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INSEE_ CTION NQTICE
Cit, of Tigard Bailding D, egone97223
13125 861 Hall f lvd. Tigard, orego
Inspection Line (Rec-o-Phone)s 639-4175 Business Phone: 639-4171 k
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Inspection:
ei► Mech. Rough-in Appr/Sdwlk
Footing Pibg• Dnderelab g
Found.
Plbq. Top Out Gas Line llINALt
post/Beam struct.. San. Bawer
Framing -Bldg.
Post/Beam Mech.
Rain Drain Insulation -Plumb
Plbq. t)nderloor Nater Line s LiGyp. Bd.
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Date Requested e �J e J•�/�s � /l
Address$ L [/
Builders
THE FOTAOWINO ODRUCTIONS ME REQUIRED),
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-_ Date--�
(x/_l,PPROVED DISAPPROVED - —_ APPROVED SUBJECT TO 1:BOVE
Call For Reinsp.
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CITY OF TIGARD
COMMUNITY DEVELOPMENT DEPARTMENT
15,. 13126 8W Hall Blvd.Tigard,Oregon 072234199 (603)630.4171
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('.111'Y OF' T I GARD RECEIPT OF PAYMENT RECEIPT NO. 993--241677
CHECK AMOUNT" a 15. 75
JAMF a BUTLER, SCOT 1' CASH AMOUNT 0. 00 i
)DDRE:SS 2 9220 SW MIL_L.EN PAYMENT DATE s 06/24/9;
SUBDIVISION s
TIGARD, OR T 7224—
PURPOSE: OF PAYMENT AMOUNT PAID PURPOSE CIF PAYMFNT AMOUNT PAID i
='L..UMBING PERM 15. oel ST. BUILD PER . 0. 75
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APPLICATICN - STREET IMPROVEMENT/EXCAVATION Y/, / COPY TO:
[X (WHITE)•FILE
ORDINANCEN0. 74 14 ® (YELLOW)-INSP.
(INSTRUCTIONS ON S PARATE SHEET) (PINK)•OTHER AGENCYbldg.
-Y-_' '7 (BL-UE)-APPLICANT
APPROVED APPLICATION NO.:
NOT APPROVED CI I•Y O IIGARD, OREGON FEE AMT.: f-_-4'00 _
PENDING FEE. PMT. ❑ CI I1 HALL RECEIPT NO,: 041680
PENDING SECURITY [] PUB-/C WORKSDEPAF 'ENT BY c �� DATE_-�6 4 '
PENDING AGENCY ''OK'' [] AIllilication and Progress Record - w -
MAINTENANCE BOND
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS RI-QUIREU
ANNUAL
PENDING VARIANCE i EXPIRATION DATE:
PERMIT NO.:
DATE ISSUED: - - / t` -f,� BY r
()) APPLICATION iS HEREBY MADE TO EXCAVATE FOR ANP INSTALL -.-_,._SPRINKLERS
- -_ -_ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
r,i. !.r_ A. Butler 9220 S.W. Millen Drive Tigard, OR 97224 6�0-4007
APPLICANT --- ---- — -- CITY --.274-9273 - -
9
NAME ADDRESS ---` -
CONTRACTOR - Same
PLANS EY ___S" attached Sketch -
--� 'NAME -•- ----'-� ADORE88 _'- —� — CITY --- - PHONE ---
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ 50.00
— ---- DOLLAR:
(2) EXCAVATION DATA: ran OFFICE USE:
'1.04 X f
�_T
l STREET DESCRIPTION PR)GRESS & INSPECTION STATUS
--NAME SURFACE CUT CUT CUT MATERI/ L IN4TAlLED ITkM DE
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY ATREMARKS/TYPE BY
— STREET
_ OPENED
-
92r1d Ave. a e att 'hed _ INSPEC-
' E TION
-- U
ESTIMATED STREET OPENING DATE: E —
S
ESTIMATED STREET CLOSING DATE: / / T
F
(3) SECURITY NO. _ SECURITY AMT.: $ 50.00 STREET
LOSED
SURETY CO.: FINAL
- _
CF.RT�FIED CHECK ll
_ _ _ CASH_ u ec,ND INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL � - SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
' 1. t'U_tity City inspector Letha _
ThrxTr s (639-4171) 7.4 hrs. before
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a`c Egwork wItnin po c
—
I 1L(IC-44)
2. ORS 757.541-.571 applies (I 'lityl'
cUAe+ A. - - -� Company's notificatiai, beture
S. W. 92nd Ovenue H
9y ny, etc.)
__* — __ --.._____ ten 3. This is to be cunsidered a
temporarynstall.ation; dan►age
-+�+✓-1 ) ' -- __._._ - , 1 to, rewoval of, or relocaffixi of, 1
lIt necessary, shall solely
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- "a owners r Bk a[0 evense.
(S) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPL-ICANTS TO CONDUCT WORK WHERE
i RIGHT OFWAV JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, -O COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF 'THE W� RK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY IN IURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
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APPLICANTS S,GNATURE _
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