Permit CITY OF TIGARD SITE WORK PERMIT
` ; COMMUNITY DEVELOPMENT Permit #: SIT2010 -00010
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/20/2010
Parcel: 1 S136CD01001
Jurisdiction: Tigard
Site address: 11747 SW PACIFIC HWY
Subdivision: Lot: 0
Project: Chevron
Project Description: Site work for construction of new canopy, fueling facility and new office building.
Owner: FEES
CAIN PETROLEUM INC Description Date Amount
4512 SW KELLY AVE Permit Fee - Site Work 07/20/2010 $717.96
PORTLAND, OR 97239 Plan Review 04/20/2010 $466.67
PHONE: 503 -546 -3535 Plan Review - Fire Life Safety 04/20/2010 $287.18
12% State Surcharge - Building 07/20/2010 $86.16
Contractor: Erosion Control 07/20/2010 $80.00
DOUBLE R PRODUCTS /DEL J INC Erosion Plan Review CWS 07/20/2010 $26.00
901 NW E STREET Erosion Plan Review COT 07/20/2010 $26.00
GRANTS PASS, OR 97526
PHONE: 541 -476 -1387
FAX:
Type of Use: COM
Class of Work: ALT
Site Specifics:
Excavation Volume: 0 cu. yd.
Fill Volume: 484 cu. yd.
Impervious Surface: 203 sq. ft.
Engineered Fill: No Soil Report Required: No
Paving: Yes Grading: Yes
Landscaping: Yes Site Prep: Yes
Stom Drains: Yes Retaining Wall: No
Fire Underground: No Accessible Parking: Yes
Fence:
Total $1,689.97
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: Permittee Signature: efiv- „9- e,51-77 el f
124
CaII 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 i-v , 0 Q9- c 00 3 E
Site Work RE - FOR OFFICE USE ONLY
City of Tigard C ' V Date /B PIA V 1 1--)b- / Permit No.: 3�'-T 0 �w
IIII 13125 SW Hall Blvd., Tigard, OR 97223 q Plan Revie
C ' , Phone: 503.639.4171 Fax: 503.598.1960 APR 2 Q 2 ! Date /B : ,r
� �L d Ann Other Permit: e ).0 L
T 1 GA RD Inspection Line: 503.639.4175 Date Ready _ Juris. ® See Page 2 for
Internet: www.tigard - or.gov CITY O' F it UMrt_ r Notified/Method: Supplemental Information
BUILDING
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
® Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION
work indicated on this application.
1=I 1- and 2- family dwelling ® Commercial /industrial Valuation: $
❑ Accessory building El Multi-family Number of bedrooms:
1:1 Master builder El Other:
Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 11747 SW Pacific Highway New dwelling area: square feet
City/State /ZIP: Tigard, OR 97223 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Cain Chevron Covered porch area: square feet
Cross street/directions to job site: Near Hwy 217 Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: 1001 Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Sec 36, T1 S Rl W 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.
Construct site improvements for construction of new canopy, fueling facility Valuation: $82,500.00
and new office building. Existing building area: square feet
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name: Cain Petroleum Inc. Type of construction:
Address: 4512 SW Kelly Occupancy groups:
City/State /ZIP: Portland, OR 97239 Existing:
Phone: (503)546 -3535 Fax: ( ) New:
® APPLICANT ® CONTACT PERSON NOTICE
Business name: PDG All contractors and subcontractors are required to be
Contact name: Dave Kimmel licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 1335 SW 66th Ave, Ste. 201 jurisdiction in which work is being performed. If the
City /State /ZIP: Portland, OR 97225 applicant is exempt from licensing, the following reasons
apply:
Phone: (503) 329 -5399 Fax: : (503) 327 -8456
E -mail: pdgplanning @comcast.net
CONTRACTOR
Business name: Double R Products BUILDING PERMIT FEES*
Address: 901 NW E Street (Please refer to fee schedule)
Structural plan review fee (or deposit):
City /State /ZIP: Grants Pass, OR 97526
Phone: (541) 476 -1387 Fax: ( ) FLS plan review fee (if applicable):
CCB lic.: 40432 Total fees due upon application:
Amount received:
Authorized signature: / ,, 1 ' e This permit application expires if a permit is not obtained
/ G� within 180 days after it has been accepted as complete.
Print names v>0 (/, / Date: 4 2 .�U * Fee methodology set by Tri-County Building Industry
Service Board.
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•
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: 0 cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) 484 cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) 484 cu. yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
❑ Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks, and paving: 203 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 -1 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
54.49 for each additional $1,000.00 or
fraction thereof.
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