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Permit CITY OF TIGARD MASTER PERMIT COMMUNITY DEVELOPMENT Permit#: MST2020-00348 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/24/2021 I 9 Parcel: 2S103AA00800 Jurisdiction: Tigard Site address: 11047 SW ERROL ST Subdivision: None Lot: None Project: Goalby/Taylor Project Description: New detached 781 sf ADU and 355 sf covered porch. NO FINAL INSP UNTIL WATER METER UPSIZED. NOTE: Loft area is for storage only and not to be used for sleeping purposes. BUILDING Floor Areas Required Setbacks Required Stories: 1 Bedrooms: 2 First: 781 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 12 Bathrooms: 2 Second: 0 sf Garage: 0 sf Front: 20 Smoke Dwelling Units: 1 Third: 0 sf Right: 5 Detectors: Yes Total: 781 sf Value: $111,943.22 Rear: 15 PLUMBING Sinks: 1 Water Closets: 2 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 1 Urinals: 0 Lavatories: 2 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Storm Sewer: 100 Tubs/Showers: 1 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Drains: 0 Catch Basins: 0 Bckllw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 2 Backwater Value: 1 Drywell-Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 2 Clothes Dryers: 1 Natural Gas Heat Pump: Y Hoods: 1 Other Units: 0 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 3 Fum>=100K: 0 ELECTRICAL Residential Unit Service Feeder _Temp SrvcfFeeders Branch Circuits 1000 sf or less: 1 0-200 amp: 1 0-200 amp: 0 W/Svc or Fdr: 0 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 8,Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: Y BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: NEW ADU VB R-3 781 Owner: Contractor: GOALBY,JOHN& NOMARCO INC Required Items and Reports(Conditions) TAYLOR-GOALBY,SHELBY PO BOX 462 11045 SW ERROL ST WOODBURN,OR 97071 TIGARD,OR 97223 PHONE: PHONE: 503-793-6506 FAX: Total Fees: $13,400.08 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 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. �cl\Issued By: ' \(�Y\VQ�\ P ,� Permittee Signature: opi_->1 i u- k� Call 503. 39.4175 by 7:00 a.m.for the next available Inspection date. _r 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. . 60 ect-tz X 4.6u, Building Permit Application .,. JP?' 1l 1(T12 a Residential FON OFFICE.rSI. t)yI City of Tigard Receivedy: 12/ Jr AO 0 NuiiitNe,tlWrza ze po3yS 114 = 13125 SW Hap Blvd.,Tigard,OR 97223 plea Rev ew ck Other l � i20„rya G) Phone: 503.718.2439 Fax: 503.598.1960 Date/By: W f 1 �gvt T.t GAR D tnspectiem Lute: 503.639.4175 Date Ready/By: �n/ luris. ®See page ' Internet: www.tigard-or.gov No d/Method2/J'II.Zi `�ljQ f!4 Statplemeatal Idat®atoo Eiti t _ --TAG // TYPE OF WORK 1, REQUIRED DATA:I-AND 2.FAMILY DWELLING 2 ew construction 0 Demolition Permit tees*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,and the rofit for the,._ CATEGORY OF CONSTRUCTION Work indicated on this application. 1 ,` ,143.. bitre Z ❑1-and 2-family dwelling 0 Commercial/indusirial Valuation Sid [ ccessorybuilding ❑Multi-family Number of bedrooms: a Ptin ❑Master builder ❑Other: Number of bathrooms: Z +- g : '1 b14L JOB SITE INFORMATION AND LOCATION Total number of floors: 77 Job site address: j i 0y ' 7 , y/ 6rr .� v ) Sly-,, - ,RD" New dwelling arca:. " square feet City/State/ZIP: T 1,3 curd DR c1 i aa,3 Garage/carport area: square feet te/bl /apt.no.: Project name: A I GvkL%' Covered porch area square feet � nl�d�"� �; + uI`76rn4 r , 't6I'1 ' /I b k area. square feet „� 6'/ "EZS 4 W A- t. 9,arz, /-ECd o.a� ` Other structure area: ` square feet —IY NitA Pfr- TO CEOAl!�a t 7 1Jf P L'G fitkit J2---� REQUIRED DATA:COMMERCIAL-USE CHECKLIST .�� ID /fAreLT a Permit fees*are based on the value of the work performed. TnaP Pare 9'�tL 7 ` `G .,7 C�>� S�� Indicate the value(rounded m the nearest dollar)of all Tax / el no.:, ut3�� c � equipment,materials,labor,overhead,and the profit for the ✓�A 1✓7i-C1_ �s td'^t i ,a ' ftt6- work indicated on this application. t'3S C w ' ZL. Valuation: $ ws( Lon dcr h exs ft r dw,'e ': /-vx;ll, u+ut '-i (° fW)t. 6 c T/Onl i T/J /Ssu�hs,r7r Existing building area square feet c g—�. v ^t ,y/s e'i. /10 y1s s� 6, 24 L New building area: square feel dicl5 PROPERTY (AVNE'/R PU i V lTOO,0 0 TENANT f id 1'74'� -"D elah4of stories: Name: I?j tdtt TA i o r. t. J-4 tt,J ()Mal y Type of construction: Address: l / a t{S S V rrlV 1 S+rez t / Occupancy groups: City/State/ZIP:Tj� R 1 r ci7 `a•?sExisting Phone:( ) Fax:( ) New: Q API7.ICANT ❑ CONTACT PERSON BUILDING PERMIT FEES* . Meow rarer w Fee schedok) Business name: NU/Yl 2� I n C Structural plan review fee(or deposit): 73 3. 9 y Contact name: C h Lee K Don't&Yl FLS plan review fee(if applicable): Address: f-/0b2 Le S E WO* )rci:ri c Pei- Total fees due upon application: City/State/ZIP:W ppd \ `^l �A ( Amount received: Phone:(AO%) 3�10-'3I Si, 777���ppp I Fax::( ) a PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* E-mail:C �t 18D ma's l- CaT1 Commercial and residential prescriptive installation of CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System. Business name: _��1� /n I._ Submit two(2)sets of roof plan with connection details and fire department access,along with the 2010 Oregon Address: Li O(P t D % E 11 j o}`- V',r-ry,rt a 1241 Solar Installation Specialty Code checklist. �Oga t- 1 rj-R c-1 0 1 1 Permit Fee(includes plan review Ci(y/State/ZIP: S180.00 and administrative fees): Phone:(gO ) 'fan-ps-(o'a, Fax:( ) State surcharge(12%of permit fee): UM CCB lic.: 1\Ck 5 T Total fee due upon application: S201.60 Authorized signs ler 1 This 180 daapys t h be if a permit is not mpl obtained. pwithin days after tt has been acceptedpermitas complete. I Print name- I rate: , 1 *Fee methodology set by Tri-County Building Industry '/- 7 -.2o)-0 /4.4-&L, ELG Lt ItJn T P4.40/l- TU a S zi-er Aili'd c'i Building Permit Application Checklist One- and Two-Family Dwelling FOR OFFICE t SE ONLY City of Tigard Received Permit No. J 13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits: Date/By: - Phone: 503.718.2439 Fax: 503.598.1960 24-Hour Inspection Line: 503.639.4175 0 Electrical 0 Plumbing 0 Mechanical f9GARC) Internet: www.tigard-or.gov 0 Ot1ef: THE FOL.i.OW1\G ITEMS >,RF REQUIRED FOR PL;A\ REVIEW tea v0 Nil 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. r ■ ■ 2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. lE 3 Verification of approved plat/lot. 4 Fire district approval required. Name of district: 5 Septic system permit or authorization for remodel. Existing system capacity ■ 6 Sewer permit. 7 Water district approval. 8 Soils report. Must carry original applicable stamp and signature on file or with application. 0 9 Erosion control 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 basin protection,etc. 10 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state 0 ❑ 0 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. I I Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if 0 0 0 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. 12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size ❑ 0 0 and location. 13 Floor pleas. Show all dimensions,room identification,window size,location of smoke detectors,water heater, 0 ❑ 0 furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc. 14 Cross sectlon(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,roofing,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 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 0 locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered 0 Cl 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 ❑ 01 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 architect licensed in Ore:on and shall be shown to be au.licable to the .ro'ect under review. JERiSDiCT1O\ UI, SPECIFICS 23 Three(3)site plans are required for item II above. Site plans must be 8-1/2"x 11"or 11"x I7". ■ U 24 Two(2)sets each are required for Items 16, 19,20 and 22 above. ■ 25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. ■ ■ 26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. 0 ■ 27 "Drawn to scale"indicates standard architect or engineer scale. 0 28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard 0 Street Tree List, 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 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, 0 0 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. Mechanical Permit Application Ft)r, OFFICE l 'i tt\I 1 City of Tigard Received roans No p 13125 SW Hall Blvd.,Tigard,OR 97223 listed➢y' �y-5/7 2 Q-4 0'3`iO _ Plan Renew Phone: 503.718.2439 Fax: 503.595.1960 Danny. Other Permit: 'TA G A R D Inspection Line: 503.639.4175 Date Ready/By: Lois: 0 See Page 2 for Internet: www.tigard-or.gov Nailed method: 77 Sapplemenlal lnformatlee TYPE OF WORK COMMERCIAL FEE*SCHEDULE—USE CHECKLIST cln�w construction Mechanical permit fees*are based on the value of the work -New 0 Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all ❑Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit. Value:$ CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT/SYSTEMS FEES* ❑ 1-and 2-family dwelling 0 Commercial/industrial EtAccessory budding For special iefonesiien use checklist ❑Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning �••%, 46.75 Job site address: f/ 0 q 7 S( fry a i S y-et_f,. Furnace 100,000 BTU(ducts rema) 46.75 City/State/ZIP: l Furnace 100,000+BTU(duns/vents) 54.91 T l�t'1-�rrJ� 012 l�t� Suite/bldg./apt.no.. Project name: if-I Heat pump 61.06 I7�U I Q lk� BY Duct work 23.32 Cross street/directions to job site: U Hydronic hot water system _ 23.32 Residential boiler(radiator or hydrunic) 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: Lot no.: 2332 Other fuel appliances: Tax map/parcel no.: Water healer 23.32 DESCRIPTION OF WORK Gas fireplace/insert 33.39 Flue vent for water heater or gas e e) StS-Iiii6 Siru.olzh't -LA) 1 1., I tt iGLCjJ(j 4 fireplace 23.32 tl /ll Log lighter(gas) 23.32 Wood/pellet stove 33.39 Wood fireplace/insert 23.32 Chimney/liner/flue/vent 23.32 Other: E -PROPERTY OWNER 0 TENANT 23.32 Environmental exhaust and ventilation: Name: (p(ry vtLe, Range hood/other kitchen Address: v Ip�l.� ��S V1f 01 SA- equipment exhaust I 33.39 , City/State/ZIP: --� Cfl� Clan 3 Single-duct let compartments, (bathrooms, J" toilet compartments,utility moms) 23.32 Phone:( ) Fax:( ) Attic/emwlspace fans 23.32 0 APPLICANT 0 CONTACT PERSON Other: 23.32 ' Fuel piping: Business name: N o m(z.r CO (.1A G s/a.ls for first four;Se.os for each additional Contact name: J t Sr S p t7 f`0.Ot.YI Fltmace,etc. ' Address: LiCklAR S ttiotI Fra-tCte- act Gas heat pump Wall/suspended/unit heater City/State/ZIP: 1iJ00dblor(A 1 b12 G1-1 OZ t Water heater I Phone:(50b) Fax::( ) Fireplace `t'� �Oln Range F-mail: 00-, n 0, 01 r.Q,t® ,t. C.o Tr Barbecue COPTRACTOR Clothes dryer(gas) me Other. Business na No( z.d i Ill n MECHANICAL PERMIT FEES* Address: y n 1 eto.S r�l trott -Prot.;ne 4 Subtotal AA .93 City/State/ZIP: w 0 oa\ctix n i op_ el-7 D---1` Minimum permit fee($90.00) Plan review(25%of permit fee) .55:bt Phone:( 3 )1a1_ Fax:( ) State surcharge(12%ofpermit fee) 2,. It.55 r /CB lie.: —I t(,�5g TOTAL PERMIT FEE O�,OA l This penult 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 Electrical Permit Application FOR OFFICE 1 "I ONI 1 City of Tigard • Received Date/By: Permit#:M S r 2n70.'1103 9ef' 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Phone: 503.7182439 Fax: 503.598.1960 Date/By. Related Permit i6. - Inspection Line: 503.639.4175 Ready Date/By: Briar ® See Page 2 for I<_,'.,1;I3 Internet: www.tigard-or.gov Notified/Method: vq• Supplemental Information TYPE OF WORK PLAN REVIEW [-ew construction ❑Addition/alteration/replacement Please check all that apply(submit z sets of plans whiting checked): ❑Service or feeder 400 amps or more 0 Building over three stories. Demolition ❑Other: where the available fault aunt ❑Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volt or 0 Floating buildings. ❑ 1-and 2-family dwelling 0 Commercial/industrial ID-Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural amps for all other installations. buildings. ❑Multi-family 0 Master builder 0 Other 0 Fire pump. 0 Installation of 150 KVA or JOB SiTE INFORMATION AND LOCATION ❑Emergen:ysystem. larger separately derived r ❑Addition anew motor load of systern. Job#: Job site address: I i 61). (S -Err-°I S-1 l0OHP or more. ❑"A".'E•"t•2"•`t•s", i /,�(p q� ❑Six or more residential units. "cony. City/State/ZIP: *vol 1_ Vh t-.0 , 0Heahh-care facilities. 0 Recreational vehicle parks. Suite/bldgJapt.#: Project name: A-D o -( ((me,_ ❑Hazardous locations. ❑Supply voltage for more than ❑Service or feederer60 0 amps or more. 600 volts nominal. Cross street/directions to job site: FEE SCHEDULE mwripthw i Orr. I Each I Total ) New residential single-or multi-family dwelling unit. Subdivision: Lot#: Includes attached garage. 1,000 sq.ft.or less r 168.54 (Id,‘.511 4 Tax map/parcel#: Ea add'I 500 sq.it or portion 33.92 1 DESCRIPTION OF WORK Limited energy,residential 75.00 2 - (with above sq.R.) N t� Si I?.dk i c 't-.1^ 0.-k.1 Limited energy,multi-family 75.00 2 residential(with above sq.ft) 0 TENANT Renewable Energy CI See Page 2 4tl Eg-PROPERTY OWNERServices or feeders instaton,alteration,and/or relocation \A}I(r/j Name: ' k --ro,, y C 200 amps or less ( 100.70 /oc.70 2 Address: 1 \O4S SLY() LVY ...,4C{ � 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 City/State/ZIP: '11'CA/F, 3- 0 971a�t 3 601 amps to 1.000 amps 301.04 2 Phone:( ) �" Fax:( ) Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or Email: relocation Owner installation:This installation is being made on property that I 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 mops to 599 amps 168.54 2 0 APPLICANT I Q CONTACT PERSON Branch circuits-new,alteration,or extension,per panel A.Fee for branch circuits with Business name: �malr.e e� ,n G above service or feeder fee, 742 2 \n each branch circuit L7e Contact name: S S v-ii,„-La,r B.Fee for branch circuits without service or feeder fee,first i 56.18 Si,,I G 2 Address: 4-4iP S Ell t 1)ft°A-t re, QGl branch circuit City/State/ZIP:-1� `OOX it n"fZ`riCSl( Each add'}hranch circuit 7.42 2 \ Miscellaneous(service or feeder not included) Phone:( ) Fax::( ) Each manufactureel or modular 67.84 2 dwelling,service and/or feeder Email: Is(trtft f.lrr a f` 1 ft, f 7Yi Reconnect only 67.84 2 "_� ONTRACTOIR�`. Pump or irrigation circle 67.84 2 Business name: ` I1 Q c. r i�c 'V.(, Signor outline lighting 67.84 2 Signal circuit(s)or limited-energy 0 see Page 2 2 Address: c 6 r 2 0.J Zit -or SE panel,alteration,or extension. City/State/ZIP: �p�,� Each additional inspection over allowable in any of the above tY `kl)t2 " \ 1.o Additional inmpa.don(l hr min) 6625/hr Phone:(�)L f..4 ci.,"[ 1,7 Fax:( ) Investigation(1 hr min) 90.00/hr Email: T f Industrial plant(I hr min) 78.18/hr . C Inspections for which no foe is 90.00/hr CCB Lie.: aatiiii,Scrt 1 Electrical Lie.: f, ICI l ci ` Suprv.Lic,575 LI, 5 specifically listed(Ye hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: Subtotal: 3 $.tl.3., Print name: e pt(p�/ CoK: Date: /I F 70 ❑Plan Review Required(25%of permit foe): ''I .33(p • _ f7 State surcharge(12%of permit fee): sq.05 Authorized sign TOTAL PERMITFEE: n it. 3 1 ^_`_. ' This permit sppik... expiresif a permitTis not sheathed withinn 180 Electrical Permit Application-City of Tigard Page 2-Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Renewable Fee for all residential systems combined: $75.00 Description I 1 xa� I roan I y Renewwable electrical energy systems: Check Type of Work Involved: s kva ariesa 100.70 2 5.01 to 15 kva 133.56 2 O Audio and Stereo Systems* 15.01 to25 kva 200.34 2 Wind generation system in excess of 25 kva: ❑ Burglar Alarm 25.01 to 50 kva 301.04 2 50.01 to 100 kva 552.26 2 O Garage Door Opener* >l0o kva(fee in accordance 552.26 2 with OAR 91 B-309-0040) ❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 Eva: System* Each additional kva over 25 7.42 3 ❑ Vacuum Systems* >100 kva-no additional charge 0.0 3 Each additional Inspection over allowable In any of the above: Each additional inspection is 6625/hr 1 1 ❑ �: charged at an hourly(1 hr min) Inspections for which no fee is 90.00/hr specifically listed(%hr min) COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES Fee for ea h commercial s stem: $75.00 Subtotal(Enter on Page 1): „�� �' * Mother of inspections allowed per permit. (SEE OAR 918-309-0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data TelecOttln]Unication Installation .J Pim Alarm Installation 44VAC Instruniiiikerm ❑ latenvoiliind Pang Systems ❑ Landscape irrigation Control* ❑ Medical ❑ Nurse Calls ❑ Otrldoot Landscape Lighting* ❑ Protective Signaling ❑ Other: Total number of commercial systems: — *No licenses are required. Licenses are required far all . . „ .. Plumbing Permit Annlication Building Fixtures FOR of-FIC I I ,i :iNi 1 City of Tigard8 Received PmmtNo. Teo 20 1003911 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review ■ Phone: 503.718.2439 Fax: 503.598.1960 may. Other Permit No.: Inspection Line: 503.639.4175 Date Ready/By: l fd See Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information TYPE OF WORK FEE* S IEDULE 0-New construction 0 Demolition Nor special information use checklist. Description I Qty. I Ea. { Total ❑Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 1001L for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 ❑1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 0 Accessory building 0 Multi-family Each additionalbath/kitchen 7< 25.02 ❑Master builder 0 Other Fire sprinkler( , sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: j + 0 Li- iS'w Ert'c I tj i r i:L Catch basin or area drain 18.76 City/State/ZIP: -11 plod De ci 12,a 3 Footi 0'leach line,or trench drain 18.76 J i Footing drain(no.linear ft.:_) Paggere 2 Suite/bldgJapt no.: Project name:it DoTG-1�10r Manufactured home utilities 50.03 Cross street/directions to job site: 1 Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:_, ) / Page 2 Storm sewer(no.linear fit.: ) / Page 2 Water service(no.linear ft.:__) / Page 2 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backtlow preventer 3127 DESCRIPTION OF WORK Backwater valve 12.51 � r . �' Clothes washer / 25.02 IA Sko-i l ne 5! 4 X l)(lW'i S Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 [,PROPERTY OWNER ( 0 TENANT Expansion tank 12.51 Name: In,I'lt�0. T- �S,f- Fixture/sewer cap 25.02 Address: Floor drain/floor sink/hub 25.02 1 o� �W S� Garbage disposal 25.02 City/State/ZIP:1 5a \ cse a 3 Hose bib ) 25.02 Phone:( ) Fax:( ) Ice maker 12.51 ❑y-APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02 Business name: �N.Lo 1 vx` Medical gas(value:$_) Page 2 Primer 12.51 Contact name: Roof drain(commercial) 12.51 Address: `\CARI.e S t ll o kt.re,+_;f''.t'- , Sink/basin/lavatory 3 25.02 City/State/ZIP:'\ LA r,r1 ‘ h9. a\-,Qom\ Solar units(potable water) 62.54 Phone:(:.)S)-\ac(_051p a Fax::( ) Tub/shower/shower pan / 12.51 E-mail Nrsmufrt.OLV“..� f a=.L .(_am Urinal 25.02 CONTRACTOR Water closet 2 25.02 4 Water heater / 37.52 Business name: &Tex'jor . ude/l�ivt ref 0Ir. jr t lY 1. Water n in WV 56.29 J XJ PP g� Address: ( S 1 \'t\,).M t'fJY� Se-wool R.d1 Nis Other. 25.02 City/State/ZIP: W 0CAkJwrin 1 D 'Tv:711 Subtotal 5ba•f57 Phone: p3) ,64_ \34--1 �Y Fax:( ) Minimum permit fee: 572.50 U Plan review (25%of permit fee) {(All a. /GCB Lie.: I S11 t,-1 11A Plmnbing Lie.nm.:n loss r1 ,/ �/�,/s L> State surcharge TOTAL of fee) Ip'}S,$ Authorized signature: // ' %�� Vi / (�i'1 t TOTAL PERMIT FEE ell 1. i Lp Print name: 414(4, ta,7 W ct J.Q Date://. /_ 0 This permit application expires it a permit is not obtained winds MO days /` after it has bees accepted as complete. Plumbing Permit Application- City of Tigard Page 2 -Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee: Footing drain-1"100' 50.03 0 to 2,000 $121.90 Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69 100' 62.54 3,6012 to 7,200 8233.20 Sewer-1st I L�y 7, 01andgreater $327.54 Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 Storm&Rain Drain-1st 100' ` 62.54 Valuation: Permit Fee: L $1.00 to$5,000.00 Minimum fee$72.50 Storm&.Rain Drain-each additional 100' iY 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for Other Inspections or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to P and including$10,000.00. Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to (minimum charge-1/2 hour) and including S25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to Reinspection Fees 90.00/hr and including$50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for (minimum charge-1/2 hour) _ each additional S100.00 or fraction thereof: Subtotal: 11,5Ve Commercial Fixture Work: Are you capping,adding or replacing fixtures? If"yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations Quaad by Fixture Type Plan review is required for any of the following. Fixture Type for Replace/ Please check all that apply. Work Performed: Capped Added Relocate Baptistry/Font ❑ Any new commercial building with water service 2"and greater,except systems designed and stamped by licensed Bath: -Tub/Shower -Jacuzzi/Whirlpool engineer. Car Wash: -Each Stall ❑ New exterior plumbing site utilities for any complex structure -Drive tall as defined in OAR918-780-0040. Cuspidor/Water Drivetor ❑ Medical gas and vacuum systems for health care facilities. Dishwasher: -Commercialirator ❑ Any multipurpose fire sprinkler system. Domestic 0 Any complex structure as defined in OAR918-780-0040. Drinking Fountain Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: -2" 3" Isometric or Riser Diagram 4" 0 Isometric or riser diagram is required for new buildings -Car Wash Drain that meet the qualifications above. Garbage -Domestic non-food Disposal: -Domestic food related -Commercial food related -Industrial food related Ice MaehJRefiig.Drains Comments regarding fixture work: Oil Separator(Gas Station) Rec.Vehicle Dump Station Shower: -Clang -Stall Sink: -Lav/Bar non-food related -Bradley -Com/Serv/Util food related -Service *Note: lithe fixture work under this permit results in an Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and Washer-Clothes fees assessed for the sewer increase must be paid before the Water Extractor Water Closet-Toilet plumbing permit can be issued. Urinal Other Fixtures: City of Tigard 1 9 '2-6 ia g COMMUNITY DEVELOPMENT DEPARTMENT T 1 G A n Building Permit Review — Residential Building Permit #: ti 5-r Zo`2,0 co3Ya Site Address: 11047 SW Errol St Project Name: Goalby/Taylor ADU Lot #: Planning Review Proposal: Convert accessory structure into detached ADU • )p r,( 4r s-Pits /'F/ /f(s�/ ❑✓ Verify address/suite #active in Accela. ❑✓ In River Terrace: LJ No ❑ Yes, River Terrace Review Addendum Site Plan Elements: Erosion Control eli copies of site plan on 8-1/2"x 11"or 11 x 17"paper _tetained trees with drip line and tree protection measures el III rawn to scale(standard architect or engineer scale) ootprint of new structure (including decks)and FFE II 0 orth arrow tility locations&easements(required for new and additions) D.ite address,project or subdivision name and lot number ,.Sidewalk/driveway approach 10 pplicant information (name and phone number) ✓_A lion of wells/septic systems ILr dimensions and building setback dimensions xeet tree size,type and location ., it.quare footage of buildings to be demolished ✓'tr names sting structures on site xner elevations(2'contours if more than 4'differential E), t area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? 'es o impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? 'es ° To 0 Clean Water Services—Service Provider Letter (lot platted prior to 9/10/1995): Required: ❑✓ Yes,applicant was notified ❑ No Received: ❑✓ Yes ❑ No ❑ Water Meter Fixture Unit Worksheet—Additions,Remodels and ADUs Required: ❑✓ Yes,applicant was notified ❑ No Received: ❑ Yes ❑✓ No ❑ SDC Exemption for ADU applied for: ❑✓ Yes ❑ No Received: ❑ Yes ❑✓ No ❑✓ Public Facilities Improvement(PH) Permit: Required: ❑✓ Yes,applicant was notified ❑ No Applied For: ❑✓ Yes ❑ No,stop intake ❑✓ Land Use Case#: ADU2020-00012 ❑✓ Zoning: R-4.5 ❑✓ Required Setbacks: Front: 20 Rear: 15 Side: 5 Street Side: N/A Garage: N/A ❑✓ Building Height: Max. Height: 25 Actual Height: <12 .:.•.scape Area: % 0 Lot Coverage Max: °, Entrance ! -t back no more than 8'from street-facing wall / ❑ Paralle > -treet or offset 45 degrees or less Windows 111 minim %of area of all street-facing facades Garage I Gara e door is be -• widest street-facing wall V II Yes ElNo,one of the following is met: ❑gDoor extends no more .-_ 5' from w. - .nd there is a covered porch extending beyond garage. ❑u Door extends no more than ' '." - all and there is a 12 sq ft.window above garage on 2nd floor. ❑ Gara•e door width is I or less I 50'.o . ess of facade 60°/n or less and includes 7 of following: I Covered •. Recessed entrance I Wa I . -t ❑ 1'Roof eave Roof offset F. • gles Lap Siding ❑ Roof itch I Ga. - . or gambrel roof ❑ Dormer 2 i Accent siding 1 Window trim U Window recess . + •. . projection ❑Balcony ❑ V' ... Clearance ❑ Urban Forestry'Plan Sensitive Lands: ❑ Yes ILI No Type: ❑ Conditions met prior to issuance of building permit CO Fzr/z- P140I411 e Notes: Do not issue until applicant obtains all sewer connection ermits "a`'s El Approved By Planning: �-�' �,, Date: 12/23/20 op,/7 Revisions (after B ding Submittal only) Review �✓ ate El1: Approved Not Approved "-- — A i Revision 2: ❑ Approved ❑ Not Approved 1:\Buil ding\Forms\BldgPermitRvw_RES_122419.do cx Building Permit Submittal Original Submittal Date: /1l l'3/ZJ Site Plans: # Building Plans: # -: Building Permit#: 0-Enter building ermit# above. Workflow Routing: ID-Planning engineering I -ftri n'^nit Coordinator L I t tding Workflow Sign-off: El-Sign-off for Planning(include notes from planning review) Route Application Documents: u-Engineering: (1) copy of permit application, (1) site plan, (1) building plan and 9 iginal 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: 0i e(4 Date: /Z/��r/2O Engineering Review ❑ Slope at building pad: ❑ Conditions "Met"prior to issuance of building permit O Easements (encroachments) per engineering conditions of approval and plat ❑ Water Quality/Quantity Facility: • Assess Water Quality Fee in-lieu: ❑ Yes ❑ No Assess Water Quantity Fee in-lieu: ❑ Yes ❑ No LIDA Facility on lot: ❑ Yes ❑ No ❑ Final Plat Recorded: E NOT Approved by Engineering: A,10,f !_ neke 7 Date: l2,I31'2p?p j Notes: Vt.,Js /PII7$ Conne*t- holge, to 11UnJ, , S (s /ay" se.......44) 1N46+-61e. FF1 1.ssuav c.e_ 1 [Approved by Engineering: LJ rg. 11 flgh2k y Date: I h I ZUZI Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Permit Coordinator Review 49 Conditions "Met"prior to issuance of building permit -ys/hd\ -(.r P, i Ave Approved, NOT Released: Ai_ I Date: Notes: Revisions (after Building Submittal only) J Revision Notice 1: Date Sent to Applicant: / / /12 LS Revision Notice 2: Date Sent to Applicant: 0 SDC Exemption: 0 Received ❑ Does not aply- itCavl+ Sol'Id 1 -) pL.t re4 ESDC Fees Entered: Wash Co Trans Dev Tax: Yes N/A Tigard Trans SDC: Yes ❑ N/A Parks SDC: Yes ❑ N/A LIDA ❑ Yes 13N/A I-D4)° -ErOK to Issue Permit fl VXi Approved by Permit Coordinator: AlrQ�.Q tP�-- Date: I I ILI I2,12, I;\Building\Forms\B1dgPermitRvw_RES_122419.doex I 15' APPROVED linacs,15:16:26,12/2312020 , \ I-- Is PROPOSED ADU APPLICANT MUST CONNECT I I TO PUBLIC SEWER 1NI I I I I Q SEWAGE PUMP I I Girl OF TIcAHU I 1 1 I Approved by P anning Date: y I I I Initials: ____ 2__-_-- I 1 , I I 'c I W -_--i I I Applicant: Normaco, Inc. I > SEPTIC TANK 1 (503) 729-0562 Q AND DRAINFIELD i I I 1 I STE DLA \ 1 I SCALE: 1/32" = 1 '—O" EXISTING DWELLING I 11047 ADU 11045 SW ERROL STREET I I PORTLAND, OREGON I 1 1 I O. •• rirkel4einOeNgn 504 Moro Aicruc --------{ -- ---------------- -- --- ilverton,Oregon 9 1N8I 03.813.8215 richadf idad4drrrrruoorn SW I— RROL STRF LT . Water Meter Fixture Unit Worksheet for Additions/Remodel DUs Please complete the followin information: /t'ISTA 0.2 O —iqe. ZdOP Customer Name: 4 ki t/1 t./ /i o y7 VED Service Address: Street/Suite #: u1 S1w 12crd( 54 City: T Ifolexycl State: (`Jg Zip: "1722 Phone Number: 5-a3 _1j _"Nyi13 Email: S\r p \kitjA-g0grna1). Gam 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 total. Multiply the quantity by the point value to arrive at the proposed total. Fixture Unit Current Point Current Proposed Point Proposed Quantity Value Total Addition Value Total Bar sink x 1 = Bidet j X I = ( x 1 = Clothes washer _i -� x 4 =_�— x I = Dishwasher _ x 4 x 1.5 = _a x 1.5 Hose bib 2.5 2.5 __ 1 ,s Hose bib,each I =-- � x i Kitchen sink _ x 1.5 = t (5 IOC 2 x 1.5 — — Laundry sink x 1.5 = • = ' Lavatory - _ x 1.5 = x 1 - t 2 x I 2 Water closet, 1.6 GPF - •� x 2.5 = Z- x Bathtub/whirlpool ,- ; - x x 4 = 4 = 4 4 Shower stall 14 I x 2 = 9.. x 2 - 2- Bath/shower combo x 4 a ,z.ccMS ,f x 4 = t PRtwt 4-a ` 31 g Current Points: -1- � ,l-�,t. Proposed Increase: ` 18.00 6.TO•L— 49 I�� nt Points+Proposed Increase = n =New Total Points =Required Meter Size Meter Sizes: 1 to 30 p:tint:— 5/8" 30.5to37 zicIts6=3/4" 37.5and over points= 1" �w�S2E + Pt✓ni ( I T — i) a 5��0(? • t>G -SrGJe I1-. Coin146c7ic New Meter Size Needed for New Total Points: 1 Cost: $ 24,886.00 (see page 1) Current Meter Size per Utility Billing: 5/8 Cost: $ 9'495.00 (see Page 1) New Meter Size Cost minus Current Meter Size Cost= $ 15,391.00 (This is Your Cost to Increase Meter Size Due to Additional Fixture Units) FOR OFFICE USE ONLY Jill Bentley Current Meter Size Confirmed with UB 02/18/2021 US RepSignatureresentative resentative Date of p aterMeters_070119_Add.docX Page 2 l:/BuiidingjForms/t'V .; Dianna Ornelas From: UB Online Sent: Thursday, February 18, 2021 10:13 AM To: #Building Permit Technicians; Jess doman Cc: Allyson Armstrong; 'cjdoman80@gmail.com' Subject: RE: 11047 w Errol st tigard Attachments: 11045_11047 SW Errol St 021821.pdf Categories: Dianna Attached please find the signed Water Meter Fixture Unit Worksheet ADU for 11045_11047 SW Errol St.The ADU will require the meter be ugraded to one (1) inch. Please contact our office Monday through Thursday, 8 a.m. to 6 p.m.. 503-718-2460 to make payment. Kind Regards, Jill (she/her/hers) ...IA A Wtik U Jill oicANBEpyy City of Tigard-Utility Billing Senior Accounting Asst F 'TIAR.I r mg)826-72n pay!rents (503)718-2460 UB Main Jilib@tigard-or.gov (503)718-2494 13125 SW Hall Blvd. Tigard,OR 97223 From:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov> Sent: Friday, February 12, 2021 5:53 PM To:Jess doman <jessdoman@gmail.com> Cc:Allyson Armstrong<AllysonA@tigard-or.gov>; UB Online <UBOnlinepay@tigard-or.gov>; 'cjdoman80@gmail.com' <cjdoman80@gmail.com> Subject: RE: 11047 w Errol st tigard Hello Jess, I am following up to provide you with a status update as follows: • The attached water meter worksheet was received by the building division on 1/11/2021 however we do not have a record of Utility Billing Division (UB) receiving this for review. I am copying UB on this email so that they can review the attached worksheet and respond to let us know if the water meter needs to be upsized to accommodate the new detached ADU located at 11047 SW Errol St. (primary dwelling at 11045 SW Errol St). The size of the meter required will determine if we need to assess additional sanitary sewer system development charges. • We are waiting for a recorded system development exemption form for the ADU. I have previously reached out to Chuck on 1/11/2021 for an update on the status of the exemption, but have not heard back. We need this information before we can invoice the permit fees and system development charges due. 1 • Our office is closed on Monday, February 15th for the holiday. Hopefully we will receive the above information and we can make this permit ready and invoice fees next week. Thank you and please let me know if you have any questions. Dianna L. Ornelas 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:Allyson Armstrong<AllysonA@tigard-or.gov> Sent: Wednesday, February 3, 2021 1:09 PM To:Jess doman <iessdoman@gmail.com> Cc:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov> Subject: RE: 11047 w Errol st tigard Hello, The permit is in post review. The permit technicians will send you an email with instructions for pick up when ready. Thank you, Allyson From:Jess doman <iessdoman@gmail.com> Sent: Wednesday, February 3, 2021 1:02 PM To:Allyson Armstrong<AllvsonA@tigard-or.gov> Subject: 11047 w Errol st tigard Caution!This message was sent from outside your organization. Allow sender I Block sender Hi Allyson. Just reaching out to see if you know the status of the permits on this project(11047 sw Errol st). Thanks Jess Doman 5037937506 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." 2 4 Vicinity Map 8eaverron . I _MapTitle ..... �a , ..b + a !y T i!i r n City of Tigard, Oregon 1 ..,,,.-_,L iidlr. i • Significant Tree Groves • �:^,' Sanitary Manhole illti _. .1•J • In Service • 4 � •+ e 0 * New Construction 'L'� .ry y, „ � ,. 0 Abandoned --. ._ ,. ' Sanitary Flow Arrows A v "" In Service l } Abandoned R w Sanitary Main r., ♦{ — In Service `' New Construction 111 , r Abandoned Sanitary Lateral f Y _. iili Unimproved Right of Way r Ns s,a . t •q 711 :.: w i t ?7<I IL 11.4.4 lit P- r:rS S • I S yA F n, 1 13' U$8 ' e" ^it'a11 Dale.a eer.aa r,am mwup e.•,«....aT•r-ry m r-q a,e ,., C . r .n mare:n In 0 1 r ante of a ff.....: • ... y i q 1 e o m x ap inovvd ro poara mol l ' e or ma aar d � Y„ � efsunt I DI-y y s a a' 5 inaccuracies 1 theInformationprovided req artllass of .• — now caaeee ti f tilk1! rYP R yy • • N r Scale: 0.02 Miles al - r 5?ila a •, .: y. • ":« . , City of Tigard Sli r :rirs• - • � 13125 SW Hall Blvd '` ' Tigard, OR 97223 t' rr �''• b f — -_ Map Created: (503) 639-4171 11124/2020 www.tigard-or,gov MS7 -o.a f/©N7 er '3t CleanWateServices SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT Clean Water Services File Number 20-003283 1. Jurisdiction: Tigard 2. Property Information(example: 1S234AB01400) 3. Owner Information Tax lot ID(s): 2S103AA00800 Name: John Goalby Company: //dy 7 Address: 11045 Sw Errol St OR Site Address: 1..y94 sw Errol st City,State,Zip: Tigard, Or, 97223 City,State,Zip: Tigard, Or,97223 Phone/fax: 503-334-7443 Nearest cross street: SW Fonner St. Email: shelbytg@gmail.com 4. Development Activity(check all that apply) 4. Applicant Information ❑ Addition to single family residence(rooms,deck,garage) Name: Jess Doman ❑ Lot line adjustment ❑ Minor land partition Company: Nomarco ❑ Residential condominium ❑ Commercial condominium Address: 4066 S. Elliott Prairie rd ❑ Residential subdivision 0 Commercial subdivision City, State,Zip: Woodburn, OR, 97071 ❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 15037936506 Other Convert existing outbuilding into ADU Email: jessdoman@gmail.com 6. Will the project involve any off-site work? ❑Yes 0 No 0 Unknown Location and description of off-site work: 7. Additional comments or information that may be needed to understand your project: there is a dog in the back yard, that would need to be put away if a site visit were necessary.503-334-7443 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 Jess Doman Print/type title\LP Signature ONLINE SUBMITTAL Date 12/9/2020 FOR DISTRICT USE ONLY O 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. X 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,p �VI LETTER IS REQUIRED. Reviewed by ��..Ct..c_t " i :..— -l6'^' Date 12/21/2020 Once complete,email to:SPLReview@cleanwaterservices.org • Fax: (503)681-4439 OR mail to: SPL Review,Clean Water Services,255C SW Hillsboro Highway, Hillsboro, Oregon 97123 Revived 22070 Main Office • 2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • p: 503.681.3600 f: 503.681.3603 • cleanwaterservices.org I d d c .d 1 h /� o pose..d - �A Du 1 ,-(---i r I I ;If:sim. N 1 15\opt y I- MJ .IoQser 0 t ic'ic sv4 1 Ergot mot-. a-h a,�,..r t, t C__ p J � 1 5 k %At Ot4 cc_ f -' ✓,ro 1 5} - — Scanned by Cam Scanner