Permit (2) it. , CITY OF TIGARD MASTER PERMIT
I. . COMMUNITY DEVELOPMENT Permit#: MST2023-00089
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 05/31/2023
Parcel: 2S111 AC04800
Jurisdiction: Tigard
Site address: 14855 SW 92ND AVE
Subdivision: LAUNALYNDA PARK Lot: 16
Project: Lewis
Project Description: Adding 432 sq ft for home office,family room, and storage.Trade permits to be pulled separately.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 0 First: 432 sf Basement: 0
sf Left: 5 Parking Spaces: 0
Height: 12 Bathrooms: 0 Second: 0
sf Garage: 0 sf Front: 15 Smoke
Dwelling Units: 0 Third: 0 sf
Right: 5 Detectors:
Total: 432 sf Value: $65,175.84 Rear: 15
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 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!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:
ALT SF VB R-3 432
Owner: Contractor:
LEWIS,NICHOLAS D&ABIGAIL ANNE ORIVERLAND HOMES INC Required Items and Reports(Conditions)
14855 SW 92ND AVE PO BOX 2432
TIGARD,OR 97224 LAKE OSWEGO,OR 97035
PHONE: PHONE: 503719-5524
FAX:
Total Fees: $3,234.37
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 are set forth in OAR
oc9-nn1-nnin thrni,nh(1AP Qc ..nnl-nnon Yn,,maw nhtain a nw n a'lilac nr rlirart n„actinnc fn(fi INC.FA/Tallinn ring 929 10R7 nr 1 Ann 2 9244. '
Issued By: � C Gf PBrmittee Signature: /� (
7"' . 1. .639.4175 by 7:00 a.m.for the next available inspection d�te. `�
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 c7NLt
City of Tigard Received /
q DateB : /�m iiAl I __ '-//D,
w 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review /
Phone: 503.718.2439 Fax: 503.598.196P�, -„ -'4( !,t DateB : �� Other Permit-
".I c,A i,t) Inspection Line: 503.639.4175 i ',Jr Date Ready/B : Juris
` g± r��y► 81 See Page 2 for
Internet: www.tigard-or.gov ! r.EFJ� 9.1FJ S O Notified/Method: Supplemental Information
BN
❑New construction ❑Demolition Permit fees*are based on the value of the work performed
Indicate the value(rounded to the nearest dollar)of all •
4 Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
� r' € ss` work indicated on this application.
ix] 1-and 2-family dwelling ❑Commercial/industrial Valuation: $. 6,4?g8'' ✓( l i
Number of bedrooms: 3 Existing-None added❑Accessory building ❑Multi-family
❑Master builder ID Other: Number of bathrooms: 2 Existing-None added
° ".4-.�,_ Q Total number of floors: 1 Existing
Job site address: 14855 SW 92nd Ave . New dwellingarea:(N)Added-432 square feet ''"`,""Ot(fGj"f`pT3F—tg4e'�. q i,.��o�d
City/State/ZIP: Tigard,OR 97224 Garage/carport area: .(E)-4Z.9.— square feet
Suite/bldg./apt.no.: Project name: Lewis Residence Addition Covered porch area: (E) 49— square feet
Cross street/directions to job site: Heidi Ct Deck area: N/A square feet
Other structure area: N/A square feet
,'it,',./,�t,'ilt e ► TA.;, t, t,,t , •w t'"i8': 1L:I� S€T.
Subdivision: "LAUNALYNDA PARK" Lot no.: LOT 16 m Permit fees*are based on the"value of the work performed.
Tax map/parcel no.: TX MAP-2 S1 11 AC/T.L.4800 R-500531 Indicate the value(rounded to the nearest dollar)of all
equipment,materials,labor,overhead,and theprofit for the
I ` •t tr• _ r 3 work indicated on this application.
432 Addition to(E)single family residence,to include a home office space,family room, Valuation: $
and storage.77 / �t //3 �/'� `14rdl Sr,/ 1a1-A Existing building area: square feet
New building area: square feet
, ' Number of stories:
Name: Nick&Abby Lewis Type of construction:
Address: 14855 SW 92nd Ave Occupancy groups:
City/State/ZIP: Tigard,OR 97224 Existing:
Phone:( 503 )319 2832 Fax:( ) New:
i '
Business name: Andrew Feldon Designer '
Structural plan review fee(or deposit):
Contact name: Andrew Feldon
FLS plan review fee(if applicable):
Address: 833 SE Main#102
City/State/ZIP: Portland,OR 97214 Total fees due upon application:
Phone:( 503 )451 3137 Fax::( ) Amount received:
0 S u i * „' ' T k'
E-mail: af@andrewfeldon.com l '�
Commercial and residential prescriptive installation r
is t` , roof-top mounted Photovoltaic Solar Panel System
Business name: Riverland Homes LLC. Submit two(2)sets of roof plan with connection
and fire department access,along with the 201f
Address: PO Box 2432 Solar Installation Specialty Code checklist.
City/State/ZIP: Lake Oswego,OR 97035 Permit Fee(includes plan review
and administrative fees):
Phone:( 503 )719 5524 Fax:( 503 )719 5526 State surcharge(12%of permit fi
CCB lie.: #56049
j: .,....PrAp.f.Atr--1—
Total fee due upon appli
Authorized signature: ciolorv--_ This permit application expir-
within 180 days after it h
Print name: Andrew Feldon Design Date: 3/13/23 *Fee methodology set by Tr
Service Board.
-\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613 T(1 1/02/COM/WEB)
Buildi.. , Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USE ONLY
City of Tigard Deceived
Permit No.:
13125 SW Hall Blvd.,Tigard,OR.97223 Y
Associated permits:
Phone: 503.718.2439 Fax: 503.598.1960
24-Hour Inspection Line: 503.639.4175 El Electrical 0 Plumbing 0 Mechanical
t t C;,i i.i> Internet: www.tigard-or.gov 0 Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No N/A
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ 0
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 El 0
6 Sewer permit. 0 0 0
7 Water district approval. 0 0 0
8 Soils report. Must carry original applicable stamp and signature on file or with application. 0 0 0
9 Erosion control 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 ❑ 0
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state 0 0 0
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 0 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.
12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size 0 0 ❑
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, 0 0 ❑
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 ❑
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 ❑ ❑
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 0 0 ❑
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.
20 Manufactured floor/roof truss design details. X❑ 0 0
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required 0 0 ❑
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 0 ❑ El
architect licensed in Ore on and shall be shown to be a licable to the ro'ect under review.
Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or,11"x 17". 0 ❑ El
Two(2)sets each are required for Items 16, 19,20 and 22 above. 0 0 ❑ .
`wilding plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 ❑ ❑
eversed"building plans must meet criteria outlined in the Permit&System Development Fees document. 0 ❑ 0
'm to scale"indicates standard architect or engineer scale. 0 ❑ ❑
to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard ❑ ❑ 0
e List.
include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, ❑ ❑
measures must be drawn to scale and must include the project arborist's signature of approval.
-vices'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, 0 0 ❑
in covers(over non-impervious surface)and accessory structures to existing residential dwellings
roved prior to September 9, 1995.
\pp.doc 02/24/2011 440-4613T(11/02/COM/WEB) •
City of Tigard
;111 COMMUNITY DEVELOPMENT DEPARTMENT
Building Permit Review - Residential
TIGARD �
Building Permit #: Art
//
/�)3
Site Address: ��tSc SW q`2�'( f _%verified in Accela
Project Name: 2.44lS 1,�1111 Lot/Unit #:
Proposal: c c Q hrArli bm Zone: s•F5 -B
Housing Type:tSFR( 'Single Detached ❑ Duplex El Triplex El ADU) 0 Rowhouse❑Cottage Cluster❑ CYU ❑Quad 0 Other
Required Site Plan Elements:
6J 3 copes of site plan on max 11x17"
(Drawn to standard scale Retained trees, drip line/ tree protection
,North arrow ,Street and site trees shown / labeled
'Site address, project name, lot # R e calculating tree canopy at maturity
de-Street names (N/A for SFR)
,zf Applicant name and phone # ur yard rectangle dimensioned (if applicable)
, lot and setback dimensions isluri Llearance triangle
Zxisting structures &square footage AN Utility locations &easements
i'Footprint of new structure and FFE .Property corner elevations
idewalk/driveway dimensioned ZJtfBAf>1,000 sf disturbance)
Lot area and lot coverage percentage ❑ Erosien control
Required Elevation Plan Elements:
(For S R: calcs needed only on street-facing) Summary table with calculations for:
Drawn to standard scale ❑ Total façade area
Building height dimensioned ❑ Total window and door area
.Facade dimensioned
Windows and doors dimensioned
0 Garage doors dimensioned
Required Floor Plan Elements:
(Not- wired for SFR) 0 Summary table that includes
❑ Each ' ensioned 0 Total floor area
❑ door area ca ❑ Floor area per story
Planning Review
The following standards have /
been�met:
Setbacks Ja'Front: IS Rear: 15 7 Side: J Min/Max Street Side: IS' / Garage:
Height 4lax. Height: SO Proposed Height: ILl coke.IIU-1) *patched km, 1S
,le Yes 0 WA Landscape 'WV (AMU , rmai < ve4 el
❑ YesA Screening (Quad only)
Yes El N/A % Window Coverage
❑ Yes P11/A Garage (SFR Only) Parking (Other Res) O.C tiwie
O Yes'N/A Entrance (SFR, Rowhouse, Quad only)
❑ Yes Ja'N/A Other building design standards (Rowhouse only)
❑ Yes17"N/A Accessory Structure Standards
❑ Yes4No Qualifying pre-existing unit exempt from standards (Cottage unit only)
Additional standards for Courtyard Units, Cottage Clusters, Rowhouses, and Quads:
s 0 N/A Unit Count:
❑ Yes N/A Lot Widt Size
❑ Yes ❑ N ay
Additional ndar s rt ard Units and Cottage Clusters only:
❑ Ye /A Unit Area:
es 0 N/A Floor Area (per story)
O Yes 0 N/A Courtyard
O Yes 0 N/A Fence
Tes 0 No ❑N/A Clean Water Services - Service Provider Letter(lot platted prior to 9/10/1995)
❑ Yes 0 No ON/A Public Facilities Improvement (PFI) Permit:
Required: 0 Yes 0 No
Applied For: ❑ Yes 0 No, stop intake
/CS Sensitive Lands: ❑ Yes iff-No
figMain Land Use Case #s: 0 Conditions met
❑Applicant notified of land u e expiration date:
Approved By Planning: Date: 3 (tez3
Notes
Revision 1: ❑ Approved ❑ Not Approved Date:
Revision 2: 0 Approved 0 Not Approved Date:
Building Permit Submittal
Original Submittal Date:
3
Site Plans #:
Building Plans #: 3 hzC ,,L$
Building Permit #: .--Building permit # entered on page 1
Workflow Routing: ,B-Ptanning.a-Enfgineering ermit Coordinator lding
Workflow Sign-off: ,&gn-off for Planning (include notes from planning review)
Route Documents: , Engineering: (1) copy of permit application, (1) site plan, (1) building plan
and original plan review routing form.
,uilding: original permit application, site plans, building plans, engineer and
beam Iculations and trust details, if applicable, etc.
Permit Technician: Date: S /�6- �Z7.1
Notes:
Engineering Review
t'PFI Permit: n/it.
C"Slope at building pad: 3 4.4 oh
_
IR(Conditions met prior to issuance of permit n tit-
IYEasements (encroachments) per engineering conditions of approval and plat
C"Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: 0 Yes dNo
Assess Water Quantity Fee in-lieu: ❑ Yes I‘No
LIDA Facility on lot: 0 Yes I/No Add Fee: 0 Yes ❑ No
/Final Plat Recorded n{,W
El NOT Approved: Date:
Notes:
Approved By Engineering: -4 •
uM�� _ Date: 3 40 f202:
Revision 1: ❑"Approved ❑ Not A roved _ Date:
Revision 2: 0 Approved 0 Not Approved Date:
Permit Coordinator Review
onditions met prior to permit issuance
❑ Approved, NOT Released: Date notified applicant:
❑ ENG Revisions Required: Date notified applicant:
SDC Exemption: 0 Applied for 0 Received oboes not apply
terSDC Fees Entered: Wash Co Trans Dev Tax: 0 Yes . 'N/A
Tigard Trans SDC: ❑ Yes -r(N/A ❑ Deferred
Parks SDC: 0 Yes 1 /A ElDeferred
LIDA ❑ Yes , /A
/OK to Issue/Approved by Permit Coordinator: Date: SiS01 t11;
Revision 1: 0 Approved ❑ Not Approved _ Date:
Revision 2: ❑ Approved 0 Not Approved Date:
C1eanWaterServices
SENSITIVE AREA PRE-SCRE > SITE .ASSESSMENT
Clean Water Services File Number 23-000818
1. Jurisdiction:
Washington County
2. Property Information(example: 1 S234AB01400 "'` 3. Owner Information
Tax lot ID(S): �4 Name: Nick and Abby Lewis
Company: Private Residence
Address: 14855 SW 92nd Ave
OR Site Address: 14855 SW 92nd Ave City, State,Zip: Tigard,or,97224
City, State, Zip: Tigard,or,97224 Phone/fax: 503 319 2832
Nearest cross street: Email:
4. Development Activity(check all that apply) 4. Applicant Information
❑x Addition to single family residence(rooms, deck, garage) Name: Andrew Feldon
❑ Lot line adjustment ❑ Minor land partition Company: Andrew Feldon Design
❑ Residential condominium ❑ Commercial condominium Address: 833 SE Main#102
❑ Residential subdivision ❑ Commercial subdivision City, State,Zip: Portland,OR,97214
Single lot commercial Phone/fax: 503 451 3137
❑ g ❑ Multi lot commercial
Other Email: af@andrewfeldon.com
6. Will the project involve any off-site work? ❑yes x❑ No ❑ Unknown
Location and description of off-site work:
7. Additional comments or information that may be needed to understand your project:
This application does NOT replace Grading and Erosion Control Permits,Connection Permits, Building Permits,Site
Development Permits,DEQ 1200-C Permit or other permits as issued by the Department of Environmental Quality,
Department of State Lands and/or Department of the Army COE. All required permits and approvals must be obtained and
completed under applicable local,state,and federal law.
By signing this form, the Owner or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water
Services have authority to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering
information related to the project site. I certify that I am familiar with the information contained in this document, and to the best of my
knowledge and belief, this information is true, complete,and accurate.
Print/type name Andrew Feldon Print/type title Principal
Signature ONLINE SUBMITTAL Date 3/13/2023
FOR DISTRICT USE ONLY
❑ Sensitive areas potentially exist on site or within 200'of the site.THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO
ISSUANCE OF A SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural
Resources Assessment Report may also be required.
❑ Based on review of the submitted materials and best available information sensitive areas do not appear to exist on site or within 200'of the
site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if
they are subsequently discovered.This document will serve as your Service Provider Letter as required by Resolution and Order 19-5, Section
3.02.1,as amended by Resolution and Order 19-22.All required permits and approvals must be obtained and completed under applicable
local, State and federal law.
II Based on review of the submitted materials and best available information the above referenced project will not significantly impact the
existing or potentially sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to
evaluate and protect additional water quality sensitive areas if they are subsequently discovered.This document will serve as your Service
Provider Letter as required by Resolution and Order 19-5,Section 3.02.1,as amended by Resolution and Order 19-22.All required permits and
approvals must be obtained and completed under applicable local,state and federal law.
❑ THIS SERVICE PROVIDER LETTER IS NOT VALID UNLESS CWS APPROVED SITE PLAN(S)ARE ATTACHED.
❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT
OR SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed by Date 3/13/2023
Once complete,email to: SPLReview@cleanwaterservices.org • Fax: (503)681-4439
OR mail to: SPL Review, Clean Water Services, 2550 SW Hillsboro Highway, Hillsboro,Oregon 97123
Main Office 2550 SW Hillsboro Highway Hillsboro, Oregon 97123 p: 503.681,3600 f. 503.681.3603 cleanwaterservices.org
..`\4(
CleanWaterr Services
SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT
an Water Services File Number 23-000818
1. Jurisdiction: Washington County
2. Property Information(example: 1S234AB01400) r ,. ' 3. Owner Information
Tax lot ID(s): Name: Nick and Abby Lewis
66A8CCompany: Private Residence
, -- J DIN SIO'` Address: 14855 SW 92nd Ave
OR Site Address: 14855 SW 92nd Ave City, State,Zip: Tigard,or,97224
City, State,Zip: Tigard,or,97224 Phone/fax: 503 319 2832
Nearest cross street: Email:
4. Development Activity(check all that apply) 4. Applicant Information
ID Addition to single family residence(rooms, deck, garage) Name: Andrew Feldon
❑ Lot line adjustment ElMinor land partition Company: Andrew Feldon Design
❑ Residential condominium ❑ Commercial condominium Address: 833 SE Main#102
❑ Residential subdivision 0 Commercial subdivision City, State, Zip: Portland,OR,97214
❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 503 451 3137
Other Email: af@andrewfeldon.com
6. Will the project involve any off-site work? ['Yes x❑ No 0 Unknown
Location and description of off-site work:
7. Additional comments or information that may be needed to understand your project:
This application does NOT replace Grading and Erosion Control Permits,Connection Permits, Building Permits, Site
Development Permits,DEQ 1200-C Permit or other permits as issued by the Department of Environmental Quality,
Department of State Lands and/or Department of the Army COE. All required permits and approvals must be obtained and
completed under applicable local,state,and federal law.
By signing this form, the Owner or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water
Services have authority to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering
information related to the project site. I certify that I am familiar with the information contained in this document, and to the best of my
knowledge and belief, this information is true, complete,and accurate.
Print/type name Andrew Feldon Print/type title Principal
Signature ONLINE SUBMI I IAL Date 3/13/2023
FOR DISTRICT USE ONLY
❑ Sensitive areas potentially exist on site or within 200'of the site.THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO
ISSUANCE OF A SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural
Resources Assessment Report may also be required.
❑ Based on review of the submitted materials and best available information sensitive areas do not appear to exist on site or within 200'of the
site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if
they are subsequently discovered.This document will serve as your Service Provider Letter as required by Resolution and Order 19-5,Section
3.02.1,as amended by Resolution and Order 19-22. All required permits and approvals must be obtained and completed under applicable
local,State and federal law.
• Based on review of the submitted materials and best available information the above referenced project will not significantly impact the
existing or potentially sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to
evaluate and protect additional water quality sensitive areas if they are subsequently discovered.This document will serve as your Service
Provider Letter as required by Resolution and Order 19-5,Section 3.02.1,as amended by Resolution and Order 19-22. All required permits and
approvals must be obtained and completed under applicable local,state and federal law.
❑ THIS SERVICE PROVIDER LETTER IS NOT VALID UNLESS CWS APPROVED SITE PLAN(S)ARE ATTACHED.
❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT
OR SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed by ( 162f4 Date 3/132023
Once complete,email to: SPLReview@cleanwaterservices.org • Fax: (503) 681-4439
OR mail to: SPL Review, Clean Water Services, 2550 SW Hillsboro Highway, Hillsboro, Oregon 97123
Main Office 2550 SW Hillsboro Highway Hillsboro, Oregon 97123 p: 503 661.3600 f:503,681,3603 cleanwaterservices.org