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Permit (3) CITY OF TIGARD MASTER PERMIT of '`1 11 ' . COMMUNITY DEVELOPMENT j ' Date Issued: 06/05/2023 Permit#: MST2023-00183 4 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 ) 1 Parcel: 2S111 DB07100 �� '1 1 Jurisdiction: Tigard Site address: 15460 SW ALDERBROOK DR Subdivision: SUMMERFIELD NO.7 Lot: 390 Project: Pratt Project Description: Remodeling living room and kitchen.Not adding plumbing fixtures. 8/3/23: REPRINTED permit to add (1)hose bib and remove(1)duct work. BUILDING Floor Areas Required Setbacks Req uired Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left 0 Parking Spaces: 0 e: 0 sf Front; 0 Smoke 0 sf Garage: Height: 0 Bathrooms: 0 Second: g Dwelling Units: 0 Third: 0 sf Right; 0 Detectors: Total: 0 sf Value: $25,000.00 Rear: 0 PLUMBING Sinks: 1 Water Closets: 0 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 0 Tubs/Showers: 0 Garbage Disp: 1 Water Heaters: 1 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 1 Hose Bib: 2 Backwater Value; 0 Other Fixtures: 0 Drywell-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 1 Heat Pump: N Hoods: 1 Other Units: 1 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp SrvclFeeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0 Ea add.'500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 12 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 N SecurityAlarm: N Vaccuum S N Garage Opener: N All N Audio&Stereo: N HVAC: System: 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 0 Owner: Contractor: PRATT,BERNARD DOUGLAS JR TRUSTOWNER Required Items and Reports(Conditions) 15460 SW ALDERBROOK DR TIGARD,OR 97224 PHONE: PHONE: FAX: Total Fees: $1,289.91 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:rR Oregon requires you to fo les adopted byl they Oregonn II FUtimo^ittyl1 Notinn iicatio'n,Center. RrT/i - rules are set forth in OAR c14 i in 49 l'r , Issued By:y, -��'Y Permittee Signature: i � Ca .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 o' e project. Approved plans are required on the job site at the time of each inspection. CITY OF TIGARD MASTER PERMIT ` 1 - . COMMUNITY DEVELOPMENT Permit#: MST2023-00183 Date Issued: 06/05/2023 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S111 DB07100 Jurisdiction: Tigard Site address: 15460 SW ALDERBROOK DR Subdivision: SUMMERFIELD NO.7 Lot: 390 Project: Pratt Project Description: Remodeling living room and kitchen. Not adding plumbing fixtures. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 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: 0 sf Value: $25,000.00 Rear: 0 PLUMBING Sinks: 1 Water Closets: 0 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 0 Tubs/Showers: 0 Garbage Disp: 1 Water Heaters: 1 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 1 Hose Bib: 1 Backwater Value: 0 Other Fixtures: 0 Drywell-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 1 Heat Pump: N Hoods: 1 Other Units: 2 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp SrvcIFeeders 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: 12 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 0 Owner: Contractor: PRATT,BERNARD DOUGLAS JR TRUSTOWNER Required Items and Reports(Conditions) 15460 SW ALDERBROOK DR TIGARD,OR 97224 PHONE: PHONE: FAX: Total Fees: $1,288.01 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 Notfication Center. T rules ar set forth in OAR QS9-nn1-n(11n thrni inh fIAR Qc,9-M1-nnQn Vni i mw n nv of tha rnlac nr rlirart nnactinne to(ll imr..by rollinn Z 919 1oR7 4 1 R( 4. 9 Issued BY: Permittee Signature: 0 ki 1/ all 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 o e project. Approved plans are required on the job site at the time of each inspection. Building Permit Application Residential FOR OFFICE FSE O\I 1 City of Tigard RECEIVE ReceivedDat /`// 2 S p �o]� U� l 3 13125 SW Hall Blvd.,Tigard,OR 97223 A a t'' , ; Plan Reviey. - 7 - (� ■ 1`�h• 4 4 a` /!c 2 Other Permit: Phone: 503.718.2439 Fax: 503.598.1960 DateBy: t �` } Inspection Line: 503.639.4175 Date Ready/By: / ]uris: H See Page 2 for Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: �/ J A. Supplemental Information BUILDING DIVISION .t.:-1,u TYPE OF WORK REQUIRED DATA: 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 ryi Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the CATEGORY OF CONS UC—ON , , work indicated on this application. Valuation: $ ;,I 5 Q 0 0, Q D j<1-and 2-family dwelling 0 Commercial/industrial f/r I ❑Accessory building 0 Multi-family Number of bedrooms: ❑Master builder 0 Other: Number of bathrooms: JOS SITE INFORMATION R LOCATION Total number of floors: l Job site address: I 0 S.W. A I dq. ri a 3dew�dwelling area: square feet City/State/ZIP:.-r;c,and / 0 rta 1 V Garage/carport area. square feet Suite/bldg./apt.no.:►��'!I Proj ame: Covered porch area: square feet Crossr street/directions to job site: Deck area: square feet $•1G�. A tClertDrOD >j c r 4 ()V'`ve, Other structure area: square feet REQUIRED DATA:COMMERCIAL-USE UIIt CKLIST Subdivision: Lot no.: Permit fees*are based on the value of the work performed. Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the A t DESCRIPTION OF WORK work indicated on this application. geozott i v 1I oo I• ' i IL.�� Valuation: $ Existing building area: square feet New building area: square feet � PROPERTY OWNER 0 TENANT Number of stories: f 91?),S1Name: )0 i lel --r Type of construction: Address: p. , Occupancy groups: City/State/ZIP: jp i- Existing: Phone:(SO $C q- _.1 ' Fax:( ) New: El APPLICANT 0 CONTACT PERSON BUI DING PERMIT ICES* (Please refer to feeschatut0 Business name: Structural plan review fee(or deposit): Contact name: FLS plan review fee(if applicable): Address: City/State/ZIP: Total fees due upon application: Phone:( ) Fax::( ) Amount received: E-mail: D �ef YL t B ce �"I h r C . c a•�l el PHOTOVOLTAIC SOLAR PANEL SYSTEM'FI�ES* Commercial and residential prescriptive installation of CUsInG COI2" roof-top mounted PhotoVoltaic Solar Panel System. Business name: 6.7�pi etSubmit 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: and administrative fees): $180.00 Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60 CCB tic.: Total fee due upon application: $201.60 Authorized si ature:D, p ��. This permit application expires if a permit is not obtained ttt / / within 180 days after it has been accepted as complete. Print nam . 4 41111_c ,.�./a // Date:/4/ 00.3 *Fee methodology set by Tri-County Building Industry L Service Board. I:\Building\Permits\B/RESPennitApp doe 02/ 4/2011 440-4613T(11/02/COM/WEB) Mechanical Permit Application FOR OFI ICH: l'SE Ovl,' City of Tigard Received Permit No.:/14 yr UPI13125 SW Hall Blvd.,Tigard OR 97223 Date/By: / �t7---0 c7�g Plan Review Phone: 503.718.2439 Fax: 503.598.1960 DateBy: Other Permit: i i t_A R P Inspection Line: 503.639.4175 Date Read B Juris: 2 Internet: www.ti and-or. ov y y' S See Page l for g g Notified/Method: Supplemental Information TYPE OF WORK COMMERCIAL FEE*SCHEDULE—1/SE CHECKLIST Mechanical permit fees*are based on the value of the work ❑New construction Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all ❑Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit. Value:$ CATEGORY OF CONS'tR1JtTIUN RESI1 EN11ALEta1JIPT4fENTISYSTE1tit�3FEES* , 01.1-and 2-family dwelling ❑Commercial/industrial 0 Accessory building For special information use checklist. ❑Multi-family 0 Master builder ❑Other: Description Qty. Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning 46.75 Job site address: 1546 0 S,W I ld r r ak ,�y'( Furnace 100,000 BTU(ducts/vents) 46.75 City/State/ZIP: -'l /,fmj1 ( O`(' - ' � Furnace 100,000+BTU(ducts/vents) 54.91 �I 1!/t Heat pump 61.06 Suite/bldg./apt.no.: 'J Projec e: Duct work 02_ 23.32 Cross street/directions to job site: I Hydronic hot water system 23.32 •'A Residential boiler(radiator or 54). AI6r19`©cl.Orcue �o� f ek1 Prce hydronic) 23.32 Unit heaters(fuel-type,not electric), in-wall,in-duct,suspended,etc. 46.75 Flue/vent for any of above 23.32 Subdivision: Lot no.: Other: 23.32 Other fuel appliances: Tax map/parcel no.: Water heater 23.32 3E CRIPTION of R'OIiK Gas fireplace/insert 33.39 Flue vent for water heater or gas pff-ii,fa, fireplace 23.32 • ict g nw tr �► Log lighted/pell (gas) 33.39 /r G 't ! Wood/pellet stove 33.39 A'-S 6 vi t!l e'l o fir v s P Wood fireplace/insert 23.32 a �e Chimney/liner/flue/vent 23.32 Other: 23.32 PRO'ERTI OWNER ❑ NANT Environmental exhaust and ventilation: Name: IF/ `��- Range hood/other kitchen i 33.39 . L equipment Address: w/� Clothes dryer exhaust I 33.39 City/State/ZIP: W„e w/" i ©rce -1�--M`1,., r� Single-duct exhaust(bathrooms, �"'C� toilet compartments,utility rooms) 23.32 Phone:66 ger�`' `lz3,Sf lax:( ) Attic/crawlspace fans 23.32 0 APPLICANT a CONTACT PERSON Other: 23.32 Fuel piping: Business name: — $14.15 for first four;$4.03 for each additional Contact name: Furnace,etc. Gas heat pump Address: Wall/suspended/unit heater City/State/ZIP: Water heater Phone:( ) Fax::( ) Fireplace Range E-mail: Barbecue CON tRACTOR Clothes dryer(gas) Other: Business name: — . DGt/1,,1 r.„,.., mFE AI ICAL pl l trr FEES* Address: Subtotal City/State/ZIP: Minimum permit fee($90.00) Plan review(25%of permit fee) Phone:( ) Fax:( ) 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: / Tr'. , 0 3 * Fee methodology set by Tri-County Building Industry Service Board Print name: O,,a i r ,�� Date: �. 4-2 a) L\Building\Permits\MEC_Pe pp_040113.doe 440-461TT(11/02/COM/WEB) Electrical Permit Application FOR OEFicE 1 sE O:y1I City of Tigard DateBe: Per> !' 'ao?-77 — 00 / .& 1111 • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review ■ Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Related Permit#: Inspection Line: 503.639.4175 Ready Date/By: Juris: H See Page 2 for 1 I t ,\R D Internet: www.tigard-or.gov Notified/Method: Supplemental Information TYPE OF WORK PLAN.REVIEW ❑New constructionAddition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked): ❑Service or feeder 400 amps or more ❑Building over three stories. ❑Demolition 0 Other: where the available fault current 0 Marinas and boatyards. CATEGORY-OF CONSTRUCTIO1I,., exceeds 10,000 amps at 150 volts or ❑Floating buildings. g 1-and 2-family dwelling ElCommercial/industrial ❑Accessory building less to ground or exceeds 14,000 0 Commercial-use agricultural amps for all other installations. buildings. ❑Multi-family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or JOB'MR INFORMATION AND LOCATION 0 Emergency system. larger separately derived Job#: Job site address:15460 S' A brook 0,• ❑Addition of new motor load of system.A ��V IOOHP or more. ❑"A","E","I-2","1-3", City/State/ZIP: r1 R ❑Six or more residential units. occupancy. �� ) V T ell ❑Health-care facilities. 0 Recreational vehicle parks. Suite/bldg./apt.#: � Projec4jJa"e: ❑Hazardous locations. 0 Supply voltage for more than ❑Service or feeder 600 amps or more. 600 volts nominal. Cross street/directions to job site: / 1rcve.. FEE SCHEDULE S'L` er IACOD, /+ c l o1eilOif Description I Qtyi Each TotalllI r1V1V"_- 1V\ New residential single-or multi-family dwelling unit. Subdivision: Lot#: Includes attached garage. 1,000 sq.ft.or less 168.54 4 Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 33.92 1 DESCRIPTION OF'WORE Limited energy,residential k ,e^octet, e.. ��l,� 1 ``,try ��y yA (with above sq. lti 75.00 2 Itr/RW` /1! �/ t V , W v 1 Limited energy,multi-family Jresidential(with above sq.ft.) 75.00 2 Renewable Energy 0 See Page 2 Itiic:PROPERT'!' 0 ++++��^^^^ El TENANT Services or feeders installation,alteration,and/or relocation Name: sleW Tiilr 200 amps or less 100.70 2 * t 201 amps to 400 amps 133.56 2 Address: V 16 r_ 401 amps to 600 amps 200.34 2 City/State/ZIP: i cite S 1 O �J - 601 amps to 1,000 amps 301.04 2 Phone:6 Fax:( ) Over 1,000 amps or volts 552.26 2 �� Temporary services or feeders installation,alteration,and/or Email: abe��(e i. C j \ relocation Owner i allation:This installation i be' g made on property that I own which is not 200 amps or less 59.36 1 intended for sale,le ,rent,ore Chang , or i to ORS 447,449,670,an 701. 201 amps to 400 amps 125.08 2 Owner signature: Date: 401 amps to 599 amps 168.54 2 0 API'Li ❑ CONTACT PERSON Branch circuits—new,alteration,or extension,per panel A.Fee for branch circuits with Business name: above service or feeder fee, each branch circuit 1 7.42 " Contact name: B.Fee for branch circuits without Address: service or feeder fee,first 56.18 2 branch circuit City/State/ZIP: Each add'1 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 Email: Reconnect only 67.84 2 CONTRACTOR Pump or irrigation circle 67.84 2 Business name:Ucr.4,1 t47- Sign or outline lighting 67.84 2 Address: Signal circuit(s)or limited-energy ❑ See Page 2 2 panel,alteration,or extension. City/State/ZIP: Each additional inspection over allowable in any of the above Additional inspection(I hr min) 66.25/hr Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr Email: Industrial plant(1 hr min) 78.18/hr Inspections for which no fee is 90.00/hr CCB Lic.: Electrical Lic.: Suprv.Lic.: specifically listed(/2 hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: Subtotal: Print name: Date: 0 Plan Review Required(25%of permit fee): A `'� State surcharge(12%of permit fee): Authorized si ture: D 0, /'r V v TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 Print name: �� / �/ �� Date:S '�" l . days after it has been accepted as complete. L * Number of inspections allowed per permit. I:�Building\Permits\ELC_Permit•pp_:LR_ERE.doe Rev 06/17/201 440-4615T(11/05/COM/WEB Plumbing Permit Application Building Fixtures FOR OFFICE 1 SI. ()Nil City of Tigard Received � ,, g Date/By: Perm '`"�r/r-O� '-0 13 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit No.: T 11,A R D Inspection Line: 503.639.4175 Date Ready/By: Juris H See Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information `1E YPE OF W{1«I FEE*SCHEDULE ❑New construction ❑Demolition For special information use checklist Description Qty. 1 Ea. Total f Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OFCONSIIIII ON SFR(1)bath 312.70 pt1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78 El Accessory buildingSFR(3)bath 500.32 ❑Multi-family Each additional bath/kitchen 25.02 ❑Master builder 0 Other: Fire sprinkler( sq.It.) Page 2 J011 SITE INFORMATION AND LOCATION Site utilities: 1 544,0/ /1 5e f e ►, t / cow_ �,/ Catch basin or area drain 18.76 Job site address: •.r(�V u/ lA��/ r • City/State/ZIP: `� V•� �� Drywell,leach line,or trench drain 18.76 l!• Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.• Project name: Manufactured home utilities 50.03 Cross street/directions to job ite: G Manholes 18.76 S,i, , A �$ 110 (::'( J�(h Y1/1`.,�1w \,1[9 Rain drain connector 18.76 `'�` ' ►�/ /)rt v v Sanitary sewer(no.linear ft.: ) Page 2 Storm sewer(no.linear ft.: ) Page 2 Water service(no.linear ft.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 D1 SCRI1PTION-O Backwater valve 12.51 Clothes washer 25.02 R �}�.Gl.� �'r Dishwasher I• 25.02 e(o K`f ` iti,vt r 0 . Drinking fountain 25.02 Ejectors/sump 25.02 PROPERTY. O It © TENANT Expansion tank 12.51 Name: Dow'ta S ! $ r ,Tr Fixture/sewer cap 25.02 i Floor drain/floor sink/hub 25.02 Address: [Td Garbage disposal , 25.02 City/State/ZIP: C 1 l 1 1--C�6 Hose bib 25.02 Phone:( 0 .-b` Fax:1( ) 1 Ice maker I 12.51 vv IJ APPLICANT ❑ CONTACT PERSON - Interceptor/grease trap 25.02 Business name: Medical gas(value:$ ) Page 2 Primer 12.51 Contact name: Roof drain(commercial) 12.51 Address: Sink/basin/lavatory r 25.02 City/State/ZIP: Solar units(potable water) 62.54 Phone:( ) Fax::( ) Tub/shower/shower pan 12.51 E-mail: Urinal 25.02 Water closet 25.02 Water heater F 37.52 Business name: /,,le, r„� t� �l Water piping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal Phone:( ) Fax:( ) Minimum permit fee: $72.50 CCB Lic.: lambing Lic.no.: Plan review (25%of permit fee) State surcharge(12°/u of permit fee) Authorized s.+ attire: TOTAL PERMIT FEE Print nam•:1 `e: / Date:5�1 z� This permit application expires if a permit is not obtained within 180 days ►- l J lI after it has been accepted as complete. i *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\PL 6 'ermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB) 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. EDPlease check the appropriate box: i 4,,_ I own, reside in, or will reside in the completed structure and my general contractor is: BU{�®F/ ' 8N 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`X 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. 6) I V PrZid \3 r - Print Na e o Permit .It•Iicant rjj • po it, f i 1 \ID .iii, )1 si..4_02 .5 Signature • Permit Applicant Date Permit#: cl,5T 0, -3 (A)Ur) •7�.� Address: / �C) � vgd0,211 / ,.- s �� • /• S rho,' ;: . 7-- :.,„,r cie- 1-0)-41 . • Issued by: 4 Date: t f57'4 04 This Copy for Permit Offices ' t>., 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, call 503-945-8091 or go to htto://www.oregon.gov/DOR/BUS/docs/211-055.pdf for the appropriate forms. • 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 503-947-7815. • 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, call the IRS at 1-800-829-4933 or visit their website at 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 9-23-08 This Copy for Permit Applicant