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Permit CITY OF TIGARD MASTER PERMIT i _ COMMUNITY DEVELOPMENT Permit#: MST2021 00328 Date Issued: 10/11/2021 T I G A R.D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S103DA02300 Jurisdiction: Tigard Site address: 10880 SW DERRY DELL CT Subdivision: DERRY-DELL NO.2 Lot: 25 Project: Vukovich Project Description: New 528 sf accessory structure. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 14 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Total: 0 sf Value: $27,075.84 Rear: 5 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 1 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 100 Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Bckflw Prevntr: 0 Other Fixtures: 0 Drywell-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Fum<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Fum>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 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&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All N Other: N Other Description: Ecompasing: BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: NEW ACS VB R-3 0 Owner: Contractor: VUKOVICH,STEVE&EUNICE SURENA OWNER Required Items and Reports(Conditions) 10880 SW DERRY DELL CT STEVE VUKOVICH 1 Ersn Cntrl 503-639-4175 TIGARD,OR 97223 10880 SW DERRY DELL CT TIGARD,OR 97223 PHONE: PHONE: 503-481-9556 FAX: Total Fees: $1,208.32 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 Q49-nnl-nnln thrnnnh()AP oc ..nn1-nnon Vnii mow nhtain a rnnw of 1ha mlae nr rlirant nnacfinne tn ru it i(hw roliinn cm 917 10137 nr 1 5(1(1 139 914d Issued By: Flo{(y Va- Di:Wege Permittee Signature: OwArt1d 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 lob site at the time of each inspection. Building Permit Application B_ : S a Residential RECEIVE) 1 OR t)Il 1( 1 1 SI 0\I.1 City of Tigard A U G 05 Received h z/ =��) Permit No �'I(J�� + DateB :(J 13125 SW Hall Blvd.,Tigard,OR 97223 2021 plan Review : Phone: 503.718.2439 Fax: 503.598.1960 OF _ t ' Other Permit: CITY Date/By: T 1 G A R[7 Inspection Line:g503.639..4175 I G1�R(� Date Ready/By: ,A�i �� jp�._ ® See Page 2 for Internet: www.ti and-or. ov BUILDING DIVISION N ed/Method: _D ` ire Supplemental Information TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING ( 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 profit�for t!he CATEGORY OF CONSTRUCTION work indicated on this applicarion. .��ji��z� 7 ri ❑ 1-and 2-family dwelling 0 Commercial/industrial Valuation: $ 1 INt Accessory building 0 Multi-family Number of bedrooms: 0171 O'75 Pi n El Master builder ❑Other: Number of bathrooms: V� JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: j o S n 6(LILY. b L_C C.,I New dwelling area: square feet City/State/ZIP: T 1( iT it' {,.O R �, — 7 Z Z 3 Garage/carport area: square feet Suite/bldg./apt.no.: Project name: ,.. 00 V y-- 13 JI L. t�itxtb Covered porch area: square feet Cross street/directions to job site: Deck area: square feet (" 't y W Tr.' 1Ni'g K s T T EtUL'j 0 t &L_ c.1 Other structure area: �� square feet REQUIRED DATA:COMMERCIAL-USE CHECKLIST Subdivision: giLit:y ��U.. PLAT . 2 1 Lot no.: .S Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all Tax map/parcel no.: 2 S 1.03 b A 0 Z 3 o 0 equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. CA,N16'c2il `T a uT 13kit 1--‘ 1 �h SZ`$ 41 Valuation: $ #6114/14( 'e P .tsder le Y r/` , ytt� / Existing building area: square feet ((( e J Y r// New building area: square feet PROPERTY OWNER 0 TENANT Number of stories: Name: 5'j E V G 0Vtj(,o v.I Gti Type of construction: Address: j C7 5 5 $ W 10 artLQ:/ b E1.4.. t...T Occupancy groups: City/State/ZIP: 'Ti(a 4tL , V(L, Gil 2_23 Existing: Phone:(5O3) 1-g ( C1 S 5(p Fax:( ) New: (APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES* Business name: (Please refer to fee schedule) Structural plan review fee(or deposit): Contact name: S Vt. 1/'td K a V t c.-1 1 FLS plan review fee(if applicable): Address: j p seo S Yu' b u a, b 1L7 �L _ City/State/ZIP: `T-t 6 V1IL: e cAL /q 7 2 2 3 Total fees due upon application: Phone:(5b ) 44S 1...-9 5 5 @ I Fax::( ) Amount received: E-mail: S C t C• V Loco if c 1-t 4h e (n y►, 1 t_a corn PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* Commercial and residential prescriptive installation of CONTRACTOR roof-top mounted Photo Voltaic Solar Panel System. Business name: Submit two(2)sets of roof plan with connection details and fire department access,along with the 2010 Oregon Address: Solar Installation Specialty Code checklist. City/State/ZIP: Permit Fee(includes plan review $180.00 and administrative fees): Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60 CCB lic.: Total fee due upon application: $201.60 Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Date:Print name: S' (/` V u j�0 V CC,agj/ *Fee methodology set by Tri-County Building Industry `6,1,Z( Service Board. I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(I 1/02/COM/WEB) r , Building Permit Application Checklist One- and Two-Family Dwelling 1(,1t ()l l I( I ( SI (1\1.1 City of Tigard Received Pent*No.: DateB • 13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits: I Phone: 503.718.2439 Fax: 503.598.1960 24-Hour Inspection Line: 503.639.4175 0 Electrical 0 Plumbing 0 Mechanical T I G A R I) Internet: www.tigard-or.gov ❑ Other. TILE: FOLLOWING I"I'E.1IS ARE RBA;IREI) FOR PLAN REVIEW. lc, `o " 1 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ • ■ 2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. 0 ❑ ❑ 3 Verification of approved plat/lot. ❑ 0 0 4 Fire district approval required. Name of district: • 0 ❑ ❑ 5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ ❑ 6 Sewer permit. 0 0 0 7 Water district approval. ❑ 0 ❑ .8 Sbils report. Must carry original applicable stamp and signature on file or with application. 0 ❑ 0 9 Erosion control 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 0 basin protection,etc. 10 3 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. 11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if wr 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 plans. 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 section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- ❑ ❑ ❑ 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 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 ❑ ❑ 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 ❑ 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 0 over 10 feet long and/or any beam/joist carrying a non-uniform load. 20 Manufactured floor/roof truss design details. ❑ Cl 0 21 Energy Code compliance. identify the prescriptive path or provide calculations. A gas-piping schematic is required 0 0 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 El ❑ architect licensed in Ore on and shall be shown to be a licable to the ro'ect under review. 23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x I1"or 11"x 17". 0 24 Two(2)sets each are required for Items 16,19,20 and 22 above. 0 ❑ 0 25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 0 0 26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. 0 ❑ 0 27 "Drawn to scale"indicates standard architect or engineer scale. gr 0 0 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, ❑ 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(1 l/02/COM/WEB) Plumbing Permit Applicatio 1. Building Fixtures � VE roil OFFICE USE O\1.1 City of Tigard AUG O 2021 Received Date/By: Permit Nottl.: ou'Cr328 1111 • 13125 SW Hall Blvd.,Tigard,OR 97223 PlanPlan Review = Phone: 503.718.2439 Fax: 503.598 19 1'TY OF TIGARD Date/By: Other Permit No.: Inspection Line: 503.639.4175 9(JE( fUNt0 (11� lr2 n Date Ready/By: Juris: l IGARU Internet: www.ti and-or. ov -'J J� I y' ® See Supplemental Information g g Notified/Method: SupplementalInformation TYPE OF WORK FEE* SCHEDULE ( New construction 0 Demolition For special information use checklist Description I Qty. I Ea. I Total 0 Addition/alteration/replacetnent 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 0 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 Accessory building 0 Multi-family Each additional bath/kitchen 25.02 0 Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: 10` El D 5 W 0ap..y �2� �� Catch basin or area drain 18.76 Y lC�lv�t2� (�(Z q 7 Z Z ! Drywcll,leach line,or trench drain 18.76 Cit /State/ZIP: i Footing drain(no.linear fr.: ) Page 2 Suite/bldg./apt.no.: Project name: 00 J/L `1 Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 qq w TO !1�K. S'j- .r t ` Z,,/ t)gv- �"'. Rain drain connector , 18.76 f \_gel//;(41/ 1J i �J Sanitary sewer(no.linear ft.:_) Page 2 Stof,/1,4 / f/rg /rrWater sewec (n..ilinearfar t: Page 2 V (i (� jJ� Water service(no.linear ft.:_) Page 2 Subdivision:Va,j.-j !LL r1309-T #Z Lot no.: 45 Fixture or item: Tax map/parcel no.: 2 5 iv 3 b �.U23 J Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 �` 2 Clothes washer 25.02 CC,t4 5 1,1LJ a A-4 Ovt 6 i .)l L.1 i Wci Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 PROPERTY OWNER I 0 TENANT Expansion tank 12.51 Name: S T VE v l&rj v i c. Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: t c,e J„iv- 'n ev,i...y '®at. L i Garbage disposal 25.02 City/State/ZIP: ri(q A Q.t I C7 al Cli -3 Hose bib 25.02 Phone:(50$) 4.'1-e 7 W S Fax:( ) ice maker 12.51 iiif APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02 Business name: Medical gas(value:$ ) Page 2 PContact name: S�Evt rimer 12.51 V��Vice--`1 Roof drain(commercial) 12.51 Address: 10 38o 5w''�� •v UZy I).--..."---(-L t 1 Sink/basin/lavatory 25.02 City/State/ZIP: "C'FCq a tL�] ,UR._, '7 2-t3 Solar units(potable water) 62.54 Phone:(col) 4-g, cif C 5 CU Fax::( ) Tub/shower/shower pan 12.51 E-man: "r'EVCwaKvV 1 C1.1 i.G e. G in A i L...,CCU/A Urinal 25.02 CONTRACTOR Water closet 25.02 Water heater 37.52 Business name: Water piping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal Phone:( ) Fax:( ) Minimum permit fee: $72.50 CCB .. Plumbing Lie,no.: Plan review (25%of permit fee) State surcharge(12%of permit fee) Authorized signature 14 TOTAL PERMIT FEE Print name: S T CVv f��KD v'f i,i Date: B /. / his permit application expires if a permit is not obtained within ISO days ` after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. 1:\Building\Permits\PLMU-PermitApp.doc 10/0 t/09 440-4616T(10/02/COM/WEB) 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 3,601 to 7.200 $233.20 Sewer-1st 100' 62.54 7,201 and greater $327.54 Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 Valuation: Permit Fee: Storm&Rain Drain-1st 100' ' 62.54 $1.00 to$5,000.00 Minimum fee$72.50 Storm&Rain Drain-each additional 100' 37.52 S5,001.00 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 h 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$25,000.00. 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$100.00 or fraction thereof. Subtotal: 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 Quantity 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 El Any new commercial building with water service 2"and greater,except systems designed and stamped by licensed Bath: -Tub/Shower engineer. -Jacuzzi/Whirlpool Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure Drive as defined in OAR918-780-0040. Cuspidor/Water Aspirator • ❑ Medical gas and vacuum systems for health care facilities. Dishwasher: Commercial El Any multipurpose fire sprinkler system. Domestic ❑ 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 Garbage Domestic non-foodthat meet the qualifications above. Disposal: -Domestic food related -Commercial food related -Industrial food related Ice Mach./Refrig.Drains Comments regarding fixture work: Oil Separator(Gas Station) Rec.Vehicle Dump Station Shower: -Gang -Stall Sink: -Lav/Bar non-food related -Bradley -Com/Serv/Util food related -Service *Note: If the 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: L\Building\Permits\PLMF PetmitApp.doc 08/04/2011 2 City of Tigard a COMMUNITY DEVELOPMENT DEPARTMENT TIGARD Building Permit Review — Residential Building Permit #: 14STZ 021 -00328 Site Address: 10880 SW Derry Dell Ct Project Name: Vukovich Lot #: Planning Review Proposal: new accessory structure ] Verify address/suite# active in Accela. E In River Terrace: $7 No ❑ Yes, River Terrace Review Addendum Site Plan Elements: &]Erosion Control 73 copies of site plan on 8-1/2"x 11"or 11 x 17"paper PRetained trees with drip line and tree protection measures Drawn to scale(standard architect or engineer scale) Footprint of new structure(including decks)and FEE ]North arrow XEUtility locations&easements(required for new and additions) ®Site address,project or subdivision name and lot number fi idewalk/driveway approach ]Applicant information(name and phone number) focation of wells/septic systems ®Lot dimensions and building setback dimensions n®Street tree size,type and location !quare footage of buildings to be demolished 1]Street names KExisting structures on site LICorner elevations(2'contours if more than 4'differential) h Lot area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? �1A CI No impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? ❑Yes ❑No ® 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: El Yes,applicant was notified El No Received: ❑ Yes El No SDC Exemption for ADU applied for: El Yes El No Received: El Yes El No C] Public Facilities Improvement (PFI) Permit: Required: ❑ Yes,applicant was notified ® No Applied For: ❑ Yes ❑ No,stop intake IN Land Use Case#: ® Zoning: R-3.5 0 Required Setbacks: Front: n/a Rear: 5 Side: 5 Street Side: n/a Garage: n/a ® Building Height: Max.Height: 15 Actual Height: 14 di Landscape Area: % Q Lot Coverage Max: • e ❑ Set back no more than 8'from street-facing wall ❑ Parallel to street or offset 45 •-• . ess Windows -• . 12%of area of all street-facing facades Garage ❑ Garage door . - .:dest street-facing wall ❑ • — o,one of the following is met: ❑ Door extends no more ch extending beyond garage. ' Does not apply. ❑ Door extends no more tha dow above garage on 2nd floor. ❑ Garage door width i or less ❑ 50%or less o . ,- • 60%or less and includes 7 of following: Cl • - ..rc ❑ Recessed entrance ❑ Wall offset ❑ 1 • •. - ❑ Roof offset ■ Fire shingles ❑ Lap Siding ❑ Roof pitch ❑ Gable,hip,or gambrel roo 11• mer ❑ Accent siding ❑ Window trim ❑ Window recess ❑ Window projection ❑ B co n Visual Clearance or� Urban Forestry Plan ® Sensitive Lands: ❑ Yes © No Type: t® Conditions met prior to issuance of building permit Notes: Q,� E7 Approved By Planning: Date: IS t2-1202( Revisions (after Building Submittal only) Reviewer Date Revision 1: 0 Approved 0 Not Approved Revision 2: El Approved 0 Not Approved I:\Building\Forms\BldgPermitRvw_RES_122419.docx Building Permit Submittal Original Submittal Date: 08/I2O2i Site Plans: # Building Plans: # Building Permit#: [CY<nter building permit# above. Workflow Routing: [VPlanning Engineering Permit Coordinator L uilding Workflow Sign-off: ID--"Sign-off for Planning(include notes from planning review) Route Application Documents: [VEngineering: (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 an. .st details,if applicable, etc. Notes: By Permit Technician: %in:Y/ '6i Date: 1 / 0 Engineering Review RrSlope at building pad: 3% Q�Conditions "Met"prior to issuance of building permit l/o. C^✓7/ a /Easements (encroachments) per engineering conditions of approval and plat H/ R Water Quality/Quantity Facility Assess Water Quality Fee in-lieu: ❑ Yes Q'No Assess Water Quantity Fee in-lieu: ❑ Yes Y.No LIDA Facility on lot: ❑ Yes R No Qr-Final Plat Recorded: P/i- ❑ NOT Approved by Engineering: Date: Notes: GYApproved by Engineering: �'y,1,trf _ / Date: r/(?/ZUZ( Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ 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: VSDC Exemption: ❑ Received 4 Does not apply SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes X N/A Tigard Trans SDC: ❑ Yes , 'N/A Parks SDC: ❑ Yes ,'N/A LIDA ❑ Yes / N/A 73 OK to Issue Permit Approved by Permit Coordinator: Date: (6I t1.1(101't I:\Building\Forms\B1 dgPermitRvw_RES_122419.docx ''� Information Notice to Owners About Construction Responsibilities (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, go online to the Oregon Business Registry. For questions, call 503-945-8091. • 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 800-452-0288. • 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, go online to 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 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 9-2016 This Copy for Permit Property Owner Statement AUG 05 z�? Regarding Construction Responsibilities 8UITYOF LDtE`If'8!V/ION 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 , 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. S-r6V6 VtAKvVIC 14 Print Name of Permit Applicant zczi:,.7(10.7( 48/&/7-I Signature of Permit Applicant Date Permit#: ____Address: ----_--__- (-6F � yr-,. Issued by: Date: ___-_-- j This Copy for Permit Offices C1eanWate��Services SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT Clean Water Services File Number 21-002249 1. Jurisdiction: Tigard 2. Property Information(example: 1S234AB01400) 3. Owner Information Tax lot ID(s): Name: steve vukovich 2S103DA02300 Company: Address: 10880 SW DERRY DELL CT OR Site Address: 10880 SW DERRY DELL CT City,State,Zip: TIGARD,Oregon, 97223 City,State,Zip: TIGARD,Oregon,97223 Phone/fax: 5034819556 Nearest cross street: Park Street Email: stevevukovich16@gmail.com 4. Development Activity(check all that apply) 4. Applicant Information I J Addition to single family residence(rooms,deck,garage) Name: steve vukovich ElLot line adjustment ❑ Minor land partition Company: ❑ Residential condominium El Commercial condominium Address: 10880 SW DERRY DELL CT ❑ Residential subdivision 0 Commercial subdivision City,State,Zip: TIGARD,Oregon,97223 ❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 5034819556 Other Email: stevevukovich16@gmail.com 6. Will the project involve any off-site work? ❑Yes 0 No ❑ Unknown Location and description of off-site work: 7. Additional comments or information that may be needed to understand your project: 22'x24'outbuilding. 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 steve vukovich Print/type title Signature ONLINE SUBMITTAL Date 7/26/2021 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. 151 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 Sty./ , Date 9/7/2021 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 Main Office • 2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • p. 503.681.3600 f 503.681.3603 • cleanwaterservices.org