Loading...
12210 SW ANN COURT-1 12210 ANN COURT 1 OF 1 FILMED 2004 u ' \ 7.5 ' 111 44 r y/ 4 .r.\ � '- d 4 �, y / • \4 p. / `n \A -- -1 ' .4 , .,jr' / 11 \ I. P. F. 1 '' '. 17 <lb / A; .0.4--,"\ • \ Z 9s 1 C*1 - ----- -- \ \-;( 7.) .)1y//4)% NN • _ eIT -E N 4 7 � Pa.S,�R•\a0 "\ N g�358.68 2 • 5.0' \\ .b2.--4).„...........---------",. 82.501 ,� ' �,% 101. Oct' - - \ 1 - 25' NORM DaAINAGE CENTERLINE CURVE DATA s/e� I. R. F. - X37.88' �2 6 3, \ \ ,vZ i ,x•51 E s nn T. o �. fr / \ \ I w C`,� N •n { CODE . DELTA RAD T�U S LENGTH CHORD CI P /�� / 17. 7 2 W \ \ �� a \ 0 k o. Q , . \ \_ 3- t c� ► 2 2 Q 24°50 ' 05 " 100 . 00 43 . 35 43.01 N 0Q0 / Ili :r \ \ ti t :r. / , o_ I9 1- 20 \ \ o/ :r `� Q' o \ 2 11 I • BOUNDARY LINE CURVE DATA �/ \ , ,i.y. ,3 '2.\ ,- 0 CODE DELTA RADIUS LENGTH CHORD C} N , / - z �.43•oc 39.80' 87. 00 \ 62. 29 P=3o o s- � ,,,, \ b It _ _-_ -\ 1%c.8 �2 A 29036142 " 85 . 00 4 3 3 43 . 44 S- y a 0,00.5.6,-.i " -_jam b. _ / , , _____-_24. 2. 00. \ N-88-25'2014 * • -.'_ 42sr ; 152 ` 19.84 n � ' _'' ` cP 4p6 \ \6d- 00 ,.u.• 148. 00' N• 8 25 20- 4J ., s /1\ r /' w o� - 'I N-`. T. LR.F.4 \ . rs=3d' �� u� !� 2 3 ''- �, LOT CURVE DATA ? I I.AK TERRACE P. - ' / / / A 2" I. [-. F. M H ,W \ ♦ \ , ! �1� r // I REMOVED IN C�7NST. o !: � IA ) \ _-�`� , �j� �" LOT DELTA RADIUS I.ENGTH CHORD ,• / I � fn \ s,� '.� • 19 21 °25 ' 16" 115 . 00 43 . 00 42 . 75 I _ o ( 1`'� \ J•� ,, 2`kg• \ 21 29°00 ' 06" 50 . 00 25 . 31 25 . 1 3 I 1- 'jak�ti \ ‘': \ 4 6t 21 41 °24 ' 34" 30 . 00 21 . 68 21 . ? 1 I •, ` '�s z .1 W /s-, sks,'�,9 y�� 0•��. 22 7221 59 50 . 00 63 . 15 59 . 04 \ 1 .� 23 84° 33 ' 22" 50 . 00 73 79 67 . 27 i I ;: � or `�1\ \ c� \ --4\6' �O: _^c t© 8 5.61' • 24 28° 35 ' 35" 50 . 00 24. 95 24 . 69 I • r-- - -a. - --- - -- -- --- - -- --- __ _ . z. or- _. _ 1 h 25 �s` • � � \ j �► 25 74°52 ' 05" 50 . 00 65 . 34 60 . 79 I . . z 4- i N-86.141' 55°- E I < o I ? 4) Y 25 67°58 ' 32" 30 . 00 35 . 59 33 . 54 .:• � v, -- Q Fs� \ \/ I 0 SAN. 51F!R. E S MT. I \, ` F I !� '1ra\� \ i!o tot 70.84' N-43°22'00"-E I �^ W \, 1 I :.i.. INITIAL POINT ,�' o 2 .. _ 0 I •,:i• SET 2"x36 .G. I. P. CO \ \-4 W •f. " DEEP I /1 118 `10 I 20' SWORN DRAINAGE a I S - 721 . 7 I6 90to - . o,t5 EASEMENT I E • 737. 60 / I �3O ) 0 1 \' �E 1 \ 1 I OF N. W. COR . MH �, ,i ,I \ 1 I SEC . 3 T- 23 R-1 w Qs. �� . Ioilo �o s t I W. M. „ X2.8 0 /.82. 1 \o. ♦ I EASEMENT NOTE -- - - - - - -_ - _ _ _ (Fa 3�r� + .R), TRACT "A " , : �• MH le {. R. F. -� % \ SAN . SWR. IN ADDITION TO THOSE EASEMENTS. SHOWN , ALL LAKE TERRACE `. \ 5-54.24'26.-1E I � � . � R AND SIDE LOT LINES ARE TO HAVE A 5 . 00 FT . i I 30 #�W SANITARY SEWER, STORM AND DRAINAGE , POTABI 11 3-53.40141E \ 'ZZ-, Q .6cN Ate.\� SUPPLY AND UTILITIES . J_EGEND 'Ns. • 5 • DENOTES POINTS FOUND ` Mh LOT 1 ' LACE TERRACE 0 DENOTES POINTS SET \ 5/ 8" x 30" IRON ROD SIDE I 0 r_riiIIIIIIIiIIIIIIIIIIIIIimililliplia III111 III 111111 III IIIr I IIIIII III III III III IIII I IIIIll III III ill IIIIIII IIII III Ill III III III Iljllll III III IIIA INOTICE. IF THE PRINT OR TYPE ON ANYI I I ( ` l l y I I r � � (,2640 -5/ 1 4i s 8 ____. 11 1 {MAGE IS NOT AS CLEAR AS THIS NOTICE, No.� A ��� IT IS DUE TO THE QUALITY OF THE _ _ _ ORIGINAL DOCUMENT Z SZ1LZ 9Z Z P1 S Z IZ OZ tit LI 9i 2I 1t tigliIII t 6 8 L 9 ' 4 s L TMUMrt 11 Ilii HII Illllllll IIII 1111 11111 1111 Hll 1111 Illi 111111 6, 1 . Ill IHl tilt III I{U 111111111 1111 IIIIIrIHIH1111,1111 111. .1111 IIII {111111 IIH 11III 11111111111 I 111111111 11.1.1111 Ilii llll.l►II.1II►_«iI i►11. 1lhlllLllll.11lLll�llL1111.111114 r r I � 1 r� 12210 SW ANi i COURT CITY OF TIGARD BUILDING INSPECTION DIVISION MST f cycjy 03) 3� 24-Hour Inspection Line: 639-4175 Business Line: 639-4171 t� BUP ___— __—_pate Requested -1 - Z2-- 9 9 AM PM BLD Location ( 2-Z!L) ArA. C-1. SuiteC_ _ ME Contact Person ' p_ Ph (0l11'+ Sy ! PLM Contractor -- Ph 7O U321 3WR r -UILDI Tenant/Owner ELC Retaining Wall ELR Footing Access:,Ck� ' I �+ - FPS Ftg[7rarn —l SGN Crawl Drain Inspection Notes: Slab ��� �� SIT Post& Beam Ext Sheath/Shea' - - Int Sheath/Shear Framing Insulation —� Drywall Nailing Firewall Fire Sprinkler Fire Alarm Susp'd Ceiling Roof Mrsc _ ret r ��- PART FAIL P i BINCi Post& Beam — -- — -- — Under Slab Top Out Top Out ----- - ---- Water Service Sanitary Sewer - Rain Drains Final --- — PASS PART FAIL _ MECHANICAL Posta Beam -- - "+ — - -- — --. Rough In Gas line Smoke Dampers Final — PASS PART FAIL ELECTRICALService Rough Rough In --�- -- --- — tJG/Slab Low Voltage Fire Alarm — - - - Final PASS PART FAIL SITE Backfill/Grading --- — —_-.-- Sanitary Sewer Storm Drain i I Reinspection fee of$ required before next inspection Pay at City Hall, 13125 SW Hall Blvd Catch Basin Fire Supply t ine ( )Please call for reinsoectinn RE j Unsble to inspect - no access ADA Approach/Sidewalk - C Other Date Inspector Ext Final PASS PART - FAIL DO NOT REMOVE this inspection record from the job site. CITY OF TIGARD BUILDING INSPECTION DIVISION MST 24-Hour Inspection Line: 639-4175 Business Line,-639-4171 q G BUP --- Date Requested 1-� 1 AM PM _� BLp Location 17.v 1t�, V))) C-4 -=uitte ---- MEC -- Contact Person 66-11.1) Jc(IC(ed: Y\1 Ph (0 2q web' PLM Contractor _ Apr ph SWR BUILDING Tenant/OwnerELC Retaining Wall - ELR q, 7 - O( ' 7 MVOIMMEIr Footinc, Access Foundation FPS _ Ftg['rain SGN Crawl Drain Inspection Notes. ') Slab ---- — U TIA.0 y/�iwt — SIT Post & Beam Ext Sheath/Shear Int Sheath/Shear Framing _ • - Insulation _ Drywall Nailing .��. - - - Firewall Fire Sprinkler --_--- - _ Fire Alarm Susp'd Ceiling --- R oof Misc — k Ir• - — ---- Final v---- - ----- PASS PART FAIL -- — --PLUMBING Post Post& Beam Under Slab -- - - Top Out Water Service _ -- ----------._.--- Sanitary Sewer Rain Drains -- ----- — --- ----- Final PASS PART FAIL MECHANICAL Post& Beam Rough -- - -- - -- --- Rough In GasLine - - ---------------- ----- ------------------- --- - Smoke Dampers Final _�-.----------------- --- - -- ---- - - PASS PART FAIL. [E TRICAL - —— --- --- - - -- - S,er Vice -- ---_-- - -'-------- -_--- �- _----- Rough In ow Volta Fire Alarm -- --- - - - -_._- -- _— Fi AS PART FAIL ---- ---- -- - - - - - a Backfill/Gradinr) -- - ` - - ----- ---- Sanitary Sewer Storm Drain I J Reinspection fee of$ _required before next inspection Pay at City Hall, 13125 SW Hall Blvd Catch Basin no access Unable to Fire Supply line 1 J Please call for reinspection RE I Iinspect ADA Approach/Sidewalk Other Date .//7 7 Insuector �:�_Ext _— G. Final PASS PART FAIL 0 NOT REMOVE this inspection record from the Job site. CITY OF TIGARD DEVELOPMENT SERVICES ELECTRICAL PERMIT - pa .4L 13125 SW Hall Blvd., Tigard, OR 97223 (503)639-4171 RESTRICTED ENERGY PERMIT *: EL.R97-0117 DATE ISSUED: 04/14/97 PARCEL: 291313B1-3000 SITE ADDRESS : 12210 SW ANN CT SUBDIVISION : ZONING: BLOCK : LOT • JIJRISDICTN: Oro ect Description: DickPOMLAPAIAM A. Rf ' iDENrIAL - B. COMMERCIAL - - - - ALlDIO R STEREO. . . : AUDIO & STEREO. . : INTERCOM R PAGING. . : BURGLAR ALARM. . . . :X BOILER • LANDSCAPE'IRRIGAT. . : GARAGE OPENER. . . . : CLOCK • MEDICAL • HVAC • DATA/TELE COMM. . : NURSE CALLS • VACUUM SYSTEM • FIRE ALARM t OUTDOOR LANDSC LITE: OTHER: : : HVAC PROTECTIVE SIGNAL . . : INSTRUMENTATION. : OTHER. . : TOTAL. M OF SYSTEMS: 0 Owner: ---- ---- FEES - --- ---DAVI D JACKSON type amount by date recpt 12210 SW ANN CT PRMT $ 40. 00 TAT 04114/97 97-293209 TIGARD OR 97223 5PCT f 2. 0M TAT 04/14/97 97-29320 Phone N: 524-6578 r,nntractor: -- -- - - ------ ADT SECURITY ALARMS S 42. 00 TOTAL 70.3 NE HANCOCK REQUIRED INSPECTIONS --- PORTLAND OR 97212 Ceiling Cover Elect' 1 Service Phone N: 503-284-3265 Wall Cover Elect' l Final Reg N. . : 000599 This peralt is issued subject to the regulations contained in the Tigard Municipal Code, State of 0e. Specialty Codes and all ether Peraitee\Signat'arM) applicable lam. All work will be done in accordance with approved plans. This verait will expire if work is not started within les days of issuance, or if work is suspendnd for pore than IAS days. I ssred By - OWNER INSTALLATION ONLY Theinstallation is being mode on pr•oc rty I own which is not intended for sale, lease, or rent. OWNER' S SIGNATURE: DATE: - - CONTRACTOR INSTALLATION ONLY - - S I GNATURE OF SUPR. ELEC' N: DATE: 1 I CENSE NO: --___ __ _—_.-___._-___ Ca11 for inspection - 639-4175 CITY OF TIGARD RESTRICTED ENERGY ELECTRICAL APPLICATION Recd by: 13125 SW HALL BLVD /9Date Recd: TIGARD OR 97223 9 PRINT OR TYPE V - 503-639-4171 X304Permit#: L./' 9 7.01) 7 F - 503-684-7297 / . i INCOMPLETE OR ILLEGIBLE APPLICATIONS Cust CaII'd: WILL NOT BE ACCEPTED Name of Development Project TYPE OF WORK INVOLVED -RESIDENTIAL Restricted Ene.gy Fee $40.00 (FOR ALL SYSTEMS) JOB Street Address Ste 0 APPRESS /d49/p S a) AWN CT --- CheckType of Work Involved Gt /S l Zi Phone n Audio and Stereo Systems V-23 _5,2 5, Name _ 6 S 1C I tBurglar Alarm ...DAY 11) fiCKS6 N ❑ Garage Door Opener' OWNER Mailing Address City/State Z p Phone 0n Heating,Ventilation and Air Conditioning System' Name ❑ Vacuum Systems' t vapor strictS,INC. 703 NE HANCOCK n Other -- ---- CONTRACTOR Mailing AdcfglA3.WL uui7T21Z MVO TYPE OF WORK INVOLVED-COMMERCIAL (Prior to issuance a City/State Zip Phone 0 Fee for each system $40.00 copy of all licenses _ (SEE OAR 918-260-280) are required if Oregon; - N Exp Date expired in C 0 T Check Type of Work I evolved • data base) Electri 1 Conti i , Exp Date n , �-/{ _ Audio and Stereo Systems C 0 orM etro Lic 0 Exp Date ❑ Boiler Controls Owners Name ____ ❑ Clock Systems OWNER - Mailing Address APPLICANT ❑ Data Telecommunication Installation City/State Zip 7 Phone 0 [1] Fire Alarm Installation This permit is issued under OAE 918-320-370 This applicant agrees to El only restricted energy installations(100 volt amps or less)under this HVAC permit and to do the following n Instrumentation I Only use electrical licensed persons to do installations where required Certain residential and other transactions are exempt from licensing n Intercom and Paging Systems These have asterisks(') Al:others need licensing E.] Landscape Irrigation Control' 2 Call for inspections when installation under this permit a.e ready for inspection at 303-814.4118; F-1 Medical 3 Purchase separate permits for all installations that are not ready for an n Nurse Calls inspection when the inspector is out to inspect under this permit 4 Assume responsibility for assuring that all corrections required by the ❑ Outdoor Landscape Lighting' inspector are done.and. n Protective Signaling 5 Assume responsibility for calling for a final inspection when all of the �1 corrections are completed LJ Other Permits are non-transferable and non-refundable ana expire if work is not started within 180 days of issuance or if works suspended for 180 days Number of Systems The person signing for this permit must be the applicant or a person • No licenses are required lrenses are required for all other instaitations authorized to bind the applicant - FEES: !� w AIL.. - — ENTER FEES $ LVO ' v v ignstu r- �� 5%SURCHARGE(.05 X TOTAL ABOVE) $ `��• Authority if other than Applicant TOTAL $ T-" • V Ci - ,veseie doc 12/96 1 CITY OF TIGARD v` __MASTER PERMIT PERMIT#: MST1999-00139 .4 4I1DEV'ELiOPall eMENTlvd., rOR SERVICES 639 4171 DATE ISSUED: 4/19/99 SW13125 SITE ADDRESS: 12210 SW ANN CT PARCEL: 2S103BB-13000 SUBDIVISION: LAKE TERRACE NO. 2 ZONING: R-4.5 BLOCK: LOT: 023 JURISDICTION: TIG REMARKS: 140 sq. ft. accessory structure BUILDING REISSUE STORIES t FLOOR AREAS REQUIRED SETBACKS REQUIRED CLASS OF WORK: ACS HEIGHT II FIRST. 140 II BASEMENT: sl LEFT t, SMOKE DETECTORS TYPE OF USE. SF FLOOR LJAD 41 SECOND. sl GARAGE: d FRONT PARKING SPACES TYPE OF CONST. 5N DWELLING UNITS. FINBSMENT sl RIGHT 5 VALUE: S 3.000 00 OCCUPANCY CRP• R3 BDRM BATH TOTAL sl REAR. 5 PLUMBING SINKS WATER CLOSETS WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN TRAPS LAVATORIES DISHWASHERS FLOOR DRAIN, SEWER LINES: SF RAIN DRAINS CATCH BASINS. TUB/SHOWERS GARBAGE DISP WATER HEATERS WATER LINES: BCKFLW PREVNTR GREASE TRAPS OTHER FIXTURES MECHANICAL FUEL TYPES FURN<TOOK BOIL/CMP<3HP. VENT FANS CLOTHES DRYER FURN...TOOK UNIT HEATERS: HOODS OTHER UNITS• MAX INP btu FLOOR FURNANCES VENTS. WOODSTOVES GAS OUTLETS ELECTRICAL RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC/FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS 1000 SF OR LESS 0 • 200 amp 0 • 200 amp W/SVC OR FDR PUMP/IRRIGATION PER INSPECTION EA ADO'L 500SF 201 • 400 amp 201 - 400 amp 1st W/O SVC/FDR SIGN/OUT LIN LT PER HOAR LIMITED ENERGY 401 . 600 amp 401 • 600 amp EA ADDL BR CIR SIGNAL/PANEL. IN PLANT MANU HM/SVC/FOR 601 • 1000 amp 601.anws-1000v MINOR LABEL 1000.amp/volt PLAN REVIEW SECTION Reconnect only -- ' 4 RES UNITS SVC/FDRS<225 A >600 V NOMINAL CLS AREA/SPC OCC ELECTRICAL•RESTRICTED ENERGY A.SF RESIDENTIAL B COMMERCIAL __- AUDIO 11 STEREO VACUUM SYSTEM AUDIO$STEREO FIRE ALARM INTERCOM/PAGING OUTDOOR LNDSC LT BURGLAR ALARM OTH BOILER HVAC I ANUSCAPE/IRRIG PROTECTIVE SIGNL GARAGE OPENER CLOCK INSTRUMENTATION MEDICAL OTHR HVAC DATA/TELE COMM NURSE CAL LS TOTAL s SYSTEMS Owner: Contractor: TOTAL FEES: $ 105.46 This permit Is subled to the regulations costa:sed in the DAVID JACKSON OWNER Tgard Municipal Code. State of OR Specialty Codes and 12210 SW ANN CT SIGNED RESPONSIBILITY FORM all other applicable laws All work will be done In TIGARD Oft 97223 IN FILE accordance with approved plans This permit will expire rf work is not started within 180 days of issuance, or if the work is suspended for more than 180 days ATTENTION Phone: 524.65TO Phone• Oregon law requires you to follow rulea adopted by the Oregon Utility Notification Center Those rules are set Regio forth In OAR 952-001-0010 through 952-001-0080 You • may obtain copies of these rules or direct questions to OUNC by calling(503)246-1987 REQUIRED INSPECTIONS Footing Insp Framing nsp Final Inspection Building Final f _ Issued By : t h"t&'V,,,,`- Permittee Signatur ,. i.,.. - cie6ap-�-� Call (503) 639-4175 by 7:00 p.m. for an inspection need the next bust us dj►'1 CITY OF TIGARD Residential Building Permit Application Plan Check# --2-1()(2"- 13125 -Z-13125 SW HALL BLVD. Additions or Alterations Reed By Date Recd - ' TIGARD, OR 97223 Single Family Detached or Attached (Duplex) Date to P E 1.15 'i°I V 503-639-4171 Date to DST -rJ `1 4 Rr F 503-684.7297 Permit 0 1\4i I'2 MI Print or Type Called 4- - 4- Incomplete Incomplete or illegible applications will not be accepted if= '0" – —__ ,PSE w/ ',Pot, ) Name of Project Le Name Job /4K kit, ':Z a 3 -- -- Address Site Address Architect Mailing Address PR/(S 5 F`) Ay u City/State —_ --Zip Phone rame -IAV t b 30CA_L.Carl ---- Name Owner Mailing Address t 1 ° '''' Pr) Engineer Mailing Address City/State Zip Phone g 1 r `• .i c_Lt /_ ' r-1,', 1 `,,L,/ (4;,14S Crty/State Zip Phone -- General Nem . Contractor Itav IL .1 \P i* ' Describe work Newb1 Addition 0 Alteration 0 Repair 0 la Mailing Address to be done - Prror to permit I =t . ' jar,rs '- ' 4 Additional Descriptipq of Work: issuance.a copy ^City/State Zip Phone l', r < 1 <, , ` 1'' ' - lb • - of ati licenses I 1 � c L 1 ': ‘ are required H Oren Const Cont Board Exp Date / PROJECT , ) C expired in COT Lic M VALUATION $ 2T r database 4 Mechanical Name - `-___--' NEW CONSTRUCTION ONLY: Sub- Sq. Ft. House. T Sq. Ft. Garage Meiling Address I/ l Contractor g -- --- Prior to permit Indicate the restricted energy installation by the electrical issuance,a copy City/State Zip Phone subcontractor in the following areas _ -� of all licenses Restricted Audio/Stereo ;ire required tf Oregon Const Cont Board Exp Date -' Energy System Alarms expired in COT Lica Installations Vacuum Irrigation database System System Plumbing Name (check all that Other: Sub- apply) Contractor Malting Address — Corner Lot YES NO Flag Lot YES NO (check one) _ icheck one) Has the Subdivision Plat recorded? N/A YES NO Prior to porn.t City/State Zip Phone issuance a copy ---- of all licenses are Oregon Const Cont Board Exp Date required if Lic S -- -- expired in coT I hearty acknowledge that I have read this application,that the database Plumbing Lie a r 'Exp Date information given is correct,that I am the owner or authorized agent of the owner, and that plans submitted are in compliance with Oregon State laws _ _ _ Name Signature o Owner/A9ent Date Electrical _ -- Sub- Mailing Address • tad Peso afTts Phone N , -Jo _Y1QktA, • c- Contractor '—��- N 5)S.-45 75 City/State Zip Phone Prior to permit issuance a copy FOR OFFICE USE ON Y: of all licenses are Oregon Consf Cont Board Exp Date 4 required if Lic S Plat I ' lir , t ! Ma5L0 3, �n/y� expired in COT lY ' t) [J� /0 g -/3 Qj database Electrical Lic N Exp Date Il «. • ' r\ Zone__ _ Solar, Electrical Supervisor Lic 0 Exp Date E , • ng Approval. Plannint Approval TIF'l n 1 i ldsts\forms\sfaddalt doc 11/20/98 I Permit 111sri994 -00/3 9 0 •s\ 74/0 s A) /49,mi..q4;60 w- V, ; r ` Issued by: Date: 1859 Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli- cants who are not registered with the Construction Contractors Board to sign the following statement before a building permit can he issued. This statement is required for residential 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 will he filed with the permit. Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 3B: El1. I own, reside in, or will reside in the completed structure. 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale before or upon completion. ❑ 3A. My general contractor is_ (Name) Contractor regis. # I will instruct my general contractor that all subcontractors who work on the structure must be registered with the Construction Contractors Board. OR 3B. I will be my own general contractor. It 1 hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. If I change my mind and hire a general contractor, I will contract with a contractor who is registered with the CCB and 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 do understand the Information Notice to I'roperty Divers about Construction Responsibilities on the reverse side of this form. plirant) �-- � (Date) �--_\Signature _ J (White cope to issuing agency permit file, pink copy to applicant) A -* � .d S . 1 ,-,,o-Dr- 1, 1. �� 4- �S c.i.e, .., - g5 . 0 \,,,f c-, m �► T _ • , ..m N Q.) I '1S I\. '\ 1 _ -------i09-' eir‘j r ccZ kis) r a , c- ,_y 0-) II G) ,, S UU C �` s3 1 SEE 35MM ROLL# 22 FOR LARGE DOCUMENT