Permit Support Document Vo ; r
NCity of Tigard • COMMUNITY• /
DEVELOPMENT DEPARTMENT . 1//L/ 4 0
Request for Permit Action
T I( ,\R n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor r
Check(1)one DI City Staff
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE- ACTION FOR THE ITEM(S) CHECKED (1):
CANC VOID PERMIT APPLICATION.
D PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: C 021.000Z-
(40
3000213
Site Address or Parcel#: 15350 SW SEQUOIA PKWY, STE. 105
Project Name: JESSICA CORWELL
Subdivision Name: Lot #:
EXPLANATION: Permit was duplicated, original permit number FPS2021-00025
Signature: / j�
Print Name: g �/ Date: G3-eP9-202/
E. ie M. . .nado
Refund Policy
1. The city's Community Develop ent Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
i
Route to Sys Admin: Date By Route to Records: Date ' /T
1 Refund Processed: Date /✓ A- By 0 Invoice Processed: Date �i/u By v
Permit Canceled: Date / B
.� `Pf 2/ T.t�'r.� Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 05 8.doc
Building Permit Application , , ��
Fire Protection System unit tau ncy USE ONLY
City of Tigard and RECEIVED Received i� tpw�'
g Date/By: a3 O� ��� PermltNo.:�s2,��/�
III ' 13125 SW Hall Blvd.,Tigard,OR 97223 MAD Plan Review
>z Phone: 503.718.2439 Fax: 503.598.19 it 04 2021 Other Permit:
Date.By:
TIGARD; Inspection Line: 503.639.4175 -t-�� Date React'By: Inns: 0 See Page 2 for
Internet: www.fi and-or. ov C�t T I i. �P l Notified/Method:
g g BUI���1� a Supplemental Information
LJ
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 the
CATEGORY OF CONSTRUCTION : work indicated on this application.
❑ I-and 2-family dwelling IX)Commercial/industrial Valuation: $
❑Accessory building ❑Multi-family Number of bedrooms:
❑Master builder ❑Other: Number of bathrooms:
JOB SITE. INFORMATION AND LOCATION Total number of floors:
Job site address:15350 SW Sequuoia Parkway New dwelling area: square feet
City/State/ZIP:Tigard,OR 97224 Garage/carport area: square feet
Suite/bldg./apt.no.:105 Project name:PCC241 Jessica Conwell Va 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.
Fire Alarm Notification-relocate only Valuation: $$401.00
Existing building area: square feet
New building area: square feet
0 PROPERTY OWNER : ® TENANT Number of stories:
Name:PCC241 Jessica Conwell Vacancy Type of construction:
Address:15350 SW Sequuoia Parkway Suite 105 Occupancy groups:
City/State/ZIP:Tigard,OR 97224
Existing:
Phone:( ) Fax:( )
New:
0 APPLICANT ❑ CONTACT PERSON
NOTICE
Business name:Point Monitor Corp. All contractors and subcontractors are required to be
Contact name:Brooke Williams licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address:5863 Lakeview Blvd#100 jurisdiction in which work is being performed.If the
City/State/ZIP:Lake Oswego,OR 97035 applicant is exempt from licensing,the following reasons
apply:
Phone:(503)627-0100 Fax::( )
E-mail:bwilliams@pointrnonitor.com
CONTRACTOR BUILDING PERMIT FEES*
Business name:Point Monitor Corp. (Please refer to fee schedule ,—
Address:5863 Lakeview Blvd#100 Permit fee: 7 �` .
State surcharge(12%of permit fee):
City/State/ZIP:Lake Oswego,OR 97035 FLS plan review(40%of permit fee):
Phone:(503)627-0100 Fax:( ) (Due upon application submittal.)
CCB tic.:135901 Total permit fees:
{ Amount received:
Authorized signature: �' This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name:Ben Breit Date:3/3/2021
* Fee methodology set by Id-County Building Industry
Service Board.
I Braiding Penni,FPS-PcrmitApp-.031016.dnc 440-4613T(1P02 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: 1
® 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: PIan review required and
(3) sets of plans. (3) sets of plans.
Additional description of work: Fire Alarm Notification- relocate only
Type of System(Complete A, B, C or D as a Tlicable)
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: Ls
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: $ 401
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.
-- i
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: $
C:AUsers\be•illiams\Desktop\PI'.RMTI FORMS\Fire permit-city of tigard.doc 2
RECEIVED
City ofTi and MAR 04 2021 x
FP8202/- OZ&
11114
Tigard Permit No.:
• 13125 sw Hall Blvd.,Tigard,OR 97223 I,��7/
I Phone: 503.718.2439 Fax; 503.598.19 CITY OF TiGARD
Date Received: O3/�fCf L
Inspection Line: 503.639.4175
TIGARE UILDING DIVISION CPI � - /'-W
Internet: www.tigard-or.gov By: � �`/`
FIRE ALARM SYSTEM AFFIDAVIT FOR ALTERATIONS
OR TENANT IMPROVEMENTS
(MAXIMUM OF 5 DEVICES WITHOUT PLANS) OFFICE COPY
Project Name: PCC241 Jessica Conwell Vacancy Occupancy: Same
Job Address: 15350 SW Sequuoia Parkway Suite 105 Suite: 105
Contractor: Point Monitor Corp. Phone: 503-627-0100
Valuation of work: $401
Type of System: (check one) f}Required :Non-required
(check one) EAutomatic EManual DBoth
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(max 5) /To be Relocated(max 5) 1
I, Ben Breit 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. 1
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,1 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 document with a copy of the sketch attached shall be available for all inspections.
Signature: - ----- Date: 3/3/2021
Print Name: Ben Breit
1:\Building\Fonns\FireAlannAffidavit_071514.doex Page 1 of 1
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