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Name
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Appl1catlOn 11~2S- (3 for
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WORK SHELl'
Construction Permits & Inspection
\
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5pP /s..lIJ,
Type of Constructlon
Group
Fire Zone
Use Classificatlon
.T.O....l'F rVPFD ON PERI-1T1" \UCl()Il,<-'\nvr.: '-~I"TAU,Alln^1 c::.1..f.A1...I. f',k 11\.)"',..,A-1..I,I<-,,_
.ExAr1LY 1\\1 4((OR:n/.h'r~ ,ul-(L.t IC.Rn Af011,1lHj- MA~)l\o/A(;:(iLR1"'R'.:s
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74-164
;;0,_"- / ~ tJ'~D
( .' Slgnature
Date 1~/;117f
I~~'''.
DEPARTlIENT OF ENVIRONI1ENTAl 11ANAGEMENT
PSB, 125 EAST 8TH AVENUE
EUGENE, OREGON 97401
Job Address ),LJ:;O 4rt'v-e dAL-<:...
~ , ~ < - - ,.
rownt~lp. R~nge. Sect,~~. Tax tot
Sllbqiyilif<>n 1?:-.I.2..'1jJ.-:2-3 -,~~---q<::7/n
Appl,cat,on for U ~ ;:,,:; d ~~,
Structures now on the property ~~~~ r.7 .
ProPO$a4 U$'l QT Pl'VPl;rty\ IJ?/ RlI~jdlllltHI.' CI ,CIll1ll1l~n::ial
Aff,davlt I, /(}il-A_""';' (D, A-",~~
(ple~Sll 1'1'1nt)
If thl5 appllcatlon 15 for an agrlcultural bUlldlng It wlll be used for purposes allowed by the State BUlldlng Code and
La~ejCounty Code Chapter 10 (zonlng) and for no other purpose I have the followlng legal ,nterest In the property
~ owner of record, contract purchaser, lessee, holder of an excluslve optlon to purchase.
, duly authorlZ.e~} to act for the owne~ who 15 knowledgeable of thlS appllcatlOn \
S,gnature/Address JJJ/ t-.-t-AA'A (0"./ -4.-L''''J<, :1'-1s,r) aH/v.ed L> L ,~.~:0.>it(Z'P) CI7I.J 'J()
Telephone ],'1.(;;- C/u 2.c.J~ or Date I -/7"'7 Of
When pe~~ 1S ready not,fy ~pl'cant I~I Owner I~I Contractor kl I~I ma,l ~Phone
Owner ,I ) J;;/'( N 1$ (', &:- E? ,lJC I? (Z1O \ Phone
Contractor If( 'I-.rJI !J;l<f2k2~r (ZlO) Phone
X Contractor's o~# \ ~ Plumblng by
C1ty
(1 ~~I;'{/f
. II
r;,~/I"
Appllc.l;i~n #
J,C -.::: ~..2S~...-7t?
- ' ,
At$l9"~q NUmbec~
-Lot
MOCk
CI lndu.trial
o I'"blk'
l hereby cert,fy that thl5 lnformatlon 1S true and accurate
If Commerclal
ReSldent,al
# of $wri$
K ~f bedl'OOmS
51 test holes ready
DO NOT WRITE BelUW THIS lINE
# of employees 'rof unIts
50S: I~I Ex,st,ng, BP #
I~I Proposed, SI #
Unit
~$t
PI/A-
,
~e _,A:~
Code lle$crloUc" It c1' Sit&$
~~'(A./~"'d./~~
~;-A~~_)-g~--A_
Valuatlon
Fee
~
n Check # /l
R.,celVed by.! !&h...~
$
1'1~ing flxtur&S at $
Sewer/water COflG. at $
each
each
$
$
$
$
$
$
$
$
$
$
$
$ /.5/ 6C)
Total ValuatlOn
Subtotal
Wa ter Supp 1 y
Proposed
Year Installed
EXlstlng
4% State surcharge
Plans check fee
Change of Occupancy
TOTAL
, lnt
Parcel Slze ~ ~
rear
PERMIT PROCESSING
Mlnlmum setbacks
Zone .I1/' ;?;-- Part #
1, front 1, s,de
Parcel #
Comments
To be typed on perm,t
F, re Zone
5~t:r
;7
;Y
BY~ Date /z,-7~77
Use Class,f,catlon .:;~~~.
CP&I Type '7fV
To be typed on permlt
~
Group
,::iff
/2--,7
hJtP.e.t::-
.3
call (area lnspector)
cJ..J/u,r!",., J? J...,dc.J7
Q ,,'~ d I-IbL-CA c; /~
Plans to CP&] setls)
WPC ----- set(s)
By ~ U6
?f/Mnl;.
LA/' A.u 7'~ (J.",~~, d " L,
J{,:'J.'I
Date
Phone
IZ -/9 -71'
d,f5'7 - 31th 1
For plans lnformatlon
~lrectlons to slte
Date
Requlred
Hold Sl,p
to pec
Date
Comp 1 et,e1-
/2 '1't
Da te to
pcc
/~I Pl anm ng
/~/ Publ,c Works
CI Elevat,on C/ n/a
el Address
CI Faclllty Permlt
~I Envlronmental Health
FOR INFOR~~TION about progress of your appllcatlon call
C74-171
Permlt Control Center
6B7-HElP (687-4357)
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ApPROVED
REMARKS
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ApPROVED 1--/ OJ SAPPROVED
FR~MING INSPECTION
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ApPROVEO /~ 01 SAPPROVEO /7
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rll,AL INSPECTlo/ ~ //
ApPROVEO rstJ DISAPPROVEO ~ DATE_/2-~/..=7-~NSPECTOR ~
RfMARKS~- ~JeA-I--1? .G.~ '''o"T '. :~..... _"~_ '"-/_~~_-~
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CERTlrlCATE OF OCCUPANCY
READY TO ISSUE / / NOT READY TO ISS~E I / DATE
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