Permit CITY OF TIGARD MASTER PERMIT
= COMMUNITY DEVELOPMENT Permit#: MST2022-00230
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/16/2022Parcel: 2S109A612600
Jurisdiction: Tigard
Site address: 14188 SW ALPINE CREST WAY
Subdivision: ALPINE VIEW Lot: 7
Project: Herr
Project Description: Converting 211 sf of crawl space to habitable sitting room.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 0 sf Basement: 211 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors:
Total: 211 sf Value: $27,552.38 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 0
Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0
Bckflw Prevntr: 0 Catch Basins: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Drywell-Trench Drain: 0 Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 1
Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn>=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 201400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 1
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:
ALT SF VB R-3 211
Owner: Contractor:
HERR,BEN TRUIT&JUDY ANN HERR JCOWNER Required Items and Reports(Conditions)
REVOCABLE LIVING TRUST
14188 SW ALPINE CREST WAY
TIGARD,OR 97224
PHONE: PHONE:
FAX:
Total Fees: $1,330.24
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 re uires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
at;,)-nn1-nolo fhmnnh nAR 9-not-n Qn V i av n ain nnv of tho ruloc nr rlirarf niieetinnc to nl INn by Tallinn SM Lr 1 Ann'249 94dd
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.
Building Permit Application
Residential FOR OFFICE USE ONLY
City of Tigard RECEIVED Received
— v
13125 SW Hall Blvd.,Tigard,OR 97223 IUL1 8 2022 Plan Review
= Phone: 503.718.2439 Fax: 503.598.1960 Date/By: 7/ Other Permit:
Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION N ed/Method: I Supplemental information
5961
TYPE OF WORK REQUIRED DATA:I-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.
Valuation: Maicr.k�S $ 0 �j
1-and 2-family dwelling ❑Commercial/industrial
❑Accessory building ❑ Multi-family Number of bedrooms:
❑ Master builder ❑Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors: qA
Job site address: H l$$ Sin/ 4( 1 ne cet5+ levo. New dwelling area: 1 square feet 02.3>`10
City/State/ZIP: �i u�a 6(z 17 Li Garage/carport area: square feet
(L Suite/bldg./apt.no.: Project name: Remwcko-I/aj ,tt 00 14-A ✓ rwo, Covered porch area: square feet
I� Cross street/directions to job site: Deck area: square feet
u 133 — A 10 i he- V t J — A I ►r G C M6+ W s^ Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: N F BAI BULL VAot,uh+e,, v1 Lot no.: Permit fees*are based on the value of the work performed.
z 5 109 A g I Z d 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.
Valuation: $
FI c.ol+t.d ev, '510PA. , R,4 1.raA. "v►. 5 rta `n k iA
Existing building area: square feet
o k u fo w� a -> o VI etae e revs �rl+'n
D,' -v' e�m'�' e tt+ t �i�^�– (� o W. y'rA �' New building area: square feet
C�LFROPERTY OWNER ❑ TENANT Number of stories:
Name: &✓t H w V- Type of construction:
Address: Iq l 3 6W A( j A-r, Crt54- \rJOccupancy groups:
City/State/ZIP: `r, p fc{ DQ' G+��Z Existing:
Phone:(130'I) ) 7Qq _+6q j Fax:( ) New:
APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
-- (Please reer to fee schedule)
Business name:
– , Structural plan review fee(or deposit):
Contact name: ��h ,r/j/
FLS plan review fee(if applicable):
Address: SG e a6 rJ e
Total fees due upon application:
City/State/ZIP:
Amount received:
Phone:( ) Fax::( )
E-mail: bin r;J►–t-hma,
I L o W1 PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
� l°I �
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic 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.
Permit Fee(includes plan review
City/State/ZIP: $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.
Print name:h Date: ) *Fee methodology set by Tri-County Building Industry
f4—Y V 7/ /��� Service Board.
1:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received
g Date/By: Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits:
Phone: 503.718.2439 Fax: 503.598.1960
24-Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanicai
Internet: www.tigard-or.gov ❑ Other:
REQUIREDTHE FOLLOWING ITEMS ARE .
PLAN REVIEW Yes No NRO
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district etc. ❑ ❑
3 Verification of approvedplat/lot. ❑ ❑
4 Fire district approval required. Name of district: ❑ ❑ Q
5 Septic sstem permit or authorization for remodel. Existing system capacity ❑ ❑
6 Sewer permit. ❑ ❑ DO
7 Water district approval. ❑ ❑ RJ
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑
9 Erosion control ❑plan ❑permit required. Include drainage-way protection,silt fence design and location of catch- ❑ ❑ t9
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state [ ❑ ❑
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 ❑ ❑
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 ® ❑ ❑
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, ® ❑ ❑
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- C ❑ ❑
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. ❑ ❑ ❑
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- ❑ ❑ ❑
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 ® ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered [� ❑ ❑
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 ❑ `❑ ❑
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. ❑ ❑ ❑
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is requi d [a ❑ ❑
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 ❑ ❑ ❑
architect licensed in Oregon and shall be shown to be a2dicable to the ro'ect under review.
JLJRISDICTIONAt, SPECIFICS
23 Three 3 site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 1 1"x17". ❑ ❑ ❑
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 tans will not be accepted. ❑ ❑ ❑
26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document.. ❑ ❑ ❑
27 "Drawn to scale"indicates standard architect or engineer scale. ❑ ❑ ❑
28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard ❑ ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, ❑ ❑ ❑
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, ❑ ❑ ❑
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\Permits\BUP-RESPetmitApp.doc 02/24/2011 440-4613T(I1/02/COM/WEB)
a
Mechanical Permit Aumication
City of Tigard Received 70ther
13125 SW Hail Blvd.,Tigard,OR 97223 eBy:
RECEIV 1 Review
i Phone: 503.718.2439 Fax 503.598.1960 t:
eBy:
Inspection line: 503.639.4175 'I� ® Zo� Date Rea /B �w s
Internet: www.tigard-or.gov U d y la SeePage2for
Notified/Method: Supplemental Information
xti
TYPE OF WORKI'l X111 .1 COMMERCIAL FEE* SCHEDULE— USE CHECKLIST
Mechanical permit fees*are based on the value of the work
❑New construction Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment labor,overhead and profit.
CATEGORY OF CONSTRUCTION Value:$
RESIDENTIAL EQUIPMENT/SYSTEMS FEES*
® I-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checkhst
❑Multi-family ❑Master builder ❑Other: Description Qty. I Ea. Total
JOB SITE INFORMATION AND LOCATION Heats CO°
' t Air conditionin 46.75
Job site address: 144117 5 W 1 n,e ✓,S'�- W q Furnace 100,000 BTU ducts/vents 46.75
City/State/ZIP: ;f A Y 0� 97 2� Furnace 100,000+BTU ducts/vents 54.91
p
Suite/bldg./apt.no.: Project name: GACA Heat 61.06 Heat
23.32
Cross street/directions tojob site: H dronic hot water system 23.32
Residential boiler(radiator or
h dronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct suspended,etc. 46.75
,�r p Flue/vent for any of above 23.32
Subdivision: J
N E p m ,Y t �M 1 r Lot no.: � Other: 23.32
,M
Other fuel appliances:
Tax map/parcel no.: 2-5 1 o 9A g 1160 o Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert 33.39
Flue vent for water heater or gas
1 O Y.h,'4 p� kowic _ fireplace 23.32
b u 10 c+ I r g n + Q +O r a G r✓1 Log light- as 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
❑ PROPERTY OWNER ❑ TENANT Other. 23.32
Environmental exhaust and ventilation:
Name: h r Range hood/other kitchen
nff
equipment 33.39
Address: �L�) $ s TI ttiC (_VCS+ AWj h Clothes dryer exhaust 33.39
City/State/ZIP: "`� ar �� �7Z CI Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 23.32
Phone:(so3 ) 7c1oq—��l S Fax: ( ) Attic/crawlspace fans 23.32
❑ APPLICANT ❑ CONTACT PERSON Other: 23.32
Fuel
Business name:
$14.15 for first four;$4.03 for each additional
Contact name: 3 Qy� Furnace,etc.
Address: Gas heat pump
Wall/sus ded/tmit heater
City/State/ZIP: Water heater
Phone:( ) Fax: :( ) Fireplace
E-mail: Range
Barbecue
CONTRACTOR Clothes dryer as
Business name: Other:Ot,JIl1�Y — Yf MECHANICAL PERMIT FEES*
Address: Subtotal
City/State/ZIP: Minimum permit fee($90.00)
Phone: Fax:
Plan review(25%of permit fee)
( ) ( )
State surcharge(12%of permit fee)
CCB lie.: TOTAL PERMIT FEE
This permit 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
Print name: 3 ye, Date: 7110 17.1
l:\Building\Permits\MEC_PemutApp_040113.doc 440-4617f(11/02/COM(WEB)
Electrical Permit Application
Received
City of Tigard DateB Permit#:
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
= Phone: 503.718.2439 Fax: 5DateB : Related Permit#-
Inspection Line: 503.639.4175 E I M,I E Ready Date/By: Juris: ®See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF PLAN REVIEW
❑ Please check all that apply(submit I sets of plans w/items checked):
New construction �Additton/a�t�>♦/t>�i
❑Demolition ❑Other: BUILDING DIVISION [3 Service eavailor er4 faults rentor ❑Marinas and three stories.
where the available fault current [3 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
ER 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
El Multi-family ❑Master builder El Other: (I Fire pump. ❑Installation of150KVAor
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived
Job#: Job site address: �� $$ SVJ ❑Addition of new motor load of system.
1 h P � -ftL Wh 100HP or more. ❑-A","E","1-2","1-3",
City/State/ZIP: Tski/ �� Q y [3 Six or more residential units. occupancy.
❑Health-care facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#: Project name: R'tip W% A40k Al y1 ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total
�.y New residential single-or multi-family dwelling unit.
Subdivision: Wt w NE aklel t) o Lot#: -7 Includes attached garage.
1,000 sq.R.or less 168.54 4
Tax map/parcel#: 2 61 Q q 12 too 1,000
add'I 500 sq.ft.or portion S 33.92 1
DESCRIPTION OF WORK Limited energy,residential
Roo
W ♦ � (with above sq.ft.) 75.00 2
1NQ 0. // i i In.S 1 t?� f♦ Q 0 Lunited energy,multi-family
L t t S lQ�ahs w✓l� t1 S Q residential with above s .f 75.00 2
PROPERTY OWNER Renewable Energy ❑ See Pace 2
❑ TENANT Services or feeders installation,alteration,and/or relocation
Name: 3$� v4r 200 amps or less 100.70 2
Address: 141$7 �yt/ M I v.e 6 MIti 201 amps to 400 amps 133.56 2
�f 401 amps to 600 amps 200.34 2
City/State/ZIP: I t itj 601 amps to 1,000 amps 301.04 2
Phone:(5a ) 7A— S S Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: b.Lyk err Li I Wwot► c (O yr relocation
Owner installation:This installation is b ing made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease rent,or exge,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: p eY 401 amps to 599 amps 168.54 2
A❑ APPLICANT CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee, 7.42 2
each branch circuit
Contact name: .0 to B.Fee for branch circuits withota
service or feeder fee,fust 56.18 2
Address: branch circuit
City/State/ZIP: Each add']branch circuit 7.42 2
Miscellaneous service or feeder not Included
Phone:( ) Fax::( ) Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Entail: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: O aW IN e- 1( Sign or outline fighting 67.84 2
Signal circuit(s)or limited-energy
Address: pancl,alteration,or extension. 1 ❑ See Page 2 2
City/State/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(I hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(I hr min) 90.00/hr
Email: Industrial plant(I hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lie.: Electrical Lic.: Suprv.Lic.: specifically listed i/2 hr min
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal:
Print name: 13�?In (Ire Date: —7/60 Z ❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Print name: h Date: 7 days after it has been accepted as complete." Number of inspections allowed per permit.
I:\Building\Pennits\ELC_PennitApp_ELR_ERE.doc Rev06/17/2015 440-4615T(i 1/05/COM/WEB
FOR OFFICE USE ONLY—SITE ADDRESS:
This form is recognized by most building departments in the Tri-County area for transmitting information.
Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Transmittal Letter
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: 50 r A -1ro h 9 DATE RECEIVED:
DEPT: BUILDING DIVISION Iq RECEIVED
FROM: uC
�"h 4er r !JUL 2 0 2022.
CITY OF%AF iD
COMPANY: rAt 0 W hclr '8'UfiL.t31NG tom"A
PHONE: 163 —70 9 —6 S H 5 [By.
a�:J�
EMAIL: beY1�..c.r r '{ 1 q J rAa� L (.OM_
RE: MIT 5W A-Ip,nr cry" -_ w0ty T;�R� 1-n5, 21,�CX)z�3r)
(Site Address) (Permit Number)
(Project name or subdivision name and lot number)
ATTACHED ARE THE FOLLOWING ITEMS:
Copies: Description: Copies: Descri tion:
Additional set(s)of plans. Revisions:
Cross section(s)and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
Beam calculations. Engineer's calculations.
Other(explain):
REMARKS: 1: a0+ct c.W k'}4i✓ w A 4v c.&- (7 h 5 e 1 CC Y Ga
AJ nn J41 c� na rwn,1-S
FQR OIFFICE USE ONLY
Routed to Permit Technici Dat ZZ Initials:
Fees Due: Yes Tee Description: Amount Due:
$
$
Special
Instructions:
Reprint Permit(per PE): Yes No Don
Applicant Notified: Date: -- Initials:
Property Owner Statement
Regarding Construction Responsibilities
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
❑ I 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.
!��k ��V I/,--
Print Name of Per i plicant
Si ature of Permit App ant Date
Permit#: _. F
Address:
t:
F:
YI'
Issued by: Date:
This Copy for Permit Offices
F
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