Permit CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
11111
COMMUNITY DEVELOPMENT Permit#: FPS2022-00078
Date Issued: 5/25/2022
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 450
Project: ACE American Insurance Subdivision: WEST PORTLAND HEIGHTS Lot: 9-25, PT
Project Description: Fire alarm permit:Adding(3)notification appliances. Affidavit submitted.
Contractor: POINT MONITOR CORPORATION Owner: PACIFIC REALTY ASSOCIATES L P
5863 LAKEVIEW BLVD STE 100 ATTN: N PIVEN
LAKE OSWEGO, OR 97035 15350 SE SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: 503-627-0100 PHONE:
FAX: 503-627-0110
FEES
Description Date Amount
Specifics: Permit Fee-COM 05/17/2022 $112.96
12%State Surcharge-Building 05/17/2022 $13.56
Type of Use: COM Plan Review-Fire Life Safety-COM 05/17/2022 $45.18
Class of Work: ALT Type of Const: Info Process/Archiving-Sm$0.50(up to 05/17/2022 $0.50
Occupancy Grp: Height: ft 11x17)
Stories:
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:
Pull Station Required: Smoke Detectors Req:
Battery Calcs Provided: Cut Sheets Required:
Total $172.20
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $3,385.00
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 ar set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
Issued By: / 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.
t B iilding Permit Application
Fire Protection System FOR OFFICE USE ONLY
of Tigard , Received
FIVE® DateB : I A . 1� 'emit
o. miedt7' PIZO.. _ Ail
III
13125 SW Hall Blvd.,Tigard,OR 97223i �
i EffilillIMINOther Permit -.��
Phone: 503.718.2439 Fax: 503.598.196b : ,, ,
T I Ci R D Inspection Line: 503.639.4175 MAN( 1 7 2022 Date Ready/By: illy, 0 See Page 2 or
Internet: www.tigard-or.gov Notificd/Method: 5 . Supplemental Information
TYPE OF WORK' (r 1N9 1) REQUIRED DATA:1-AND 2-FAMILY DWELLING
❑ New construction 0 Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
E Addition/alteration/replacement 0 Other. equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
Valuation: $
❑ 1-and 2-family dwelling ❑Commercial/industrial
ElAccessory building 0 Multi-family Number of bedrooms:
❑Master builder 0 Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 1 2909 SW 68th Parkway New dwelling area: square feet
City/State/ZIP: Tigard, OR 97223 Garage/carport area: square feet
Suite/bldg./apt.no.: 450 Project name: ACE American Insurance Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: 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.: equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Modify fire alarm circuit as required per NFPA72 for a new Valuation: $3,3 gs;-.
floor plan. Existing building area: square feet
New building area: square feet
D PROPERTY OWNER L TENANT Number of stories:
Name: ACE American Insurance Type of construction:
Address: 12909 SW 68th Parkway#450 Occupancy groups:
City/State/ZIP: Tigard, OR 97224 Existing:
Phone:( ) Fax:( ) New:
E APPLICANT 0 CONTACT PERSON NOTICE
Business name: Point Monitor Corporation All contractors and subcontractors are required to be
Contact name: Sharon Erickson licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 5863 Lakeview Drive jurisdiction in which work is being performed.If the
applicant is exempt from licensing,the following reasons
city/state/ZIP: Lake Oswego, OR 97035
apply:
Phone:(503 ) 627-0100 Fax: :( )
E-mail: sercckson@pointmonitor.com
CONTRACTOR BUILDING PERMIT FEES*:.
Business name: Point Monitor Corporation (Please refer`e fee schedule)
Permit fee:
Address: 5863 Lakeview Drive
y Lake Oswego ' 97035 State surcharge(12%of permit fee):
City/State/ZIP:
FLS plan review(40%of permit fee):
Phone:(503 ) 627-0100 Fax:( ) (Due upon application submittal.)
CCB lie.:13591 , Total permit fees: /7i
Authorized signatu �i``i/ //,� Amount received: ;Iv
/(� This permit application expires if a permit is not obtained
Print name: Sharo ick on Date:05/17/2022 within 180 days after it has been accepted as complete.
* Fee methodology set by Tri-County Building Industry
Service Board.
1,Bui1ding\ermils`.FPS-PermitAppl03 I 0 16.doc 440-4613T(11,02,COMi WEB)
a.
City of Tigard: Fire Protection Permit Checklist
Page 2- Supplemental Information
Desei ` 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:
❑ 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: $
Oth �a�ro •
C.) Fire Alarm
Submittal shall Battery Calculations ❑ Yes
include: Individual Component 0 Yes
Cut Sheets
Fire Alarm Project Valuation: $ 3 p',j, `o
i
D.) Residential Sprinler (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): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $
FLS Plan Review (40% of permit fee): $
TOTAL: $
I:\Building\Permits\FPSOPernitApp fl031016.doc 2
City of Tigard Permit No.: /=/PSgeiN•"(XjV7g'
III a 13125 SW Hall Blvd.,Tigard,OR 97223
C Phone: 503.718.2439 Fax: 503.598.1960 Date Received: 57,7/32
Inspection Line: 503.639.4175 T
T'IGAEtt7 Internet: www.tigard-or.gov By: 47 r-f
FIRE ALARM SYSTEM AFFIDAVIT FOR ALTERATIONAECF1VED
OR TENANT IMPROVEMENTS
MA` 17 'i `.t't
(MAXIMUM OF 5 DEVICES WITHOUT PLANS) CCIY OF TIGAiiD
BUtLOINC DIVISION 1
Project Name: ACE American Insurance Occupancy:
Job Address: 12909 SW Parkway Suite: 450
Contractor: Point Monitor Corporation Phone: 503.627.0100
Valuation of work: $3,385.00
Type of System: (check one) *Required [Non-required
(check one) ❑Automatic ❑Manual ■❑Both
Total number of devices added or moved under this permit process is 5 total per tenant space.
Number of Proposed Smoke/Heat Detectors: To be Added(max 5) /To be Relocated (max 5)
Number of Proposed Manual Alarm Stations: To be Added(max 5) /To be Relocated(max 5)
Number of Proposed Notification Appliances: To be Added roux 5) 3 /To be Relocated(max 5)
1, Point Monitor Corporation Oregon Construction Contractors Board No. 135901
certify the following is true and defines the scope of work for this project:
a) All work complies with the current state-adopted NFPA-72 and the authority having jurisdiction.
b) All notification appliances are located in accordance with the current state-adopted NFPA-72.
c) Smoke/Heat detector spacing complies with current state-adopted NFPA-72 and the authority having
jurisdiction.
d) Exposed wiring will not be covered until inspected.
e) Final approval shall be subject to on-site tests and inspections.
f) Voltage drop is adequate to operate all appliances.
g) Battery supplies are capable of supporting the system modifications.
h) Compatibility of appliances and devices are in accordance with the FACP manufacturer's specifications.
In addition, I understand the following is required:
• Submit(3) copies of a sketch showing the area of work within the building's structure.
• Building fire protection system permit.
• Electrical permit.
• A copy of this docu nt with a copy of the sketch attached shall be available for all inspections.
Signature: . Date: 05/16/2022
Print Name: Sharon Erickson
I:\Building\Forms\FireAlarrAffidavit_071514.docx Page 1 of 1