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E-TION NOTICE
City of Tigard Building Department J
13125 811 Ball Blvd. Tigard, Oregon 97223
Inspection Line (Roc-O[-Phone/)): 6s9-4175 Buaineoa Phone: 639-4171
Inspection:
Footing Pl,bg. Underalab Mech. Rough-in Appr/Bdwlk
Found. Plbg. Top Out Gas Line �lINAL�
Poet/Beam Struct. San. Sevier Framing -Bldg. r
:oat/Beam Mech. Rain Drain Ine,:lation -Plumb.
Plbg. Underfloor Nater`Line Gyp. Bd. -lfeoh.
Date Requested& 2�( '_ r � Timet �I�11M ^Px
Addreee: 1 L lll _ Permit ft EL)�1
1
Builder:
THE FOLLOWING ..-RRECfIONS ARE REQUIRED:
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Inrapeotort �•"``-'
11PP110VlD DISAPPROVED APPROVED SUBJEr7' TO APOVF.
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For RoinsP.
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CITY OF TIGARD
COMMUNITY DEVELOPMENT DEPARTMENT
43125 SW Hall Blvd.Tigard,Oregon 97223.9100 (503)639-4171
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Residential Building Permit Application
City of Tigard
13125 SW Nall Blvd.
Tigard, OR 97223
(503) 639-1171
i Jobsite Address:
Subdivision: Lot # Office Use Only
Valuation: /�1�� - /%� Plandc/Rec#
Permit#
lwner: ,'� �" Yl(l hIn ���S.J i4 LLQ Reissue of �_! _--
Address:�� ��r �,� Ael
..Approvals Required
tanningn
Phone: ?`
Contractor: �1Z�I _--___-- Other
Address:
items R uired
Phone: Suocontractors
......--^._� --
Contractor's License # Truss Details
(attach copy of current Oregon license) Clther ' Itt
Subcontractors: I
Plumbing:
Mechanical:
(attach ropy of current OR Contractor's License)
ArchltecUEngineet:
Address:
Phone:
COMMENTS:
Applicant Signature & Phone number
Received by: i Date Received:
Permit # Account Description Amount Amt. Pd. Sal. Due ,
Alr� - D3 0 Bldg. Permit (BUILD)
Plumb. Permit (PLUMB)
Mech. Permit (MECH)
State Tax (TAX) Z )r / v
Bldg: /.
Plumb:
Mech:
Plan Check (PLANCK)
Bldg: �n Z
Plumb:
Mech:
Sewei Connection (SWUSA)
Sewer Inspection (SWINSP) _
Parks Dev Charge (PKSDC)
Storm Drainage Chg (SDSDC)
Residential TIF (TIF-R)
Mass Transit TIF (TIF-MT)
Commercial TIF (TIF-C) _
Industrial TIF 'TIF-1)
Institutional TIF (TIF-IS)
Office TIF (TIF-0)
- Water Quality (WOUAL)
J
"later Quantity (WOUANT)
'IY
Fire District (FIRE) _
TOTALS: �2'5 0
Fes, Permit No:
Address:
Issued by:_ _ Date:
"• ••/ ----_.FOR OFFICE USE ONLY__
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, OF'„� 701.055(4) , requires residential construction permit
applicants wro are not registered with the Construction Contractors Board to
sign the following statement before the bidding 7--mit can be issued. This state-
ment is required for rebidential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement wi!I be
filed with the permit.
Fill in the applicabie blanks, and initial boxes 1 and 2, and either box 3A or 3B:
1 . L__"E!V/6 own, reside in, or will reside in the completed structure.
2. [_ ,/ 1 understand that i must register as a construction contractor if the structure is sold
or offered for sale before o upon completion.
3. A.1 1 My general contractor is
Contactor registration number
I v0I instruct my general contractor that all subcontractors who work on the struc-
ture must be ,'egistered with the Construction. Contractors Board.
OR
3. B.C>�will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. If I change my mind and do hire a general contractor, I will
contract with a contr&ctor who is registered with the Construction Contractors Board
anc: I will immediately notify the office issuing this building permit of the name of
the contractor.
I hereby certify that the above information is correct and that I have read and understand
the Pnformation Notice to Property Owners about Construction Responsibilities on the
reverse sine of this form.
Signature of Permit Apolicant Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
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