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Permit
i ,q my ® T' gARD _ MASTER PERMIT T PERMIT ft: MST2009 -00081 I ° COMMUNITY DE!,1LOPMENT DATE ISSUED: 2/20/2009 A rGAR D' 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 1S133DD-00700 SITE ADDRESS: 11689 SW 129TH PL ZONING: R -4.5 SUBDIVISION: VILLAGE AT SUMMER LAKE PARK 2 LOT: 046 JURISDICTION: TIG PROJECT: BARBU Project Description: New walls for bedroom & bathroom. Work completed prior to permit. BUILDING REISSUE: STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED CLASS OF WORK: ALT HEIGHT: FIRST: sr BASEMENT: sf LEFT: SMOKE DETECTORS: TYPE OF USE: SF FLOOR LOAD: SECOND: of GARAGE: sl FRONT: PARKING SPACES : TYPE OF CONST: 5N DWELLING UNITS: THIRD: s/ RIGHT: VALUE: ' OCCUPANCY GRP: R3 BDRM: 1 BATH: 1 TOTAL: 0 sf ' 2,100.00 REAR: PLUMBING SINKS: WATER CLOSETS: 1 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS: LAVATORIES: 1 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: 1 CLOTHES DRYER: FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: ELECTRICAL RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVCIFEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS 1000 SF OR LESS: 0 • 200 amp: 0 • 200 amp: W /SVC OR FDR: - PUMP /IRRIGATION: PER INSPECTION: EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/0 SVCIFDR: 1 SIGN /OUT LIN LT: PER HOUR: LIMITED ENERGY: 401 - 600 amp: 401 • 600 amp: EA ADDL BR CIR: SIGNAUPANEL: IN PLANT: . MANU HM /SVCIFDR: 601 • 1000 amp: 601•amps- 1000v: MINOR LABEL: 1000= amp /volt : PLAN REVIEW SECTION Reconnect only: > =4 RES UNITS: SVCIFDR> =225 A.: > 600 V NOMINAL: CLS AREAISPC OCC: ELECTRICAL - RESTRICTED ENERGY . A. SF RESIDENTIAL B. COMMERCIAL . AUDIO & 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 6 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 DAN & VIORICA BARBU OWNER laws. All work will be done in accordance with approved plans. This 11689 SW 129TH PL 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: 503- 747 -5125 Contact #: questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Reg #: TOTAL FEES: $ 337.63 REQUIRED ITEMS AND REPORTS Issued By : l ( L Q Permittee Signature : ----"ggifil 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. ® Tidemark Advantage [Gary Noble - GN] . 0,97.1g1 File Edit Options Window Help i it Exit New Open Task List OBE GIS ■ II I Clove Edit Project Group Add Clone Parcel Activity People Foes Valuation Condition:, Case Notes Tags Documents GIS Case La P Bit ,es r? Query IMIN GIS 1 Help I Cancel j 1. Case# —„ Number: Fraction: Prefix: 2. Address ___ 4 i h 1689 I 3. Master # - . , 4. Name Street Name: Unit: - a 5. Parcel # 1129 6. P Name •a� , _ - . . _ ' : :. _ ' : _: _ , ' Case No Status Address la Plumbing PLM892445 umbing Permit -- Status F '-' MST 2009 1 11689SW 129TH PL Name:DON MORISSETTE Updated: 4/12/1990 BLT General `' BUP892236 F 11689 SW 129TH PL • Address :11689 SW . 129TH PL Jur: IG MEC892446 F 11689 SW 129TH PL ' } _ MST93 -00519 F 11689 SW 129TH PL Description: Master *1892236 Pro 92236 ; ' Fixtures • - - - - - - -- • PLM892445 F 11689 SW 129TH PL ` SWR892447 F 11689 SW 129TH PL Misc. Number of Fixtures Sinks: 1 1 Washing Machines: 3 1 . Lavatories: I 3 Floor Drains: f Tub /Showers: 3 Water Heaters: 1 1 • Water Closets: 3 3 Laundry Trays: 1 Dishwashers: 3 1 Urinals: 1 Garbage Disposals: I 1 Other Fixtures: 3 " . .._ _ . ;Ready 'lasErkti ` si Tidemark Advantage �__ _r__ 1 p FA. 12:08 PM • . . , , „ . ir,i, , . 12! Tidemark Advantage [Gary Noble - GN] 1c El File Edit Options Window Help , . 1 tg-4 0 0 I:11 MI e i Exit New Open Task List QBE GIS I _J ,• i I E1 4 D GC -5 RI a 0 4 1; i ;1 ggi It? .k. CI C21 a 1 Close Edit Project Group Add Clone Parcel A tivitu .People Pets Valuation Conditions Cave Notes Tags Documents GIS Case I - -- Activity! • •. • • - " • . . - , . . . . ' ( 1-311)v,-..e ' . • ' • • .. . • - • . ' • - ,. . • • . . - • . . , . . . . . . . .. - Query 1 GIS Help I Cancel 1 ... ., , „. :•., ' . •- . ' . : , " ' .. . -. - - ' , -1 i • , . . ,. '• • - 1. Case # 1 = , - . . . • . . ... • • . .......... - - - 0 Number Fraction: Prefix: . .. . .,.: --.. 2. AddreSs 1 = .. . --- ...... • [11689 1 1 .... . 3. Master # . • _ . . , . .• . . . , . . . 4. Name Street Name: Unit: . , - • ... . . . . , 5. Parcel # 1129 6. Project Name Building Permit (BUP) BUP892236 Status F in __ --., -.....,.., ,....,,, 1 „...,... . Case No Status Addres N DON MORISSETTE • Updated: 511511990 JLH - General . .., MST 2009 I 11689 SW 129TH PL Address: 11689 SW 129TH PL - . Jur: frid --• -.' = 3 -•–• ' ; - •••?-1' – –" '''.! ' ' -- ` • BUP892236 - F 111 89 SW 129TH PL 6 - Sp - - Description: Master 0392236 Project 92236 ecifics & --------, .•• • • _'. MEC892446 F 11689 SW 129TH PL - : Areas . . -!--;... t-='.• , - -.... = - • ..-.! MST93-00519 F 11689 SW 129TH PL $30 for 2 red line copies 1 .,-- • •7.. • ' Setbacks -, :---•= PLM892445 F 11689 SW 129TH PL , , 7 :- . . SWR 892447 F 11689 SW 129TH PL --.-'-: .-------.:* ---* --,- . ,..,. „ - --- 'z: r":,4: 4 , – - - • . - , — ' Const. ,,,,...., Specifics Floor Areas (sf) , . • -'-'•„,----- ` *Stories: 1 2 First: EiTOE5 Second: 1 1,120 • _ . , t , . • 1 1 1 Height: I30 . . • • . . . . .. , . Basement?: 1 _ ___ __ _ ._ . .. . . - . .• ..- . ... ., _ .. . „. • , , . - • • Mezzanine?: 1 , Totals (sf) . ..-,. Floor Load: 1 40 psf Total Area 17,1i6 . , .... . . . .. . , _ - . _ • .-- - • . • % - -- - *Dwelling Units: 1 1 " , , , • , ,• , • . • . _ .• . _ „ . Basement 1 ------ Garage: 1 441'. - • .... *Bedrooms: 1 4 _ . • • • . , ■ ■ # Bathrooms: 1 3 • . - ' • -- .. .. - .. • , , • . • • . •., , - , • . • . - • - . , _ . , ____ -- ------ View/Add Activities 1 tall id • •.) _ T• .ematkAdvaritage 0 - a& - . - ........ -_____ 12:10 PM Tidemark Advantage [Gary Noble - GN] 151Ld File Edit Options Window Help _ _ _ fig _.. _ -- _ �_ ii V�a 0 J EF`s — _____. i( Exit New Open Task List QBE GIS Ia Close Edit Project Group Add Clone Parcel Activity People fees Valuation Conditions Case Notes Tags Documents GIS Cave Query ] l GIS 1 Help 1 Cancel 1, Case # Number Fraction: Prefix: 2. Address___ P 111689 1 3. Master # _ • 4, Name Street Name Unit 5, Parcel # 1129 -;__•` 6. Project Name t ` Ma ster Permit - MST93 - 0 0 5 1' 9 S tat us F ..:: r Cas No Status Address _; ' Z" MS T2009.00081 I 11689 SW 129TH PL Name :MAX ANGELES Updated: 3/1411994 JF - General `. BUP892236 F 11689 SW 129TH PL Address :11689 SW 129TH PL Jur: IG ,• :' MEC892446 F 11689 SW 129TH PL Description: Master # MST93 - 00519 _ 'Project: /VILLAGE AT SUMMERLAK - 6uilding , MST93 16 89 SW 129TH PL ' 00519 f . 1 - _ _ -. _ __._. _ - -- - � - STATE LICENSE ADULT FOSTER CARE HOME -- MAXIMUM 5 RESIDENTS AND 2 '_ PLM892445 F 11689 SW 129TH PL . " ._ SWR892447 F 11689 SW 129TH PL CAREGIVERS. Mechanical _� . . - Plumbing '', Floor Areas (Square Feet) Setbacks , 4 # of Stories: 1 First Floor 617 Left: j 33 Right: j 5 Electrical Height of Building: [ 16 FT Second Floor Front I Rear 25 ' F loor Load: 4 PS Th ird Floor , ` ` Electrical . ' - - Required Items ' Dwelling Units: 1 _ Total Floor 617 -Smoke Detectors: Yes _ _ " # of Bedrooms: 4 Basement # Parking Spaces: Restricted Elecrical # of Bathrooms: 1 Garage: Residential Restricted Elecrical -- ;., Commercial, ;Ready _ .. ___ ____ _Ttdemar}c Advantage ': ,, , _ .. _ _ . P ' e 12:07 PM j �� Tidemark Advantage [Gary Noble - GN] in File Edit Options Window Help Exit New Open Task Li -.t OBE GIS i l i M Clot% Edit Project Group Add Clone Parcel Activity People Fee: Valuation Condition: Ca :e Now Tog: Document GIS Ca.c I Query 1On GIS 1 Help 1 Cancel I 1. Case #_ — — I Number: Fraction: Prefix: , 2. Address , � 1 3. Master # V__ h1689 I - 4. Name I Street Name: Unit: 5. Parcel # . 1 1129_ . . Cr 6. Proje Name 1 Ra' la Master Permit -- MST93 -00519 Status F - Case No Status . __._ ___- address '. ': MST2009 -00081 I 11689 SW 129TH PL Name:MAX ANGELES Updated: 3/14/1994 JF General BUP892236 F 11689 SW 129TH PL Address :11689 SW 129TH PL Jur: IG r MEC892446 F 11689 SW 129TH PL Description: Master # MST93 -00519 Project: !VILLAGE AT SUMMERLAK u s MST93.00519 F 11689 SW 129TH PL 6 9 S 9 STATE LICENSED ADULT FO CARE HOME -- MAXIMUM 5 RESIDENTS AND 2 ' PLM892445 F 11689 SW 129TH PL ' " .. SWR892447 F 11689 SW 129TH PL ,CAREGIVERS Mechanical Plumbing S inks: 1 Floor Drains: 1 Backflow Drains: I 1 E Electrical ��� Lavatories: Water Heaters: Traps: cal Tub/Showers: f 1 i Laundry Trays Catch Basins: I Water Closets: i 1 ' Sewer Line: — ! Grease Traps: Electr Dishwashers: Water Line: Other Fixtures: Restricte • Garba Dis Rain Drain: Elecrical Y Residential Washing Machines: SF Rain Drains: 1 Restric Elecrical Commercial Ready �____� . _ _ _ _ �___ �..__ _v .._ I. tig&fill i) { 0 Tide a' 12 07 r "Advantage opa A ; � PM �' — — -- CITY OF TIGARD • BUILDING DIVISION PERMIT #: MST2009-00031 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 2/20/2009 Phone: (503) 639-4171 Inspection Requests (24 Hrs.): (503) 639-4175 INSPECTION WORKSHEET FOR DATE: 2/23/2009 TIME: 7:00AIY1 PAGE: 14 SITE ADDRESS: 11689 SW 129111 PL. CLASS OF WORK: SUBDIVISION: VILLAGE AT SUMMER LAKE PARK 2 LOT #: 046 TYPE OF USE: PROJECT NAME: BARBU DESCRIPTION: Now waft for bedroom & bathroom. Work cornpleted prior to permit. OWNER: BARN.), DAN & VIORICA PHONE #: 503-747-5126 CONTRACTOR: OWNER PHONE #: Inspection Request Scheduled For: Date: 2/23/2009 Pour Time: Code # Inspection Description nfirm Contact # Message 399 Plumbing final 0130739-02 \503.747-5125 Corrections/Comments/Instructions: ) A ow.iskuukftn El PASS 0 PARTIAL APPROVAL 0 CANCEL 0 NO ACCESS Ki FAIL CALL FOR INSPECTION El ADDITIONAL FEES ASSESSED Inspector: G—. Pje, U Date: 2 13- O Phone #: (503) 718- 1-141/10 rr VP/ OF TIGARD BUILDING DIVISION PERMIT #:1A151 2 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 2I1:401 Phone: (503) 639 -4171 ICI Inspection Requests (24 Hrs.): (503) 639 - 4175:_.. INSPECTION WORKSHEET FOR DATE: (,I 1 3/ ®9 TIME: PAGE: SITE ADDRESS: I I Ith9 S W 1 29 P L-• CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: DESCRIPTION: OWNER: b (Firc--) PHONE #: CONTRACTOR: 0 vArdit PHONE #: Inspection Request Scheduled For: Dater 3101 Pour Time: Code # Inspection Description Confirm # t Contact # Message ` 1 E �° PEAL Corrections /Comments/ Instructions: PA'S n PARTIAL APPROVAL ❑ CANCEL n NO ACCESS ❑ FAIL U CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: Cr 6 Dater 4 a 6 9 Phone #: (503) 718- VW) CA=W OF TIGARD BUILDING DIVISION #: MS12009000131 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 2)20/2009 Phone: (503) 639-4171 Inspection Requests (24 Hrs.): (503) 639 -4175 1. . INSPECTION WORKSHEET FOR DATE: 2/2312(109 TIME: 7:00AM PAGE: 13 SITE ADDRESS: 11609 SW 129TH PL. CLASS OF WORK: SUBDIVISION: VILLAGE AT SUMMER LAKE PARK 2 LOT #: 046 TYPE OF USE: PROJECT NAME: DARI3U DESCRIPTION: New walls for bedroom & tmthroom. Work completed prior to permit. OWNER: f3ARBU, DAN & VIORICA PHONE #: 503 -747-5125 CONTRACTOR: (DINNER PHONE #: Inspection Request Scheduled For: Date: 772312009 Pour Time: Code # Inspection Description Confirm # Contact # Message 199 Electrical final 000738 -03 503747.5125 • N Corrections /Comments/ Instructions: d - Af • ,6" ■ = I VW\ ers7)14 acicsiy\ CliVitziv■.- Pca • t 5' 2 • a pRLDvdQ-4 kcor i-NA0t4 A I em, ALL 16 beat) n\w...Logsr3C0 C 1. ►.. • ALL, O v . Lr \ . v' ► _,�t 1 ,. x..41_ : t .k j d • 3 • • t . A L-1--- C.6104 } A 4011111MlatilLAi pczio‘lib l r ac. (V tit) vA D rn n PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS FAIL ri CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: N66 L Date: )- "13 "J Phone #: (503) 718- 10, CITY OF TIGARD 077/ BUILDING DIVISION PERMIT #: MST2009 O'.. !0F31 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 7J20 2009 Phone: (503) 639 -4171 Inspection Requests (24 Hrs.): (503) 639 -4175 INSPECTION WORKSHEET FOR DATE: 2/23/2009 TIME: 7:Q0AM PAGE: 12 SITE ADDRESS: 11669 SW 129TH PI CLASS OF WORK: SUBDIVISION: VILLAGE AT SUMMER LAKE PARK 2 LOT #: 046 TYPE OF USE: PROJECT NAME: L3ARL3U DESCRIPTION: Neu =nor drooirrk throop Work completed pli r to permit. OWNER: L3ARBU, DAN & VIORIt A PHONE #: 503- 747 -5125 CONTRACTOR: OWNER PHONE #: Inspection Request Scheduled For: Date: 2123/2009 Pour Time: Code # Inspection Description Confirm # Contact # Message 299 Final in pection 06071%01 503.747.5125 N Corrections /Comments/ Instructions: Nne-- . n PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Vtt Inspector: Date: 2'3 q Phone #: 503 (503) 718 CITY OF TIGARD �� BUILDING DIVISION PERMIT #: yMST2009 -00031 13125 SW Hall Blvd., Tigard, OR 97223 1� DATE ISSUED: 2/20/2009 Phone: (503) 639 -4171 � Inspection Requests (24 Hrs.): (503) 639 -4175 , "'I I.. INSPECTION WORKSHEET FOR DATE: 2/73/2009 TIME: 7 : 00AM PAGE: 15 SITE ADDRESS: 11689 SW 129TH PL CLASS OF WORK: SUBDIVISION: VILLAGE AT SUMMER LAKE PARK 2 LOT #: 045 TYPE OF USE: PROJECT NAME: F3ARBU DESCRIPTION: New walls for bedroom & bathroom. Work completed prior to permit. OWNER: F3ARE3tJ, DAN & VIORICA PHONE #: 503 -747 -5125 CONTRACTOR: OWNER PHONE #: Inspection Request Scheduled For: Date: 272312009 Pour Time: Code # Inspection Description Confirm # Contact # Message 699 Mechanical final 080739 -01 503-747-5125 N Corrections /Comments /Instructions: e) "ei 6/ 1A- AtAJ — IAA OV � )Z1\1 ate + - et • PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS ❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED V (52-----"--- D Inspector: Date: 9 Phone #: (503) 718- `-'-1-04 - ` Building Permit Application Residential FOR OFFICE USE ONLY Received City of Tigard Date/By: IR 0 ` I Permit No.: ?— g / 31 4 I • 13125 SW Hall Blvd., Tigard, OR 97223 R Phone: 503.639.4171 Fax: 503.598.1960 Plan DateB view 2 - t 9 0 9 /13 Other Permit: T I GA R D I / ta Inspection Line: 503.639.4175 Date ReadReady/By: � Ju�ri / s ^ : 0 See Page 2 for Internet: www.tigard - or.gov Notified/Method: t Supplemental Information 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. ❑ I- and 2- family dwelling ❑ Commercial /industrial Valuation: $ c I /DD ❑ Accessory building ❑ Multi- family Number of bedrooms: / ❑ Master builder ❑ Other: Number of bathrooms: / JOB SITE INFORMATION AND LOCATION Total number of floors: I Job site address: /1 ' .5 W /2 64 Pore New dwelling area: square feet City /State /ZIP: 7 7 QQ / ©,e! 722 3 Garage /carport area: square feet Suite/bldg. /apt. no.: / Project name: C* o Ne S Covered porch area: square feet Cross street/directions to job site: / Deck area: square feet Other structure area: 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.: equipment, materials, labor, overhead, and the profit for the �!/ DESCRIPTION OF WORK work indicated on this application. d /V.6I/j4q /4c. LLt4%y w N Li 'roOW 1 Grs e . v19 a u -, 0 4.4 Valuation: $ /mu . Golps i+9 ck ho t� -bj4 row )co A lieu) I (bD A, Existing building area: square feet / New building area: square feet $ PROPERTY OWNER ❑ TENANT Number of stories: Name: , ice & v /64,1 eea- 1 i, cap 6 U Type of construction: Address: //C4 .Sw /29' Place Occupancy groups: City /State /ZIP: j,' a w ! Q ? 57.22 . 3 Existing: Phone: (503) 7'7• / - Jf- `,/25 Fax: (5:0 3) - $ 72 - 57d c94 New: 0 APPLICANT ❑ CONTACT PERSON NOTICE Business name: e.iryy,,Att e6 he ,ohP/ i4r. Aram- as r . All contractors and subcontractors are required to be Contact name: YID � �e i f �� d �J licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: //6' ' OW ( 2 .9' 7 j%CP • jurisdiction in which work is being performed. If the City /State /ZIP: , /� ero./ © X 9'7 3 applicant is exempt from licensing, the following reasons r apply: Phone: (503 ) 74 67 5 Fax: : (5b3) - 3 72 -5/5)4 E -mail: CONTRACTOR Business name: CIO i, ) Ea- BUILDING PERMIT FEES* Address: �W (Please refer to fee schedule) City /State /ZIP: Structural plan review fee (or deposit): Phone: ( ) Fax: ( ) FLS plan review fee (if applicable): CCB lic.: ,., Total fees due upon application: Amount received: Authorized signatureis This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: ,d A t,./ ,, ,,,e,e, Date: 2 / /,epp 9 * 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 FOR OFFICE USE ONLY City of Tigard Received permit No I II 1 3125 SW Hall Blvd., Tigard, OR 97223 Date By: 11 Phone: 503.639.4171 Fax: 503.598.1960 Associated permits: T I GA R l) 24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical Internet: www.tigard - or.gov ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No N/A 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑ 2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑ 3 Verification of approved plat/lot. ❑ ❑ ❑ 4 Fire district approval required. Name of district: . ❑ ❑ ❑ 5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ ❑ 6 Sewer permit. El ❑ ❑ 7 Water district approval. ❑ El ❑ 8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑ 9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑ basin protection, etc. 10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ El El building 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 copyright violations exist. 11 Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ El there 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 ❑ ❑ ❑ and location. 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑ 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 ❑ ❑ ❑ . 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. ❑ ❑ ❑ 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 El ❑ ❑ 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 El ❑ ❑ locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ El ❑ 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 ❑ ❑ ❑ over 10 feet long and/or any beam/joist carrying a non - uniform load. 20 Manufactured floor /roof truss design details. ❑ ❑ ❑ 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑ 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 ❑ ❑ ❑ architect licensed in Oregon and shall be shown to be a..licable to the I ro'ect under review. JURISDICTIONAL SPECIFICS 23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" 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. ❑ El ❑ 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. ❑ El El 28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ El ❑ Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑ and protection measures must be drawn to scale and must include 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. I.\ Building \Permits\BUP- RES- PennitApp.doc 03/21 /06 440- 4613T(II /02ICOM/WEB) Electrical Permit Application FOR OFFICE USE ONLY City of Tigard Received Date /By: % I T o g Permit No.: p.../ 9— w ilig • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review s Phone: 503.639.4171 Fax: 503.598.1960 Date /By: Other Permit: T I G A R D Inspection Line: 503.639.4175 Date Ready /By: hurls: 0 See Page 2 for Internet: www.tigard- or.gov Notified/Method: / Supplemental Information TYPE OF WORK PLAN REVIEW ❑ New construction ❑ Addition/alteration/replacement 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. El Demolition ❑ Other: 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 ❑ 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 JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ", Job no.: Job site address: L' P SW /291` P6ac t. Six or or more residential Recreational ❑ Six or more residential units. ❑Recreational vehicle parks. City/State /ZIP: ' — ' �,r © 4 �j722' 3 • CI Health-care facilities. ❑ Supply voltage for more than / �/ 600 volts nominal. A • 2 ' I C.A. 0 locations. Suite/bldg. /apt. no.: Project name: - - . , - _ 'J * ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total New residential single- or multi- family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4 Tax map /parcel no.: Ea. add'I 500 sq. ft. or portion 33.40 1 Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) k ,' /�l�"" ( t i.. haq --�« .a °w t added 4 .� • X�x4 Limited energy, multi- family / � et • �' residential (with above sq. ft.) 75.00 2 a s re9 4 4y CePoir , Services or feeders installation, alteration, and/or relocation / 200 amps or less 80.30 2 RA PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2 Name: ,('q, ti & VIQ,/`ii hei 401 amps to 600 amps 160.60 2 601 amps to 1,000 amps 240.60 2 Address: Ile ? 9 S i4/ ) 29' f4 ?Lace, Over 1,000 amps or volts 454.65 2 City/State /ZIP: c. ii% p R 9722 3 • Temporary services or feeders installation, alteration, and/or relocation Phone: 67) 3) - 74 7.- 6 Fax: (,,Ir) 3 ) -372- 5 /84 . 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, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2 Branch circuits — new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with IN APPLICANT I ❑ CONTACT PERSON above service or feeder fee, each branch circuit 6.65 2 Business name: pl//yl>°i, /T , 7`; 6 • B. Fee for branch circuits s VII U fir st without service or feeder fee, / Contact name: V/ D / 1 / Cq / pa VII branch circuit 46.85 2 Address: / le 6 [ l -S PV, l2 P aQc e - . Each add'! branch circuit 6.65 2 Miscellaneous (service or feeder not included) City/State /ZIP: /t C (/J �c / D a e 9 2.2 2 � . Each manufactured or modular 90.90 2 dwelling, service and/or feeder 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: (A.) { v ^ , /n Signal circuit(s) or limited - L ((� 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 Lie.: Electrical Lic.: Suprv. Lie.: Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: Plan review (25% of permit fee): Print name: ` Date: State surcharge (12% of permit fee): GL Authorized signature: >0 TOTAL PERMIT FEE: Print name: i j //y' , j � / f1 ,6. a Date: 2//e/2_.02, This permit days after it has been accept d as co plete. d within 180 * Number of inspections allowed per permit. I: \ Building \Permits\ELC- PermitApp.doc 05/23/06 440- 4615T01/05 /COM/\EB Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: Fee for all residential systems combined $75.00 Check Type of Work Involved: ❑ Audio and Stereo Systems* ❑ Burglar Alarm ❑ Garage Door Opener* ❑ Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* ❑ Other: COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC n Instrumentation n Intercom and Paging Systems n Landscape Irrigation Control* n Medical n Nurse Calls ❑ 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- PermitApp.doc 03/23/06 Mechanical Permit Application FOR OFFICE USE ONLY City of Tigard Date /By: d l 9 0 9 Permit No.: 1 / lig • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review i . Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit: T I G A R D Inspection Line: 503.639 Date Ready /By: Ion s 0 See Page 2 for Internet: www.tigard - or.gov Notified/Method: ' /t) Supplemental Information TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST Mechanical permit fees* are based on the value of the work ❑ New construction ❑ Addition/alteration/replacement performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit. CATEGORY OF CONSTRUCTION Value: $ RESIDENTIAL EQUIPMENT / SYSTEMS FEES* ❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist. ❑ Multi- family ❑ Master builder ❑ Other: Description Qty. I Ea. I Total JOB SITE INFORMATION AND LOCATION Heating/cooling Job site address: / Air conditioning or heat pump � � {�j �� 9 c G �E' (requires site plan showing placement) 14.00 City/State /ZIP: // e2 t7/ 772 3 Furnace 100,000 BTU (ducts /vents) 14.00 ' / Furnace 100,000+ BTU (ducts /vents) 17.90 Suite/bldg. /apt. no.: Project name: j L (/ Gas heat pump 14.00 Cross street/directions to job site: Duct work I 10.00 Hydronic hot water system 14.00 Residential boiler (radiator or hydronic) 14.00 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 14.00 Subdivision: Lot no.: Flue /vent for any of above 6.80 Other: 10.00 Tax map /parcel no.: Other fuel appliances DESCRIPTION OF WORK Water heater 10.00 y �J / 4 Gas fireplace 10.00 / Cu 7 1' x'' e Q rt f 2 .i � iA/0C4 1� G1 0, %e /" -PVO t , , Flue vent for water heater or gas r ^e o f ye /1/ 1.t ca / Gi 490 :X7c chre Czeici/ai �'•/ /e. cl. fireplace 10.00 / ` J/ 5 Log lighter (gas) 10.00 c . ex ex( factil de c J - t;-, j/2! // eat d 4 - fie w/ Wood/pellet stove 10.00 Wood fireplace /insert 10.00 ❑ PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 10.00 Other: 10.00 Name: 4C- 1 Viorieet , ' / Environmental exhaust and ventilation Range hood/other kitchen Address: //6 s w /29)/4 PA,,,° . equipment 10.00 City /State /ZIP: 7;r 0 , 7223 Clothes dryer exhaust 10.00 Single -duct exhaust (bathrooms, Phone: ()3) -74i /25" Fax: ( ) toilet compartments, utility rooms) ( 6.80 ❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 10.00 �/ / � Other: 10.00 Business name: Suf9f/r /! ✓4,00e A 7.` C Fuel r in PP K Contact name: Via r / t - q / c l','6 U $5.40 for first four; $1.00 for each additional Furnace, etc. Address: l ,ff SW / y /4 P/c re Gas heat pump City/State /ZIP: 77,5 / 6,Q. C i7Z2 3 Wall/suspended/unit heater Phone: (5V ') — 74. 5,(25 Fax: : (5 3) - Z72- 6;4'4 ‘ Water heater Fireplace E -mail: Range CONTRACTOR Barbecue , ^ Clothes dryer (gas) Business name: r )�, n I 2 Other: Address: v MECHANICAL PERMIT FEES* City/State /ZIP: Subtotal Minimum permit fee ($72.50) Phone: ( ) Fax: ( ) Plan review (25% of permit fee) CCB lie.: State surcharge (12% of permit fee) , TOTAL PERMIT FEE 2 " This permit application expires if a permit is not obtained within 180 Authorized signature days after it has been accepted as complete. Print name: .d t., ,Qje�(,) Date: Z j/9/2 * Fe e methodology set by Tri- County Building Industry Service Board \ C\ Building \PermitsMEC- PermitApp.doc 01/19 /07 44 -4617T (l I /02 /COM/WEB) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial Fee Schedule: Total Valuation: Permit Fee: $1.00 to $2,000.00 Minimum fee $72.50 $2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and $1.80 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and $1.35 for each additional $100.00 or fraction thereof, to and including $50,000.00. $50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and $1.25 for each additional $100.00 or fraction thereof, to and including $100,000.00. $100,000.01 and up $1,396.50 for the first $100,000.00 and $1.10 for each additional $100.00 or fraction thereof. Note: All new commercial buildings require 2 sets of plans. I:\Building\Permits\MEC- PermitApp.doc 01/19/07 2 Plumbing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard Received n I � t ki b �� J � &/ • 13125 SW Hall Blvd., Tigard, OR 97223 Date/B �( ( Q rJ Permit No.: 7 1111 ■ DateBy: Phone: 503.639.4171 Fax: 503.598.1960 an Review Other Permit No.: Inspection Line: 503.639.4175 Date Read /B turf 0 See Pa e ntel 2 for T I l A R l) ard -or. ov y o Internet: www.ti �� g www.tigard-or.gov Notified/Method: / Kea Sappleme Info TYPE OF WORK FEE* SCHEDULE ❑ New construction ❑ Demolition For special information use checklist. Description I Qty. I Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 ❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 Each additional bath/kitchen 45.00 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: /( d'g ,S1,{/ 729 ( )'1 qcr - Catch basin or area drain 16.60 City/State /ZIP: e7 9 7 22 3 Drywell, leach line or trench drain 16.60 / / - Suite/bldg. /apt. no.: Project name: A51/9-A'6 (J Footing drain (no. linear ft.: ) Page 2 Manufactured home utilities 110.00 Cross street/directions to job site: Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: l Lot no.: Water service (no. linear ft.: ) Page 2 Fixture or item Tax map /parcel no.: Absorption valve 16.60 DESCRIPTION OF WORK / Backflow preventer Page 2 1- , YX1.- / � kr 9 Q J-t Lt k cl' / 0. .--/ a' . Backwater valve 16.60 / Clothes washer 16.60 Dishwasher 16.60 ❑ PROPERTY OWNER ❑ TENANT Drinking fountain 16.60 Ejectors /sump 16.60 Name: 4 & Oe y-t '2f'� ii Expansion tank 16.60 Address: //6 7t S'L4) / 7 Lace Fixture /sewer cap 16.60 City /State /ZIP: 175 Ck /0/ OiC ??"7223 Floor drain/floor sink/hub 16.60 Phone: ( Z) 74 / 5/2 e Fax: ( 1)-- - v72- 57674 Garbage disposal 16.60 ® APPLICANT ❑ CONTACT PERSON Hose bib 16.60 � Cl ,,�/�lP f / r 41)-7.-/-/e, Ice maker 16.60 Business name: / 't Interceptor /grease trap 16.60 Contact name: V /t✓iIPfC " ,4/')e 5 C/ Medical gas (value: $ ) Page 2 Address: (// S 14) /25 ' 21«C"(''' • Primer 16.60 City /State /ZIP: 77, Qin// IV . 97223 Roof drain (commercial) 16.60 Phone: (5 - 72, .5 9 j Fax: : ( :0 3 ) -372- 67V-/ Sink/basin/lavatory / 16.60 Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet / 16.60 Business name: C:)( R 1, 1 E, Water heater 16.60 Address: `�-' Other: City/State /ZIP: Subtotal Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) C State surcharge (12% of permit fee) Authorized signature: TOTAL PERMIT FEE Print name: ( 49//t/ /j (1 Date: 2//912009 This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. t:\ Building \Permits\PLMF- PennitApp.doc 12 /27/06 440- 4616T(10 /02/COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: Footing drain - 1' 100' 55.00 0 to 2,000 $115.00 Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00 3,601 to 7,200 $220.00 Sewer - 1st 100' 55.00 7,201 and greater $309.00 Sewer - each additional 100' 46.40 Water Service - 1st 100' 55.00 Medical Gas Systems: Water Service - each additional 100' 46.40 Valuation: Permit Fee: Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and including $10,000.00. Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to (minimum permit fee $36.25) 27.55 and including $25,000.00. Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for each additional $100.00 or fraction thereof, to Inspection of existing plumbing or and including $50,000.00. specially requested inspections - per hour 72.50 Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for each additional $100.00 or fraction thereof. Fixture Work: Plan Review for Plumbing Installations Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following. please indicate work performed by fixture. Failure to Please check all that apply. accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed Fixture Type: Replace engineer. Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure Baptistry/Font as defined in OAR918- 780 -0040. Bath - Tub / Showcr ❑ Medical gas and vacuum systems for health care facilities. - Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system. Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040. -Drive Thru Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher - Commercial - Domestic Drinking Fountain Isometric or Riser Diagram Eye Wash ❑ Isometric or riser diagram is required for new buildings Floor Drain/sink - 2" that meet the qualifications above. - 3" -4" Car Wash Drain Garbage - Domestic Comments regarding fixture work: Disposal - Commercial - Industrial Ice Mach./Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley *Note: If the fixture work under this permit results in an - Commercial increase of sewer EDUs, a sewer permit will be issued and - Service fees assessed for the sewer increase must be paid before the Swimming Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet - Toilet Urinal Other Fixtures: is\ Building \Permits\PLM- PermitApp.doc 12/27/06 Property Owner Statement Regarding Construction Responsibilities 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: own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or I jj< 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 select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. Print Name of Permit plicant est, 2/2 /0 0, Signature of Permit Applicant Date Permit #: \‘ S d 9 — B I F a 0 Address: < < (c t �- c l ►` n L * '' . • 2 e)2. q7 a2 3 NI tmro ) 2 : . / Issued by: A (9 D Oat:: _ ._ %;`, 5 This Copy for Permit Offices a < " 4 4): - `4, � Information Notice to Owners About Construction Responsibilities E ST q N (ORS 701.055 (5)) Homeowners acting as their own general contractors to construct a new home or make a substantial improvement to an existing structure, can prevent many problems by being aware of the following responsibilities: • Homeowners who use labor provided by workers not licensed by the Construction Contractors Board, may be considered an employer, and the workers who provide the labor may be considered employees. As an employer, you must comply with the following: • Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Department of Revenue at 503 - 378 -4988. • Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503 - 947 -1488. • Oregon's Business Identification Number (BIN): is a combined number for both Oregon Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms. • Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs if one of your workers is injured on the job. For more information, call the Workers Compensation Division at the Department of Consumer and Business Services at 503 - 947 -7815. • Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov. Other Responsibilities of Homeowners: • Code Compliance: As the permit holder for a construction project, the homeowner is responsible for notifying building officials at the appropriate times, so that the required inspections can be performed. Homeowners are also responsible for resolving any failure to meet code requirements that may be found through inspections. • Property Damage and Liability Insurance: Homeowners acting as their own contractors should contact their insurance agent to ensure adequate insurance coverage for accidents and omissions, such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not otherwise covered as employees by Workers Compensation Insurance. • Expertise: Homeowners should make sure they have the skills to act as their own general contractor, and the expertise required to coordinate the work of both rough -in and finish trades. CONSTRUCTION CONTRACTORS BOARD 700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052 Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007 Website Address: www.oregon.gov /ccb f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant