Permit CITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit#: MST2023-00146
Date Issued: 05/25/2023
T L C ARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S 104AD00300
Jurisdiction: Tigard
Site address: 12775 SW MARIE CT
Subdivision: BELLWOOD Lot: 12
Project: Anderson
Project Description: Non-Habitable Accessory Structure w/toilet, lavatory and bar sink.WATER METER UPSIZE
REQUIRED.TRADE PERMITS TO BE PULLED SEPARATELY.
BUILDING
Floor Areas Required Setbacks Required _
Stories: 1 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 15 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 15 Smoke
Dwelling Units: 0 Third: 0 sf Right: 5 Detectors:
Total: 0 sf Value: $30,000.00 Rear: 5
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 1 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 Catch Basins: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Bckflw Prevntr: 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: 0
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: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
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:
NEW SF VB U 0
Owner: Contractor:
ANDERSON,JAIMI S&SPENCER D OWNER Required Items and Reports(Conditions)
12775 SW MARIE CT
TIGARD,OR 97223
PHONE: PHONE:
FAX:
Total Fees: $1,120.22
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. ATTENTI : Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
ag9_nn1_nnln thrn,,nh(1 Qr,9_ _ma nil maw n in 7 rnn,oft a r,,in nr riirart n iactinne to('U INC!Yw, Iiinn ring 1Q317 nr 1 Rnn 119 9144
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
ResidentialRECEIVFF
FOR OFFICE 1 SE O\1.1
City of Tigard Received y// r/� %//
13125 SW Hall Blvd.,Tigard,OR kf ?"t Date/By:
{{ 9 Plan Review I
' a Phone: 503.718.2439 Fax: 503.598. 60 z Date/By: Gj / , Other Permit:
T I G +I:D Inspection Line: 503.639.4175 !^� r . Date Ready/By:` /� luris: ® See Page 2 for
Internet: www.tigard-or.gov CITY't° r 13 Notified/Method: '2q'2d'L3 fV� Supplemental Information
BUILDING,G, LiTil.°' :' , i'vICkAM.c pfinceir
TYPE OF WORK . RIMMED DATA..I-AND I.-FAMILY DWELLING
/El,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
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
ORY OF CONS RUj. work indicated on this application.
❑ 1-and 2-family dwelling 0 Commercial/industrial Valuation: $ tj
3 / O
Accessory building 0 Multi-family Number of bedrooms:
❑Master builder 0 Other: Number of bathrooms:
JOB inv RMA'TION AND'L 1noN Total number of floors:
Job site address: New dwelling area: square feet
City/State/ZIP: ` z') s•v'j Ma tr 1 c_-i-. "-c--16 1i 1 1 c C -')zi3 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: NeW 'etuchQ�S he.✓ Covered porch area: square feet
Cross street/directions to job site: i ZY�h Cu-1 c. - •c&r •t`_ CA— Deck area: square feet
a"� \i t a I I(1 kiii-4-- Other structure area: square feet
DATA: : QA�CHECKLIST
Subdivision: jZ PI 1 v.CO cl Lot no.: \2 Permit fees*are based on the value of the work performed.
Tax map/parcel no.:'BP,
)0‘.._ i 5 A p-, r<y I D Indicate the value(rounded to the nearest dollar)of all
Q 2�1 ?„� equipment,materials,labor,overhead,and the profit for the
' c Otf work indicated on this application.
t,v`" Valuation: $
Nlp n \ .r%';-i~•-b1•p.-bc- ha-La Existing building area: square feet
Wi[ e r &T&fL ups =itz_ea,N New building area: square feet
a� r
OWNERss .u_M . ., , •., u� . .. '. �- s. • s Number of stories:
Name: S.t y-� x-- s�11 a_ ,..�C'.C.l �.
�`.�, p�q rn) ��r yam(� Type of construction:
Address: i Z -i S i1v t -11a,r 1 t. L
t"- Occupancy groups:
-t-� City/State/ZIP: 1
,fit ( 1 (�y Gl l'� 1 L 1 7 Z Z 3 Existing:
Phone:( 1 7 I 3 �.J ( ( )
•
Z Fax.. . New:
„AFPI YCA+i ,v C A,‘"i_ 'N, `" II ILDING PERMIT FEES*
CS Business name: Ot+til4tr
Contact name: or)
Structural plan review fee(or deposit):
ex)
Address:
cs� . FLS plan review fee(if applicable):
City/State/ZIP: 1 G�Y 1r_ Total fees due upon application:
o ' . 1 NZ.. '1 ZZ3
0. Phone:((.i 71) 3 - _(00 y ) Fax::( ) Amount received:
•
E-mail: m l I. C r PHOTOVOLTAICSOLAR PANEL SYSTEM FEES*
L. 'L '�C�CG�� C yip
CO CTflIC Commercial and residential prescriptive installation of
_ _ roof-top mounted PhotoVoltaic Solar Panel System.
3
Business name: A/_ .4 - Submit two(2)sets of roof plan with connection details
_ ��1���. and fire department access,along with the 2010 Oregon
• Q Address: Solar Installation Specialty Code checklist.
0
. " City/State/ZIP: Permit Fee(includes plan review
and administrative fees): $180.00
- Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60
o) d CCB lic.:
Total fee due upon application: $201.60
Authorized signature: � _ This permit application expires if a permit is not obtained
L within 180 days after it has been accepted as complete.
Print name: G ' � f- Date: - l ~..2.....S
*Fee methodology set by Tri-County Building Industry
r
7P �f�^ )
✓� I:\Building\Permits\BUP-RESPetmitApp.doc 01/25/2023 440-4613T(11/02/COM/WEB) Service Board.
'1`
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE 1.SE OM
City of Tigard Received Permit No.:
Date/By:
1114 ill 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 0 Plumbing ❑ Mechanical
T I G A R D Internet: www.tigard-or.gov ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRE I) FOR PLAN REVIEW l" No "./.t
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. 0 I •
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. 0 0 0
3 Verification of approved plat/lot. 0 0 0
4 Fire district approval required. Name of district: . 0 0 0
5 Septic system permit or authorization for remodel. Existing system capacity 0 0 0
0 0 0
6 Sewer permit. 0 0 0
7 Water district approval. 0 El 0
8 Soils report. Must carry original applicable stamp and signature on file or with application.
9 Erosion control 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 0
basin protection,etc. 0 0 0
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 ❑ ❑ 0
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. ❑ 0 0
12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size
and location. 0 0 0
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- 0 0 0
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. 0 0 0
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- 0 0 0
prescriptive path analysis provide specifications and calculations to engineering standards. 0 0 0
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 0 0 0
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 ❑ ❑ 0
over 10 feet long and/or any beam/joist carrying a non-uniform load. 0 0 0
20 Manufactured floor/roof truss design details.
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required 0 0 0
for four or more appliances. El El 0
22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or
architect licensed in Ore on and shall be shown to be a licable to the ro'ect under review.
23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". ❑❑ ❑❑ 0
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 plans will not be accepted. 0 0 ❑
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 0 0 0
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 0 0 0
and protection measures must be drawn to scale and must include the project arborist's signature of approval. 0 0 El
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-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Plumbing Permit Applicatio
Building Fixtures .. F<liz t>FFici usu: Oy1.1
City of Tigard / f t -7 Received
Date/By: Permit No.: 6 Q�ue'1 cya1\f(
13125 SW Hall Blvd.,Tigard,OR 97223 I a`4 J W l�('
Phone: 503.718.2439 Fax: 503.598 '.! '" f Plan Review
Inspection Line: 503.639.4175 - �i�� i V I�YI '� Date/By:Re
Other Permit No.:
T I G A R D Internet: www.tigard-or.gov Date Ready/By: Juris: gi See Page 2 for
Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
0 New construction ❑Demolition For special information use checklist
Description I Qty. Ea. I Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
❑ 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
❑Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION, Site utilities:
Job site address: ,.D.."-)--7 ai r1 c.A. Catch basin or area drainDrywe 18.76
O�2 O-7 n.2- 2 Footing
1,leach line,or trench drain 18.76
City/State/ZIP: !�
g
Footing drain(no.linear ft.: ) Pa e 2
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector ' 18,76
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
Ai
DESCRIPTION OF WORK Backwater valve 12.51
p �, _ \ l b 1�S Clothes washer 25.02
/ l Y�D� • 'R -}-0 {..2/ Dishwasher 25.02
`'LV Ap?� - S-s t tT\ Drinking fountain 25.02
t litiV t r V`VtJ , Ejectors/sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
A PLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
C Primer 12.51
G7
Contact name: ,- -p.CM
Roof drain(commercial) 12.51
Address: `") 11 S s \Lr Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:(Gl-to ?022 bit t Fax: :( ) Tub/shower/shower pan 12.51
E-mail:
Urinal 25.02
� � cory-\ Water closet
CONTRACTOR 25.02
Water heater 37.52
Business name:
Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50
CCB Lic.: Plan review (25%of permit fee)
Plumbing Lic.no.:
State surcharge(12%of permit fee)
Authorized signatur : �� TOTAL PERMIT FEE
Print name: SA,' ,CY` Di d-✓ Date: -.2_5- 3 This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
1:\Building\Permits\PLMU-PermitApp.doc 10/01/09 4404616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee:
Footing drain-15f 100' 50.03 0 to 2,000 $121.90
Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer-1st 100' 62.54 7,201 and greater $327.54
Sewer-each additional 100' 37.52
Water Service-1st 100' 62.54 Medical Gas Systems:
Water Service-each additional 100' 37.52 Valuation: Permit Fee:
Storm&Rain Drain-1st 100' 62.54 $1.00 to$5,000.00 Minimum fee$72.50
Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other Inspections or Fees
Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
and including$10,000.00.
Inspection of existing plumbing or for $10,001.00 to$25,000.00 S148.50 for the first$10,000.00 and$1.54 for
which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to
(minimum charge-1/2 hour) and including$25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to
Reinspection Fees 90.00/hr and including$50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
each additional$100.00 or fraction thereof.
(minimum charge-1/2 hour)
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
❑ Any new commercial building with water service 2"and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower engineer.
-Jacuzzi/Whirlpool ❑ New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Thru
❑ Medical gas and vacuum systems for health care facilities.
Cuspidor/Water Aspirator
Dishwasher: -Commercial 0 Any multipurpose El Any
sprinkler system.
Any complex structure as defined in OAR918-780-0040.
-Domestic
Drinking Fountain Submit 2 sets of plans with any of the above.
Eye Wash
Floor Drain/sink: -2"
3„ Isometric or Riser Diagram
4" 0 Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -LavBar non-food related
-Bradley
-Com/Serv/Util food related
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewer increase must be paid before the
Water Extractor plumbing permit can be issued.
Water Closet-Toilet
Urinal
Other Fixtures:
I:\Building\Permits\PLMF PermitApp.doc 08/04/2011 2
City of Tigard
114 Ill C
COMMUNITY DEVELOPMENT DEPARTMENT
Building Permit Review - Residential
TIGARD
Building Permit #: i /I/t S7�� `•�OO/�� t'
Site Address: 1Z 7 J , ri e-- (,T L r r'
,_ 7 e ified in Accela
Project Name: '"\Y\&Q S (') n S\.C,\ Lot/Unit #: ex
-S(include housing type): N Q-'-% S\ 4--t%.C' Zone: S ' 5
Required Site Plan Elements:
3 s of site plan on max 11x17' . . _ __.
C Drawn to standard scare—) stained trees, drip line/tre ctiort
lth arrow \Ti '.treet and site trees shown / labeled
fit ddress, project name, lot # bl sting tree canopy at maturity
et-nafftes---...-. - (N/ )
li me-a�.i-Nhfn�_' urtyard rectangle dimensioned (if applicable)
of and setback dimensinns l ision clearance triangle
EirEj.i.sting structures & square foots e }�i ity locati.ons.&E sements
li rlt_.of_-newstructu.re a t'PrQtzP y corner elevations i
i walk di ❑ LIDA (>1,000 sf disturbance)
ILot area an lot coverage percentages 0 Erosion control
Required Elevation Plan Elements:
(For SF : calcs-rnccdccl. on street-facing) ge doors dimensions
rawn t Sumn table &i calculations for:
U 'Building height dimensioned 0 Total f ' t-area.,
❑ e dimen ' D T window and door
❑ Win an doo>'Szf' ia[ied Total garage area
Require Floor Plan Elements: E mmary table that includes
h story dimensioned Cfotal floor area
I tach story floor area calculated D4loor area per story
Planning Review
The following standardshave been met:
L9 Setbacks 'Fr tt: IS Rear: (--'5) Side: 5 Min/Max Street Side: 'NII -A Garage: I A\
Heightig Max. Height: 15 Proposed Height: i1 II
2'Yes 0 N/A Landscape
❑ Yes I-(crfA Screening (Quad only)
❑ Yes EI-Id7A % Window Coverage
O Yes El-f —Garage (SFR Only)
Parking (Other Res)
❑ Yes D-Nrk Entrance (SFR, Rowhouse, Quad only)
❑ Y,�s LO-41 A Other building design standards (Rowhouse only)
R'Ves 0 N/A Accessory Structure Standards
dlards-(Cottage unit only)
Additional standards for Courtyard Units, Cottage Clusters, Rowhouses, and Quads:
Yes 0 N/A Unit Count: _......_.
❑ Ye A Lot Width and Size ,_
❑ Yes 0 N/A `Pat okay ......._-
Additional standards for yrdtt is and Cottage Clusters only:
❑ Yes ❑ N/A Unit Area
❑ Yes ❑ N/A F Area (per story)
❑ Yes 0 N/A Courtyard
O Yes 0 N/A Fence
❑ Yes 0 No @f�/ Clean Water Services - Service Provider Letter (lot platted prior to 9/10/1995)
❑ Yes 0 No CiN/A Public Facilities Improvement (PFI) Permit:
Required: 0 Yes 0 No
Applied For: ❑ Yes 0 Ntop intake
❑ Sensitive Lands: Yes or-"No
`
❑ Land Use Case #: 1\t I` ❑ Conditions met prior permit issuance
Approved By Planning: J • 1\l , &I A yN i S Date: CI I I 113
Notes
Revision 1: 0 Approved 0 Not Approved Date:
Revision 2: 0 Approved 0 Not Approved Date:
Building Permit Submittal //
Original Submittal Date: y((7/)--3
Site Plans #: 3
Building Plans #: 3
Building Permit #: in-Building permit # entered on page 1
Workflow Routing: '❑-Planning Engineering hermit Coordinator,.--0 Building
Workflow Sign-off: -Sign-off for Planning (include notes from planning review)
Route Documents: AEI-Engineering: (1) copy of permit application, (1) site plan, (1) building plan
and original plan review routing form.
Building: original permit application, site plans, building plans, engineer and
beam ca culations and trust details, if applicable, etc.
/0441- 4/119:
Permit Technician: // 1",/: Date:
Notes:
Engineering Review
1"PFI Permit: n'A.
Id Slope at building pad: 1% oh
VConditions met prior to issuance of permit
CirEasements (encroachments) per engineering conditions of approval and plat
"Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: 0 Yes ®'No
Assess Water Quantity Fee in-lieu: 0 Yes eNo
LIDA Facility on lot: ❑ Yes C'No Add Fee: 0 Yes 0 No
"Final Plat Recorded Aid-
0 NOT Approved: Date:
Notes:
Approved By Engineering: T f /3rth° ( Date: 41/1-4/Zo2.3
Revision 1: ❑ Approved 0 Not Approved Date:
Revision 2: 0 Approved ❑ Not Approved Date:
Permit Coordinator Review
❑ Conditions met prior to permit issuance
❑ Approved, NOT Released: Date notified applicant:
❑ ENG Revisions Required: Date notified applicant:
SDC Exemption: 0 Applied for 0 Received (Does not apply
4 /SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes N/A
Tigard Trans SDC: ❑ Yes N/A ❑ Deferred
Parks SDC: ❑ Yes N/A ❑ Deferred
LIDA ❑ Yes jN, (�/�A1
AOK to Issue/Approved by Permit Coordinator: <2.bV00\ "' Date: 1 . 7, 1: ..5
Revision 1: ❑ Approved ❑ Not Approved Date:
Revision 2: 0 Approved 0 Not Approved Date:
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.
Print N e f Permit Applicant
ignature of Permit Applicant Date
Permit#:
Address:
f it11�7 i .'f
f 1f j f
Issued by: Date:
This Copy for Permit Offices
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
http://www.oregon.gov/DOR/BUS/dots/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
Water Meter Fixture Unit Worksheet for Additions/Remodels/ADUs
Please complete the following information:
Customer Name: i 6_IJL.E. Ai pE-1e-Spr)
Service Address: Street/Suite#: ( 27 75 SW NIAP-(E_ L j1)1-r
City: T(G?/{t_D State: 0g_. Zip: /7343
Phone Number: ei"j j 3)4-- (,of I Email: . p¢,A1 C4j -A1 0 MAIL,, (—eM
Please fill in the number of each fixture you currently have. Please fill in the number of fixtures you propose to add.
Multiply the quantity by the point value to arrive at the current Multiply the quantity by the point value to arrive at
total. the proposed total.
Fixture Unit Current Point Current Proposed Point Proposed
Quantity Value Total Addition Value Total
Bar sink x 1 = I x 1 = f
Bidet x 1 = x I =
Clothes washer I x 4 = [{ x 4
Dishwasher ( x 1.5 = (,5- x 1.5 =
ll Outside Water Spigot I x 2.5 = 2.. Jr x 2.5 =
Water Spigot,each add'l a x 1 = g x I =
Kitchen sink ( x 1.5 = (,C x 1.5 =
Laundry sink ( x 1.5 = (, 7 x 1.5 =
Lavatory(bathroom sink) dl x I = t , x 1 =
Water closet. 1.6 GPF(toilet) 3 x 2.5 = 7,5' ( x 2.5 ,5-
Bathtub/whirlpool x 4 = x 4 =
Shower stall 2.. x 2 = y x 2 =
— —
Bath/shower combo ( x 4 = l x 4
Current Points: 31, 5 Proposed Increase: q,J5-
Current Points+Proposed Increase= 3 if
p 3� =New Total Points =Required Meter Size ��{
Meter Sizes: I to 30 points=5/8" 30.5 to 37 points=3/4" 37.5 and over points= 1"
/ I/
New Meter Size Needed for New Total Points: 3/ Cost: $ f 6, 0 / (see page 1)
Current Meter Size per Utility Billing: V`b Cost: $ I I Z 5 ' (see page 1)
New Meter Size Cost minus Current Meter Size Cost= $ y, 13 Z.
(This is Your Cost to Increase Meter Size Due to Additional Fixture Units)
*************************************************************************************
FOR OFFICE USE ONLY
Current Meter Size Confirmed with UB
D Rae 5/15/2023
Signature of UB Representative Date
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