Permit CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
!PI $ COMMUNITY DEVELOPMENT Permit#: FPS2021-00126
Date Issued: 11/2/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1 S 1260000300
Jurisdiction: Tigard
Site address: 9374 SW WASHINGTON SQUARE RD R05
Project: Peloton Subdivision: None Lot: None
Project Description: Fire alarm permit-(13)additional notification devices.(6)ceiling mount speakers,(6)ceiling mount strobes,and
(1)wall mount strobe.
Contractor: SIEMENS INDUSTRY INC Owner: PPR WASHINGTON SQUARE LLC
15201 NW GREENBRIER PKWY BY MACERICH RET
SUITE A4 PO BOX 4085
BEAVERTON, OR 97006 SANTA MONICA,CA 90411
PHONE: 503-207-1839 PHONE
FAX: 503-207-1901
FEES
Description Date Amount
Specifics: Permit Fee-COM 11/02/2021 $112.96
12%State Surcharge-Building 11/02/2021 $13.56
Type of Use: COM Plan Review-Fire Life Safety-COM 11/02/2021 $45.18
Class of Work: ALT Type of Const: VB Info Process/Archiving-Lg$2.00(over 11/02/2021 $12.00
Occupancy Grp: M Height: ft 11x17)
Stories: 1 Info Process/Archiving-Sm$0.50(up to 11/02/2021 $6.00
11x17)
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard.
Density: 0 Design Area: 0
K Factor: 0
Commercial Fire Alarm System:
Fire Alarm Required: Yes Alarm Type: Automatic
Pull Station Required: Yes Smoke Detectors Req: Yes
Battery Calcs Provided: Yes Cut Sheets Required: Yes
Total $189.70
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $3,411.00
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
Issued By: Ho{ V De Were, Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
RECEIVED
OCT ae 2021
CITY OF TIGARD
BUILDING DIVISION Building Permit Application B_ 1012,0 21
Fire Protection System FOR OFFICE USE ONLY
/,e� IReceivedCity of Tigard Date/By: Permit No 00/2
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax:503.598.1960 Date/By: 1) f' Other Permit:
(s\1 t t� Inspection Line: 503.639.4175 Date Ready y: / j -I ®See Page 2 for
Internet:www.tigard-or.gov red/Method: / i/ /v„11.Supplemental Information
TYPE OF WORK REQUIRED DATA:I-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
Igi Addition/alteration/replacement IT]Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION equipment,
indicated on this application.
Valuation: $
% ❑1-and 2-family dwelling ix Commercial/industrial
❑Accessory building 0 Multi-family Number of bedrooms:
❑Master builder Number of bathrooms:
❑Other:
1„ JOB SITE INFORMATION AND LOCATION Total number of floors:
iJob site address: 9374 SW Washington Square Road New dwelling area: square feet
t City/State/ZIP:Tigard,Oregon 97223 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: 44OP-315186 WSQ Peloton Covered porch area: square feet
NA
Cross street/directions tojob site: Deck area: square feet
Near Nordstrom West Entrance q
Other structure area: square feet
L REQUIRED DATA:COMMERCIAL:USE CHECKLIST
p
y` Subdivision: l Lot no.: Permit fees•are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
k Tax Wrap/parcel no.: equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Addition of(13)notification devices to accommodate tenant improvement Valuation: 3,411.00$
for new store moving into retail space.Adding(6)ceiling mount speaker Existing building area: square feet
strobes(6)ceiling mount strobes and(1)Wall mount strobe New building area: square feet
Nilllj PROPERTY OWNER ❑TEN.ANT Number of stories:1
Name: Maria Halstead Type of construction:Type 1
Address:9585 SW Washington Square Road Occupancy groups:Group M
City/State/ZIP:Tigard,Oregon 97223 Existing:
Phone:(503)693.8865 Fax:( ) New:
I4 APPLICANT 0 CONTACT PERSON -- NOTICE
tBusiness name:Siemens All contractors and subcontractors are required to be
Contact name: Ashley Smallwood licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address:15201 NW Greenbrier Parkway Suite A4 jurisdiction in which work is being performed.If the
City/State/ZIP: Beaverton,Oregon 97006 applicant is exempt from licensing,the following reasons
apply:
Y
Phone:(971)998.4551 Fax::(503)207-1901
E-mail:ashley.smailwood@siemens.com
kJ CONTRACTOR BUILDING PERMIT FEES*
Business name:Siemens (Please refer to feesehedr�
Permit fee: $102.20
. •t:.,•Address,15201 NW Greenbrier Parkway Suite A4
State surcharge(12%of permit fee): $12.26
c City/State/ZIP: Beaverton,Oregon 97006 FLS plan review(40%of permit fee):
V Phone:(971)998.4551 Fax:(503)207-1901 (Due upon application submittal.) $40.88
CCB lic.: 133041 //' Total permit fees: $155.34
sr's‘1 52 ., / Amount received:
Authorized signature: u
N This permit application expires if a permit is not obtained
atiZA Print name: Ashle Smal od Date:10/8/2021 within 180 days after it has been accepted as complete.
y • Fee methodology set by Tri-County Building Industry
Service Board.
1:\Building\Pennits\FPS-Pew,itApp 031016.dac 440-4617T(I IPo2/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2-Supplemental Information
Describe work to be,done:
1.) Type of Work: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices:
❑ New system Number of sprinkler heads: Number of alarm devices: 13
® Addition or ❑ 1-10 heads: Affidavit required and ❑ 1-5 devices: Affidavit required and
Alteration (3)copies of sketch showing area (3)copies of sketch showing area
to existing of work within building structure of work within building structure
system
❑ 11+heads: Plan review required and ® 6+devices: Plan review required and
(3)sets of plans. (3)sets of plans.
Additional description of work:
Type of System(Complete A,B,C or D as applicable):
A.) Commercial Sprinkler
Sprinkler Type ❑ Wet ❑ Dry
Additional Standpipes
Information: Sprinkler Supply Line ❑ Yes ❑ No
Hazard Group
Density
Design Area
K.Factor
Sprinkler Project Valuation: $
B.) Type I- Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
Submittal shall Battery Calculations ® Yes
include: Individual Component ® Yes
Cut Sheets
Fire Alarm Project Valuation: $3,411.00
D.) Residential Sprinkler(Stand Alone System)
Square Footage: Permit Fee: _
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq.ft.
Fire Protection Permit Fees
Project valuation subtotal(see A,B&C above): $3411.00
Permit fee based on project valuation(see fee schedule): $102.20
Permit fee based on square footage(see D above):$
State Surcharge(12%of permit fee): $12.26
FLS Plan Review(40%of permit fee): $40.88
TOTAL: $3 566 34
I:\Building\Pemmits\FPS_PermitApp_031016.doc 2
Julie Drinkwater
From: Holly Van De Wege
Sent: Tuesday, November 2, 2021 11:42 AM
To: Julie Drinkwater
Subject: FPS2021-00126; Peloton, 9374 Washington Square Rd
Hi Julie,
Please use David Hemmer as the contact for this permit. His email address is: david.hemmer@siemens.com
Thanks!
Holly Van De Wege
Program Development Specialist
City of Tigard I COMMUNITY DEVELOPMENT
13125 SW Hall Boulevard
Tigard,Oregon 97223
www.tigard-or.gov
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
= may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
is
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LABOR/EQUIPMENT/MATERIAL SUPPLIER
UNCONDITIONAL FINAL WAIVER OF LIEN
(FOR USE BY YOUR SUPPLIER(S).IF THEY HAVE THEIR OWN FORM,IT MUST BE A NOTARIZED FORM!)
Ashley Smallwood
(PRINTED AUTHORIZED SUPPLIER REPRESENTATIVE'S NAME)
being duly sworn, deposes and says that he/she/they make (s)this affidavit on behalf of
SIEMENS INDUSTRY
(SUPPLIER COMPANY NAME)
having entered into agreement with PRANCER ELECTRIC
(COMPANY NAME MATERIALS WERE SUPPLIED TO)
The Sub-Contractor for the construction of WARBY PARKER
(PROJECT NAME THE MATERIALS WERE SUPPLIED FOR)
on the premises of the Owner located WASHINGTON SQ MALL-TIGARD, OR
(MALL OR ADDRESS AND CITY/STATE)
that all labor, material, equipment and services committed for have been fully paid and indebtedness dis-
charged to the date of this affidavit. Furthermore, for and in consideration of$ 7,954.00 ,which
represents the account PAID IN FULL,paid to the undersigned the receipt whereof is hereby acknowledged,
the undersigned does hereby waive release and relinquish any and all claims or rights of lien which the
undersigned may now have upon the premises above described for labor, material, equipment and services of
construction or alteration, and/or otherwise.
Liability to the State of for Sales and or Use Tax,where applicable has been discharged.
Signed this 19 day of tober 2021
By
OFFICIAL STAMP (Sign
" a.- ALEX JOSEPH PYLE
k NOTARY PUBLIC-OREGON �,p
Title �'� -d`-)"4-�'r
COMMISSION N0. 1012083 AA
MY COMMISSION EXPIRES MAY10,2025 ( UTHORIZED SUPPLIER REPRESENTATIVE)
This form will not be accepted unless completed in FULL.