Permit (761) A . CITY F TIGARD SITE WORK PERMIT
i�. DEVELOPMENT SERVICES PERMIT #: SIT2002 -00021
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 12/15/03
SITE ADDRESS: 16035 SW PACIFIC HWY PARCEL : 2S1156A -00500
SUBDIVISION: ZONING :
BLOCK: LOT: JURISDICTION : KIN
CLASS OF WORK: OTR PAVING ?: RESO. NO:
TYPE OF USE: COM GRADING ?: VALUE: 10,000.00
EXCV VOLUME: cy LANDSCAPING ?:
FILL VOLUME: cy SITE PREP ?:
ENG FILL ?: STORM DRAINS ?:
SOILS RPT REQD ?: IMPERV SURFACE: sf
Remarks: Convert existing residence to dental office.
Owner:
FEES
TOIVA SEPP
16035 SW PACIFIC HWY Description Date Amount
KING CITY, OR 97224 [BUPPLN] Pln Ck - Valu 8/29/02 $90.55
[FLS] FLS Pln Rv 8/29/02 $55.72
Phone: 503-620-2185 [BUILD] Prmt Fee -Valu 12/15/03 $139.30
[TAX] Valu 8% State Stu 12/15/03 $11.14
Contractor:
Total $296.71
ROLOFF ONS 'UCTION, INC.
11004 SW ' AVE.
PORTLAN • , 97219
Phone: 503 - 245 - 3895
Reg #: LIC 140721
Required Inspections
Erosion Control Insp 846 -8444
Grading
Paving Insp
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law
requires you to follow 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 copies of these rules or direct questions to OUNC by
calling (503) 246 -6699.
•
Issued By:
Permittee Signature: /6'
Call (503) 639 -4175 by 7:00 P.M. for an insp = - n needed the next business day
it ;7
Buliding tt _. _. O • O Permit Application a ; ? 4` �� ',r s .4 Yar 7' - t r.
Date received: g A9 dR Permitno.: iii
"-1) {l�y��" City of Tigard
' °_:.�► Project/appl. no.: Ex r ire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 r — '�,
Phone: (503) 639 -4171 Date issued: By / Receipt no.:
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: I &2 family: Simple Complex:
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a r >r / slr 1 ,a q � i+ •. , ;TYP OF PERMIT, 0 ,t ; ` ( . ti ( ., v 1s`.,; , tit" �s ^,, V . Lte ; lt
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❑ 1 & 2 family dwelling or accessory ❑ Commercial /industrial ❑ Multi - family LI New construction ❑ Demolition
Cl Addition/alteration/replacement ❑ Tenant improvement ❑ Fire sprinkler/alarm El Other:
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s : -. i.,a . , i i o .4 ,,,,, , v . ,-:it.t,?,� , INFORMATION r , }xs '.a ,, 4 . x 1 _. � h t . ^w' at ,cr.H . . ,y
,
'Job / / 0 c- L i P e i L i c //t 31/ Bldg. no.: Suite no.:
Lot: ) Block: 'Subdivision: t` I Tax map /tax lot/account no.:
Project name:
Description and location of work��o1l1/n��pTElrep)mises /special conditions:
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, :,..ir .h._ . /.1" . ;,�, .�,. �,:.,* °� :rys:,.. .n._r,. { _, :: ?t,?•tiLs 11 1. !X. 5.., FOR SPECIAL I NFORMATION , , USE CHECICISIST�
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Name• 2- , S t ,/, �, �k (F loodplam, septiccapacity; solar, etc) ,', o. ,
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Mailing address: j/,, 0 3 5 . /, \J ,i:--;'6 C/� i C A ...) y 1& 2 family dwelling:
i'City:_' /� /i..G- G ', IState:0, ZIP:, c?7 z / 9 ' Valuation of work $
(Phone: (S03) k ZO -2 / I fr x: E -mail: No. of bedrooms /baths
Owner's representative: Total number of floors
Phone: Fax: E -mail: New dwelling area (sq. ft.)
«`� ' ' i r i:: 'v i'vu tj 'CANT i`" ;, " R � w „ " '' Garage /carport area (sq. ft.)
�:,.! ... .. ,. , , eon tn t r, ..� ,...- .,... �,.. _ 5l� � .Ik�i! �, x': �' ' � ,
Name: Covered porch area (sq. ft.)
Mailing address: Deck area (sq. ft.)
City: I State: I ZIP: Other structure area (sq. ft.)
Phone Fax E-mail: Commercial/industrial/multi-family:
aw � c � � r r ; yz �, r . , v Valuation of work r 6, fE WV 214 $ � (� C d d
f , WI -, _ ' ry CONTRACTOit r , . fig," * �,, C exit- `
Existing bldg. area (sq. ft) r y'
(Business name: 070 CV S .w� irJ - 1 -L "' —
C New bldg. area (sq. ft.)
Address: 1/ DO 4 S c. -./ ? y_" / -1- cit
State: 0 ZIP:- °j 7? Number of stories
eity: F2.7 x I ,I i
`Phone ;%S'a3 \,2e/�66 I E -mail: Type of construction
/ a Z� Occupancy group(s): Existing:
CCB no.: New:
City /metro Ile no.: Notice: All contractors and subcontractors are required to be
4 t} , 4 :401A; , PAR /
C DESI kER G RM.V. , , ,e licensed with the Oregon Construction Contractors Board under
Name: provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
City: I State: ZIP: exempt from licensing, the following reason applies:
t
Contact person: Plan no.:
Phone: Fax: E -mail:
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Name: Contact person: Fees due upon application $ /Y In • ,2 7
Address: Date received:
City: 'State: IZIP: Amount received $
Phone: I Fax: ' E -mail: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached checklist. All provisions of laws and ordinances governing this ❑ Visa ❑ MasterCard
work will be complied with, whether spe herein or not. Credit card number: / '/
/ /ice Z �/ ? /� Expires
~Authorized: signature:,' � � � � � � i Date: Z / � Name of cardholder as shown on credit card
Print name: X ez e_ / / /, ' $
C P � Cardholder signature r Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (limo /COM)
f
SITE WORK PERMIT CHECK LIST
Commercial, Multi- Family (R -1 occupancy) and Residential:
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) Li Rock
❑ CMU
❑ Concrete
❑ Other
*Total new impervious area including all buildings,
sidewalks, and paving: sq. ft.
Site Utilities Plumbing Work:
Complete the "TAN" 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 *Parking (including ADA) and
ADA compliance Lighting Plan
Grading Plan and details *Landscaping Plan
Erosion Control Plan and details Soils Report (if required)
Retaining Structures
*Does not apply to 1 and 2- family dwellings.
TYPE OF SUBMITTAL # of Plans
Required at
(Includes New, Additions or Alterations) Submittal
Commercial 4
Multi - Family R -1 Occupancy 4
One- & Two - Family Dwelling 4
NOTE: Plan review is dependent upon submittal of a completed application and plans.
After plan review approval, the Plans Examiner will contact the applicant to request
additional sets of plans for distribution purposes (for Contractor, City of Tigard,
Washington County, and Tualatin Valley Fire & Rescue).
is \dsts \forms\sitechecklist.doc 09/24/01
CITY OF TIGARD
BUILDING DIVISION PERMIT #: SIT2002 -00021
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12/15/2003
Phone: (503) 639 -4171 9 p , I�tll�lh
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 7/14/2005 TIME: 7:11AM PAGE: 2
SITE ADDRESS: 16035 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: SEPP PROFESSIONAL OFFI
DESCRIPTION: Convert existing residence to dental office.
OWNER: SEPP, TOIVA PHONE #: 503 - 620.2185
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 7/14/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
499 Final inspection 011434 -01 503-620 -2185 N
Corrections/Comments/Instructions:
PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: ("AA 4. Date: 1.. / — 65 #: 503 718 - �/l` d
P y