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Permit CITY OF TIGARD f' MASTER PERMIT .14 ,, �.s 7 Permit#: MST2020-00175 COMMUNITY DEVELOPMENT �/�h TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 `� Date Issued: 07/07/2020 Parcel: 1 S134BD10800 Jurisdiction: Tigard Site address: 10942 SW 118TH CT Subdivision: PENN LAWN ESTATES NO.2 Lot: 36 Project: Brandt Project Description: 1,765 sf 2-story addition to include bonus room,2nd master bed/bath, and 5th bedroom; add 440 sf patio cover. WATER METER UPSIZE REQ'D PRIOR TO FINAL INSPECTION&C OF O. BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 2 First: 582 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 26 Bathrooms: 1 Second: 1183 sf Garage: 0 sf Front: 20 Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Yes Total: 1765 sf Value: $226,864.70 Rear: 15 PLUMBING Sinks: 2 Water Closets: 1 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 2 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 100 Tubs/Showers: 2 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Drywell-Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: Y Vent Fans: 3 Clothes Dryers: 0 Natural Gas Heat Pump: N Hoods: 0 Other Units: 0 Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 2 Furn>=10OK: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 1 0-200 amp: 0 W/Svc or Fdr: 10 Ea add'I 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+amp/volt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ADD SF VB R-3 1765 Owner: Contractor: BRANDT,MICHAEL&JESSICA OWNER Required Items and Reports(Conditions) 435 E MAIN ST MIKE BRANDT 1 Ersn Cntrl 503-639-4175 COTTAGE GROVE,OR 97424 10942 SW 118TH CT 2 Special Inspection Bolts in TIGARD,OR 97223 Concrete PHONE: PHONE: 971-205-8577 FAX: Total Fees: $7,665.08 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 throu AR 952-00 - 090. You may obtain a/copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. _ /I Issued By: 1.C`/'7/Yt L_� J Permittee Signature: t�'V �! "�Omil/ Call 503.639.4175 by 7:00 a.m.for the next available Inspection date. This permit card shall be kept In a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. CITY OF TIGARD MASTER PERMIT s~ - COMMUNITY DEVELOPMENT Permit0: MST2020-00175 TIGAR D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/07/2020 Parcel: 1 S 134 BD 10800 Jurisdiction: Tigard Site address: 10942 SW 118TH CT Subdivision: PENN LAWN ESTATES NO.2 Lot: 36 Project: Brandt Project Description: 1,765 sf addition; remove portion of existing 1st floor and rebuild 1st and 2nd floor to include bonus room and 2nd master bedroom/bathroom. WATER METER UPSIZE REQUIRED PRIOR BUILDING Floor Areas Reauired Setbacks Required Stories: 2 Bedrooms: 2 First: 582 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height 26 Bathrooms: 1 Second: 1183 sf Garage: 0 sf Front: 20 Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Yes Total: 1765 sf Value: $226,864.70 Rear: 15 PLUMBING Sinks: 2 Water Closets: 1 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 2 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 100 Drains: 0 Tubs/Showers: 2 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Other Fixtures: 0 Drywell-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: Y Vent Fans: 3 Clothes Dryers: 0 Natural Gas Heat Pump: N Hoods: 0 Other Units: 0 Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 2 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 1 0-200 amp: 0 W/Svc or Fdr: 10 Ea add.'500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+ampNolt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Ecompasing: N Other: N Other Description: BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ADD SF VB R-3 1765 Owner: Contractor: BRANDT,MICHAEL&JESSICA OWNER Required Items and Reports(Conditions) 435 E MAIN ST MIKE BRANDT 1 Ersn Cntrl 503-639-4175 COTTAGE GROVE,OR 97424 10942 SW 118TH CT 2 Special Inspection Bolts in TIGARD,OR 97223 Concrete PHONE: PHONE: 971-205-8577 FAX: Total Fees: $7,665.08 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 9 01-0090. ou obtain a co y of the rul or direct questions to OUNC by calling 503.232.1987.187 or 1.800.332.2344. Issued By: Permittee Signature: C�L�--- �" Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Building Permit Application 17r' :IVED 1_ �, 1111F— „O.-.� ResideMtial MAY 1 2020 FOR OFFICE USE ONLY City of Tigard Received Date/By: lv L'a 0 Permit Not'!S'1 J 190/7.5 • 13125 SW Hall Blvd.,Tigard,OR 97223 , n N T!f° ? � Plan Review:II Phone: 503.718.2439 Fax: 503.598.1960 Date/By: G KS �� Other Permit: TIGARD Inspection Line: 503.639.4175 Date ReadyBy. /� / kris: H See Page 2 for Internet: www.tigard-or.gov oufi hod: / Supplemental Information TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING 0 New construction ❑Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all ®Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead.and the ofit for the CATEGORY OF CONSTRUCTION work indicated on this application. �� Valuation: $ �..$l3r9A0' E I-and 2-family dwelling 0 Commercial/industrial Number of bedrooms: 2 ❑Accessory building 0 Multi-family ElMaster builder ❑Other: Number of bathrooms: 1 JOB SITE INFORMATION AND LOCATION Total number of floors: 2 Job site address: 10912 SW 118 T'H Cl. New dwelling area: 1765 square feet City/State/ZIP: TIGARD,OR 97223 Garage/carport area: 0 square feet i/b3 Suite/bldg./apt.no.: Project name: BRANDT ADDITION Covered porch area: square feet Z Cross street/directions to job site: 118TH CT.AND SPRING).WOOD Covered patio area: 440 square feet �l/ -$q)S i t/ /2-�l-t is t1� / 2-Ce Jt 1 'L f ,�i2-. f"! f�� Other structure area: square feet '1.4.i 5/Z L� /"r-'fY A AC/cL ' e_ 0_C V . -1° . _ +1A:COMMERCIAL-USE CHECKLIST Subdivision: PENN LAWN ESTATES#2 I Lot no.: 36 Permit fees*are based on the value of the work performed. Tax map/parcel no.: R 1416186 Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. REMOVP_l.OF EXISTING 1ST FLOOR LIVING SPACE AND Valuation: $ REBUILDING A 2 LEVEL ADDITION WITH ADDITIONAL MAS1%K. Existing building area: square feet 14 i l et';IC c '1 1 i`'YT1'f121X'.1 Ji�(,L r New building area: square feet ® PROPERTY OWNER 0 TENANT Number of stories: Name: MIKE I3RANDT Type of construction: Address: 10942 SW 118TH CT. Occupancy groups: City/State/ZIP: TIGARD,OR 97223 Existing: Phone:(971 ) 205-8577 Fax:( ) New: 133 APPLICANT. 0 CONTACT PERSON BUILDING PERMIT FEES* Business name: (Please refer to fee schedule) Structural plan review fee(or deposit): ‘ 4249 . 9. Contact name: MIKE BRANDT Address: 10942 SW 118TH CT. FLS plan review fee(if applicable): City/State/ZIP: TIGARD,OR 97223 Total fees due upon application: Phone:(971 )205-8577 Fax: :( ) Amount received: E-mail: brandtaddltion[I,Tmail.Corr PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* 5 Commercial and residential prescriptive installation of CONTRACTOR roof-top mounted Photo Voltaic Solar Panel System. Business name: �,t N/�/� Submit two(2)sets of roof plan with connection details v �" and fire department access,along with the 2010 Oregon Address: Solar Installation Specialty Code checklist. City/State/ZIP: Permit Fee(includes plan review and administrative fees): Phone:( ) Fax:( ) State surcharge(12%of permit fee): �'"'a'"' /j, A /� ��` Total fee due upon application: Authorized signature: //�, y /"�' This permit application expires if a permit is not obtained ll// "-- within 180 days after it has been accepted as complete. Print name: MICHAEL BRANDT Date: 5/18/2020 *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB) IlBuilding Permit Application Checklist One- and Two-Family Dwelling FOR OFFICE USE ONLY 4 a City of Tigard ReceivedDate B : I'ernet`'e: • 13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits: i I Phone: 503.7182439 Fax: 503.598.1960 24-Hour Inspection Line: 503.639.4175 Cl Electrical 0 Plumbing 0 Mechanical T I C A It D Internet: www.tigard-or.gov 0 Other. THE FOLLOWING ITEMS ARE REQUIRE!) FOR PLAN REVIEW Yes No N/A 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑ 2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. ❑ ❑ ❑ 3 Verification of approved plat/lot ❑ ❑ ❑ 4 Fire district approval required. Name of district: El El ❑ 1 5 Septic system permit or authorization for remodel. Existing system capacity El El 0 6 Sewer permit. 0 0 0 7 Water district approval. 0 0 0 8 Soils report. Must carry original applicable stamp and signature on file or with application. 0 0 0 9 Erosion control 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 [_J basin protection,etc. 10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state ❑ ❑ ❑ building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if copyright violations exist. 11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if ® ❑ ❑ there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements and driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction indicator;lot area;building coverage area;percentage of coverage;impervious area;existing structures on site;and surface drainage. C 1.0 12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size ❑ ❑ ❑ and location. S2.1 13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, El ❑ ❑ furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc. 14 Cross section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- ❑ 0 ❑ floor,wall construction,roof construction. More than one cross section may be required to clearly portray construction. Show details of all wall and roof sheathing,roofmg,roof slope,ceiling height,siding material,footings and foundation,stairs,fireplace construction,thermal insulation,etc. 15 Elevation views. Provide elevations for new construction;minimum of two elevations for additions and remodels. 0 0 0 Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope. Full-size sheet addendums showing foundation elevations with cross references are acceptable. 16 Wall bracing(prescriptive path)and/or lateral analysis plans. Must indicate details and locations;for non- ® 0 0 prescriptive path analysis provide specifications and calculations to engineering standards. 17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing ® 0 0 locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered 0 ❑ ❑ systems,see item 22,"Engineer's calculations." 19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists 0 0 ❑ over 10 feet long and/or any beam/joist carrying a non-uniform load. 20 Manufactured floor/roof truss design details. ® ❑ 0 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required ® 0 ❑ for four or more appliances. 22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or 0 0 0 architect licensed in Ore:on and shall be shown to be .licable to the .ro'ect under review. .JURISDICTIONAL SPECIFICS 23 Three(3)site plans are required fbr Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". ❑ ❑ ❑ 24 Two(2)sets each are required for Items 16,19,20 and 22 above. El El El 25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 El El 26 -Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document ❑ El ❑ 27 "Drawn to scale"indicates standard architect or engineer scale. ❑ ❑ ❑ 28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard 0 0 ❑ Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 0 0 ❑ and protection measures must be drawn to scale and must include the project arborist's signature of approval. 30 A Clean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, El ❑ 0 including decks,patio covers(over non-impervious surface)and accessory structures to existing residential dwellings on a lot of record approved prior to September 9,1995. I:\Building\Pennits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB) , • Mechanical Permit Applicatio 1 -IV , _' FOR OFFICE USE ONLY Received .� l i25 W all Blvd Penult NotS7 .2C,0o1 )5 �s 11125 SW Hall Blvd.,Tigard,OR 97223 FI .- 2�� Date By: (/ Phone: 503.718.2439 Fax: 503.598.1960 Date/By:an Review Other Permit: ('' `' ^� r T.161 ll Inspection Line: 503.639.4175 1...i i i E �,i)" I (..: Date Ready/By: lnris: ® See Page 2 for Internet: www.tigard-oLgov [TALON I }N . ri114. N.tified/Method: Supplemental Information t r TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST Mechanical permit fees*are based on the value of the work ❑New construction Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all ❑ Demolition ❑ Other: mechanical materials,equipment,labor,overhead,and profit. -- Value:$ CATEGORY OF CONS"I RUCI ION , RESIDENTIAL EQUIPMENT/SYSTEMS FEES* ❑� 1-and 2-family dwelling ❑ Commercial/industrial ❑Accessory building For special information use checklist. ❑Multi-family ❑ Master builder 0 Other: Description Qty. Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning 1 46.75 46.75 Job site address:10942 SW 118th Ct. Furnace 100,000 BTU(ducts/vents) 1 46.75 46.75 City/State/ZIP:TIGARD, OR 97223 Furnace 100,000+BTU(ducts/vents) 54.91 Heat pump 61.06 Suite/bldg./apt.no.: Project name:BRANDT ADDITION Duct work 23.32 Cross street/directions to job site: Hydronic hot water system 23.32 Residential boiler(radiator or 118TH CT. AND SRPINGWOOD hydronic) 23.32 Unit heaters(fuel-type,not electric), in-wall,in-duct,suspended,etc. 46.75 Flue/vent for any of above 23.32 Subdivision:PENN LAWN ESTATES#2 Lot no.:36 Other 23.32 Other fuel appliances: Tax map/parcel no.: R1416186 Water heater 23.32 DESCRIPTION OF WORK Gas fireplace/insert 1 33.39 33.39 Flue vent for water heater or gas HOME ADDITION INCLUDING BONUS ROOM AND fireplace 23.32 MASTER SUITE Log lighter(gas) 23.32 Wood/pellet stove 33.39 Wood fireplace/insert 23.32 Chimney/liner/flue/vent 23.32 ❑� PROPERTY OWNER _ 0 TENANT Other: 23.32 4 Environmental exhaust and ventilation: Name: MICHAEL BRANDT Range hood/other kitchen equipment 33.39 Address: 10942 SW 118TH CT. Clothes dryer exhaust 1 33.39 33.39 City/State/ZIP: TIGARD, OR 97223 Single-duct t(bathrooms, toilet compartments,utility rooms) 3 23.32 69.96 Phone:( )971-205-8577 Fax:( ) Attic/crawlspace fans 23.32 I] APPLICANT ❑I CONTACT PERSON Other: 23.32 Business name: Fuel piping: $14.15 for first four;S4.03 for each additional Contact name: MIKE BRANDT Furnace,etc. 1 14.15 Address: 10942 SW 118TH CT. Gas heat pump Wall/suspended/unit heater City/State/ZIP: TIGARD, OR 97223 Water heater Phone:( ) 971-2055-8577 Fax: :( ) Fireplace 1 14.15 Range E-mail. brandtaddition@gmail.com Barbecue CONTRACTOR Clothes dryer(gas) Business name: 2 BROTHERS HEATING AND COOLING other: NNIECHANICALPERMIT FEES* , Address: PD BOX 311 Subtotal 258.54 City/State/ZIP: OREGON CITY, OR 97045 Minimum permit fee($90.00) Plan review(25%of permit fee) 64.64 Phone:( )971-533 2359 Fax:( ) State surcharge(12%of permit fee) 31.03 CCB lie.: 210623 5j/fee tz TOTAL PERMIT FEE 354.21 This permit application expires if a permit is not obtained within 180 / days after it has been accepted as complete. Authorized signature: * Fee methodology set by Tri-County Building Industry Service Board Print name: MICHAEL BRANDT Date:6/1/2020 I'.1 Building\Permits\MEC_PermitApp_040113.doc 440-4617T(1I/02/COM/WEB) .....a as.cal 1 ca W1L tilJUllc4t tan .— 4-... r. 1\ i City o,f Tigard T Received • 13125 SW Het!BEvd.,Tigard OR 97223 ^n DateBv Femme a (r ''vat i,3 • a Phone: 503.718.2439. Fax 503.598.1960 J iJ I I ? �O L U Plan Review IN Related Permit 1, Y T 1 r,,R D Inspection Lino 503 639.4175 Rehr - Internet wwwtigard-or.gov 'k• I `fi n N�ed/iMethod: 1�vic S1 pie Page l Ilos nf.•< ; �s-"�.'-?r�, ,,„ :'� ��_ - Supplemental Information ..i, =.7 x -- :T.YPLOF,WORK« Z ,.. ,a, "3. • - R;,. �.p .,.,ra---_ ❑New construction �. Ple .chock ll that y LAN>REa7EW s was _ ? y' ®Addition/alteration/replacement �. Please abak all apply(submit j eats of plans writaan checked):. CI or feeder 400 amps or mote '❑Building over three stories.' , ❑Demolition 0 Other: Z. 'n' ""h agtx'CATEGORY:OF`,' OIVS"CRU rION « _ where the available fault current ❑Menus end boatyards. : t.s,�. .�...;x `. exceeds 10,000 snips at 150 volts or ❑Flmtiog buildings:, 1 ® I and 2-family dwelling 0 Conune1cuial/industrial 0 Accessory building leas to ground or exceeds 14,000 ❑Commercial-use a cultural 1 ❑Multi-family amps for as other installations bui Installation c . . -- l 0 Master builder �,x�-Y- -,"+�::. � -.w ❑Viso pump. 2,. 'ri4>: , -.,.,,. JOH:SITE"INFORMATION A );L '"` ` -r ❑larger separately at iso eve or OGTION,.X,= x` e,�nf�:" �: ❑F'°�+S�Y�re 6rBampuetelyderived Job#: 1 Job site address:10942 SW 118TH CT. ['Addition of new motor toad of system 1001 @ or more. ❑`q^,"H•,"1.2","1-3", City/State/ZIP:TIGARD,OR 97223 ❑six or more residential unite. occupancy. ❑Health-care facilities. CI Recreational vehicle parka. Suite/bldg./apt#: 1 Project name:BRANDT ADDITION ❑Hazardous locations. fl Supply volIag for more than Cross street/directions to job site: ['Service or feeder 600 amps or more. 600 volts nominal i -fir:, ,;, _ FEE SCIIEDULE.Y- ? 118TH CT.AND SPRINGWOOD DeerlatIo I ore• I each I Total I • New residential single-or multi-Gangly dwelling unit. Subdivision: PENN LAWN ESTATES#2 . , 1 Lot#:36 Includes attached garage. Tax map/parcel#: R1416186 1,000 sq.ft.or less 168.54 , 4 :; i-•=..:a- ;n. x ...s ,wz^ rr.: sr«; � Fa midi 500 sq.R or portion 33.92 - I --- < L,;. c� ARSCRIPTIOI .. ... OIZI['+c . al; • , energy,residential - Limiledema "75.00 - 2 HOME ADDITON INCLUDING BONUS ROOM AND - (with above sq.ft.) Limited energy,multi-family • .. - -• MASTER SUITE residential(withabovesq.4.) ' ' 7300 . '_1 , ;2: t� Q See Page 2 l PROUPERTY OW.INER • • Renewable feeders �" "° r'�' T " Services or feeders ttlstallatio alteration,ardlor relocation Name: MIKE BRANDY 200 amps orless 190.70 2 Address: 10942 S W 118TH CT. 201 amps to 400 amp 133.56 2 City/State/ZIP: TIGARD, OR 97223 aol amp`to boo amp 200.34 2 601 amps to 1,000 amps • 301.04. - • 2, Phone: ( )971-205-8577 Fax: ( ) Over 1,000 amp or volts 552.26 2 Fmsi1: brandtaddition@gmail.cam Te1mo�rs�rncesor feeders lrastauatton,anerltton andror relocation Owner installation:This installation is being made on property that I own which is not 200 amps or less 5936 1 intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 - . ' 2 Owner signature: Date: 401 amps to 599 amps 168.54 .r ... 2 p ; IN;-APPLICANT„ , __, .:- ❑ CONTACT-PER50Pi ;, z T : Branch circuits—new,alteration,or extension,per panel ...-... '.,..s...u..,..,: A.Foe for branch circuits with Business name: above service or feeder fee, - each branch circuit - ',',..1 ` 7.42' 2 Contact name: MIKE BRANDT B.Fee forbnmch circuits without Address: 10942 SW 118TH CT. aerviworfeedafee fast branch circuit 56.18 2 City/StateJLIP: TIGARD, OR 97223 Each add'I branch circuit .. 7.42 ' 2 Phone: Miscellaneous(service or feeder not included) ( )971-205-8577 Fax: :( ) Each manufactured or modular Email brandtaddition@gmail corn dwelling,service and/or feeder b7.84 2 .x, Reconnect 67.84 .. .. ''.•. :-' .. a a '7' 00NTRAfiaOI u ,> 9r n ' xE to Pump or ie ig�'on'cete 7 '84 Business name:DAVIS ELECTRIC Sign or outline lighting 67.84 , Address: PO BOX 933 Signal oircuit(s)or limited-energy See c 2 panel,alteration,or extension. Each additional inspection over allowable litany of the above City/State/ZIP:SILVERTON,OR 97381 r,"`a:-_ Additional inspection(1 hr min) 66.25/hr Phone:(5jo-31 SC g arcs i Fa>c( -) Investigation(1 hr min) 90.00/hr F il: daviselectricpdx@gmail.com Industrial plant(1hrmin) ' , 78.18/hr Inspections for whist'no fee is CCB Lic.:196274 Electrical Lic.: a �/hr g Suprv.Llc.: CJS4 5 Psatty listed(�4 6r min) Suprv.Electrician signature,required \`r `��_ c`, : ELEGTRICALrP.E tMl EES i Print name: UIak� Subtotal: ��J l S Date: �IZI'� _ El Review Required(25%of permit fee): 1 state surcharge(12°%of permit fee) Authorized signature: TOTAL PERMIT FEE: This permit application expires Ira permit is not obtained within I: I Print name: c? ^,,,las "�1,,,.v1 S Date: (4\ 2 z c - • Number of inspections allowed per permit days after it has been accepted as complete. 1:1&ulduglPamm\ELC PemitApp_ELR ERE.doc Rev 06/17/2015 4a0d61TT(I Iro57CoM/wFa`5 Plumbing Permit Application .EC �" -- Building Fixtures JUN 0 3 2020 FOR OFFICE USE ONLY Cityof Tigard r1 ✓ t"1 tr n�- Received g . `I- ..d`,' Permit No.: ■ 13125 SW Hall Blvd.,Tigard,OR 922 4,ti r/ �` `` ! ,�, Plan Review S 1 Plan Aeview 1 • Phone: 503.718.2439 Fax: 503 �8 t960-i v Date/By: Other Permit No.: TIGARD Inspection Line: 503.639.4175 Date Ready/By Jarv, ® See Page 2 for Internet. www.ligard-or.gov NotitiedlMelhod. Supplemental Information TYPE OF WORK ¢W«+tilt ... FEE* SCHEDULE For special information use checklist ❑ New construction ❑ Demolition Description I Qty. I Ea. I Total ❑■ Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTR ON SFR(1)bath 312.70 ❑ 1-and 2-familydwellingSFR(2)bath 437.78 ❑Commercial/industrial ❑Accessory building El Multi-family SFR(3)bath 500.32 Each additional bath/kitchen 25.02 ❑Master builder ❑Other: Fire sprinkler(_sq.ft.) Page 2 JOB SITE INFORMATION AND Li_ e: Site utilities: Job site address:10942 SW 118TH CT. Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76 City/State/ZIP: TIGARD, OR 97223 Footing drain(no.linear ft.:_) Page 2 Suite/bldg./apt.no.: I Project name:BRANDT ADDITION Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 118TH CT. AND SPRINGWOOD DR. Rain drain connector 18.76 Sanitary sewer(no.linear ft.: ) Page 2 Storm sewer(no.linear ft.:1 b y) 1 Page 2 112.57 Water service(no.linear ft.: ) Page 2 Subdivision:PENN LAWN ESTATES 2 Lot no.:36 Fixture or item: Tax map/parcel no.: R1416186 Back low preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Clothes washer 1 25.02 25.02 HOME ADDITION INCLUDING BONUS ROOM AND Dishwasher 25.02 MASTER SUITE Drinking fountain 25.02 Ejectors/sump 25.02 0 PROPERTY OWNER ;r ❑ TENANT Expansion tank 12.51 Name: MIKE BRANDT Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: 10942 SW 118TH CT. Garbage disposal 25.02 City/State/ZIP: TIGARD, OR 97223 Hose bib 25.02 Phone:( )971-205-8577 Fax:( ) Ice maker 12.51 El APPLICANT El CONTACT PERSON Interceptor/grease trap 25.02 Business name: Medical gas(value:$_) Page 2 Primer 12.51 Contact name:MIKE BRANDT Roof drain(commercial) 12.51 Address:10942 SW 118TH CT. Sink/basin/lavatory 2 25.02 50.04 City/State/ZIP:TIGARD, OR 97223 Solar units(potable water) 62.54 Phone:( )971-205-8577 Fax: :( ) Tub/shower/shower pan 2 12.51 25.02 E-mail:brandtaddition@gmail.com Urinal 25.02 Water closet 1 25.02 25.02 ,t ,:: CONTRACTOR J Water heater 37.52 Business name: WEEKEND PLUMBER LLC Water piping/DWV 56.29 Address: 3807 NE 10TH AVE. Other: 25.02 City/State/ZIP: PORTLAND, OR 97212 Subtotal 237.67 Phone:( ) 503-939-8968 Fax:( ) Minimum permit fee: $72.50 /,L6 Plan review (25%of permit fee) 59.42 /�ee CCB Lic.:192185 e ( Plumbing Lic.no.: pB1032 Authorized signature: �� State surcharge(12%of permit fee) 28.52 TOTAL PERMIT FEE 325.61 Print name:MICHAEL BRANDT Date:6-1-2020 This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-46I6T(10/02/COM/WEB) City of Tigard 1114 COMMUNITY DEVELOPMENT DEPARTMENT ■ TIGARD Building Permit Review — Residential Building Permit #: tl Si- 2624 -c c ( '7S Site Address: IO' ` 2- SW $,t (A--. Project Name: ?)rOv►G{-f' Avldlthw1 Lot #: Planning Review Proposal: Aztal tL,vl "I,Verify address/suite # active in Accela. In River Terrace: l No El Yes, River Terrace Review Addendum Site Plan Elements: P' rosion Control Ai copies of site plan on 8-1/2"x 11"or 11 x 17"paper 'etained trees with drip line and tree protection measures Drawn to scale(standard architect or engineer scale) IIII! 'ootprint of new structure(mcluding decks)and FFE North arrow (kRility locations&easements(required for new and additions) „R;Site address,project or subdivision name and lot number tdewalk/driveway approach $Applicant information(name and phone number) location of wells/septic systems %Lot dimensions and building setback dimensions ntt.treet tree size,type and location WA-Square footage of buildings to be demolished �0.treet names XXxisting structures on site Ij orner elevations (2'contours if more than 4'differential) sJ Lot area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? ❑Yes No impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? ❑Yes. o Clean Water Services—Service Provider Letter(lot platted prior to 9/10/1995): Required: ❑ Yes,applicant was notified ,KNo Received: gz Yes ❑ No 1�Water Meter Fixture Unit Worksheet—Additions,Remodels and ADUs Required: 12LYes,applicant was notified ❑ No Received: ,,'Yes ❑ No I\--?4 DC Exemption for ADU applied for: El Yes ❑ No Received: ❑ Yes ❑ No • Public Facilities Improvement (PFI) Permit: Required: ❑ Yes,applicant was notified $ No Applied For: ❑ Yes ❑ No,stop intake kliPcLand Use Case#: n- Zoning: 12--1,S` .8" Required Setbacks: Front: 20 Rear:15 Side: 5 Street Side: N f PC- Garage: Building Height: Max. Height: 30 Actual Height: 21-P '"-PT Landscape Area: % Kik Lot Coverage Max: % Entrance N''.et back no more than 8'from street-facing wall SI Parallel to street or of set 45 degrees or less Windows Minimum 12%of area of all street-facing facades `A'mDvll'10 f/lafor-ickgavek el, Garage II Gar g door is behind widest street-facing wall ❑ Yes ❑ No,one of the following is met: •i oor extends no more than 5'from wall and there is a covered porch extending beyond garage. Il oor •xtends no more than 5'from wall and there is a 12 sq ft.window above garage on 2nd floor. II G ,a e do dth is ❑ 12'or less ❑ 50%or less of facade ❑ 60%or less and includes 7 of following: ❑ Co . .orch ❑ Recessed entrance ❑ Wall offset ❑ 1'Roof eave ❑ Roof offset ❑ Fire shingles ❑ Lap Siding ❑ Roof pitch ❑ Gable,hip,or gambrel roof ❑ Dormer ❑ Accent siding ❑ Window trim ❑ Window recess ❑ Window projection ❑ Balcony Visual Clearance VA Urban Forestry Plan il" Sensitive Lands: ❑ Yes ,R No Type: 1\14-Conditions met prior to issuance of building permit Notes: 'Approved By Planning: Date: 5121120 Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: El Approved ❑ Not Approved L\Building\Forms\B1dgPermitRvw_RES_122419.docx Building Permit Submittal Original Submittal Date: s1/ift o Site Plans: # Building Plans: # Building Permit#: Enter building permit#above. Workflow Routing: 42'Planning engineering E Permit Coordinator 7 Building Workflow Sign-off: C'Sign-off for Planning(include notes from planning review) Route Application Documents: I ' ngineering: (1) copy of permit application, (1) site plan, (1) building plan and griginal plan review routing form. Building original permit application,site plans,building plans,engineer and beam calculations and trust details,if applicable,etc. Notes: By Permit Technician: ��` eiec.4— Date: 0/�/Zo Engineering Review L2C'Slope at building pad: lR'r.onditions "Met"prior to issuance of building permit wilt_ 2--Easements (encroachments) per engineering conditions of approval and plat ^IO` Er-Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes E'�No Assess Water Quantity Fee in-lieu: ❑ Yes E'-No LIDA Facility on lot: ❑ Yes [ No 2"--Final Plat Recorded: "11 l6' ❑ NOT Approved by Engineering: Date: Notes:�� E r proved by Engineering: "Tre4-¢e1„ _r Date: (r`5JZo et) Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved D Not Approved Revision 2: ❑ Approved 0 Not Approved Permit Coordinator Review Conditions "Met"prior to issuance of building permit ❑ Approved,NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: Revision Notice 2: Date Sent to Applicant: SDC Exemption: 0 Received TA..Does not apply 'SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes ,1C� N/A Tigard Trans SDC: ❑ Yes N/A Parks SDC: ❑ Yes N/A LIDA ❑ Yes N/A OK to Issue Permit Approved by Permit Coordinator: Al Date: (01912,0 1:1BuildingForms\BldgPermitRvw_RES_I22419.docx City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Water Meter Fixture Unit Workshe 0 I' � [ c, ARI) ARD For Additions /Remodels /ADUs , JuN e2TY OF 1G020 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-p'jit)Ni D4 fii:.;i`i LOCATION: City of Tigard—City Hall WATER METER SALES: Utility Billing By Appointment Only: 503-718-2460 13125 SW Hall Blvd. Monday—Thursday, 9 a.m. to Noon Tigard, OR 97223 METER: SIZE: FEE: Pricing effective 7/1/2019 5/8" $9,406.00 Fee includes: 3/4" $13,425.00 water system development charge, 1" $24,645.00 water meter, and 1-1/2" $72,969.00 meter installation fee. 2" $118,163.00 DETERMINING METER SIZE FOR RESIDENTIAL CUSTOMERS City of Tigard Water Service Area uses the American Water Works Association Manual and the Oregon Plumbing Specialty Code to determine the size of meter needed to adequately serve buildings. Due to the variety of home sizes built in the Tigard area, we count the fixture units of all homes to determine the appropriate meter size. Use the worksheet on Page 2 to calculate the current number of fixture units compared to the proposed increased number of fixture units, which will determine whether an increased meter size will be required. Submit this signed worksheet with your building or plumbing permit application submittal. DOCUMENTATION Once you are ready to purchase the new meter, please provide the following items to the Utility Billing counter: • Completed water meter fixture unit worksheet for additions, remodels, ADUs, etc. (on back page). • Copy of building or plumbing permit application date-stamped by building division. • Copy of issued building or plumbing permit. Your fixture count will be verified and your request will be processed upon receipt of these documents. No exceptions. INSTALLATION TIME Once the upgraded meter size has been purchased, please contact Public Works for installation. Their number is 503-718-2591. Most meters are installed within 10-14 business days. l:/Building/Forms/WaterMeters_070119_tdd.docx Page 1 Water Meter Fixture Unit Worksheet for Additions/Remodels/ADUs Please complete the following information: Customer Name: MIKE BRANDT Service Address: Street/Suite #: 10942 SW 118TH CT. City: TIGARD State: OR Zip: 97223 Phone Number: 971-205-8577 Email: brandtaddition@gmail.com Please fill in the number of each fixture you currently have. Please fill in the number of fixtures you propose to add. Multiply the quantity by the point value to arrive at the current Multiply the quantity by the point value to arrive at total. the proposed total. Fixture Unit Current Point Current Proposed Point Proposed Quantity Value Total Addition Value Total Bar sink 0 x 1 = 0 0 x 1 = 0 Bidet 0 x 1 = 0 0 x 1 = 0 Clothes washer 1 x 4 = 4 0 x 4 = 0 Dishwasher 1 x 1.5 = 1.5 0 x 1.5 = 0 Hose bib 1 x 2.5 = 2.5 0 x 2.5 = 0 Hose bib, each 0 x 1 = 0 0 x 1 = 0 Kitchen sink 1 x 1.5 = 1.5 0 x 1.5 = 0 Laundry sink 0 x 1.5 = 0 0 x 1.5 = 0 Lavatory 3 x 1 = 3 2 x 1 = 2 Water closet, 1.6 GPF 3 x 2.5 = 7.5 1 x 2.5 = 2.5 Bathtub/whirlpool 0 x 4 = 0 1 x 4 = 4 Shower stall 1 x 2 = 2 1 x 2 = 2 Bath/shower combo 1 x 4 = 4 0 x 4 = 0 Current Points: 26 Proposed Increase: 10.5 Current Points+Proposed Increase= 36.5 =New Total Points =Required Meter Size 3/4" Meter Sizes: 1 to 30 points=5/8" 30.5 to 37 points='/a" 37.5 and over points= 1" New Meter Size Needed for New Total Points: 3/4" Cost: $ 13,425 (see page 1) 9, Current Meter Size per Utility Billing: 5 8 406 Cost: $ (see page 1) New Meter Size Cost minus Current Meter Size Cost= $ 4,019 (This is Your Cost to Increase Meter Size Due to Additional Fixture Units) FOR OFFICE USE ONLY Current Meter Size Confirmed with UB .S Er-- f 1m L— r(17'L p '-C • 'S!C d Signature of UB Representative Date 1:/Building/Forms/WaterMeters_070119_Add.dOCx Page 2 • Dianna Ornelas From: UB Online Sent: Wednesday, June 3, 2020 9:50 AM To: Dianna Ornelas; brandtaddition@gmail.com Cc: UB Online Subject: RE: MST2020-00175 - Brandt - 10942 SW 118th Ct. Utility Billing verifies that the above-mentioned address currently has a 5/8 inch meter. Kind Regards, Jill Jill III .r'r City of Tigard-Utility Billing 1 III Senior Accounting Asst TIGARD (8881826-7211Payments (503)718-2460 UB Main jiltiatigard-or gov (503)718-2494 13125 SW Hall Blvd. Tigard, OR 97223 From: Dianna Ornelas<Dianna@tigard-or.gov> Sent: Wednesday,June 3, 2020 9:44 AM To: brandtaddition@gmail.com Cc: UB Online<UBOnlinepay@tigard-or.gov> Subject: FW: MST2020-00175 - Brandt - 10942 SW 118th Ct. Hello Mike, Thank you for the documents. • Please sign and return the plumbing permit application. • UB is copied on this email to review and email approval of the attached water meter worksheet. Thank you. Dianna L. Ornelas (Howse) Building Division Services Supervisor City of Tigard I Community Development 13125 SW Hall Blvd I Tigard, OR 97223 503-718-2430 Direct 1503-718-2439 Permits From: Mike Brandt<brandtaddition@Rmail.com> Sent:Tuesday,June 2, 2020 12:29 PM To: Dianna Ornelas<Dianna@tigard-or.gov> Subject: Re: MST2020-00175 - Brandt- 10942 SW 118th Ct. Caution!This message was sent from outside your organization. Allow sender I Block sender 1 Dianna, Thank you for your response. I have filled out the mechanical and plumbing permit, and my electrician has signed/filled out the electrical permit. I have also included the new water meter fixture sheet,the owner's construction responsibilities worksheet, and a copy of my receipt from the online payment. Please let me know if you need anything else. Thanks, Mike Brandt On Mon,Jun 1, 2020 at 6:32 PM Dianna Ornelas<Dianna@tigard-or.gov>wrote: Hello Michael, We have received your permit application for the Brandt Addition. Planning has completed their review, however I have some questions regarding your submittal. Permit Applications At the City of Tigard, we create a 'master' or combination permit where we require all four disciplines(structural, mechanical, electrical and plumbing) be submitted and issued under one single master permit. The materials you provided only included a building permit application. We will need the attached applications for the trade permits completed and returned before we can route for plan review. Do not have these trade permits pulled separately by licensed contractors through our online permit system. Contractor We will need the contractor identified on the building permit application. Will it be 'owner' or will there be a licensed contractor performing the work? If owner,then we need the attached owner responsibility form completed and returned. You will also need to provide the contractor information on all trade permits prior to permit issuance. You may sign the mechanical and plumbing applications, however the electrical application requires a signature from the iii licensed signing supervisor. Water Meter Fixture Unit Worksheet In the application submittal packet there was a water meter worksheet, however it is not the correct form. Please see attached form for'additions' where you can enter the current fixture count and added fixtures to arrive at the correct water meter size for the proposed scope of work. Complete the attached form and route to our utility billing division at UBOnlinepav@tgard-or.gov to review and approval. We will need a copy of the water meter worksheet and an email from UB to let us know if your water meter will require to be upsized before we can issue the building permit. 2 • The plan review submittal fee of$620.98 is now due (see attached invoice). The fee can be paid online at https://aca.accela.com/TIGARD/Welcome.aspx by searching for the permit record number MST2020-00175 under the Building tab. Once this fee is paid, and we have the other permit applications,we will route offsite for plan review. Due to the high volume of permit activity, and remote working conditions due to COVID-19, please expect delays in processing your permit. We work on permits in the order received, and it is not necessary to contact us regarding the status of your permit as the permit technicians will be in contact with you when the permit is ready to issue and with instructions to pay the balance due. Thank you and please let me know if you have any questions. Dianna L. Ornelas(Howse) Building Division Services Supervisor City of Tigard I Community Development 13125 SW Hall Blvd I Tigard, OR 97223 503-718-2430 Direct 1503-718-2439 Permits DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e- mail may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules"City General Records Retention Schedule." 3 Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325 (2)) This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or X I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. MICHAEL BRANDT Print Name of Permit Applicant 6/1/2020 Signature of Permit Applicant Date Permit#: O F Address: tp Issued by: Date: -L This Copy for Permit Offices ..e Information Notice to Owners About � ' Construction Responsibilities Y�yYl�� 1412' (ORS 701.325 (3)) Homeowners acting as their own general contractors to construct a new home or make a substantial improvement to an existing structure, can prevent many problems by being aware of the following responsibilities: • Homeowners who use labor provided by workers not licensed by the Construction Contractors Board, may be considered an employer, and the workers who provide the labor may be considered employees. As an employer, you must comply with the following: • Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Department of Revenue at 503-378-4988. • Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488. • Oregon's Business Identification Number (BIN): is a combined number for both Oregon Withholding and Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or go to http://www.oregon.Qov/DOR/BUS/docs/211-055.pdf for the appropriate forms. • Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs if one of your workers is injured on the job. For more information, call the Workers Compensation Division at the Department of Consumer and Business Services at 503-947-7815. • Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 1-800-829-4933 or visit their website at www.irs.gov. Other Responsibilities of Homeowners: • Code Compliance: As the permit holder for a construction project, the homeowner is responsible for notifying building officials at the appropriate times, so that the required inspections can be performed. Homeowners are also responsible for resolving any failure to meet code requirements that may be found through inspections. • Property Damage and Liability Insurance: Homeowners acting as their own contractors should contact their insurance agent to ensure adequate insurance coverage for accidents and omissions, such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not otherwise covered as employees by Workers Compensation Insurance. • Expertise: Homeowners should make sure they have the skills to act as their own general contractor, and the expertise required to coordinate the work of both rough-in and finish trades. CONSTRUCTION CONTRACTORS BOARD 700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309-5052 Telephone: 503-378-4621 —Fax: 503-373-2007 Website Address:www.oregon.gov/ccb f/property_owner adopted 9-23-08 This Copy for Permit Applicant 1 ' MAY 1 g 2020 CleanWater Services SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT Clean Water Services File Number 2 0-001 1 33 1. Jurisdiction: Tigard 2. Property Information(example: 1S234AB01400) 3. Owner Information Tax lot ID(s): 1S134RD1Da00 Name: Mike Brandt Company: Address: 10942 SW 118th Ct. OR Site Address: 10942 SW 118th Ct. City,State,Zip: Tigard, OR,97223 City,State,Zip: Tigard, Or,97223 Phone/fax: 9712058577 Nearest cross street: SW Springwood Email: brandtaddition@gmail.com 4. Development Activity(check all that apply) 4 Applicant Information ® Addition to single family residence(rooms,deck,garage) Name: Mike Brandt ❑ Lot line adjustment ❑ Minor land partition Company: D Residential condominium ❑ Commercial condominium Address: 10942 SW 118th Ct. ❑ Residential subdivision 0 Commercial subdivision City, State,Zip: Tigard,OR,97223 ❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 9712058577 Other Email: brandtaddition@gmail.com 6. Will the project involve any off-site work? ❑Yes ❑ No ❑Unknown Location and description of off-site work: 7. Additional comments or information that may be needed to understand your project: This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits, DEQ 1200-C Permit or other permits as issued by the Department of Environmental Quality, Department of State Lands and/or Department of the Army COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law. By signing this form, the Owner or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water Services have authority to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify that I am familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true, complete,and accurate. Print/type name Mike Brandt Print/type title Signature ONLINE SUBMITTAL Date 4/16/2020 FOR DISTRICT USE ONLY ❑ Sensitive areas potentially exist on site or within 200'of the site.THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report may also be required. Based on review of the submitted materials and best available information sensitive areas do not appear to exist on site or within 200'of the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider Letter as required by Resolution and Order 19-5,Section 3.02.1,as amended by Resolution and Order 19-22.All required permits and approvals must be obtained and completed under applicable local,State and federal law. ❑ Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider Letter as required by Resolution and Order 19-5,Section 3.02.1,as amended by Resolution and Order 19-22.All required permits and approvals must be obtained and completed under applicable local,state and federal law. ❑ THIS SERVICE PROVIDER LETTER IS NOT VALID UNLESS CWS APPROVED SITE PLAN(S)ARE ATTACHED. ❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2).NO SITE ASSESSMENT OR SERVICE OV ER LETT R IS REQUIRED. Reviewed by �-- Date 4/28/2020 Once complete,email to:SPLReview@cleanwaterservices.org • Fax: (503) 681-4439 OR mail to: SPL Review,Clean Water Services,2550 SW Hillsboro Highway, Hillsboro,Oregon 97123 Revised 2/2020 Main Office • 2550 SW Hillsboro Highway • Hillsboro, Oregon 97123 • p:503.681.3600 f: 503.681.3603 • cleanwaterservices.org