Permit 1 ,; CITY OF TIGAR® SITE WORK PERMIT
I. ..• COMMUNITY DEVELOPMENT Permit #: SIT2010 -00006
F i G AkE;) 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 03/03/2010
Parcel: 2S102ACD0100
Jurisdiction: Tigard
Site address: 9040 SW BURNHAM ST
Subdivision: BURNHAM TRACT Lot: 4
Project: Burnham Street Improvements
Project Description: Install line from relocated vault to existing fire supression system.
Owner: FEES
STEVENSON, MICHAEL J & KAY L Description Date Amount
16815 MAPLE CIR
LAKE OSWEGO, OR 97034 Permit Fee - Site Work 03/03/2010 $51.09
12% State Surcharge - Building 03/03/2010 $6.13
PHONE:
Contractor:
KODIAK PACIFIC CONSTRUCTION
PO BOX 886
TUALATIN, OR 97062 -0886
PHONE: 503 - 783 -4300
FAX: 503- 682 -3777
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 $57.22
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. 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 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By __ a t 1 ,y't J � ` A /t n Permittee Signature: t ,{
7? Call 503.639.4175 by 7:00 a.m. for an inspection that business 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.
!Building Permit Application
' Site Work ` *' ,' ` aFOI () ici l i' ci i �� E�" ' M �'
E F a rh ' 1 t1 t 4 ' :�. ,h, k'.:.n i rl�,�,.:i',
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City of Tigard E C _ i IA eceived
`J g Date/B `_ Permit No..` • O .Oil ta .'
III
13125 SW Hall Blvd., Tigard, OR 97223 20 � Plan Review
® ;. Phone: 503.639.4171 Fax: 503.598.1960 MAR 0 3 D ateB : Other Permit:
t l Cl A It l ) Inspection Line: 503.639.4175 Date Ready/By: INI ® See Page 2 for
i Internet: www.tigard- or.gov CITY OF TIGARD Notified/Method: Supplemental Information
BUILDING DIVISION
• TYPE OF .WORK REQUIRED DATA: 1- 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
IS ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1- and 2- family dwelling 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:
Job site address: 9 040 51Ai Bu R -114AM New dwelling area: square feet
City /State /ZIP: - 1 — ca., ARD a IT_ Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: 3 t, R . »A0A-, ST — Ti—,, pp Covered porch area: square feet
Cross street/directions to job site: - i -- yt - r e_ Sec riC rJ of= AsH 4 B 4O101 • 1 4 .. A7 Deck area: square feet
0 a 77-1r Alt"./ Cme //e>Z . 13 -e-.[3 P R # ""-r- _c wit c Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHE
Subdivision: 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.
-� CtfEZ,( t/:4Lk d Cv41AIer Valuation: $
-Ll f P /2 �S9a� S}�' ltd - -r,, r LIA Lit - f N Ro W . Existing building area: square feet
New building area: square feet
12/ OPERTY OWNER ❑ TENANT Number of stories:
Name: 3 3 PR „„ j r l c , u k C E Type of construction:
Address: 9040 5 t,, 3 uQN I. rv Occupancy groups:
City /State /ZIP: 77e$ AR0 / oR. Existing:
Phone: (5 ) 9a4 - A115
1 1 5- Fax: ( SUB Co, 3 9 • 73 /0 New:
Er/APPLICANT ❑ CONTACT PERSON . NOTICE ',
Business name: KO p/A/c Ac IF -7 L CIA/ $ r7 d Al All contractors and subcontractors are required to be
Contact name: giC fAA /34›, licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: Pa 80 u 8O Co jurisdiction in which work is being performed. If the
City /State /ZIP: 17,4 A L -77 Al OR 5'7 2_ applicant is exempt from licensing, the following reasons
apply:
Phone: (4) 7 3 - 4 3cro Fax: : (? (Q 2.— 3 7 ' 7 7
E -mail:
CONTRACTOR
Business name: 5,44/0 AS A PPl -c4 BUILDING PERMIT FEES*
Address: (Please refer to lee schedule)
Structural plan review fee (or deposit):
City /State /ZIP:
FLS plan review fee (if applicable):
Phone: ( ) Fax: ( )
CCB lie.:
535 �3 Total fees due upon application:
Amount received: 9 / ,0 0
Authorized signature This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: 74 JO ,je-5 Date: 3/2_/, 0 * Fee methodology set by Tri- County Building Industry
Service Board.
L\Building\Permits \SIT - PermitApp.doc 10 /01/09 440- 4613T(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) ❑ Rock
❑ CMU
❑ 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 ❑ *Parking (including ADA) and Lighting
compliance Plan
❑ Grading Plan and details ❑ *Landscaping Plan
❑ Erosion Control Plan and details ❑ 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 - Occupancy 2 $10.76 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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