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Permit (2) CITY OF TIGARD MASTER PERMIT I:' '- COMMUNITY DEVELOPMENT Permit#: MST2023-00607 Date Issued: 12/26/2023 T 1[3 A R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S104AA05500 Jurisdiction: Tigard Site address: 12205 SW 127TH AVE Subdivision: BELLWOOD NO.2 Lot: 76 Project: Schwerdfager Project Description: 727 sq.ft.addition: New living room, kitchen, bedroom, bathroom, and covered deck. Mechanical and electrical permits to be pulled separately.WATER METER UPSIZE REQUIRED PRIOR TO BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 1 First: 727 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 19 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 15 Smoke Yes Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Total: 727 sf Value: $140,329.35 Rear: 15 PLUMBING Sinks 1 Water Closets: 1 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 1 Urinals: 0 Lavatories: 1 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 0 Tubs/Showers: 1 Garbage Disp: 1 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: 1 Other Fixture Units: Fixture cap 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: ADD SF VB R-3 727 Owner: Contractor: SCHWERDFAGER,AUTUMN M 360 HOUSES INCORPORATED Required Items and Reports(Conditions) 12205 SW 127TH AVE 1246 NW JACKSON ST 1 Ersn Cntrl 503-639-4175 TIGARD,OR 97223 HILLSBORO,OR 97124 PHONE: PHONE: 503-863-9709 FAX: Total Fees: $5,753.56 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 ac9_nn1_nntn thrnunh flAR ac9_nn1_nngn Vnn magi rnnwHFw.. Jac nr rlirart nnactinnc to(II Inv-.by rnliinn ring 7'29 10547 nr Fran 119 7141 / .i '- Issued By: . si9 r�i lttee Signature: ^�l �� (. Call r (Y3:639.4175 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 pr ct. Approved plans are required on the job site at the time of each inspection. Building Permit Application RECEIVED Residential NOV 21 2023 I.012 OF l( l l ,1,0\I.v City of Tigard CITY OF TIGAR D Received 11'�� n �� Permit No.: MS 1 W U UJ IW� ' 13125 SW Hall Blvd.,Tigard,OR 97223 111 III Alk Phone: 503.718.2439 Fax: 503.598.1960 BUILDING DIVIS Review A Other Permit: Date/By: � �� {� 1 16 A h t) Inspection Line: 503.639.4175 Date Ready/By: , 7 RI See Page 4 for Internet: www.tigard-or.gov Notified/Method: 6 ri3 I , I Supplemental Information t r4/, ,w TYPE OF WORK REQUIRED DATA:I-AND 2-FAMILY DWELLING 0 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 0 Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. Valuation: $ , 00 !L1 0 01-and 2-family dwelling ElCommercial/industrial l 321 ' 0 Accessory building 0 Multi-family Number of bedrooms: 1 0 Master builder 0Other: Number of bathrooms: 1 J JOB SITE INFORMATION AND LOCATION Total number of floors: 2 Job site address:12205 SW 127TH AVE. New dwelling area: 727 square feet City/State/ZIP:Tigard,OR 97223 Garage/carport area: 0 square feet Suite/bldg./apt.no.: Project namejditt €14401.1 Covered porch area: 0 square feet Cross street/directions to job site: Deck area: 294 square feet SW Wills PI e tr ctu> er' square feet REQUIRED DATA:COMMERCIAL-USE CHECKLIST Subdivision: ( Lot no.: Permit fees*are based on the value of the work performed. Tax map/parcel no.:2S 104AA05500 Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. NOMINAL'L'SHAPED 42'-0"X 23'-4"ADDITION TO THEN NORTH SIDE OF THE EXISTING RESIDENCE.ADDITION Valuation: $ WORK TO BE LIMITED TO EXTENT NECESSARY FOR THE CONSTRUCTION OF THE PROPOSED ADDITION. Existing building area: square feet nAg.cluoita cr..✓ .i-4.t,e.k. Cc..t 2"rn• - 6_ eU 14� New building area: square feet 0 PROPERTY OWNER �" ❑ TENANT <j� .lf'l.l� Number of stories: Name:AUTUMN SCHWERDFAGER ' Type of construction: Address:12205 SW 127TH AVE. Occupancy groups: City/State/ZIP:Tigard,OR 97223 Existing: Phone:(520 7)30 0391 Fax:( ) New: 0 APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES* (Please refer to fee schedule) Business name:M Group Engineering Structural plan review fee(or deposit): . Contact name:Chad Wallace FLS plan review fee(if applicable): Address:6775 SW 111TH AVE,SUITE 20 Total fees due upon application: City/State/ZIP:BEAVERTON,OR 97008 Amount received: Phone:406 )579-5694 Fax: :( ) PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* E-mail:CRW406@gmail.com Commercial and residential prescriptive installation of CONTRACTOR roof-top mounted Photo Voltaic Solar Panel System. Business name:360 HOUSES Submit two(2)sets of roof plan with connection details and fire department access,along with the 2010 Oregon Address:16037 SW UPPER BOONES FERRY RD.SUITE#150 Solar Installation Specialty Code checklist. City/State/ZIP:PORTLAND,OR 97224 Permit Fee(includes plan review $180.00 and administrative fees): Phone:(CELL)(503)863-0106 Fax:( ) State surcharge(12%of permit fee): $21.60 CCB lie.:211096 Total fee due upon application: $201.60 Authorized signature: I (7_441 fA4 �_ I This permit application expires if a permit is not obtained r within 180 days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Print name:Chad Wallace Date:11/20/2023 Service Board. I:\Building\Permits\BUP-RESPermitApp.doc 01/25/2023 440-4613T(11/02/COM/WEB) DrgiSign Verified -dl8efed8-b4b9-4d7a-84e9-64041 b1 a0b94 Plumbing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard RECEIVED Received ,� ? g Permit Na: C'/ y� 13125 SW Hall Blvd.,Tigard,OR Plan Ry. J J"C Plan Revaew Phone: 503.718.2439 Fax: 503.598.1960 DateBv: Other Permit No.: Inspection Liue: 503.639.417$ov I'I(,AI2.D DEC 26 2023 Date ReadyrPy: AIM ra See Page 2for Internet: �mlcti.tigard-or. g NotifiediMethod: Supplemental Information TYPE OF WOcrryARD FEE* SCHEIt(1I F; ❑Nems-construction (` SUIT�,��U hV�7 DIVISION�� For special information use checklist. DU�� Description I Qty. I Ea. I Total X Addition/alteration/rt.-placement 0 Other: New_ 2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTIONSFR(1)bath 312.70 54 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78 building SFR(3)bath 50fl.32 ❑Accessory g 0 Multi-family Each additional bath/kitchen 25.02 0 Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE;INFORMAMON:OiND:LOCATION Site utilities: Job site address: 12205 SW 127TH AVE Catch basin or area drain 18.76 s TIGARD OR 97223 Dryimell,leach Line,or trench drain 18.76 Cit ;'State/ZIP: --- Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.: Project name: Autumn Addition Manufactured home utilities 50.03 Cross street'directions to Olt site: SW WILLS PLACE1 J Manholes 18.76 Rain drain connector l 18.76 Sanitary sewer(no.linear ft.: ) Page 2 Stoma sewer(no.linear ft.:_) Page 2 Water service(no.linear ft.: ) Page 2 Subdivision: BELLWOOD NO.2 Ltt no.:76 Fixture or item: Tax map/parcel no.: 2S104AA05500 Backtlow preve ter 31.27 DESCRIPTION OF, WORK Backwater valve 12.51 ''- Clothes washer 1 25.02 Record MST2023-00607: Dishwasher 1 25.02 Residential -Master Permit Drinking fountain 25.02 Ejectors/sump 25.02 X`PROPERTY OWNER a TENANT Expansion tank 12.51 - Fixture/sewer cap • 1 25.02 Name: Autumn Schwerdfager t Floor draiMfloor sink/hub 25.02 Address: 12205 sw 127th ave Garbage disposal 1 25.02 I City/State/ZIP:Tigard OR 97223 Hose bib 25.02 i Phone:( )5034624041 Fax:( ) Ice maker 12.51 i 0 ApPU£"ANT IX CONTACT PERSON Interceptor grease trap 25.02 Business name: Medical gas(value:$ ) Page 2 360 Houses Incorporated Contact name: Mihaela Ciupei Primer 12.51 1246 NW Jackson St Roof drain(conwnercial) 12.51 Address: i Sink/basal/lavatory �� 25.02 City/State/ZIP: Hillsboro OR 97124 Solar units(potable water) 62.54 Phone:( )503-863-9709 Fax::( ) Tubishow-er.%shower pan 1 12.51 Email: 360housesredo@gmail.com Urinal 25.02 CONTRACTORWatee closet 1 25.02 Water heater 37.52 Business name: Five Star Plumbing LLC WaterpipinglDWV 56.29 Address: 6138 SE 136TH AVE Other: 25.02 City/State/ZIP: PORTLAND OR 97256 Subtotal 525.37 Phone:( ) 503-J97-5000 Fax:( ) Minimum permit fee: S72.50 CCB lie.: 176756 Plumbing tic.no.: PB370 Plan review (25%of pennit fee) State surcharge(12%of permit fec) Authorized signature: C,,oan L [D I'ALPERMIT FEE Print name: CORNEL CUREA Date:12/22/2023 This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by In-County Building Industry Service Board. I:Building Pennits.PLMU-PermitApp,doe 10'A1,'09 440-46161'(to02c M/WEB) City of Tigard II ■ " COMMUNITY DEVELOPMENT DEPARTMENT Building Permit Review - Residential TIGARD �n Building Permit #: MS� W 'Q0661� Site Address: \220S 5�,, JIB1, ` Verified in Accela Project Name: fl nrnn lira'\ Lot/Unit #: Proposal: 5 --id t(A 0A 12-1 Zone: tES - Housing Type:/eSFR(Single Detached ❑ Duplex❑Triplex❑ADU) ❑ Rowhouse❑Cottage Cluster❑CYU ❑Quad ❑Other Required Site Plan Elements: /26 co s of site plan on max 11x17" .n*o standard scale • �-Retained trees, drip line/tree protection North arrow 4 173 Street-onel site trees shown / labeled Site address, project name, lot # 1 Trrb+e-eeiealating tree canopy at maturity Street names (N/A for SFR) Applicant name and phone # • - vd rectangle dimensioned (if applicable) (Lot and setback dimensions .ra �' -.tF lar p'Existing structures &square footage ❑ U= ' y locations &easements %Foo •rint of new structure and FFE * 413,0444-werty corner elevations• F :ewalk/driveway dimensioned ❑ LIDA (>1,000 sf disturbance) area icl lot covef'acge; r,,' tage#o- Erosion control Required Elevation Plan Elements: (For SFR: calcs needed only on street-facing) Summary table with calculations for: (D ;wn to standard scale ,0'T tal façade area • • 51`dh' "--- .ZTometal window and door area ❑ Windows and doors dimensioned abSoW}e r viev> fired Floor Plan Elements: (Not require E81 ary table that includes ❑ Each story dimension ❑ Total floor area ❑ y oor area calculated ❑ Floor Ty Planning Review The following standards have been met: Setbacks ❑ Front: 15 Rear: 1$ Side: 5 Min/Max Street Side: IS / Garage: Z-0 Hei t ❑ Mix. Height: 30 Proposed Height: i 3 t Vet CAS✓ Sl� &e{ cS be Yk Yes ❑ N/A Landscape ❑ Yes grN/A Screening (Quad only) ❑ Yes 0 N/A % Window Coverage ❑ Yes Z N/A Garage (SFR Only) Parking (Other Res) ❑ Yes. N/A Entrance (SFR, Rowhouse, Quad only) ❑ Yes,1 N/A Other building design standards (Rowhouse only) ❑ Yes, N/A Accessory Structure Standards ❑ Yes,6 No Qualifying pre-existing unit exempt from standards (Cottage unit only) dditional stan ds for Courtyard Units, Cottage Clusters, Rowhouses, and Quads: es ❑ N/A nit Count: ❑ ❑ N Lot Width and Size ❑ Yes /A Pathway Addi 'o al standards for Courtyard Units and Cottage Clusters only: ❑ Y s ❑ A Unit Area: es ❑ N/ Floor Area (per story) Yes ❑ N/A Courtyard 0 Yes 0 N/A Fence Yes 0 No ON/A Clean Water Services - Service Provider Letter (lot platted prior to 9/10/1995) ' 11a ❑ Yes 0 No pt1(i/A Public Facilities Improvement (PFI) Permit: Required: 0 Yes 0 No Applied For: 0 Yes ❑ No, stop intake ill<Sensitive Lands: 0 Yes ) No 17119rairi Land Use Case #s: 0 Conditions met ❑Applicant notified of land use expiration te: Approved By Planning: - at c' 0 X(-- Notes / OOrn oY 2�-- I L"t� [�iLL e R ACe0 C` Revision 1: 0 Approved 0 Not Approved Date: Revision 2: 0 Approved 0 Not Approved Date: Building Permit Submittal Original Submittal Date: 1\1titil100ti3 Site Plans #: Building Plans #: Building Permit #: 6'Building permit # entered on page 1 Workflow Routing: V Planning Engineering 'Permit Coordinator IS/Building Workflow Sign-off: Sign-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. y Building: original permit application, site plans, building plans, engineer and beam calculations and trust details, if applicable, etc. Permit Technician: VOA-A, Date: 1144 J209 Notes: Engineering Review til PFI Permit: t\./Z'l ` 0 Slope at building pad: j /• oh M Conditions met prior to issuance of permit ® Easements (encroachments) per engineering conditions of approval and plat Y Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: 0 Yes SI No Assess Water Quantity Fee in-lieu: 0 Yes ira No LIDA Facility on lot: 0 Yes El No Add Fee: 0 Yes ,® No p Final Plat Recorded ❑ NOT Approved: Date: Notes: Approved By Engineering: t 4a4 % f Date: f Z. -5 - 23 Revision 1: 0 Approved 0 of Approved Date: Revision 2: 0 Approved 0 Not Approved Date: Permit Coordinator Review conditions met prior to permit issuance ❑ Approved, NOT Released: Date notified applicant: ❑ ENG Revisions Required: Date notified applicant: fISDC Exemption: 0 Applied for 0 Received /Does not apply SDC Fees Entered: Wash Co Trans Dev Tax: ❑'Yes X N/A Tigard Trans SDC: 0 Yes SIN/A 0 Deferred Parks SDC: 0 Yes %N/A 0 Deferred LIDA ❑ Yes /1 N/A OK to Issue/Approved by Permit Coordinator: Date: 12-tCe,`2D23 Revision 1: 0 Approved 0 Not Approved Date: Revision 2: 0 Approved 0 Not Approved Date: RECEIVED Water Meter Fixture Unit Worksheet for Additions/Re/rtode/s ibs4 2023 IGARD Please complete the fofowinginformation: CITY NG DIVISION BUILDING DIVISION Customer Name: Aci1'ufN SCR W&el PAG6".t Service Address: Sttr ct/Suite#: /2 Z.O r 5w 41 7 h 4ye cite: ©R7LA/46$ State: PA �Zri . G�2 3 Phone Number: 6 0,4 Email: r`^"m n . so i e hR C1',e9 . , CO" Plate fill in the member of each&owe you carruitdy have. Please fill in the number of fixtures you propose to add. Multiply the quantity by the point valve to arrive at the currant Multiply the quantity' by the paint value to arrive at total. the pt+opcsed total. Fixture Unit C utent Point Ctm+eat Proposed Point Proposed Quantity value Total Addition value Total Bar sink x 1 x 1 = Bidet x I - x I - oodles washer1 x 4 = 4. ✓' / x 4 = Cf I Dishwasher 1 x 1.5 = /. / 1 x 1.5 = 1 / l"ekatside Wane Spigot x 2.5 = t7' $` ✓ x 2.5 = Water Spigot,each add'l x 1 = x 1 = Kites sink 1 x 13 =...,1`. / / x 1.5 — tawdry silk x 1.5 = x 1.5 = Lavatory etswlro ee.k) � x I f ( x i j T Waxy closet,Ls Oefitouni 2 x 2.3 = / / x 2.5 = ..5 ' / Batfitubleittisipool x 4 x 4 = Shower stall f x 2 = / x 2 = ,1 Bath/shower combo I x 4 = x 4 Current Points: _t 5 '0 Proposed Increase: 12-.5- Current Points+Proposed Increase= ,3 a New Total Points =Required Meter Size $ 5 Meter Sizes: i to 30 points=sir 30.5 to 37 points='Y.^ 37.5 and over points=I" New Meter Size Neededfor New Total Points: :11 I� 7� Cost: S ► (X 1 sex page I) � Curran Meter Size per Utility Billing: , Cost: S 3 i ' (see page 1) f C)` 1 .0) New Meter Size Cost minus Current Meter Size Cost= S 111/��'+✓. /�-� (This it Your Cost to Increase Meter Sire Due to Additional Fixture Units) sssse******s*****s*sass**s**ass*s* *we*ass see****s********************set********* FOR OFFICE USE ONLY Curncoot Meter size Omfirtr ed with UB t Si *CUB Representative Dame ,'Btinldl. (Farm/vautMecm_070123J1td.dOCX Page 2 FOR OFFICE USE ONLY—SITE ADDRESS: 1'140S SW Wli i h .P/,t., 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 IIN Tran mitt 1 s a Letter T i,,,,is n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov TO: Allyson Armstrong DATE RECEIVED: DEPT: BUILDING DIVISION RECEIV:' FROM: Chad Wallace DEC Ii b 2023 COMPANY: M Group Engineering CITY OF TIGARD PHONE: 406-579-5694 BUILDING DIVIS1(��. AP EMAIL: CRW406@gmail.com RE: 12205 SW 127th Ave MST2023-00607 (Site Address) (Permit Number) Schwerdfager (Project name or subdivision name and lot number) ATTACHED ARE THE FOLLOWING ITEMS: e$ topie�. .�' iciiPtion: r, ,i:,ws„ fi, f,n:. ;.,:,�e:7-0:. , „C:F 1i0n.• :k� �F .K;aw s ),22 } ,M:. 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. 3 Engineer's calculations. Other(explain): REMARKS: Structural pages. ..FOR '' .+ uswo y ;` Routed to Permit Technic n: Date: (� (,( Z3 Initials: , - Fees Due: ❑ Yes [v]'No Fee Description. Amount Due: r N) $$ 0 Special Instructions: Reprint Permit(per PEy ❑ Yes ❑ No E Done Applicant Notified: J Date: Initials: AV CleanWate' Services SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT Clean Water Services File Number 23-003046 1. Jurisdiction: Tigard 2. Property Information(example: 1 S234AB01400) 3. Owner Information Tax lot ID(s): Name: AUTUMN SCHWERDFAGER 2S104AA05500 Company: Address: 12205 SW 127TH AVE. OR Site Address: 12205 SW 127TH AVE. City,State,Zip: Tigard,OR.,97223 City,State,Zip:Tigard,OR.,97223 Phone/fax: 520-730-0391 Nearest cross street: Email: AUTUMN.SCHWERDFAGER@GMAIL.COM 4. Development Activity(check all that apply) 4. Applicant Information Addition to single family residence(rooms,deck,garage) Name: Chad Wallace ❑ Lot line adjustment 0 Minor land partition Company: M Group Engineering(*Gaby Massaad) ❑ Residential condominium ❑ Commercial condominium Address: 6775 SW 111TH AVE,SUITE 20 ❑ Residential subdivision ❑ Commercial subdivision City,State,Zip: Beaverton,oR,97008 ❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 406-579-5694 Other Email: crw406@gmail.com 6. Will the project involve any off-site work? ❑Yes Ox No 0 Unknown Location and description of off-site work: 7. Additional comments or information that may be needed to understand your project: NOMINAL'L'SHAPED 42,0'X 23'i'ADDITION TO THEN NORTH SIDE OF THE EXISTING RESIDENCE.ADDITION TO INCLUDE A NEW LIVING ROOM,KITCHEN.BATHROOM.BEDROOM,CLOSET,AND PATIO.PROPOSED SITE WORK TO BE LIMITED TO EXTENT NECESSARY FOR THE CO 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 Chad Wallace Print/type title PM Signature ONLINE SUBMITTAL Date 11/19/2023 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. El 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. II THIS SERVICE PROVIDER LETTER IS NOT VALID UNLESS 1 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`/2 /�� � Date 11/20/2023 once efnplei'e,email to:SPLReview@cleanwaterservices.org • Fax: (503)681-4439 OR mail to: SPL Review,Clean Water Services,2550 SW Hillsboro Highway,Hillsboro,Oregon 97123 a Main Office • 2550 SW Hillsboro Highway Hillsboro. Oregon 97123 • p: 503.681.3600 f: 503.681.3603 • cleanwaterservices.org