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Permit 1 1/51/0 CITY ® TIG ARD MASTER PERMIT ` COMMUNITY DEVELOPMENT Permit #: MST2008 -00153 1 Date Issued: 11/04/2008 YTIGAREi 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 P,. ;, Parcel: 2S103CD00500 Jurisdiction: TIG Site address: 13655 SW 115TH AVE Subdivision: Lot: Project: CONLEY Project Description: Addition, garage and shop. 4/15/10, adding (1) feeder and (4) additional branch circuits. BUILDING Floor Areas Required Setbacks Required Stories: Bedrooms: First sf Basement: sf Left: 5 Parking Spaces: Height: Bathrooms: Second: sf Garage: 756 sf Front: 20 Smoke Dwelling Units: Third: sf Right: 5 Detectors: Yes Total: sf Value: $28,516.32 Rear: 15 PLUMBING Sinks: Water Closets: Washing Mach: Laundry Trays: Rain Drain: Catch Basins: Lavatories: Dishwashers: Floor Drains: Sewer Lines: SF Rain Other Fixtures: Tubs /Showers: Garbage Disp: Water Heaters: Water Lines: Drains: Bckflw Prevntr: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: Clothes Dryers: Heat Pump: N Hoods: Other Units: Fum <100K: Vents: Woodstoves: Gas Outlets: Furn > =100K: ELECTRICAL Residential Unit Service Feeder Tem Srvc/Feeders Branch Circuits 1000 sf or less: 0 -200 amp: 0 -200 amp: W/ Svc or Fdr: Ea addl 500 sf: 20 1 -400 amp: 201 -400 amp: 1st W/O Svc/Fdr: Limited Energy: 401 -600 amp: 401 -600 amp: Ea add9 Br Cir: 601 -1000 amp: 601 +amp- 1000v: 1000 +amp /volt: 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) ALLEN CONLEY 13655 SW 115TH AVE TIGARD, OR 97223 PHONE: 510 - 914 -0488 PHONE: FAX: Total Fees: $925.52 This perms issued' to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work wit be ne 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 d s. ATTENTION: Oregon aw requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 2 -001 -0010 through OAR 95 1 -0 0. You may obtain a copy of the rules or direct questions to OUNC by callin .246.6699 or 1.800.332,2344. I ued By: s��- . ✓�7 Permittee Sign e rl . MASTER PERMIT ,:- Ili .':...:': , , TY OF T PERMIT #: MST2008 00153 COMMUNITY DEVELOPMENT DATE ISSUED: 11/4/2008 [TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 2S103CD - 00500 SITE ADDRESS: 13655 SW 115TH AVE ZONING: R -4.5 SUBDIVISION: LOT: JURISDICTION: TIG PROJECT: CONLEY Project Description: Addition, garage and shop BUILDING REISSUE: CUSTOM STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED CLASS OF WORK: ADD HEIGHT: FIRST: sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y TYPE OF USE: SF FLOOR LOAD: SECOND: sf GARAGE: 756 sf FRONT: 20 PARKING SPACES : TYPE OF CONST: 5N DWELLING UNITS: THIRD: sf RIGHT: 5 VALUE: 28 516.32 OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 0 sf REAR: 15 PLUMBING SINKS: WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS: LAVATORIES: DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS: TUB /SHOWERS: GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS: OTHER FIXTURES: MECHANICAL FUEL TYPES FURN < 100K: BOIUCMP < 3HP: VENT FANS: CLOTHES DRYER: FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: ELECTRICAL RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS 1000 SF OR LESS: 0 - 200 amp: 0 - 200 amp: WISVC OR FDR: PUMP /IRRIGATION: PER INSPECTION: EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/O SVCIFDR: 1 SIGN /OUT LIN LT: PER HOUR: LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EA ADDL BR CIR: 3 SIGNAUPANEL: IN PLIANT: MANU HM /SVC /FDR: 601 - 1000 amp: 601 +amps- 1000v: MINOR LABEL: 1000+ amp /volt : PLAN REVIEW SECTION Reconnect only: > =4 RES UNITS: SVC /FDR> =225 A.: > 600 V NOMINAL: CLS AREAISPC OCC: ELECTRICAL - RESTRICTED ENERGY A. SF RESIDENTIAL B. COMMERCIAL AUDIO 8 STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM /PAGING: OUTDOOR LNDSC LT: BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL: GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR: HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS: This permit is subject to the regulations contained in the Tigard Owner: Contractor: Municipal Code, State of OR. Specialty Codes and all other applicable ALLEN CONLEY OWNER laws. All work will be done in accordance with approved plans. This 13655 SW 115TH AVE permit will expire if work is not started within 180 days of issuance, or TIGARD, OR 97223 if the 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 952- 001 -0080. You may obtain copies of these rules or direct Phone: 510 - 914 - 0488 Contact #: questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Reg #: TOTAL FEES: $ 779.49 REQUIRED ITEMS AND REPORTS Ersn Cntrl 681 -4444 - 4 / Iss - d By : ��1/1lB _e� Permittee Signature : , II/ /1 W 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. . Build' E Yeinit pplication RECEIVE FOR OFFICE USE City of Tigard L oateB d P a0 ag Permit No. • . i / j - C1�1S3 13125 S W Hall Blvd., Tigard, OR 97223 Plan Review .: Phone: 503.639.4171 Fax: 503.598.1960 n. Date/ By: �p•3t� O 9 r 4* C OCT 2 0200 y Other Permit: • T I G A R D Inspection Line: 503.639.4175 Date Ready/ y: `,�/ '11 ® pple See Page mental 2 fo In fo ation Internet: www.tigard - or.gov CITY OF MARL) Notified/Method: 4 3 i � Surm TYPE OF wl.DING DIVISION 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 1Addition /alteration/replacement ❑ 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: $ 2& bOO ❑ 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: r3& 5 6v,1 l k AJ E New dwelling area: square feet City /State /ZIP: - &k-D OP- 'Ai 1--2-3 Garage /carport area: G square feet Suite/bldg. /apt. no.: Project name: C Covered porch area: square feet Cross street/directions to job site: \/, 3 e Deck area: square feet Other structure area: B go square feet REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: Lot no.: Permit fees* are based on the value of the work performed. �� $ Indicate the value (rounded to the nearest dollar) of all Tax map /parcel no.: O equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. ADD VA� ` +E ArNfl 5*09 To e)(tCT S-F• Valuation: $ Existing building area: square feet New building area: square feet PROPERTY OWNER ❑ TENANT Number of stories: Na _• i4. 4 Name: • l 4 e j . "< ( Type of construction: Address: t73 (9 SS c, W 1 l t j '():. ME Occupancy groups: ity /State /ZIP: d it&fity. (P.- a"j']) 2- Existing: Phone: ( Skip) 0 0 4 04s °v Fax: ( ) New: (A. APPLICANT ❑ CONTACT PERSON NOTICE Business name: l'ivlit 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: *{It 2to ota. BUILDING PERMIT FEES* Address: (Please refer to fee schedule) City /State /ZIP: Structural plan review fee (or deposit): v �n 7_ �f q FLS plan review fee (if applicable): Phone: ( ) Fax: ( ) CCB lic.: Total fees due upon application: �a� /� Amount received: � '7 ` g' v Authorized signature: T his permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: 1.2-. A Aid ( Date: 10 ( tai iJ ° a * Fee methodology set by Tri- County Building Industry Service Board. I:\Building\Permits \BUP -RES PermitApp.doc 11/6/07 440- 4613T(11 /02 /COM/WEB) Building Permit Application Checklist • One- and Two- Family Dwelling iV1,, " ' .' F `' I ORO U SE i ONLY t �` f 4,," ; 3 »,. a 6 t,' 4s.> „ 9'= :'.%g�c ?� s� ' ��p^+4' A T ,I ;i tu- * 4it w: a T4 Y R eceived Permit Ho.: City of Tigard .. ' r y a 13125 SW Hall Blvd., Tigard, OR 97223 Date By: B P hone: 503.639.4171 Fax: 503 598.1960 Associated permits: 24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical l IGARD 3 „,, --,-;;;;4 - Internet: www.tigard - or.gov ❑ Other: I E O LI Z I RE RE li -- - 1F PLANT ' REVIEW QN o ! '= 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ■ ■ F. 2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ■ ■ k; 3 Verification of approved plat/lot. ■ ■ I 4 Fire district approval required. Name of district: .00NI 5 Septic system permit or authorization for remodel. Existing system capacity ■ ■ al 6 Sewer permit. ■ ■ F: 7 Water district approval. ■ ■ MI 8 Soils report. Must carry original applicable stamp and signature on file or with application. ■ ■ 2 9- , t sion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ■ ■ I basin .rotection, etc. 10 3 C ■ mplete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ? ■ ■ . ing 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 0 c :.yright violations exist. II i e /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if 12 ■ ■ lj ere 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 1 El ■ and location. 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, at ■ ■ 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- E ■ ■ 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. L! ■ ■ 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- 5 ■ ■ 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 ■ ■ g 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 ■ ■ V over 10 feet long and /or any beam/joist carrying a non - uniform load. 20 Manufactured floor /roof truss design details. El ■ iv 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas - piping schematic is required ■ ■ 1 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 ■ ■ rj architect licensed in Oregon and shall be shown to be ap to the .roject under review. tikAti R I S f, IC darn' l" "1 - 1 ..y3:., ' ?, ' `v,. ' " }, .5ii 23 ` site plans are required for Item I I above. Site plans must be 8 -1/2" x 11" or 1 I" 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 ❑ ❑ Q Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, E . ❑ ❑ and protection measures must be drawn to scale and accompanied by 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) . N .,' vl . a 'i F s' t x P z " • . Electrical Permit Application u I „ FOR'OFFICEUSE ONLY - 1`, i f „i. lig City of Tigard *I 1 y Date/By: a og \ Il 110 Permit No.: )/hf9S —ee /53 r' ° 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review OCT }} OC,; Other Permit: Phone: 503.639.4171 Fax: 503.598.1960 OCT G 020C3 Date /By: Ins ection Line: 503.639.4175 Date Ready /By: Juris: ® See Page 2 for T I C A R D! Internet: www.tigard- or.gov ' p otified/Method: Supplemental Information : ' TYPE OF W CITY OF MAR-, DIVISION. LAN_ REVIEW ❑ New construction VI Addition/alteration/replacement nt t 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 0 Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural [5i 1- 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 ❑ Emergency system. larger separately derived system. JOB SITE INFORMATION AND LOCATION " ❑ Addition of new motor load of ❑ "A ", "E ", "1 - ", "I -3 ", Job no.: Job site address: I17&SS 'v4 I (S AJ E 100HP or more. occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State /ZIP: T I(glPky -o OF- co7-7 3 ❑ Health -care facilities. ❑ Supply voltage for more than ❑ 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: S W (9t4 71)5-- Description I 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 145.15 4 Ea. add] 500 sq. ft. or portion 33.40 1 Tax map /parcel no.: O 0 gy residential R 1� v Limited energy, 75.00 2 - DESCRIPTION OF WORK. . (with above sq. ft.) Limited energy, multi- family 75.00 2 App 001 6 a A-Nit. .Hop T I , O \ST S •F•R. residential (with above sq. fl.) Services or feeders installation, alteration, and/or relocation 200 amps or less 80.30 2 ' PROPERTY OWNER ❑ TENANT. _ 201 amps to 400 amps 106.85 2 Name: 12., A q u.A 14 eo0Le( 401 amps to 600 amps 160.60 2 601 amps to 1,000 amps 240.60 2 Address: 156, L ! I t 5-11ft A.Je. Over 1,000 amps or volts 454.65 2 City /State /ZIP: - rtv}∎, L9 R e i -223 Temporary services or feeders installation, alteration, and/or relocation Phone: (�jl O) qt.:* . c24 % O Fax: ( ) 200 amps or less 66.85 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2 intended for sale, lease ent, or exchange, cc g to ORS 47, 44 , 670, and 701. 401 amps to 599 amps 133.75 2 n (0.21• or Branch circuits — new, alteration, or extension, per panel Owner signature: !�''� A. Fee for branch circuits with I NI. APPLICANT 0 CONTACT. PERSON above service or feeder fee, 6.65 2 each branch circuit Business name: B. Fee for branch circuits Contact name: 5AME without service or feeder fee, 46.85 2 first t branch circuit Address: Each add] branch circuit 'J 6.65 2 Miscellaneous (service or feeder not included) City /State /ZIP: Each manufactured or modular dwelling, service and /or feeder 90.90 2 Phone: ( ) Fax: : ( ) Reconnect only 66.85 2 E -mail: Pump or irrigation circle 53.40 2 CONTRACTOR, Sign or outline lighting 53.40 2 Business name: '' 44 Signal circuit(s) or limited - { w Iv� energy panel, alteration, or Address: extension. Describe: Page 2 2 City/State /ZIP: Each additional inspection over allowable in any of the above Per inspection 62.50 Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50 CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75 . ' ELECTRICAL PERMIT FEES . Suprv. Electrician signature, required: Subtotal: Print name: Date: Plan review (25% of permit fee): State surcharge (12% of permit fee): Authorized signature TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 Print name: Date: days after it has been accepted as complete. * Number of inspections allowed per permit. I:\ Building\Permits\ELC- PermitApp. doc 05/23/06 440- 46I5T(I t /05 /COM /WEB Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: 's; . RESIDENTIAL WORIK ONLY :. Fee for all residential systems combined $75.00 Check Type of Work Involved: n Audio and Stereo Systems* ❑ Burglar Alarm ❑ Garage Door Opener* n Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* n Other: COMMERCIAL WORK ON LYc Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems n Boiler Controls • ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation n HVAC n Instrumentation ❑ Intercom and Paging Systems n Landscape Irrigation Control* n Medical ❑ Nurse Calls n Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\ Building \Permits\ELC- PermuApp.doc 03/23/06 Information Notice to Property Owners About Construction Responsibilities Statement Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit 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 with the permit. Please check the appropriate box and complete the following statement: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. ��� \I' " i 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 contract with a contractor who is licensed with the CCB and will immediately notify the office issuing this building permit of the name of the contractor. I have read and understand the Information Notice to Property Owners about Construction Responsibilities contained on these two pages and I hereby certify that the information checked and completed above is correct and accurate. I� 444- I r Al 4���.� ^✓V► Print name of permit applicant Signature of permit applicant t( %a 4 k` 0 !› Date Permit #: ' 1 � g' 53 This form is supplied to building permit offices by the Oregon Address: 151p55 ° 06 �D`G n Construction Contractors Board, N `: ;,, 4 as required by ORS 701.055 (6) f.�' te0/9 7a- t. Issued Date: q This copy to issuing permit office i t r 1'- CleanWaier Services - - - -_- t?ur oinn ilia cnl i> clear. CWS File Number Sensitive Area Pre - Screening Jn6 . 06 73‘1 a Site Assessment Jurisdiction: c t.i,_ Property Information: (example 1S234ABo1400) Owner Information: Taxlot ID(s):— tea Name: (L• ft U.A Company: Address: Mt Sri $W lir7 Ad E Site Address: 1369ti SW I 1 Ad E City State Zip: '116 O Z �1 1 :2-1 City State Zip: 12-0 t OIZ °l1vi -3 Phone /Fax: 5 10— 914'•O4tQ / Nearest Cross Street: SW &AA 4L. . E -mail: Development Activity: Check all that apply Applicant Information: Addition to Single Family Residence (rooms, deek, garag Name: 91416. Lot Line Adjustment ❑ Minor Land Partition Company: Residential Condominium ❑ Commercial Condominium ❑ Address: Residential Subdivision ❑ Commercial Subdivision ❑ City State Zip: Single Lot Commercial ❑ M of Commercial ❑ Phone /Fax: / Other - - rl�. � t'r E -mail: • Will the project involve any off-site work: YES NO ICI Unknown Location and description of off -site work: Additional comments or information that may be needed to understand your project: This application does NOT replace the need for 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 doc,ment, � annd to the best of my knowledge and belief, this information is true, complete, and accurate. Print/Type Name: -• 4 LL 44� C N Print/Type Title: Nom` Signature: >,' , Date: O 20 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. 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 if 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. ❑ 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 if 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. ❑ This Service Provider Letter is not valid unless CWS approved site plan(s) are attached. ❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT R SER ICE PROVIDER LETTER IS REQUIRED. Reviewed By: Date: /0 D . 2550 SW Hillsboro Highway • Hillsboro, Oregon 97123 Phone: (503) 681 -5100 • Fax: (503) 681 -4439 • www cleanwaterservices.org Revised: May 8, 2007