Permit
M%i CITY OF TIGARD SITE WORK PERMIT
COMMUNITY DEVELOPMENT Permit#: SIT2010-00004
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 02/19/2010
Parcel: 2S102AD01400
Jurisdiction: Tigard
Site address: 9075 SW BURNHAM ST
Subdivision: Lot: 0
Project: Henderson Auto
Project Description: Relocate existing vault and double check valve for fire water supply line.
Owner: FEES
HENDERSON, JACK R & MARY S Description Date Amount
9075 SW BURNHAM ST
TIGARD, OR 97223 Permit Fee -Site Work 02/19/2010 $188.28
12% State Surcharge - Building 02/19/2010 $22.59
PHONE:
Contractor:
WYATT FIRE PROTECTION INC.
9095 SW BURNHAM
TIGARD, OR 97223
PHONE: 503-684-2928
FAX: 503-684-9657
Type of Use: COM
Class of Work: ALT
Site Specifics:
Excavation Volume: cu. yd.
Fill Volume: cu. yd.
Impervious Surface: sq. ft.
Engineered Fill: Soil Report Required:
Paving: Grading:
Landscaping: Site Prep:
Storn Drains: Retaining Wall:
Fire Underground: Accessible Parking:
Fence:
Total $210.87
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuanc r if work is susp Ed for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oreg
Utility otifcation Center. Thos r e set forth in OAR 952-001-0010 through OAR 952-001-0100. You may obtain a copy of the r les /
or d' ect questions to OUNC b Iling 5 3. .6699 or 1.800.332.2344. i
Is ued By: Permittee Signature: -y
Call 503.639.4175 by 7:00 a.m. for an inspection that busine day.
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.
Buildinp- Permit Application
Site WorkECEIVED Received FOR OFFICE USE ONLY
City of Tigard 5
Date/By , Permit No CI1
N 13125 SW Hall Blvd., Tigard, OR 97223. 9 4`L Plan Review v
Phone: 503.639.4171 Fax, 503.598.1960' R t ' Dare/13v Other Permit
Inspection Line. 503 639 41 75 Date Ready/By Juris 8 See Page ?for
-7
Internet www.tigard-or gov rl''F! C)f ARIA Notified/Method Supplemental Information
J'y I C, IN
I ID 11 N 011 D
TYPE OF WORK REQUIRED DATA: I- AND 2-FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
$
F] I- and 2-family dwelling P~Commercial/industrial Valuation:
❑ Accessory building ❑ Multi-family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms.
JOB SITE INFORMATION AND LOCATION Total number of floors:
.lob site address. 907S SW S New dwelling area: square feet
Citv/State/ZIP: 0 R- 9.7 Z Z_ 5 Garage/carport area: square feet
Suite/bldg./apt. no.: Project name: l Covered porch area: square feet
Coss street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work perfonmed.
Tax map/parcel no.: 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.
Valuation: S T J
D y~ ` ' l ~r r Existing building area: square feet
(i V New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City/State,/ZIP: Existing:
Phone: ( ) Fax: ( ) New:
APPLICANT El CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed. If the
City/State"ZIP: applicant is exempt from licensing, the following reasons
apply:
Phone:( ) Fax::( )
E-mail:
CONTRACTOR
Business name: ~t
/ r BUILDING PERMIT FEES*
/ l+1/ 1 / / / Please refer to fee schedule
Address t ~s
OR"
Structural plan review fee (or deposit):
Citv/State2I11:
1-2 A" 2 G
Phone: (!505 64 % - Fax: (5G3) (vg4 - FLS plan review fee (if applicable):
CCB lic. Total fees due upon application:
D
Amount received:
Authorized signature: This permit application expires if a permit is not obtained
/ ~nwithin 180 days after it has been accepted as complete.
Print name: ~ Date: : Fee methodology set by 'Fri-County Building Industry
Service Board.
I:\Building\Permits\SIT-PermitApp.doe 10/01/09 440-46131'(11/02/COM/WEB)
City of Tigard: Site Work Permit Checklist
Page 2 - Supplemental Information
Commercial, Multi - Family and One- and Two - Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way, or wetland, the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below, unless otherwise noted.
Excavation Volume: cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) cu. yds.
Retaining structure? (Check one) n Rock
n CMU
n Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks, and paving: sq. ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See "Site Work Permit Application - Plan Submittal Requirements" attached.
The following must accompany this application:
❑ Site Plan with Vicinity Map showing ADA n *Parking (including ADA) and Lighting
compliance Plan
❑ Grading Plan and details ❑ *Landscaping Plan
❑ Erosion Control Plan and details n Soils Report (if required)
• Retaining Structures
*Does not apply to One and Two - family dwellings.
Plan Submittal: Permit Fee:
TYPE OF SUBMITTAL # of Plans Valuation: • Permit Fee:
(New, Additions or Required at $.00 to $500.00 $51.09 minimum permit fee
Alterations) Submittal $500.01 to $2,000.00 $51.09 for the first $500.00 and
$2.69 for each additional $100 or fraction
Commercial 2 thereof, to and including $2,000.00.
$2,000.01 to $25,000.00 $91.44 for the first $2,000.00 and
Multi-Family R-1 Occupancy 2 $1 0.76 for each additional $1,000 or
fraction thereof, to and including
$25,000.00.
One- & Two- Family Dwelling 2 $25,000.01 to $50,000.00 $338.92 for the first $25,000.00 and
$8.06 for each additional $1,000.00 or
fraction thereof, to and including
$50,000.00.
$50,001.00 to $100,000.00 $540.42 for the first $50,000.00 and
$5.38 for each additional $1,000.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and over $809.42 for the first $100,000.00 and
$4.49 for each additional $1,000.00 or
fraction thereof.
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