Permit �� CITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit #: MST2010 -00054
Date Issued: 05/06/2010
TIGARL� 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S101 BC00500
Jurisdiction: Tigard
Site address: 12300 SW KNOLL DR
Subdivision: KNOLL ACRES Lot: 10
Project: Kim
Project Description: Finish basement to add 400 sq ft of bedroom and increase size of bathroom; and remodel existing
family room.
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: sf Value: $2,000.00 Rear: 0
PLUMBING
Sinks: 1 Water Closets: 0 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0
Tubs /Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0
Drains: 0
Bckflw Prevntr: 0
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 1
Fum <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: 1 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea add! 500 sf: 0 20 1-400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr:
Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add! Br Cir:
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
Other: N Other Description: Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
Owner: Contractor: Required Items and Reports (Conditions)
KIM, DAE H OWNER
12300 SW KNOLL DR
TIGARD, OR 97223
PHONE: 503 - 380 -5566 PHONE:
FAX:
Total Fees: $553.87
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 • • e in accorda = 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
• -ys. ATTENTION: Oreg• la eq•ires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OAR 9 101 -010' Yo ma obtain a copy of the rules or direct questions to OUNC by callin• 03.246.6699 or 1.801. .
By: Issued B : / � 1 il`L Permittee S' • • . `
v - —
1 'CIVD
Y
Property Owner Statement APR 0 8 2010
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed n� tNNG D1V i CITY OF 'CIGAR - D ON
Construction Contractors Board to sign the following statement before a building permi can be
issued. (ORS 701.055 (4))
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 withihe permit.
Please check the appropriate box:
own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
Yr 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 Name of Permit Applicant
0( 4 Q7 I D
Signature of Permit Applicant Date
Permit #: H Togo in 00054 f
Address: 14 JOO ,w
c a 02 Q 72. � 3 ••` .rtie�.t
Issue by: .: gate: C A l
This Copy for Permit Offices
Building Permit Application
Residential 4 . . , A „ I 11-1. 115G(IN1 . - •. ›
r t .. f- . � $ ; *�; t a m X0 444x N 434:0, .
City of Tigard BE DateBed II. P erit No. 13125 SW Hall Blvd., Ti ard OR 97 y �/� 1 ��� /�'DDOS�
Tigard, Plan Review
•. Phone: 503.639.4171 Fax: 503.598.1960 DateBV: /MfJ Other Permit:
QQ �_ . q—
I I ti ,\ it a 2��o Inspection Line: 503.639.4175 APR 0 U Date Ready /By: /� Juris: ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: la , . AlI Supplemental Information
CITY OF TIGARD ,- is i
TYPE OF g��.�ING DIVISION 6
R QUIRED:DATA• - 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.
(r 1- and 2- family dwelling Valuation: S�
❑ Commercial /industrial
❑ Accessory building ❑ Multi - family Number of bedrooms: 4
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site a a.30o SA,,,.. \e_ JAclk bc _ New dwelling area: +X square feet
City /State /"LIP: i f r` "173D-5, Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Pet 0_ ` Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
.' g�4 4V' e l i Q . _ Other structure area: square feet
J REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: I 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
DESCRIPTION OF WORK work indicated on this application.
pp Valuation: $ rem, Existing building area: square feet
I • �— • •_ - L 424 I — - AJtt ... .
New building area: square feet
• ,PROPERTY OWNER : ❑ TENANT Number of stories:
Name: l■� Kt vv,_ Type of construction:
Address: 1 S� r \< � _ Occupancy groups:
City /State /ZIP:' , O- t�� Existing:
r
Phone: (tD 3) Q' . G; Fax: ( ) New:
❑ APPLICANT ❑ 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: " --,. BUILDING PERMIT FEES *. •
Address: (Please refer to fee schedule) f.
City /State /ZIP: Structural plan review fee (or deposit): 67 ( ` II
FLS plan review fee (if applicable):
Phone: ( ) Fax:( )
CCB lie.: Total fees due upon application: 6 7 . Co
Amount received: 61 -7r 6s
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complet .
Print name; — 4 - Date 04 /n•Z /! v * Fee methodology set by Tri -County Building Industry .•- . �IJJ
Service Board.
I:\Building \Permits \BUP -RES PermitApp.doc 10 /01/09 440- 4613T(11/02 /COM/WEB) l g6.1?
Building Permit Application Checklist
�. .: .7 fi t e ' n: ; " , '. t r xtx rt , •>
One- and Two - Family Dwelling Y 1 014,40 H I ICF <U SI ..ONI f 4:
City of Tigard R eceived Permit No.:
� y ' a 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: t C : Phone: 503.639.4171 Fax: 503.598.1960 Associated peirnits:
� ;I'J Gr41fl
24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
.:: 1:__ Internet: www.tigard or.g o ov ICI S''' 1, ❑ Othe . �
t 1 ` R
Tfi — Ft: oire �VIC t 1y 1- � �: V
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1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑
3 Verification of approved plat/lot. ❑ ❑ ❑
4 Fire district approval required. Name of district: . ❑ ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ ❑ .
6 Sewer permit. . ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection. etc.
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 ❑ ❑ ❑
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 ❑ ❑ ❑
and location.
13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, El ❑ ❑
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- ❑ ❑ ❑
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. ❑ ❑,,. ❑
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- ❑ ❑ ❑
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 ❑ ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑
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 ❑ ❑ ❑
over 10 feet long and /or any beam/joist carrying a non - uniform load.
20 Manufactured floor /roof truss design details. ❑ ❑ ❑
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑
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 ❑ ❑ ❑
architect licensed in Ore Ion and shall be shown to be as •licable to the .ro'ect under review.
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htk��n�S7.L rz- ..0 ,..., ti ..., _.. a � ..5�1i...,,H .a' C1'a « -;afi i1r., t7 � hr oral ., . , .� ^r I ,.., '� i � b Sc"
23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
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. ❑ ❑ ❑
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 ❑ ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 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.
1:\ Building \Permits\BUP- RES- PermitApp.doc 03/21/06 440- 4613T(1 I /02 /COM/WEB)
Plumbin Permit A lication
Building Fixtures � y i .i y l cuts c �R ' � ' ` x 1r w -
,; City of Tigard Received permit No (�
g APR p 20 Date/By: �lti/(5,T70i v' 6C�US
v 13125 SW Hall Blvd., Tigard, OR 97223 ® 8 Plan Review
. '' 0 y ;. Phone: 503.639.4171 Fax: 503.598.} 1U Date/By: Other Permit No.:
' Inspecti Line: 503.639.4175 �+ OF TIGARD p Date Read /e lur s: ®See Page 2 for
f I(i iA R� I) '� n GARD Ready /By: g
• - Internet: www.tigard- or.gov BUILDING DIVI Notified/Method: Supplemental Information
TYPE OF WORK � N FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 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
'and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: (D_ cy-D e •••7 k k k ...
Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City /State /ZIP: (� G1-��
J t n Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: Project name: \ � Q J1 �0APt Manufactured home utilities 50.03
Cross street/directions to job site: tititi"`"' 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
DESCRIPTION OF . WORK.• Backwater valve 12.51
Clothes washer t 25.02 .25709,
Dishwasher 25.02
-S e•e- G Les Drinking fountain 25.02
Ejectors /sump 25.02
;PROPERTY OWNER: 1 ❑ TENANT Expansion tank 12.51
Fixture /sewer cap 25.02
Name: -061/4.8, u r\ ! � ` Lk".
Floor drain/floor sink/hub 25.02
Address: ( 7 s do kk l t Garbage disposal 25.02
City /State /ZIP: - 1 1/ „ 0..„, S t OV,.. O yZ3 Hose bib 25.02
Phone: ( ) 2, .C Fax: ( ) Ice maker 12.51
'❑ _ 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 1 25.02 ;25',02,
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan ( 12.51 a 5
E -mail: Urinal 25.02
• • Water closet 25.02
CONTRACTOR 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 7.1, .5'0
Plan review (25% of permit fee)
CCB Lic.: Plumbing Lic. no.:
State surcharge (12% of permit fee) ' . 70
Authorized signature: TOTAL PERMIT FEE
hB Date: / This permit application expires if a permit is not obtained within 180 days
Print
fx�! 07// 0 after it has been accepted as complete.
111 *Fee methodology set by Tri- County Building Industry Service Board.
I. 10/01/09 440- 4616T(I0 /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 - 1 100' 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
Storm &Rain Drain - 1st 100' 62.54 Valuation: Permit Fee:
$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 $148.50 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
(minimum charge - 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", Plan Review .for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees Please check all that apply.
Quantity_ by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: Replace greater, except systems designed and stamped by licensed
Previous Capped Added •Existing engineer.
Baptistry/Font
Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure
- Jacuzzi/Whirlpool
as defined in OAR918- 780 -0040.
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive tall ❑ Any multipurpose fire sprinkler system.
Cuspidor/Water.Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash Isometric or Riser Diagram
Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings
3 that meet the qualifications above.
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial
- Industrial Comments regarding fixture work:
Ice Mach. /Refrig. Drains.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial *Note: If the fixture work under this permit results in an
- Service increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be paid before the
Washer - Clothes
Water Extractor plumbing permit can be issued.
Water Closet - Toilet
Urinal
Other Fixtures:
I:\ Building \Permits\PLMF - PermitApp.doc 2
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Electrical Permit Applicati , , ,, , , 4,s, , , , 'f� I (�)R401 I I( 1.. US (hN h .4_ l y dr ' .
. ! City of Tigard APR 0 8 2010 Date/By: Received Permit No.: (
° 13125 SW Hall Blvd., Tigard, OR 97223 M 5T Z U I U ' O 00
C g P lan Review Other Permit:
-' 1 � , d t , Phone: 503.639.41 Fax: 503 b OF TIGARD DateBy
II G >\ R!b' Inspection Line: 503.639.4175 BUILDING DIVISIO Date Ready
BUILDING ® See Page 2 for
...:, ..!^'1 "' Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW .
❑ New construction Addition /alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
�l- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
['Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "I -3 ",
.30Tp S, I Six or or more. occupancy.
Job no.: Job site address: [
�r.oll _ ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: --1 1 /� b ❑ Health -care facilities. ❑ Supply voltage for more than
1 I l J C� ���� ❑ Hazardous locations. 600 volts nominal.
J
Suite/bldg. /apt. no.: Project name: ,,,
` ,1 ❑ Service or feeder 600 amps or more. FEE SCHEDULE •
Cross street/directions to job site: Description 1 Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
. DESCRIPTION OF WORK (with above sq. ft.) 67.84 2
Limited energy, multi - family 67.84 2
t 'st?� . 7 c-' >P_Ae—' `t_ p e ` residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
1V 1 _ ° --"e■ G-,rC a• 200 amps or less I 100.70 2
_ . - PROPERTY:OWNER ' I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: �Ov. V-;, ,,, 601 amps to 1,000 amps 301.04 2
Address: +)')3O - �W s , 1 l b . Over 1,000 amps or volts 552.26 2
,1 , Temporary services or feeders installation, alteration, and /or
City /State /ZIP: — 1. vA s> t CV.. Cr,,.).-, relocation
Phone: ((3)' ) Z r .. .r6,6, Fax: ( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that 1 own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits - new, alteration, or extension, per panel
Owner signature' � Date: O'er' /OZ / 0 A. Fee for branch circuits with
❑ APPLICANT ❑, CONTACT PERSON above service or feeder fee 7.42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
Y dwelling, service and/or feeder
Phone:( ) Fax::( )
Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: panel, alteration, or extension. Page 2 2
(Th t p ' Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (l hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed (%] hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Subtotal:
Suprv. Electrician signature, required:
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE:
Authorized sigpa` to
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: 1)�e...... t►n^_ Date: o ti l eri I n • Number of inspections allowed per permit.
\ \
I:\BuildingPermitsELC - PermitApp.doc 10/01/09 440- 4615T(11 / / 05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES: • RESIDENTIAL: WORK ONLY: • • •
•
Fee for all residential systems combined $67.84
Check Type of Work Involved:
❑ Audio and Stereo Systems*
n Burglar Alarm
❑ Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:' • .
Fee for each commercial $67.84
•
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
n Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
n Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
I Protective Signaling
n Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\ Building \Permits\ELC- PermitApp.doc 10/01/09
t` 'i, tci y Aluiz di' F Arg43441�' kWolM k V G ;,.,ur' %, x e r
Mech Permit A nlicatio *0,,,,, ,.t i � OR )1.1 I CI t tJS l )N'I'lw, ,I , k4'.' dw"I'I ;:
i .1v 1� _ . �m *b 1 bi. i......sw.U.L..i +..WYM,,vod Q :: a..s NYw. , 60.4.
:,
City of Tigard Received
Permit No.:
131 SW Hall gar
Blvd., Tigard, OR 97223 D ��j �Q &30,5-i Phone: 503.639.4171 Fax: 503.598.1960 APR 0 2 010 Plan Review
Date/By: Other Permit:
I I c x It' a Inspection Line: 503.639.4175 Date Ready/By: Juris ® See Page 2 for
Internet: www.tigard- or.gov CITY OF TIGARD Notified/Method: Supplemental Information
BUILDING DIVISION
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE 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 ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $ '
RESIDENTIAL,EQUIPMENT / SYSTEMS FEES*
f 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description 1 Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Air conditioning
Job site address:
\ Z _ 0 U S o VV >r . (requires site plan showing placement) 46.75
City /State /ZIP'"(' Oa , qty. Fumace 100,000 BTU (ducts /vents) 46.75
t Fumace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: Project name: Heat pump 61.06
Cross street/directions to job site: Duct work i 23.32
Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 23.32
r Gas fireplace 33.39
�rt.� -vn � h� Flue vent for water heater or gas
fireplace 1 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32
Other: 23.32
Name: .6 CIVe-- t4. `j \�� Environmental exhaust and ventilation
R -� - Range hood /other kitchen
Address:
1). cro 51,x �.. x . equipment 33.39
City /State /ZIP: '-/ ' at `"'rr` k Gl -' Clothes dryer exhaust 33.39
I Single -duct exhaust (bathrooms,
Phone: (QS ) ; . ccel Fax: ( ) toilet compartments, utility rooms) 23.32
❑ APPLICANT . • ❑ CONTACT PERSON . , Attic /crawlspace fans 23.32
Other: 23.32
Business name:
Fuel piping
Contact name: $14.15 for first four; $4.03 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax:: ( ) Water heater
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: Clothes dryer (gas)
� Y\Pit Other:
Address: • MECHANICAL :PERMIT'FEES*
City /State /ZIP: Subtotal
Minimum permit fee ($90.00)
Phone: ( ) Fax:( )
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee)
TOTAL PERMIT FEE
Authorized signa - This permit application expires if a permit is not obtained within 180
•' days after it has been accepted as complete.
Print name: Date: 044 0 • Fee methodology set by Tri- County Building Industry Service Board
I:\Building\Permits\MEC- PermitApp.doc 10/01/09 440 - 4617T (11 /02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi - Family Fee Schedule:
Total Valuation:. , - • • ; Permit fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $1 0,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
$2.54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
1:\ Building \Permits\MEC - PermitApp.doc 10/01/09 2
r
•
CITY OF TIGARD RECEIPT
n
a 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 180845 - 12/29/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2010-00054 $- 388.97
Total: $- 388.97
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 66469 DHOWSE 12/29/2010 $- 388.97
Payor. Dae H. Kim
Total Payments: $- 388.97
Balance Due: $388.97
•
.F 77ty C .
Tidemark
ry : System Administration
Finance Department Request
Date: A2/29/
To: Liz Lutz
Angela McCoy
From: Dianna Howse/
Re: Receipt #: /27i'53 /PAP
Please process this request as follows:
• • Journal Entry (route copy of JE to
Dianna Howse).
Reversal (fees have been reversed on
Revenue Account Report).
Credit Card Return (fees have been
•
reversed on Revenue Account Report).
Other /Explanation:
/ e 'w FMS
e 9i y d cc eTc
Thank you!
44 YG > &'44
I: \ Building \ Forms \RteSlip- FinanceReq.doc
#(-EE /d �7fES e Gr
JE .917;9-c_ //fib /19E/1
Page 1 of 1
• r
71
q CITY OF TIGARD RECEIPT
2 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
02/6 /1%/4 /
Receipt Number: 177853 - 05/06/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2010-00054 Building Permit - Additions, Alterations, 2300000 -43104 $104.12
Demolition
MST2010 -00054 12% State Surcharge - Building 1003100 -24001 $12.49
MST2010 -00054 Services or Feeders - 200 amps or less 2200000 -43103 $100.70
MST2010-00054 Branch Circuits w /Purchase Service or 2200000 -43103 $66.78
Feeder
MST2010-00054 12% State Surcharge - Electrical 1003100 -24001 $20.10
MST2010-00054 Duct Work 2300000 -43102 $23.32
MST2010-00054 Single Duct Exhaust (Bathrooms, Toilet, 2300000 -43102 $23.32
Utility Rooms)
MST2010 -00054 12% State Surcharge - Mechanical 1003100 -24001 $10.80
MST2010 -00054 Minimum Fee Adjustment - Mechanical 2300000 - 43102 $43.36
MST2010 - 00054 Clothes Washer 2300000 - 43101 $25.02
MST2010-00054 Sink 2300000 -43101 $25.02
MST2010-00054 Tub /Shower /Shower Pan 2300000 -43101 $12.51
MST2010-00054 12% State Surcharge - Plumbing 1003100 -24001 $8.70
MST2010-00054 Minimum Fee Adjustment - Plumbing 2300000 -43101 $9.95
• Total: $486.19
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Cash DADAMSKI 05/06/2010 $486.19
Payor: Dae Kim
Total Payments: $486.19
Balance Due: $0.00 ,
Page 1 of 1
Address shall be posted MS/ — coo.SX /°L A/S
and visible from street.
CITY OF TIGARD
OFFICE COPY Approved P]
Conditionally Approved [ ]
See Letter to: Follow [ ]
t Attached
S'iigkw� .bCvr ' - iei � 106114 0 Permit Number: '? 5 0 a.�J ) LL ]
k °' ,..6 A .: A.a ` o �Ctgh i�. 7� g C'�Sr — y
ct� Gt�s -� RECE
,N ,) , ,,, K M- L-ti.ln-r.+�c a- Dot r `�°� Address: By: /1� Date: 'i -. 4 -M ED
X --“ ‘r ` wA i,;teMAN vke- Li- APR 0 8 2010
+ C CITY OF TIGARD
rh? VO1D Iy £G RES)�• ;� `� � �� �= �� � BUILDING DIVISION
ep-7//6 e7P"
'■.i
A ri . i i I
i 0 t
A#6 ,,,e di)
I _ , ERm-vv.48-1
.. M di I
atle 5 . ji .y -.4.'
s-
ip M '
koes _ 7 _ 1
- Tvle.19-ke' c
: t32 ekt ilse•-.....-.—,----...r■
5A
■
D 3 SA
Co
.' !•1 k 2X4- YAK v i c-osnS- r.:ko Approved plans
5,4 shall be on job site.
SNORE A LALM5
® P.
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 .
• VI:":1,4
.1LriciAHW
August 18, 2010
Dae H. Kim
12300 SW Knoll Dr.
Tigard, OR 97223
Re: Permit No. MST2010 -00054
Dear Mr. Kim:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12300 SW Knoll Dr.
Project Name: Kim
Job No.: N/A
Refund: ® Check #66469 in the amount of $388.97.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request to cancel permit. Refund 80% of permit fees. •
If you have any questions please contact me at 503.718.2430.
Sincerely,
"'<
Dianna Howse
Building Division Services Supervisor
Enc.
L: \Buildin \ Refunds \ Administration \I,trRefund- Cancell'ermir.doc 01 /16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request ibr Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Dae H. Kim DATE: 8/17/2010
12300 SW Knoll Dr.
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 177853 Case #: MST2010 -00054
Date: 5/6/2010 Address /Parcel: 12300 SW Knoll Dr.
Pay Method: Cash Project Name: Kim
EXPLANATION: Per applicant's request; due to financial constraint cannot complete project. Refund
80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount
Building Permit Fee 2300000 -43104 $83.30
Electrical Permit Fee 2200000 -43103 133.98
Mechanical Permit Fee 2300000 - 431.&1 /O 2 , , � 72.01
Plumbing Permit Fee 2300000 -43101 /Uor CO/j Rz - c_rrd 58.01
12% State Surcharge 1003100 -24001 ,,i/ sivt00r_4,2nnfr- 41.67
TOTAL REFUND: $388.97
APPROVALS:
If under O Professional Staff CA..b
If under 2500 Division Manager
If under $800 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date: / : J / d By:
Case Refund Processed: Date: AV 9 / By:
I: \Ruilding \Refunds \Rcfundltcyucst.doc 04/13/09
I e Community Development RECEIVED
r c n ii Request for Permit Action
JUN 2 4 2010
TO: CITY OF TIGARD CITY OF TIGARD
Building Division Services Coordinator BUILDING DIVISION
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: [ Owner ❑ Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) - )tttJ��� ^ P H • i v\
Mailing Address: 1 � Si.- �
(v`p (l ...0'C
City /State /Zip: s-- k • Q . - P--)-- 77 -3
Phone No.: 1 ;0'; ' >'Q • CS7,4
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION. VOID
REFUND PERMIT FEES (attach receipt, if available). �
III INVOICE FOR FEES DUE (attach case fee schedule and explain below). I/ ' 2 //0 .FeY
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: )--‘•%" j I(,) - 0006
Site Address or Parcel #: 1 2, 2 ;p0 .4.0 ki (y)c.LD
Project Name:
Subdivision Name: Lot #:
EXPLANATION: u,A.pj t-i , Ac �„ \ coAatt - .
- ke.,--kr C.....-U-6-6..A___ e .6._./...e.c_k N I ,h.....
0 o
Signature: - ` D a , 00,40
Print Name: H. ,`t,,,,,`
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Dates I p 1515'B1 Rte to Bld : Admin: Date _ . /p B, f ' - ''''
Refund Processed: Dat- , /v By ,C�; Invoice Processed: Date By
Permit Canceled: Date ,- B `6 i�� � ' . rcel Ta• Added: Date B
Receipt # /nf5:5 Date .s1/4, //p Method Ca, 4 Amount $
I:\ Building \Forms \RegPermitAction.doc R v 07/26/07
• Community Development
TIGARD WILL CALL / PICKUP
'' Fill out this form completely and attach it securely to the
document(s). Bring it to the WILL CALL / PICK UP
area at the Permit Center Counter and file alphabetically by
last name of individual or company name.
TO: Z/90 A' //f - —
COMPANY NAME:
DOCUMENT NAME: Ch € C,�
FROM: <=2)/ /9 -- /1
DEPARTMENT: f�
DATE TO WILL CALL: eA er7/0
FEES DUE:
ATTACH FEE INFORMATION (ACCOUNTS, PERMITS, COPIES, ETC.)
Document will be returned to the originator if not picked up
within 5 business days gfjthe "DAATE –TOLL CALL ".
RECEIVED $Y.
MUST BE SIGNED BY THE PERSON LISTED ABOVE
— RECEIVED DATE: g/r i / /t7
RETURNED TO ORIGINATOR DATE:
1: \Buildin \Forms\ ItreSlip- WilICall.doc