SEWER LINE ft: @ SF RAIN DRAINS: I CATCH BASINS..
TUB/SHOWERS...: 4 GARBAr-k DISP..- I WPTER HEATERS.: I WATER LINE ft: 0 BCXFLW PREVNTR: I GREAR TRAPS..
OTHER FIXTURES: 0
-------———------- MECHANICAL —-—-—--—----------------—
FUEL TYPES--------- FURN ( 100K @ BOIL/CMr' ( 3HP: 0 VENT FANS.....: 5 CLOTHES DRYERS: I
/GAS/ / / FURN )=I@@K I UNIT HEATERS..: 0 HOODS.........: I OTHER UNITS.... I
MAX INP.: 9 FLOOR F'.r,'NACES: 0 VENTS.........: @ WOODSTOVE;.... 0 GAS OUTLETS..,: I
--------------------------------------------- ELECTRICAL
UNIT---- ---5ERVICE/FEEDE9---- --TEMP SRVC/FEEDERS-- ---BRANCH CIRCUITS--- ----MISCELLANEOUS---- --ADDIL INSPECTIONS—
1@@@ SF OR LESS: 1 0 - 200 amp..: 0 @ - M imp,.: 0 W/SVC OR FDR..: 0 PUMP/IRRIGATION: 0 PER INSPECTION: 0
EA ADD'L 5W.: 5 201 - 400 asp.. 0 201 - 1,41., amp..: @ 1st W/O SVC/FDR: @ SIGN/OUT LIN LT: @ PER HOUR......: @
LIMITED ENERGY.: 0 401 - 600 amp., 0 401 - 600 amp..: 0 CA ADDL BR CIR: 0 SIGNAL/PANEL...: 0 IN PLANT.,....:
MANF HM/SVC/FDR: 0 601 - I@N alp. @ 41+a5ps-1889 V: 0 MINOR LABEL -10: @
ION+ alp/volt. 0 --------------------------------- PLAN REVIEW SECTION -------
Reconnect only.: 0 . :4 RES UNITS..s SVC/FDR)=225 A.: ) 600 V NOMINPLi CLS AREA/SPC OCC:
----- ---- ------------------------------------- ELECTRICAL - RESTRICTED ENERGf -- -------------------------------------
A. SF RESIDENTIAL--------------------------- B. COMMERCIAL------------------------------------—-------------------------------------------
PAJI)IO 4 STEREO.: VACUUM SYSTEM., AUDIO & STEREO. FIRE ALARM,....: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM..: DTH: X BOILER.........: HVAC...........: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER.. CLOCK..........: INSTRUMENTANIJIN: MEDICAL........: OTHR:
DATA/TELE COMM.: NURSE CALLS....: TOTAL # SYSTEMS: 0
HV,wn"er: ----------------------------Contractor,: TOTAL FEES:$ 4746.40
TYLER I DEBBIE LARSEN CORNERSTONE HOME BUILDERS INC
?989 SW SHORE BVLD. 161115 SE TAYLOR
LAKE OSWEGO OR 97035 PORTLAND OR 97223
Phone #: 699-9035 Phone 0: 503-252-1291
Rog #.,: 113680
This jersit is issued subject to the regulations contained in the Tigard M•inicipal Code, State of Ore. Specialty Codes and all other
applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started withir 180
days of issuance, or if work is suspended for more than 18111 days.
------------------------------------------------------•- REQUIRED INSPECTIONS ---------------------------- ----------------------------- -
Footing Insp PLN/Underfloor Framing Insp Gas Fireplace Water Service In Building Final
Foundation Insp Mechanical Insp Shear Wall Insp Insulation Insp Appr/SdwIk Insp Erosion Cont.,ol
Post/Beam Struct Plumb Top Out Low Voltage Gyp Boaro Insp Electrical Final
Post/Beam Meehan Electrical Servi Fireplace Insp Pain drain Insp Mechanical Final
Crawl brain Electrical Rough Gas Line Insp Water Line Insp Plumb Final
lz,pi mittee S i g n a t u r e s ._WdLfed 41 MAI I s s .led By
/I
Cali. fot- inspection — 639-4175
SEWER e&04EeT-fEP4
PIE RM I T
PERMIT #. . . . . . . : SW'136-0328
CITY OF TIGARD DATE ISSUED: 07/2',4/9-6
COMMUNITY DEVELOPMENT DEPARTMENT
13125 SW Hal!Blvd.Tigard,Oregon 97223*8190 (503)639-4171 PARCEL: 2S104CA--06200
SITE A ,DRESS. . . : 122'28 SW HILLSHIRE D13
SUBDIVISION. . . . : HILLSHIRE ZONING: R-7 PD
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . 0 62'
TENANT NAME.
USA NO. . . . . . . . . . : FIXTURE UNITS. . . : 0
CLASS OF WORK. . . :NEW DWELLING UNITS. . : I
TYPE OF USE. . . . . .9F NO. OF BUILDINGS. I
INSTALL TYPE. . . . :BUSWR IMPERV SURFACE: 0 sf
Remarks : PIATH I
Owner: FEES
TYLER & DEBBIE LARSEN type amol-trit by date t,ecpt
3989 SW SHORE BVLD. PRMT $ 2C200. 00 JMH 07/24/96 96-281986
1N3P, $ 35. 00 JMIA 07/24/96 96--iF.'81986
LAKE OSWEGO OR 97035
Phone #: 699-3035
Contr,actor-:
CONTRACTOR NOT ON FILE
...........
F-fic le #: s oo TOTAL
Rep
REQUIRED INSPECTIONS
This Applicant agrees to comply with all the rules and regulations Sewer- Inspection
of the Unified Sewage Agency. The permit expires 180 days from
thq date issued. The total amount paid will be forfeited if the
permit expires. The Agency does not guarantee the accuracy of the
side sewer laterals. If the sewer is not located at the measurement
given, the installer shall prospect 3 feet in ali directions from
the distance given. If not so located, the installer shall purchase,
a "Tap and Side Sewer" Permit and the Agency will install a lateral. ----------
I
Pler-mittes- Signatl-tt-e: zomid 1( nl'a
Issi-ted By :
Call for inspection 639-4175
Residential Bu
ildingPermit Ap lication
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223
(503) 639-4171
Jobsite Address: _Z2- 5•��• (-1��
Subdivision: Lotft
Valuation: _$ .' rt _ l �- __ ��Contact Dater U Initials
Result ;'/; �,.� C
New Construction Only: (Square Footac
Planck/Rec#
Howe _ _.-_-- Garage: Permit# _Irl S t fG 0322 �—
Reissue of
Corner Lot? f ® Flag Lot? Y Map &TL# c''WAC%r,
Zone
t1.125
Owner: -;�.1� Plat#„�_� -�'_--
Address:
JeA C�exnv ' np- �'1p3�_ Planning Setbacks Solar /
Engineerng
Pho ie l �oQ1�•9�a ---- -- Other ------._ -_—
`_j(�jfJ w►liir �1 t�QS�11.1[.
Contractor: tom_—_.—
Address �p t 5 Sty k�{LoR- _ _ Subcontractors_1�� �` ra,
Truss Details
Other --- ---
Phone L�Q3 ) �v��Z-12�j�j� N-9-tel
i
Contractor's '_,ccnse#
!attach copy of current 0,Egon license)
Contact Name �t.t� pM�Crra�—_ ------- -- --- -- --_ - .___—_ _.
Contact Phone (S03 L25�-• 129�`� •r1.30'�
Subcontractors: MArchitect/Engineer:
'-'4-250PI3 -� �2-31�`9l
Plumbing: MCEM&O T-L t, AA 15l0C Address
Mechanical �t_
(attach copy of current OP Contractor's Bceh3e)
ElectricalPhona: �_----- - - - -- -
J06 DESCRIPTION ��-�'
L L—
Applicant Signature Applicant Phone number
Received by Date Received: r
�:og,n ern ns�pC
Permit $ Account Description Amount Amt. Pd. Bal. Due
/�I.;l 1rr G Ste' Bldg. Permit (BUILD)
Plumb. Permit (PLUMB) u
Mech. Permit (MECH) ya �fj
State Tax (TAA) 4G
Bldg:
Plumb:
Mech:
Plan Check (PU\NCK) D�/ 1 U
Bldg:
Plumb:
Much:
z-1,(196-D %f` Sewer Connection (SWUSA) o UU
Sewer Inspection (SWINSP) ��
Parks Dev Charge (PKSDC) _ A)s0 54
Residential T'F (TIF-R) c 70
Mass Transit TIF (TIF-MT)
Commercial TIF (TiF-C)
Industrial i IF (TIF-1)
Institutional TIF (TIF-IS)
iff ice TIF (ITIF-O)
Water Quality (WCUAL) �
Water Quantity (WQUANT) r U U loa
Fire Life Safety (FLS) _
Erosion Cntrl Permit (ERPRMT)
1=rosion Planck/USA (ERPLAN) _ J• U _ p 1/_
Eros ^n Planck.'COT (EROSN)
TO TA L S: ' �(�
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
ACE ELECTRIC COMPANY
2535 SW PALATINE STREET
PORTLAND OR 97219
I
Flectrical Signature Form 1
Permit # . • . . : MST96-0332
Date Issued. : 07/24/95
Parcel . . . . . . : 2S104CA J6200
Site Address : 13228 SW HILLSHIRE DR
Subdi\,ision. : HILLSHIRE
Block. L >t : 062
Zoning . . . . . . . R-7 PD
Remarks :
PATH I
Your company has been indicated as the electrical contractor for the permit indicated above. In
order for the electrical permit to be valid, the signature of the supervising electrician
is required.
Please have the appropriate individual from your company sign below and return this Electrical
Signature Form prior to the. start of work. No eli,ctrical inspections will be authorized until
this completed form is received.
AN INK SIGNATURE IS REQUIRED ON THIS FORM
ELF(7TRICAL CONTP-4CFOR:
TYLER & DEBBIE LARSEN ACE ELECTRIC COMPANY
3989 SW SHORE BVLD. 2535 SW .i4T,ATINF STREET
LAKE OSWEGO OR 97035 PORTLAND OR 9721.9
Phone # : 699-9035 Phone # :
Reg # . . : 36043
X
nature of'Sup I.: ectrician
Please return this completed form to the address ab e.
ATTN: Building Dept.
it you have any questions, please call 639-4171 , ext. #310
CITY OF YIGARD
13125 S.W. HALL BLVD.
'rIGARD, OR 97223
IMPORTANT PERM11 NOTICE
MODERN PLUMBING
11120 SW INDUSTRIAL WAY
TUALATIN OR 97062
Plumbing Signature Form
Permit # . . . . . MST96-0332
Date Issued. : 07/24/96
Parcel . . . . . . : 2S104C:A-06200
Site Address : 13228 SW HILLSHIRE nR
Subdivision. : HILLSHIRE
Block. . . . . . . . ho . 062
Zoning. . . . . . : R-7 PD
Remarks :
PATH I
Your coropany has been indicated as the plumbing contractor for the permit indica'ed above. In order
for the piumbing permit to be valid, please have the appropriate individual from your company sign
below and return this Plumbing Signature Form prior to the start of work. No plumbing inspections
will be authorized until this completed form is received.
AN INK SIGNATURE IS REQUIRED ON THIS FORM
OWI11"P : PLUMBING CONTRACTOR:
TYLER & DEBBIE LARSEN MODERN PLUMBING
39e9 SW SHORE BVLD. 11120 SW INDUSTRIAL, WAY
LAKE OSWEGO OR 97035 TUALATIN OR 97062
Phone # : 699-9035 Phone # :
Reg # . . : . 87906
Signature of AuthorizeOlumber
Please return this completed form to the address above.
AT*TN: Building Dept.
If you have any questions, please call 639-4171 , ext. #310