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Permit • 910 •i 2Q CIW OF TIGARD MASTER PERMIT COMMUNITY DEVELOPMENT Permit #: MST2009 -00213 T i GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/20/2009 Parcel: 2S 111 BA00803 Jurisdiction: Tigard Site address: 9960 SW MCDONALD ST Subdivision: Lot: 0 Project: Engel Project Description: Adding 300 sq ft. 2/9/10, add feeder to scope of work. BUILDING Floor Areas Required Setbacks Required Stories: 1 Bedrooms: 1 First: 300 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: Yes Total: sf Value: $33,000.00 Rear: 20 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 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: 0 Clothes Dryers: 0 • Heat Pump: N Hoods: 0 Other Units: 0 Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Fum > =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 8 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) ENGEL, JOHN B GERRITZ CUSTOM HOMES 9960 SW MCDONALD ST 11012 NW MALIA LN TIGARD, OR 97224 Porltand, OR 97229 PHONE:' 503- 939 -7638 PHONE: 503- 320 -7280 FAX: • Total Fees: $1,585.05 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 -001 g R 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 B (� 1i/.li( J Permittee Signature: ocer( 1 a CITY OF TIGARD + 1 MASTER PERMIT °; COMMUNITY DEVELOPMENT Permit #: MST2009 -00213 1 7 [ G AR D. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/20/2009 Parcel: 25111 BA00803 Jurisdiction: Tigard Site address: 9960 SW MCDONALD ST Subdivision: Lot: 0 Project: Engel Project Description: Adding 300 sq ft. BUILDING Floor Areas Required Setbacks Required Stories: 1 Bedrooms: 1 First: 300 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: Yes Total: sf Value: $33,000.00 Rear: 20 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 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 Tvpes Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Fum > =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'I 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'I 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) ENGEL, JOHN B GERRITZ CUSTOM HOMES 9960 SW MCDONALD ST 11012 NW MALIA LN TIGARD, OR 97224 Porltand, OR 97229 PHONE: 503 - 939 -7638 PHONE: 503 - 320 -7280 FAX: Total Fees: $1,472.27 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and at other applicable law. All work will be done ' 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. TENTION: Ore n law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 95 01 -0010 through OAR 2- - 100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. / ' I Is ued By: J/� / Permittee Signature: r v '■`ti� a / 41111 Q Building Permit Application N ... 4 esidential FOR OFFICE ICE 1,1: ONLN City of Tigard CEIVED Date/B� . ©e ` 4 Permit No.: N -- r - ��di/i; . • Z q 13125 SW Hall Blvd., Tigard, OR 97223 2009 Plan Review C Phone: 503.639.4171 Fax: 503.598.1960 NOV 05 2009 Date/I3 : v ' ( her Per""t: T I G A' R D Inspection Line: 503.639.4175 Date Ready/By: Juri IA See Page 2 for Internet: www.tigard CITY OF TIGARD Notified/Method: / 4 Supplemental Information o` WILDING DIVISION 1 , TYPE OF WO REQUIRED, DATA: 1- AND 2- FAMILY DWELLING 01 Permit fees* are based on the value of the work erformed. p ❑ N ew cons ❑ Demolition P gal Indicate the value (rounded to the nearest dollar) of all \‘Q ACAddit on/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the �i' work indicated on this application. '' CATEGORY OF CONSTRUCTION ov \ 1 1- an .2 a f amily dwelling ❑ Commercial/industrial Valuation: $ ❑ Accessory building ❑ Multi- family Number of bedrooms: J Master builder ❑Other: Number of bathrooms: Ad ,-„„ S Nei r�CJJ ' JOB SITE INFORMATION AND LOCATION Total number of floors: J Job site address: CI 1 (i 0 3w V\ CO N c,,LA Si . New dwelling area: square feet 3 Garage/carport area: s uare feet T'i 3".v ) c7�FZ: City /State /ZIP: el 1 :�4 q c. Suite/bldg. /apt` no.: Project name: Covered porch area: square feet ( Cross street/directions to job site: 1 ii- Deck area: square feet \� Other structure area: square feet y REQUIRED DATA: COMMERCIAL -USE CHECKLIST 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. Valuation: $ kelci 0 N,) 1Si )( 20 (3eol o -' u AL 3005 F-T �, 1; Existing building area: square feet ) New building area: square feet I a PROPERTY OWNER I ❑ TENANT Number of stories: N. Name: J p Vx + `O e...•■4 i - L t, e U 5,..(-- Type of construction: Address:, q 1 ( Q 5. L . ) , m O Q N o Occupancy groups: "• City/State /ZIP: ' 1 i. V Ot 0 Q ' 9 a 1 " Existing: i Phone: ( ,'7 ( ) ,C11_ _ (� Fax: ( �)--- New: • N. E APPLICANT ❑ CONTACT PERSON NOTICE Business name: G - 4 '' �.5 • y� 'f L J y- 0 .r All contractors and subcontractors are required to be Contact name: S h trrt . U E • ..,C. t 4 Z licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the A 1112 N . ,„ J 11 t>.Li a LEI jurisdiction in which work is being performed. If the ,, City /State /Z1P: () *-L J RI D.--),.1 apply: is exempt from licensing the following reasons apply: Phone: (SA ) 3 a ,., - n .. 0 Fax:: ( ) ` E- mail: ` O ^ l'e & ( . . 2 C, tom • J v CONTRACTOR C� iv1 - • Business name: G e , s, k A- ti C AAs i 04_ Vi 01^-42, BUILDING PERMIT FEES* (Please refer to fee scheduled .' ? .: ‘ Address: 1 1 Z N „,, \I o► Li a L t•l \ City /State/ZIP: p . 2 2 Structwal plan review fee (or deposit): j f FLS plan review fee (if applicable): Phone: (mil) 3 0 _ 9 2 43 Fax: ( ) CCB lic.: 9 7/It—ICI C1/4 / A 0 j� /C) Total fees due upon application: C Amount received: # 35 Authorized signature: I / ilit I ` This permit application expires if a permit is not obtained • t � within 180 days afterit has been accepted as complete. Print name: ate: 1/_ / ( * Fee methodology set by Tri County Building Industry t fah" • C c: , e, &/ ' Plunbing Permit Application Building Fixtures 1:012 OFFICE USE ONLY I City of Tigard C�IVE R �� Penult No.: ? OO al 3 I v 13125 SW Hall Blvd., Tigard, OR 97 2. Plan Review Date/By: 0 Phone: 503.639.4171 Fax: 503.598.1960 Other Permit No.: • Inspection Line: 503.639.4175 Date Ready/By: Juris: See Page 2 for T I G A R D Internet: www.ti ard or. ov N O V O 5 2009 Ready/By: H g g Notified/Method: Supplemental Information TYPE OF WORgfy OF TIGARD _ FEE* SCHEDULE . ❑ New construction data ,DIVISION For special inforntalion use checklist Description 1 Qty. 1 Ea. 1 Total gAddition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION ' SFR (1) bath 312.70 yl l- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 ❑ Accessory building SFR (3) bath 500.32 ry g ❑ Multi- family Each additional bath/kitchen 25.02 Zf/Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB. SITE INFORMATION AND LOCATION Site utilities: /� r � c Catch basin or area drain 18.76 Job site address: "Ic S' V\ c f.) c ic%L,1 S i Drywell, leach line, or trench drain 18.76 'City/State /ZIP: - C j -J j 0 \q . li 4 1 a..2 Li Footing drain (no. linear ft.: ) Page 2 . Suite/bldg. /apt. no.: v .I Project name: Manufactured home utilities 50.03 Cross street/directions to job site: w tSw 1(v\ C,'(:),z es Lk SA. 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 A �� t 1 / { - ^ 1 Clothes washer 25.02 k 1 ON 1/ 1 O 1"' .d t 7 Dishwasher 25.02 / Drinking fountain 25.02 t� Ejectors /sump 25.02 1CI PROPERTY OWNER • I ❑ TENANT Expansion tank 12.51 � ,(� Fixture/sewer cap 25.02 Name: ^J O "N!^ i' ►✓ S 1 Y e e G N E L • Floor drain/floor sink/hub 25.02 Address: CkOk�X) SW V\ CO c 1c & Garbage disposal 25.02 City /State /ZIP` ; ayiik j 0 (2. cvi 7,2'1 Hose bib 25.02 Phone: (C))) Ci 3 9 _ G.-z, V Fax: ( _-) -__ Ice maker 12.51 . RI APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02 Business name: C:-,e, , `( `( v--\- L C. \.,\ G „ .�- Medical gas (value: $ ) Page 2 (� Primer 12.51 Contact name: �0�t^ VI • (St, Roof drain (commercial) 12.51 Address: 1 I i Z (\) 1N , cL r v, L IJ Sink/basin/lavatory 25.02 City/State /ZIP: t'e „� \_c., ,w a OR 0 1 1 1 2 7 f Solar units (potable water) 62.54 Phone: ( Fax: : ( ) Tub /shower /shower pan 1 12.51 ( Z.1-5( E -mail: 4 G Yl)1ith3 Si" OvQi d'O Q.N't t Cd►n Urinal 25.02 - � �f Water closet 25.02 CONTRACTOR Water heater 37.52 Business name: Ty- O e L+I ' S Ofi , J . 1 \i C t Water piping/DWV 56.29 Address: 2 0 O S N LA 1 6v Other: 25.02 City /State /ZIP: S15 epkv IC Y k) , 0'Q 01. 1� O 0 b Subtotal _t2. 1 Phone: (903) C--7 D G.... v Fax: (5 62) (419- X 3 � 1 1 ( j ( Minimum permit fee: $72.50 51 , c / n Plan review (25% of permit fee) • V CCB Lie.: i S3 O bS Plumbing Lic. no 2 C4"o)9 1 V- < c� State surcharge (12% of permit fee) r ° `\ Authorized signature: TOTAL PERMIT FEE ( r 2.0 I y / ' This permit application expires if a permit is not obtained within 180 days Print name: Date' V ) after it has been accepted as complete. +R.:o .,.wh..A..l...,...4. M, T.;1',......., R..:U :..., Ina...4,s, Cn..nrn 11,.u.,1 ECecte-ical Permit Applicatio® , , • I OR I) I ICE: l Sl O NL eceived �/ City of SW Hall Blvd., R Tigard, OR 972 ,' ' CEIVED DateB : .'o9 MI Permit No.: W917 ,/ 0 ,�pu3 e ° 13125 g Other Permit: ' Phone: 503.639.4171 Fax: 503.598.1960 5 q ( DatePlan /H iew Rev U PI T I G A R D Inspection Line: 503.639 NOV 0 5 2009 Date ReadyBy ® See Page 2 for - - Internet: www.tigard - or.gov Notified/Method: Supplemental Information TYPE OF W(l ckl I OF`TIGAD PLAN REVIEW `�j Addition/alte I1 ement Ili " V lS ON El New construction - Please check all that apply (submit 2 sets of plans w /items checked below): Other: ❑ Service or feeder 400 amps or more ❑ Building over three stories. Demolition ❑ ❑ 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 'J 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. building. ❑ Multi - family i:1 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 - ", "I - ", 9 `-� C /' (� (� 100HP or more. occupancy. Job no.: Job site address: 1 � 0 e5 W t \c. V J1Jn1.Nta S . ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State /ZIP: i ; 6 61 > 0 �1 ❑ Health-care facilities. ❑ Supply voltage for more than �sC ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more. FEE SCHEDULE . Cross street/directions to job site: /001C d fin C. >.l�C.vi .S./ Description 1 Qty. 1 Fee. 1 Total 1 • New residential single- or multi- family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4 c :,°;, , 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 tA) t yi (- C Y OWN," LLD S. t " . 9UVt v a \_ 03, L residential (with above sq. ft.) 67.84 2 �J 9 1 J Services or feeders installation, alteration, and/or relocation \ 3 e 1-41-- U 0 " �' • `r0 % - v . 200 amps or less 100.70 2 • 1,31 PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2 Name: '-' ,..01A 4N . 0 es •1 . ee S *) - L 401 amps to 1, 0 amps am 30 2 ` �p � e 601 amps to 1,000 amps 301.04 2 Address: 01Ct b O S W V\ C'(Jc,a. Si'. Over 1,000 amps or volts 552.26 2 City /State /ZIP: vi i 2 Q� f� - L� Temporary services or feeders installation, alteration, and/or • !a relocation Phone: (� Lf C) "3 ci - t ., 7 Fax: (.._.--)--__ 200 amps or less 59.36 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2 intended for sale, lease, rent, or exchange, according.to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2 Branch circuits - new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with V APPLICANT • ' 1 , 0 CONTACT PERSON above service or feeder fee, each branch circuit 7.42 2 Business name: .� I I L c K$d 01`'; O'v --t(; r B. Fee for branch circuits Contact name: ` n without service or feeder fee, O - vx ►. � t (1 C v i(' . "} Z first branch circuit f 56.18 I€ 2 Address: 1 (0 1, '1 1,S 43 . ifV\ek A Ly- J Each add'I branch circuit 2 7.42 t A, 2 Miscellaneous (service or feeder not included) City/State /ZIP: p y,f_-} Lot� f C? Q pts1 -a-L el Each manufactured or modular / dwelling, service and/or feeder 67.84 2 Phone; 5 ' tj (s ) . , eta' Q Fax: : ( )----- Reconnect only 67.84 2 E - mail: ` 01.Nyk 0 'x -0 tAH d S j '� v 1p ;Y" -t'(_: S r COw Pump or irrigation circle 67.84 2 • yj CONTRACTOR V Sign or outline lighting 67.84 2 N f ' � . Signal circuit(s) or limited- Business name: h I S(>_y ;LL Leciv C �th/L energy panel, alteration, or Address: '( ( 3, - /' o r, extension. extension. Describe: Page 2 2 { J City/State /ZIP: 1.16 ( , V (Ji op t" ^fi ' f Q '3Z Each additional inspection over allowable in any of the above Phone' (3. 3) 9g, 1 y ( _ �3) C ' % 1- (,f t ( , 1 3 Per inspection 66.25 r7 d Fax: ( 1c � Investigation per hour (I hr min) 66.25 p �' Industrial plant hour 78.18 CCB Lic.: ' �� O j Elect Lic.: C 3 � Suprv. Lic.: ��� f 5 P per . - ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: 1 I T Subtotal: 7 (,� Print name: C Cl 6 w . Date: / ` _ y _ 0 Plan rev (25% o f permit fee): r Cr C r 1 State surcharge (12% of permit fee): 5 r ' . Authorized signature: TOTAL PERMIT FEE: (t 5A— Print name: 1 Date: This permit application expires if a permit is not obtained within 180 • • J.E. KRAUSE REEVED ARCHITECT, P.C. NOV 0 5 2009 S 711 Cover Letter (ORS 455.y (FTIGARD Date: 11/03/2009 BUILDING DIVISION Permit Owners Office: City of Tigard Name: John & Desiree Engel 13125 SW Hall Blvd. Tigard, OR 97223 Site Attn: Brian Blalock Address: 9960 SW McDonald St. Building Official Tigard, OR 97224 Permit # Project # 09069 Name: Engel Remodel This review is is for a type VB building and R -3 occupancy. The drawings and related design documents for the proposed work were reviewed and found to be in compliance with the State of Oregon 2008 Residential Speciaty Code, based on the 2006 IRC. As the architect of record, we will be responsible for our drawings, specs, and calculations. All applicable code issues have been addressed and we assume full liability for errors and omissions. If you have any questions feel free to give us a call. pectfully, • sep . Krasu J . Krause Architect P.C. Ph. 503.656.4111 15259 SE 82nd Drive Suite # 202 Clackamas, OR 97015 Fax 503.656.6297 ms s, H5i aoo9- Bo r 3 RECEIVED NOV 12 2009 CITY OF TIGARD BUILDING DIVISION ENVIRONMENTAL HEALTH MEMORANDUM Washington County Dept. of Health and Human Services Refer: Septic System Environmental Health Subject: HHS Approval 155 N. First Ave. Suite 200 Location: 2S1 -11 BA -803 Hillsboro, Oregon, 97124 9960 SW McDonald Street Phone: (503) 846 -8722 Applicant: John & Desiree Engel Purpose: Addition to home with no increase in number of bedrooms. Health and Human Services requirements have been met in full: YES: X NO Additional requirements, as follows, must be met before the Dept. of Health and Human Services approval can be given: YES: NO: X COMMENTS: (1.) No change of use to take place (2.) No increase in sewage flow (3.) All DEQ setbacks must be observed 9 . 1, . 2 =tt'S t ( / c . /el 0 signed date 5 RECEN ED _ _ _ • ovI22 009 l ARp Clean Water Services Fil�r ii tO T Clca n« ��te \ S ices " ,i� f 1 , 1 ( ? .- 17 .SU11 DIN�' IVISION Sensitive Area Pre- Screening Site Assessment _ _ r 1. Jurisdiction: r t' y �' • ► ��� "►v' %� / f 2. Property Information (e);arnp e 1 S23444B01400) 3. Owner Information .� t 6 Tax lot ID(s)s.- .� ' t 6� f )C? %• _ ? Name: "Se !Av. 1 C) i 's J Company: t \ i Address: t- V"), _ `v J r: Site Address: f O v'-` Y��C !_1 sJr -:1 C1 `' City, State. Zip: �i, `9 I - -11 ; ;;') City. State, Zip: I i C,� �' ril (; (? . c'i r) Phone Nx: Nearest Cross Street: E -Mail: 4. Development Activity (check all that apply) 5. Applicant Information Addition to Single Family Residence (rooms, deck, garage) Name: :,11 rZ1:`. r ❑ Lot Line Adjustment U Minor Land Partition Company: { 1 Ce,.;C P Y' ��i C.�O .r I 1 ` �r. �} I:1 ii...• LJ Residential Condominium CJ Commercial Condominium Address: 9 t i` 1 v.i AriLt ni f_ e Residential Subdivision ID Commercial Subdivision City, State, Zip: ' ' C ` ij Single Lot Commercial _J Multi Lot Commercial y p '' I. _` " LbS G 1 '� )'I } f • Other Phone 6,: c: �L %.� .S i i .' _) j ; •- E -Mail: %. 1 y ea ' � i .'Viv 6. Will the project involve any off -site work? J Yes if4 No j Unknown Location and description of off -site work '.7(.if.:,} i t: F' 1 r: ��, �� / '�{ , ?� 1 ., ,) r 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. - r. r� Print/Type Namp. ( <2 �-1'' "� ! vt•a'1 1 ° „� �: r -,: i• Print/Type Title i1f' " �5. Signature /r` �. j2.1 ' / is ✓� Date % /.: b . 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. EJ 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 4 they are subsequently discovered. This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3.02.1. All required permits and approvals,must be obtained and completed under applicable local, State, and federal law. j°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 4 they are subsequently discovered. This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3.02.1, All required permits and approvals must be obtained and completed under applicable local, state and federal law. LI This Service Provider Letter is not valid unless CWS approved site plan(s) are attached. `j The proposed activitidoes not meet the definition of development or the lot was platted after 919/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED. • Reviewed by — : -s' \ .r Date ° { ti ; • z 3y , 64/ , t�., :a 2550 SW Hillsboro Highway( Hills boro Oregon 97123. Phone (503) 681 F ax n ( 503) ] nw * www cl eaaterservrces.org *s „x 1 .. j ; :.i :'iii .,0 1`.. - � 4 - +?Y., 'Y,' -a2 ..4 +-.::. g.. },: :`.'�� •k-.... alcS!.t: