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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action T l G A k D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits_@ti�gard-or.gov FROM: El Owner ❑ Applicant El Contractor ❑City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) �/y� Gr tbb Mailing Address: /5-75 jeccet41 C City/State/Zip: 7;71/2// tee CI 744 Phone No.: ( '3i 46 - r(; PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑>ANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: 572V O00)ti Site Address or Parcel#: /,rj 7575_ 3 j je-ir,.44 Project Name: 6;36 Subdivision Name: Lot#: -- EXPLANATION: ble reeolo t'h�,r- Zyv 6, J �d i:r•/ �•.r-),f 7 „1 �'1/, 7(} 771-v /1-,/•,.7 n 77./ ie. Z744 74.. 17 ITT, !aero Signature: Date: F'/5�/�v Print Name: I_�„��- !! Refund Policy �` 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. Route to Sys Admin: Date 7� By .7) Route to Records: Date d /3 2/' By.�n, Refund Processed: Date ref; j By Invoice Processed: Date By Permit Canceled: Date n/`,C9-- ByS Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_120518.doc t#jB fi114 t F.1114 M • • TIGARD City of Tigard August 13, 2021 Tom Gibb 15755 SW Serena Ct Tigard, OR 97224 Re: Permit No. MST2020-00204 Dear Applicant: The City of Tigard has processed a refund for overpayment of permit fees on the above referenced permit for the following: Site Address: 15755 SW Serena Ct Project Name: Gibb Job No.: N/A Refund: ® Check#240227 in the amount of$14.01. ❑ Credit card"return"receipt in the amount of$ ❑ Trust account"deposit"receipt in the amount of$ Notes: Reduced scope of work (master bath tub) resulted in overpayment of permit fees; refund difference. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Ornelas Building Division Services Coordinator Enc. I:\Building\Refundsgi a nttegfulUerpayldg%046pregon 97223 • 503.639.4171 TTY RPIay. rind AR4 7777 • uTQT[,T tio�ri-nr anv rr - ° City of Tigard l G n x D Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: Tom Gibb DATE: 8/10/2021 15755 SW Serena Ct Tigard, OR 97224 REQUESTED BY: Dianna Ornelas i 1 TRANSACTION INFORMATION: Receipt#: 430528 Case#: MST2020-00204 Date: 8 5 2020 Ad dress/Parcel:/ 15755 SW Serena Ct Pay Method: CreditCard Project Name: Gibb EXPLANATION: Removed master bath tub from scope of work reducing permit fees. Refund 100%of the difference. REFUND INFORMATION Fee Description From Receipt I Revenue Account No. i Refund t xample Building Permit Fee Example: 2300000-43104 $Amount Cast, U'ct 100-0000-48001 $14.01 TOTAL REFUND: $14.01 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager ,2� -e-lt..4_.--) If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY . —1 Case Refund Processed: Date: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 6 TIGARD Project Name: Gibb Site Address: 15755 SW SERENA CT /Zs- ALLN Receipt Number: 435814 - 08/13/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MST2020-00204 $-14.01 Total: $-14.01 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 240227 DHOWSE 08/13/2021 $-14.01 Payor: Tom Gibb Total Payments: $-14.01 Balance Due: $14.01 Pond 1 of 1 CITY OF TIGARD RECEIPT ..,. 0 F . a . 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Gibb Site Address: 15755 SW SERENA CT Q 4 I 6 l f(14-1/ Receipt Number: 430528 - 08/05/2020 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MST2020-00204 Building Permit-Additions,Alterations, 230-0000-43104 $1,148.23 Demolition MST2020-00204 Plan Review 230-0000-43106 $474.14 MST2020-00204 12%State Surcharge-Building 100-0000-24001 $137.79 MST2020-00204 DC Provision Review, SF-Ping 100-0000-43112 $102.00 MST2020-00204 Info Process/Archiving-Lg$2.00(over 230-0000-43135 $26.00 11x17) MST2020-00204 Info Process/Archiving-Sm $0.50(up to 230-0000-43135 $28.00 11x17) MST2020-00204 Metro CET 230-0000-24010 $127.55 MST2020-00204 Tig-Tual School CET-Residential 230-0000-24102 $1,171.80 MST2020-00204 Tigard CET-Residential-Admin 230-0000-44506 $42.52 MST2020-00204 Tigard CET-Residential-ODHCS 212-0000-24103 $153.07 MST2020-00204 Tigard CET-Residential-AH 212-0000-44504 $867.37 MST2020-00204 Services or Feeders-200 amps or less 220-0000-43103 $100.70 MST2020-00204 Branch Circuits w/Purchase Service or 220-0000-43103 $74.20 Feeder MST2020-00204 12%State Surcharge-Electrical 100-0000-24001 $20.99 MS12020-00204 Furnaces >= 100K BTU 230-0000-43102 $54.91 MST2020-00204 Duct Work 230-0000-43102 $23.32 MST2020-00204 Water Heater 230-0000-43102 $23.32 MST2020-00204 Clothes Dryer Exhaust 230-0000-43102 $33.39 MST2020-00204 Single Duct Exhaust(Bathrooms,Toilet, 230-0000-43102 $69.96 Utility Rooms) MST2020-00204 12%State Surcharge-Mechanical 100-0000-24001 $37.53 MST2020-00204 Heat Pump 230-0000-43102 $61.06 MST2020-00204 Sanitary Sewer 230-0000-43101 $62.54 MST2020-00204 Hose Bib 230-0000-43101 $25.02 MST2020-00204 Lavatories 230-0000-43101 $75.06 MST2020-00204 Water Closet 230-0000-43101 $50.04 MS12020-00204 Water Heater 230-0000-43101 $37.52 MST2020-00204 Plan Review 230-0000-43106 $272.21 MST2020-00204 Air Conditioning 230-0000-43102 $46.75 MST2020-00204 Tub/Shower/Shower Pan 230-0000-43101 $12.51 MST2020-00204 12%State Surcharge-Plumbing 100-0000-24001 $31.52 MST2020-00204 Cash Over 100-0000-48001 $14.01 <- Total: $5,405.03 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 6653129 PUBLICUSERO 08/05/2020 $5,405.03 Payor: Total Payments: $5,405.03 Balance Due: $0.00 Page 1 of 1 ill CITY OF TIGARD MASTER PERMIT I COMMUNITY DEVELOPMENT Permit#: MST2020-00204 Tk.aARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: Aug 10 2020 12:00AM Parcel: 25111 CD07600 Jurisdiction: Tigard Site address: 15755 SW SERENA CT Subdivision: KERWOOD ESTATES Lot: 11 Project: Gibb Project Description: 868 sf addition of bonus room, (1)bathroom and remodel of master bathroom. 8/5/20: Master bathtub eliminated from scope of work per homeowner. WATER METER MUST BE UPSIZED BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 0 First: 135 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 24 Bathrooms: 1 Second: 733 sf Garage: 0 sf Front: Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Yes Total: 868 sf Value: $106,295.28 Rear: 15 PLUMBING Sinks: 0 Water Closets: 2 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 3 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 1 SF Rain Storm Sewer: 0 Tubs/Showers: 2 Garbage Disp: 0 Water Heaters: 1 Water Lines: 0 Drains: 0 Catch Basins: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 1 Backwater Value: 0 Bckflw Prevntr: 0 Other Fixtures: 0 Drywell-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: Y Vent Fans: 3 Clothes Dryers: 1 Natural Gas Heat Pump: Y Hoods: 0 Other Units: 1 Furnc10OK: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 1 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+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-3 868 Owner: Contractor: GIBB,THOMAS G/COLLEEN D GIBB CONSTRUCTION&REMODELING INC Required Items and Reports(Conditions) 15755 SW SERENA CT 15755 SW SERENA WAY TIGARD,OR 97224 TIGARD,OR 97224 PHONE: PHONE: 503-407-9686 FAX: 503-549-8986 Total Fees: $5,405.03 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 952-001-0090. You may obtain a cony of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. t Issued By: �/—,,t/� �,r,.r/ Permittee Signature: 03.639.4175 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. \,17/ (p Building Permit Application Z 'Residential t J L-- limmiaitir ,?iiiiiiimin City W Tigard JUN 0 3 2020 Received /le 0 Permit NoMs•;7 , -E1'jZo1 Dare/By: 1111‘ 13125 SW Hall Blvd.,Ti OR 97223 �'x !r h � Tigard, Plan Review LV Alk Phone: 503.718.2439 Fax: 503.598.1960. ' OF I,t A rz I DatelBy: Other Permit: f I G A R D Inspection Linc: 503.639.4175 �71 i i 1 1 t`p r+ p i 1 i�-. ,. Date Ready/By: 1�eis, El Page 2 for Internet: www.tigard-or.gov 1 s ° I n� • -. Notified/Methml: 5 fit, /371 Supplemental information 40 Fp/N...,i.e el e" 6449 r TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING ❑New construction 0 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 0 Other: equipment,materials,labor,overhead,arid the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. ibko 2. Valuation: 4 1-and 2-family dwelling ❑Commercial/indushial ( Number of bedrooms: 0 Accessory building 0 Multi-family ❑Master builder 0 Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Z I Job site address: \S7 S3- GJ:.,) i ��P) Gr. New dwelling area: ��j(©� square feet 33 2 City/State/ZIP: T1 jy ((l) i on - ci 7 Z 2 41: Garage/carport area: square feet 19J `r sat ' Suite/bldg./apt.no.: Project name: 6, l3 y ' Covered area: 75{f7 square feet Q Cross street/directions to job site: ' + i r,(/j� E Deck area: square feet u1t,(t }-arM --' s L-124 �` G ' • i irt'`7 Other structure area: square feet �v/ REQUIRED DATA::COMMERCIAL-USE CHECKLIST Subdivision: kill---7--c-p, ,-i, —9 ixes.f 2- ( g.a.. t B , Permit fees'are based on the value of the work performed. p�f Indicate the value(rounded to the nearest dollar)of all ax map/ :C LJ S SE) (,l I CC P �✓i b t^I'_.� 1-(01--PEG- 4' equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. -t7 I Tt V-J of 50'V:..5 i2-AA 1 Fv.'rt-`-tVv✓IA Al Valuation. $ Mtn �Z Existing building area: square feet New building area: square feet PROPERTY OWNER 0 TENANT Number of stories: 1.1 Name: -1-12. G..1:: Type of construction: Address: 1rs 1. L$ G>„v jCp�--fro c:T Occupancy groups: City/State/ZIP: 1 GAP.rLO, L"+fl, . ell 7 2 Existing: Ri Phone:(5D3) 4 CT -`l tr8? .-, Fax:( ) New: [Er APPLICANT [if CONTACT PERSON BUILDING PERMIT FEES' n Business name: �i(;:ye e=r�-v S-=fLa,-,�'f,cam+ ttl (7�`abtw"�e`-t-<ti E, i ,-r t.. lPJeaee> r to arJklrls�y ! Structural plan review fee(or deposit): LJ.71 , 19 t CI Contact name: Address: -Ain _ FLS plan review fee(if applicable): • ,City/State/ZIP: -n i z-y,J r , fi 7 ZZ t4 Total fees due upon application: Amount received: Phone:(Co 1) .-1-kn 7 -Li (,,c;(c, Fax::( ) E-mail: G t G3?›C. a A tt.Csr m-+ L,c. ;+vvGd.S`C C. ti PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* `" CONTRACTOR Commercial and residential prescriptive installation of roof-top mounted PhotoVoltaic Solar Panel System. Business name: 67113.3 c'e3d-r- LTt c,•.+ '`'} (7„-ytnoc>4 v : t t,sr- , Submit two(2)sets of roof plan with connection details and fire department access,along with the 2010 Oregon Address: i 5-7 I S- t7.. 56 4 C'r, Solar Installation Specialty Code checklist. City/State/ZIP: j� 04.. C:(7 Z Permit Fee(includes plan review $180 00 and administrative fees): Phone:(,5'B3) 4e 7 -et 0''(o Fax:( ) State surcharge(12%of permit fee): $21.60 CCB lic.: f l7�tk p 4{C( Total fee due upon application: $201.60 Authorized signature: This permit application expires if a permit is not obtained y, within 180 days after it has been accepted as complete. Print name: j`'"h 0:1„....e.„ Date: ty( 2-4- ( Z9, `Fee methodology set by Tri-County Building Industry 1 Service Board. I:1Building\Permits BUP-RESPermitApp.doc 02/24/2011 440-4613111l/02/COM/WEB) ' Mechanical Permit Application_ I I; ..I 11, I i .1 ., City of Tigard `t h C E I V E D Receive Permit Not-is lig i- 13125 SW Hall Blvd.,Tigard,OR 97223 PlanDate RT Zf�' �� ��t Phone: 503.718.2439 Fax: 503.595.1960 Plan Review N 11 202C! may: Other Permit: , ; „ ,, Inspection Line: 503.639.4175 D gpdy/By tune: I la See Page 2 for Internet: www.tigard-or.gov ITY OF TIGARL Notified/Method: Sapp4amed learaadaa OF WORK CORUSIERCIAL FEE* SCHEDULE-USE CHECKLIST Mechanical permit fees*are based on the value of the work ii •ew construction • ,dition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all mechanical materials,equipment,labor,overhead,and profit Vir%/1� ...,tidon ■ Other: aLs, alue:S ,,aarj CATEGORY OF CONb`1RUCTION RESIDENTIAL QEQUIPMENT/SYSTEMS FEES' In 1-and 2-family dwelling ❑Commercial/industrial 0 Accessory building Foe apedat briera's:km use checklist 0 Multi-family 0 Master builder 0 Other: Description Qty. I Ea. Total JOB SITE INFORMATION AND LOCATION Hesdag/eoding: Job site address: t,.( 5 ChdrNd e r. Air Furnace 100,000 Toning J 46.75 e.7 r 1 1 BTU(ducts/vents) 46.75 City/State/ZIP: b f E/y() @{j- 9 7 Z Furnace 100,000+BTU(ducts/vents) / 54.91 51.1i Suite/bldg./apt no.: Project name: Heat pump f 61.06 Duct / 23.32 23.31- Cross street/directions to job site: Hydronic hot water systan 23.32 Residential boiler(radiator or 720 yyt hydrwic) 23.32 Unit heaters(fuel-type,not electric), \7'�, r'7 in-wall,in-duct,suspended,etc. �J/, 46.75 `� Flue/vent for any of above ',. 23.32 2-3.3 1-- - Other: 23.32 Subdivision: Lot no.: Other fuel appliances: Tax map/parcel no.: Water heater if 23.32 )3.32 DESCRIPTION OF WORK Gas fireplace insert 33.39 Flue vent for water heater or gas X )el,/ ,$N/I G0-/4 G fireplace 23.32 Z 3 Log lighter(gas) 23.32 mini/ APur Wood/pellet stove 33.39 la r((- j-. / k( ! t/lo. /.4.7!!L VC-Ain to. Wood fireplace/insert 23.32 Chimney/lina/flue/vent 23.32 PROPEBTY OWNER 0 TENANT Other: 23.32 / Environmental exhaust and ventilation: Name: (�C 03 - Range hood/other kitchen eqAddress: 0/S7 r� S w 4-C7k � U'• Clothes tit 33.39 Clothes drys exhaust ) 33.39 li 3.WI City/State/ZIP: 77 4 q`T z21 Single duet exhaust(bathrooms, r� toilet compartments,utility rooms) 3 23.32 Phone:(PI) tip)- 9G S''(. Fax:( ) Attic/crawlspace fans 23.32 1/3 APPLICANT ❑ CONTACT PERSON Other: 23.32 , Business name: (/';'?, , �/V S7NAC ri cr cq �7LiAPe'. i i/ Fad k?IPla sl4.is(or first four;S4.03 for each additional Contact name: 70yye. Furnace,etc. Address: f 5 5' L�w f. yD4 eT, Gas heat Pump Wall City/State/ZIP: 77 G ,rrip,/ Oyq , 97u` Water heater r r 213, Phone:(TO ) 'f t7 7-q G IS fe> Fax::( ) Fireplace E-mail: / iv y77Lm.1 e R erU Range efil3 Gv / �e"�11�De"ar.tG-I !rl y i Barbecue CONTRACTOR Clothes dryer(gas) Business name: pickv !4 flit 2t' N 61 .J(. Other. 1 / MECHANICAL PERMIT FEFBe Address: 7 ti c Al I,vJ 4-1-0 C. [-Elm Pit . st4(TG /10'/ Subtotal City/State/ZIP: Minimtmu permit fee($90.00) GI s13vt2�'' �7J Plan review(25%of permit fee) Phone:(441,) `i7/ - 2-or qq gy Fax:( ) State surcharge(12%ofpermit fee) CCB tic.: ZO'OOJ TOTAL PERMIT FEE This permit application eaptres If a park b not obtained within 180 daog after here Coen y Building as Industry le. Authorized signature: � / • Fee methodology set by Tri-Calory Building Industry Service Board Print name: f( Date: (o / 'q/ZD J�p 1:'as d'nerrmiMMEC_ermitApp_atal tl.dec 44016177(1{g2.COMwEB) • Electrical Permit APPhcation i .,a u i I i r l i 'I u v i 2 w...GENE 10 Received City of Tigard paw: Permit#: MS•T-7..0'U -0 0 21/t1 II • 13125 SW Hall Blvd.,Tigard,OR 97223 yq II- Phone: 503.718.2439 Fax: 503.598.1960 U N 1 1. Cu Date.'By R' Dan Rev Related Perrot it: Inspection Line: 503.639.4175 .; q,;R r Ready Date/By: Ark I la See Page 2 far Internet: www.tigardorgov - Ndified/Method: Sappls emal lafarmada t TYPE OF wdittl i'‘.r " ,.._ PLAN REVIEW ❑New construction %Addition/alteration/replacement Please check all that apply(suit a seta of plans veitems checked): ❑Demolition .0Other: 0 Service or feeder 400 amps or more ❑Building over three stories. where the available fault current 0 Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 snips at 150 volts or 0 Floating buildings. VA1-and 2-family dwelling 0 Commercia/industrial 0 Accessory building lees to ground,a exceeds 14,000 0 Commercial-use agricultural ❑Multi-family amps for as other installations. buildings. y 0 Master builder 0 Other: 0 Fire pump. 0 Retaliation of 150 KVA or JOH SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived 0 Addition of new motor load of system. lob#: lob site address: I 5-7 SS 5 t., 12.pril C l i lo0HP or more. ❑~A~,~H,~1-2~.~I-3 City/State/ZIP: Olt. Cr7a Z- 0 Six or more residential units. occupancy_ cr-' �i 0 Healthcare facilities. ❑Recreational vehicle parks. Suite/bldg./apt.#: Project name: • 0 Hazardous locations. 0 Supply voltage for more than 0 Service or feeder boa amps or more. 600 volts nominal. Cross street/directions to job site: nut SCR/NJ/ELI �..�1�L„ IMaatonaa I WY. I Math I Taal i • IA rT r7V New residential single-or melti-fatally dwelling unit. •Subdivision: Lot#: Includes attached garage. 1,000 sq.ft.or less 168.54 168 P 4 TeX map/parcel#: Fa add'I 500 sq.ft.or portion �" 33.92 3 3.'$2_ 1 DEMOTION OF WORK Limited energy,residential 75.00 2 (with above sq.ft.) NEW //4 j_f He #S�9' U S P�to t,t z Rat PV"--S Limited energy,multi-family 75.00 2 residential(with above sq.ft.) 6[PROPERTY OWNER p TENANTRenewable Energy l See Page 2 Services or feeders installation,alteration,and/or relocation Name: -7-Pyf-t &c 64, 200 amps or less 1 100.70 /00.70 2 Address: /l-7 S5- S<J 4c'a C-e, 201 amps to 400 amps 133.56 2 t5 7)0 4 0, (?at . 972-Z`! 401 amps to 1,00060 amps amps 200.341 2 City/State/ZIP: 601 amps to 301.04 2 Phone:(SO) ) d f o 7 -q fo fit. Fax:( ) Over 1,000 amps or volts 552.26 2 Temporary services or feeders insnWtbn,alteration,and/or Email: G<1166ee ve,-nmdi r t o--t [..fd.;T, r Er relocation Owner Installation:This installation is being made on property man t own which is not 200 amps or less 59.36 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 asps 168.54 2 Of APPLICANT I 0 CONTACT PERSON Brandt circuits-new,alteration,or extension,per panel A.Fee for branch circuits with Business name: G/(�i Lc'r' 73t-e.(G..r.t Er-r 't]� I a:-ioe-!^f G,14 L, above service or feeder fee, tl r 7.42 2 1 /^ each branch circuit 1 Contact name: 7 ( B.Fee for branch circuits without Address: /5 7 3-3- 'w Ste' e r branch or feeder feet fire 56.18 2 City/State/ZIP: `j 1(. a4,t 0yy - g72 -41 Each add'I botch circuit 7.42 2 Miscellaneous(service or feeder not included) Phone:(5v-3) L-p 7_ 11674 Fax::( ) Each manufactured or modular dwelling,service and/or feeder 67.84 2 Email: 6i Mtn fries-n w -4 ( -0,--7.f...t (a f t-4-c-r Reconnect only 67,84 2 CONTRACTOR Pump or irrigation circle 67.84 2 Business name: F4,442,W t!ifrs.�, 1/ Signs or outline lighting 67.84 2 _? Signal circuit(,)or limited-energy ❑ see page 2 2 Address: Po AA Z‘7,7 panel,alteration,or extension. Each additional inspection over allowable In any of the above City/State/ZIP: C er ert- 973 4 9 Additional inspection(I ter min) 66.25/hr Phone:( ) Fax:( ) Investigation(I hrmin) 90.00/hr - Email: Industrial plant(1 hr min) 78.18/hr Inspections for which no fee is gp,pp/ter CCB Lie.: /91 2 5 2 Electrical Lie.:C.1 2(e Suprv.Lie,:5's g/,S' specifically dated(.4 hr min) .rr ELECTRICAL PERMIT FEES Suprv.Electrician signature,requiredS�__. j Subtotal: Print name: ''(/Ltr� /34- -,e 4)a.J Date: G4/ O j D 0 Plan Review Required(25%of permit fee): / State surcharge(12%of permit fee): TOTAL PERMIT FEE: Authorized signature: This permit application expires If a permit la mot obtained stelae 180 Print name:S-iCb p Date: k4 7 Zip?o days after It has been accepted as complete. ' Number of inspections allowed per permit. l:11kib.€\Perm.su:t.C._Pm pp_hut_RlIE.mc Rev06/1ra015 tsrpims/COM/WEB `Plumbing Permit ADDllcation Building Fixtures I t i lt t i i I It I I .I t)N I 1 RECEIVE17.rva �' i City of Tigard Date/By PermtNo.:l i�'� , GI 0 ,� '1 • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Rev ew r I ' Phone: 503.718.2439 Fax: 503598.1960 J U N 11 202tt. Datvgy: Other Permit No.: Inspection line: 503.639.4175 Date Ready/By: Ma: ® See Page 2 for Internet: wvw.tigard-or.gov _;(TN( ` Ti Afl: Notified/Method: Supplemental Information TYPE OF WORK BUILDING DIVISION FEE* SCREDULE ❑New construction 0 Demolition For special information use checklist 0 Addition/alteration/replacement .0 Other. Description �' I Ea. I Total � wily dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 g 1-and 2-family dwelling 0 Commercial/mdustrial SFR(2)bath 437.78 SFR(3)bath 500.32 Accessory building 0 Multi-family Each additional bath/kitchen 25.02 ❑Master builder 0 Other Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site rattles: Catch basin or area drain 18.76 Job site address: l5?Cr s JJ S E'11eYPU'A t'T. Ihywell,leach line,or trench drain 18.76 City/State/ZIP: 716420.0 t tit- f 7 2-21 Footing drain(no.linear ft.:__) Page 2 Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03 Cross street/directions to Job site: Manholes 18.76 p-VL,l I"eI�Lit sn - g$i2 Rain drain connector 18.76 Sanitary sewer(no.linear R.:_j I Page 2 62 •5L1 Storm sewer(no.linear IL:_) Page 2 Water service(no.linear ft.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Clothes washer 25.02 i rcry (3irr A-V/'-r-Y/F7'to.1) ue' 64r4 Ofri S Dishwasher 25.02 Drinking fountain 25.02 ' Ejectors/sump 25.02 lif PROPERTY OWNER I 0 TENANT Expansion tank 12.51 -tom r Fixture/sewer cap 25.02 Name: ►n f�113-6 Floor drain/floor sink/hub I 25.02 Address: 5 7 S 4�142-5-^>r.4 c r. Garbage disposal 25.02 City/State/LIP: 7)(4,44-9 r Olt . 7L Z Hose bib ! 25.02 2.5-,a .. Phone:(ST)) efb 7-g68 6Fax:( ) Ice maker 12.51 lye APPLICANT ❑ CONTACT PERSON interceptor/grease trap }�I(,� 25.02 / la* 4 S]7ItiC 4 p .d a, Medical gas(value:$_) aai ell)\� Page 2 Business name: !9 t Tt v'�' t G�'s Primer 12.51 12.51 Contact name: TVA...-1 t� /L� Roof drain(commercial) -Nt)'" 12.51 Address: ( r7 3T ! •_ je'77-c`Ni/ C r. Sink/basin/lavatory 3 25.02 75;0la City/State/ZIP: 7164-0 r O-A . 77 y y Y Solar units(potable war 62.54 Phone:(1b3) 4f 0 7-16£'C. T Fax::( ) Tub/ahower/shower pan 12.51 S 1 E-mail: Ceti34 [9"rs pme Zr erl e Ctrt+ sr v e Urinal 25.02 CONTRACTOR Water closet 2_ 25.02 �•£'I( Water heater f 37.52 3"t.52 Business name: e'st.a,,r t� Plies 4•t3(NrG Water PPin8�t wv 56.29 Address: Li/i.f 5 Be'h,ri.cR+sE k pi) t ...07/7 Other: 25.02 City/State/ZIP: l ( erg_err', et 70 t S Subtotal ok(221./0I Minimum permit fee: $72.50 Phone:kni3) L o- D 7(0 3 Fax:( )Q Plan review (25%of permit fee) CCB Lic.: /5 f j7j %� Plumbing Lic.no.: f /�(p� State surcharge(12%of permit fec) 3 IU.sa Authorized signature 4:: " vt -��-. - ATOTAL PERMIT FEE 21 i r7.I Print name: yvt /� Date: (o q to 1�D �s permit application aspire.If a permit Is not obtained witty 1ae days r after It lead bees accepted m complete. "Fee methodology set by Tri Cotmty Building Industry Service Board. loBuilding'PcmitsPLMll-PramitApp.doe 10ro1/09 4404616T(t0/02/COM/WEB) City of Tigard 71 ■ COMMUNITY DEVELOPMENT DEPARTMENT T 1 G A R D Building Permit Review — Residential Building Permit #: MST-2-0 Z p _- DO 2-0 y Site Address: IS-7 55 Sv.J &ereXlct C -. Project Name: GI to►j Lot #: Planning Review . Proposal: PcMiltJvl XVerify address/suite# active in Accela. fir,,_In River Terrace: 21,,No ❑ Yes,River Terrace Review Addendum Site Plan Elements: YErosion Control '3 copies of site plan on 8-1/2"x 11"or 11 x 17"paper ''etained trees with drip line and tree protection measures ►.. %prawn to scale(standard architect or engineer scale) ootprint of new structure(including decks)and FFE 5ZlNorth arrow 0, tility locations&easements(required for new and additions) Site address,project or subdivision name and lot number F..' idewalk/driveway approach pplicant information(name and phone number) location of wells/septic systems . tot dimensions and building setback dimensions NIAgtreet tree size,type and location N4Square footage of buildings to be demolished 72 treet names Existing structures on siteIti; omer elevations (2'contours if snore than 4'differential) Opt area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? EYes No llimpervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? EYes 21.No 0 Clean Water Services—Service Provider Letter(lot platted prior to 9/10/1995): Required: Yes,applicant was notified ❑ No Received: XYes o LP Water Meter Fixture Unit Worksheet—Additions,Remodels and ADUs Ara-kV 4� Required: �.'1'es,applicant was notified ❑ No Received: -f� ess D No SDC Exemption for ADU applied for: ❑ Yes ❑ No Received: ❑ Yes ❑ No (Public Facilities Improvement (PFI) Permit: Required: ❑ Yes,applicant was notified ,IlirNo Applied For:n ❑ Yes ❑ No,stop intake Nid Use Case#: �. Zoning. R-4-S JaReuired Setbacks: Front: NI/ Rear: I rJ Side: 5 Street Side: 9 �' � ^ � N/Pr Garage: 0 A' 'Building Height: Max. Height: Actual Height: Landscape Area: % Lot Coverage Max: Entrance I,I Set back, o more an 8'from street-facing wall ❑ Parallel to street or offset 45 degrees or less Windows II Minim 12%o area of all street-facing facades Garage II k. arage d.or is b hind widest street-facing wall ❑ Yes ❑ No,one of the following is met: il Do,r ext ds no mire than 5'from wall and there is a covered porch extending beyond garage. ❑ 11,34 r ext nds no ire than 5' from wall and there is a 12 sq ft.window above garage on 2nd floor. la Garage .lox dth is A 12'or less ❑ 50%or less of facade ❑ 60%or less and includes 7 of following: ❑ Cover porch ■ 't --•ssed entrance ❑ Wall offset ❑ l'Roof eave ❑ Roof offset ❑ Fires ' gles ❑ L•. Siding ❑ Roof pitch ❑ Gable,hip,or gambrel roof ❑ Dormer ❑ Accen siding ❑ W dow trim ❑ Window recess ❑ Window projection ❑ Balcony NA—Visual Clearance (A-Urban Forestry Plan *Sensitive Lands: ❑ Yes No Type: Conditions met prior to issuance of building permit Notes: Approved By Planning: Date: CO 20 Revisions (after Building Submittal on ) Reviewer Date Revision 1: 0 Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved I:\Building\Forms\BldgPermitRvwRES_1224I9.docx Building Permit Submittal Original Submittal Date: tp f I Site Plans: # 3 Building Plans: # 3 Building Permit#: Enter building permit# above. Workflow Routing: .a-Planning 9'Engineering emit Coordinator n"-Building Workflow Sign-off: E.-Sign-off for Planning(include notes from planning review) Route Application Documents: E.-Engineering: (1) copy of permit application, (1) site plan, (1) building plan and original 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: < Dom[' rt ) Date: /2-(3/2.-0 Engineering Review Er-Slope at building pad: a'2 Er-Conditions "Met"prior to issuance of building permit J1/A 121 Easements (encroachments)per engineering conditions of approval and plat n/4 Er-Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes C"No Assess Water Quantity Fee in-lieu: ❑ Yes QNo LIDA Facility on lot: ❑ Yes C No 9-Final Plat Recorded: h /'- ❑ NOT Approved by Engineering: Date: Notes: E-Approved by Engineering: % / Date: t,/&.3/202u Revisions (after Building Submittal only) Reviewer Date Revision 1: 0 Approved ❑ Not Approved Revision 2: ❑ Approved ❑ 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: ❑ Received X. Does not apply SDC Fees Entered: Wash Co Trans Dev Tax: 0 Yes Xi. N/A Tigard Trans SDC: 0 Yes 'N/A Parks SDC: ❑ Yes gN/A LIDA ❑ Yes N/A OK to Issue Permit Approved by Permit Coordinator: Aryko ke/ Date: 4112420 I:\Building\Forms\BldgPerntitRvw_RES_122419.docx Water Meter Fixture Unit Worksheet for Additions/Remodels/AD►Us Please complete the following information: Customer Name: �` (3 Service Address: Street/Suite#: I S 7 ST +n.' (: .;,' '4- Cr, City: l 'K%" State: C -'r Zip: till Z 21 Phone Number: Email: 67 4,.x0.1/s jn's`ore t4 a.e .r. NZT 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 x 1 = x 1 = Bidet 1 = x 1 = Clothes washer I x 4 = q x 4 = Dishwasher i x 1.5 = i,.f x 1.5 = Hose bib / x 2.5 = I, 5' x 2.5 = Hose bib, each x 1 = x 1 = Kitchen sink i x 1.5 = /. r x 1.5 = Laundry sink I x 1.5 = /, S. x 1.5 = Lavatory 3 x 1 = 3 2-. x 1 = 7.- Water closet, 1.6 GPF 3 x 2.5 = `7.r' I x 2.5 = `L,a' Bathtub/whirlpool x 4 = x 4 = Shower stall r x 2 = .7— 7- x 2 = 1/ Bath/shower combo i x 4 = x 4 = Current Points: L1•S Proposed Increase: 8 , Current Points+Proposed Increase= =New Total Points =Required Meter Size r Meter Sizes: 1 to 30 points=5/8" 30.5 to 37 points='/4" 37.5 and over points= 1" 4h+ New Meter Size Needed for New Total Points: i (see page 1) 3 � Cost: $ P 3 � z�" Current Meter Size per Utility Billing: ✓l9 Cost: $ 1/ 41'' ' (see page 1) s New Meter Size Cost minus Current Meter Size Cost= $ if/ °I ' aa �.- (This is Your Cost to Increase Meter Size Due to Additional Fixture Units) ************************************************************************************* FOR OFFICE USE ONLY Current Meter Size Confirmed with UB Signature of UB Representative Date I:/Building/Forms/WaterMeters_070119.µdd.dotx Page 2