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Permit RECEIVED / r2- o _ea�y7 AUG 21 2020 CITY OF TIGARD BUILDING DIVISION CleanWater Services SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT Clean Water Services File Number 20-002244 1. Jurisdiction: Tigard 2. Property Information(example: 1S234AB01400) 3. Owner Information Tax lot ID(s): Name: Michael Hampton Company: Address: 7710 SW Cherry Drive OR Site Address: 7710 SW Cherry Drive City, State,Zip: Tigard, OR, 97223 City, State,Zip:Tigard, OR, 97223 Phone/fax: 503-969-7551 Nearest cross street: Varns Email: michael@fisherroof.com 4. Development Activity(check all that apply) 4. Applicant Information © Addition to single family residence(rooms,deck, garage) Name: Michael Hampton ❑ Lot line adjustment ❑ Minor land partition Company: ❑ Residential condominium ❑ Commercial condominium Address: 7710 SW Cherry Drive •❑ Residential subdivision El Commercial subdivision City,State,Zip: Tigard, OR, 97223 ❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 503-969-7551 Other Deck extension Email: michael@fisherroof.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 Michael Hampton Print/type title Signature ONLINE SUBMITTAL Date 8/13/2020 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. O 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. Vi 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 PROVIDER LETTER IS REQUIRED. Reviewed by ./ Oi4o i.AA Date 08/21/2020 O complete,email to:SPLReviewecleanwaterservices.org • Fax: (503) 681-4439 OR mail to: SPL Review, Clean Water Services,2550 SW Hillsboro Highway, Hillsboro, Oregon 97123 Main Office • 2550 SW I-Iiilisboro Highway • I-fiilsboro, Oregon 97123 • p: 503.68'1.3600 f: 503 681.3603 ^ cleanwaterservices.org ia3115 OL =„T 3iv25 r' U n N drz/L I SSG-696-4e.5 IC0E I t frolaHdH t 154117114 r xg N""a I rY a 3 Al tI e siN . 0 A 1 1 �j --II��oo1d I (A (Ts: �_ C7 j I 1""' 1 1 p �i 2 1/.,N1.4 7%,..,.ro j5n m,"'S 1 d 7d ril X) r, 1 d I 1 1,9 t�51 s ,SEI M m 1 n � i 1 I I J' r p 4 n. I �;„at{ t n 1 11' I I 1 a I I y I 70 ,o T I • 1 I AN:-`n•Pa ' �l'"9 is,s _ I5" Dianna Ornelas From: Lina Smith Sent: Wednesday, August 12, 2020 5:18 PM To: michael@fisherroof.com Cc: #Building Permit Technicians Subject: Permit for deck extension - 7710 SW Cherry Dr Hi Michael, I signed off on your permit and routed it to Building. You'll need to obtain a service provider letter from Clean Water Services. Please fill out this form online and upload your site plan here: https://www.cleanwaterservices.org/documents-forms/pre-screen-form/ Once you receive a response from Clean Water Services, please send it to tigardbuildingpermits@tgard-or.gov(also copied on this e-mail).This won't delay Building's review of your application, but you'll need to obtain this before they can issue the permit. Thank you, Lina Smith Assistant Planner City of Tigard I Community Development 13125 SW Hall Blvd.Tigard, OR 97223 E-mail: LinaCS@tigard-or.gov DISCLAIMER. E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail may he 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." 1 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 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. JIA $ 4 : i !'v V\ Print Name of Permit A plicant < ignature of Permit Applicant Date Permit#: /'),s-r- tiv-oogif 7 • .q (A) Address: 77/0 S 147- 401•-• • ft:MI� ---?Oted uyi y' 7, Issued by: _ Date: I - r This Copy for Permit Offices RECEIVED Information Notice to Owners About AUG 11 2020 '= Construction Responsibilities any OFTIG PD • BUILDING DI1„3'' N (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 htto://www.oregon.ciov/DOR/BUS/dacs/211-055.odf 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