Permit q CITY OF TIGARD SITE WORK PERMIT
g :. COMMUNITY DEVELOPMENT Permit #: SIT2010 -00014
TIGARD 13125 SW HaII Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/19/2010
Parcel: 2S104CD10200
Jurisdiction: Tigard
Site address: 13611 SW TRACY PL
Subdivision: HILLSHIRE ESTATES NO. 2 Lot: 101
Project: Cerbone
Project Description: 8 -12 foot retaining wall at back of property
Owner: FEES
CERBONE, ROBERT REVOCABLE LIVING Description Date Amount
13611 SW TRACY PL
TIGARD, OR 97223 Permit Fee - Site Work 08/19/2010 $419.52
Plan Review 08/10/2010 $272.69
PHONE: 12% State Surcharge - Building 08/19/2010 $50.34
Erosion Control 08/19/2010 $80.00
Contractor: Erosion Plan Review CWS 08/19/2010 $26.00
CENTERSTONE CORPORATION Erosion Plan Review COT 08/19/2010 $26.00
1233 SE 15TH AVE
CANBY, OR 97013
PHONE: 503 - 803 -2689
FAX:
Type of Use: SF
Class of Work: OTR
Site Specifics:
Excavation Volume: cu. yd.
Fill Volume: cu. yd.
Impervious Surface: sq. ft.
Engineered Fill: Soil Report Required:
Paving: Grading:
Landscaping: Site Prep:
Store Drains: Retaining Wall: Yes
Fire Underground: Accessible Parking:
Fence:
Total $874.55
Required Items and Reports (Conditions)
1 SIT Ersn Cntrl 503 - 681 -4444
2 SIT Structural Observation
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 obtain a copy of the rules
or direct questions to NC Iling 03.246.6699 or 1.800.332.2344.
Issued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that siness 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 ;
Residential RECEIVED
Holz OFFICE I IC E ; HSE O!N 1
=
City of Tigard Received
Permit No.:5 1-T 0 • - �_ /
` u 13125 SW Hall Blvd., Tigard, OR 97223 AUG 10 Date/B : /� O Plan Review I
® r. Phone: 503.639.4171 Fax: 503.598.1960 D Date/B : '- c t ' 7 - )D, Other Permit:
T I G A R D Inspection Line: 503.639.4175 �I� OF TIGARD Date Ready/By: Juris: El See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: 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: Regrading 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: $35,000
❑ Accessory building ❑ Multi - family Number of bedrooms: 4
❑ Master builder ❑ Other: Number of bathrooms: 2.5
JOB SITE 'INFORMATION AND LOCATION Total number of floors: 2
Job site address: 13611 SW Tracy Place New dwelling area: nla• square feet
City/State /ZIP: Tigard, OR, 97223 -5659 Garage /carport area: n/a square feet
Suite/bldg. /apt. no.: Project name: Covered porch area: n/a square feet
Cross street/directions to job site: Intersection of SW Boxelder and SW Essex Deck area: n/a square feet
Other structure area: n/a square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Hillshire Estates No. 2 Lot no.: 101 Permit fees* are based on the value of the work performed.
Tax map /parcel no.: 2S104CD10200 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.
Build retaining wall along property line along SW Esses and SW Boxelder, Valuation: $
respecting applicable easements. Regrade existing property. Existing building area: square feet
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name: Robert Cerbone Type of construction:
Address: 13611 SW Tracy Place Occupancy groups:
City /State/ZIP: Tigard, OR, 97223 -5659 Existing:
Phone: (503)590 -9300 home Fax: (n/a) New:
® APPLICANT Di CONTACT PERSON NOTICE
- Business name: Homeowner All contractors and subcontractors are required to be
Contact name: Robert (Bob) Cerbone licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 13611 SW Tracy Place jurisdiction in which work is being performed. If the
City/State/ZIP: Tigard, OR, 97223-5659 applicant is exempt from licensing, the following reasons
Y g apply:
Phone: (503) 590 -9300 home Fax: : (n /a)
E -mail: \0 Ce,c — \,,A-a Ve.. - At
CONTRACTOR
Business name: Steve Pfeifer, Centerstone Corp BUILDING PERMIT FEES*
Address: (Please refer to fee schedule)
Structural plan review fee (or deposit): ),7 R `p
City /State /ZIP: Canby, OR 1
Phone: (503) 803 -2689 �� `�� Fax: (503) 263 -1911 FLS plan review fee (if applicable):
F Total fees due upon application:
CCB lic.: 141604
Amount received:
Authorized signature: ii
t This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Robert Cerbone T Date: Aug 10 2010 • Fee methodology set by Tri- County Building Industry
Sd 3 — 570 -9300 Service Board.
I: \Buiiding\Permits\BUP -RES PermitApp.doc 10/01/09 440 -4613T(I I /02 /COM/WEB)
r \1 C w
t L, C 1 II 1- -,t,
Clean Water Services File Number
MAY 2 0 2010 CleanWate Services 1 10-00 / 7 1
By nsitive Area Pre - Screening Site Assessment
1. Jurisdiction: Tigard
2. Property Information (example 1S234AB01400) 3. Owner Information
Tax lot ID(s): 2S14CD -10200 Name: Robert Cerbone
Hillshire Estates No. 2, Lot 101 Company: Homeowner
Address: 13611 SW Tracy Place
Site Address: 13611 SW Tracy. Place City, State, Zip: Tigard, OR, 97223 -5659
City, State, Zip: Tigard, OR, 97223 -5659 Phone/Fax: 503 - 590 -9300 home; 503 - 310 -9300 cell
Nearest Cross Street: SW Mistletoe E-m bcerbone @verizon.net
4. Development Activity (check all that apply) 5: Applicant Information
Li Addition to Single Family Residence (rooms, deck, garage) Name: Robert Cerbone
❑ Lot Line Adjustment ❑ Minor Land Partition Company: Homeowner '
I ❑ Residential Condominium ❑ Commercial Condominium Address: 13611 SW Tracy Place
❑ Residential Subdivision ❑ Commercial Subdivision Tigard, OR, 97223 -5659
❑ Single Lot Commercial ❑ Multi Lot Commercial City, State, Zip: 9
Other Build retaining wall along property line adjacent to Phone/Fax: 503- 590 -9300 home; 503 - 310 -9300 cell
SW Essex and SW Boxelder; regrade landscape E-m bcerbone @verizon.net
6. Will the project involve any off -site work? ❑ Yes No ❑ Unknown
Location and description of off -site work
7. Additional comments or information that may be needed to understand your project
Sewer easement at east comer of property is known and retaining wall will not violate easement
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.
Print/Type Narrle1RObert r erb9A Print/Type Title Homeowner
Signature 1 i _,..r'1° 1. ,.. _, Date May 19, 2010
FO R 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
ma also be required.
: ased 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 Provide etter is not valid unless CWS approved site plans) are attached.
❑ The proposed acti d .' es not meet the defini 'in of i • vetopme o the lot w :s platted after 9/9(95 ORS 92.040(2). NO SITE ASSESS 'ENT OR
SERVICE P' • I r . - ETTER IS REQUIRE 1i. / /
Reviewed by M� 1 it A,._ _ Lai Date -2 ( o
`2550 SVJAHilfsboro +Highway Hillsboro,: Oregon 97.123 • Phone:'(503) =5100 • Fax (503) 681 4439. • www.deanwaterservices.org ,
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