Permit n CITY OF TIGARD MASTER PERMIT
' ' n ' „ .. COMMUNITY DEVELOPMENT Permit #: MST2010 -00127
T I G ARE) 13125 SW Hall Blvd. Tigard OR 97223 503.639.4171 Date Issued: 08/24/2010
. Parcel: 15134 BD08500
Jurisdiction: Tigard
Site address: 11542 SW WOODLAWN CT
Subdivision: Lot: 0
Project: Davidson
Project Description: 296 sf addition.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 70 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 226 sf Garage: 0 sf Front: 20 Smoke
Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Yes
Total: sf Value: $30,177.20 Rear: 15
PLUMBING
Sinks: 1 Water Closets: Washing Mach: Laundry Trays: Rain Drain: Catch Basins:
Lavatories: Dishwashers: 1 Floor Drains: Sewer Lines: SF Rain Other Fixtures:
Tubs /Showers: Garbage Disp: 1 Water Heaters: Water Lines:
Drains: 1
Bckflw Prevntr:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: Clothes Dryers:
Heat Pump: N Hoods: 1 Other Units: 1
Fum<100K: Vents: Woodstoves: Gas Outlets:
Fum > =100K:
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 0 -200 amp: 0 -200 amp: W/ Svc or Fdr:
Ea add! 500 sf: 20 1 -400 amp: 201 -400 amp: 1st W/O Svc/Fdr:
Limited Energy: 401 -600 amp: 401 -600 amp: Ea add! 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)
DAVIDSON, KAREN & VICTOR OWNER
11542 SW WOODLAWN CT
TIGARD, OR 97223
PHONE: 971 - 355 -4069 PHONE:
FAX:
Total Fees: $1,555.60
This permit i& 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 ne in accordan 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
ays. ATTENTION: Oregon • - - quires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -001 through OAR 9 •' r • 1 - 00. may obtain a copy of the rules or direct questions to OUNC by calling 503.246. 699 or 1.800.332.2 44.
Issued By. // i Permittee Signature: ■ AL ' / � .JL
Building Permit Application
Residential ,��� • t -. . 1 ol( oFi IcL.utic ()NIA . •
III City of Tigard � �� Received 0 4. �,1\� Date/I3 0 ► 0 p
v 13125 SW Hall Blvd., Tigard, OR 97223 tf
O� ' ' ' Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 ,_ , . ; : 66 : 91 _ • Other Permit: V ! '
l- G R r� Inspection Line: 503.639 {��() G� `. to �+ . dy/By: � l � Juri9: Fa ee Page 2 for
Internet: www.tigard- or.gov �^ ` ed/Method: Ai '! 'i 4 Supplemental Information
C 4 ` � �,,� 6
Luny C-
. TYPE OF 'WORK C ��`� • REQUIRED DATA: 1 -AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition 1, 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- and 2- family dwelling ❑ Commercial/industrial Valuation: $ 0 _0(3
12 Accessory building ❑ Multi - family Number of bedrooms: iO ')77 717
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND OCATION Total number of floors:
Job site address: 1 l ICJt,1 Z t t • ®O( 1 Ak.ZyA New dwelling area: 36/ square feet
City /State /ZIP: - Ti g fi.rd Op,. 7223 Garage /carport area: square feet
Suite/bldg./apt. no.: Project name: •Cotii.1/ 1 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 J work indicated on this application.
T4Ctev.o.un v .o,S�er Q /AA. EXletn /, Valuation: $
n
k 1 '� 0 w � -I 1 kc. L ,b � Existing building area: square feet
f New building area: square feet
lir PROPERTY 'OWNER ' ❑ TENANT Number of stories:
Name: Vi LA-0 4 Da4t V 0 Type of construction: -
Address: , f• ` `_ e-.�- Occupancy groups:
-
City /State /ZIP: ` Q t 0 . . 72 G 3 Existing:
Phone: ( , , _ 04 l 0 Fax: ( ) New:
O. APPLICANT • ❑ CONTACT PERSON 'NOTICE • _ .
Business name: 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: BUILDING PERMIT FEES*
Address: 0 10 l.i (Please refer to fee scheduled
((v // Structural plan review fee (or deposit):
City /State /ZIP:
FLS plan review fee (if applicable):
Phone: ( ) Fax:( )
CCB lic.: Total fees due upon application:
Amount received:
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name:
4/04.
il 9 y . s Date: $ 3 2.010 * Fee methodology set by Tri -County Building Industry
Service Board.
I:\Building\Permits\BUP -RES PennitApp.doc 11/6/07 440 -461 (11 /02 /COM/WEB)
Building Permit Application Checklist
One- and Two - Family Dwelling . !1 OI( p1 1 ILt us ,_OONI
City of Tigard Received permit No.:
I II 13125 SW Hall Blvd., Tigard, OR 97223 Associy:
9 Phone: 503.639.4171 Fax: 503.598.1960 Associated permits:
24- Hour Inspection Line: 503.639.4175 ❑Electrical ❑Plumbing 0 Mechanical
Tic; AIL D
Internet: www.tigard- or.gov ❑ Other:
I :TI-IE FOLLQWINC iIFNISIARFAI QUIRE1),IFOW1 L,AN..IZEVIE .:.
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. ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
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 ,74• ❑ ❑
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 ❑ ❑ ❑
there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -11. 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- ❑ ❑ ❑
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 ❑ ❑ ❑
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 Toad.
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 •ro'ect under review.
jIJRISDIC 1 IONAI_ SP[CII ICS r,
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. ❑ ❑ ❑
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 ❑ ❑ ❑
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.
1:\ Building \Permits\BUP- RES- PermitApp.doc 03/21/06 440- 4613T(11 /02/COM/WEB)
Electrical Permit Application I OR OFFICE I,ti(OV1.1
City of Tigard Received Permit No.:
Date/B :
q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
' C Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit:
f I C ;� It D Inspection Line: 503.639.4175 Date Ready/By: Juris: H 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.
❑ 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: Q t' �J Q� \ktom 100HP or more. occupancy.
_ c (� 1 (54 ` Ct.7 Q. • ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: ' r , U1` '' 7 RI ' ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: � ,, So v , ❑ Service or feeder 600 amps or more.
FEE 'SCHEDULE
Cross street/directions to job site: Description 1 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 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 • 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
w _ / —`J -' Limited energy, multi- family
> U \ t li(/le 1 Lr `I/ BD Of C /" ieK ) N pct T'CPIeH residential (with above sq. ft.) 75.00 2
Services or feeders installation, alteration, and/or relocation
CV* 'J B V Z 4 200 amps or less 100.70 2
';PROPE TY OWNER I 1 . • ❑ TENANT 201 amps to 400 amps 133.56 2
_ 401 amps to 600 amps 200.34 2
Name: t U 4` Imo, l a 601 amps to 1,000 amps 301.04 2
Address: 1 ( 5 q _ o to e L J WWW ���� j' ++'J 72 !, (043 CA- Over 1,000 amps or volts 552.26 2
r Qrd f Temporary services or feeders installation, alteration, and /or
City /State /ZIP: ` /� /�% relocation
Phone: (51? 5 z o q a i Fax: ( ) 200 amps or less 59.36 1
Owner installation: This in • allatio is b >' t g m. »» a on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale, lease, reit or : • c , , jco ° m
, g to ORS 447, 449, 670, and 701.
401 amps to 599 amps 168.54 2
t ,,� Branch circuits — new, alteration, or extension, per panel
Owner signature: , /PI Date: A. Fee for branch circuits with
above service or feeder fee,
❑ APPL CANT ❑. CONTACT PER N each branch circuit 7.42 2
Business name: B. Fee for branch circuits without
service or feeder fee, first Y 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: /State /ZIP: Each manufactured or modular 67.84 2
tY dwelling, service and/or feeder
Phone: ( ) I Fax:: ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
CONTRACTOR
Signal circuit(s) or limited- energy
• Business name: panel, alteration, or extension. Page 2 2
r Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
CI /State /ZIP: Investigation (1 hr min) 66.25/ hr
ty �� 1{) Industrial lant 1 hr min 78.18/ hr
P ( )
Phone: ( ) I Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed (Y2 hr min)
CCB Lic.: I Electrical Lic.: I Suprv. Lic.: ELECTRICAL PERMIT FEES
Subtotal:
Suprv. Electrician signature, required:
Plan review (25% of permit fee):
Print name: I Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE:
Authorized signature: T h is pe rmit application expires if a permit is not obtained within 180
/ days after it has been accepted as complete.
Print name: 4 t J s e r Date Joy • Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(11/05 /COM/WEB
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:
n Audio and Stereo Systems*
n 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
n Clock Systems
❑ Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
❑ Instrumentation
n Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1: \ Building \Permits\ELC- PermitApp.doc 07/01/10
Mechanical Permit Application FOR OFFICE USE ONLY •
City of Tigard Received
Permit No.:
IN Date/By:
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
• 0 Phone: 503.639.4171 Fax: 503.598.1960 Other Permit:
Date/By:
�.1 :; A �, I Inspection Line: 503.639.4175 Date Ready/By: Jads: ® See Page 2 for
- Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK • COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
❑ New construction ❑ Addition/alteration/replacement Mechanical permit fees* are based on the value of the work
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
El 1 - and 2-family dwelling RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
y g ❑ Commercial /industrial ❑ Accessory building
For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description
Qty. I Ea. 1 Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
^ '\ '` Air conditioning
Job site address:
II �fJ ko,u6v� (requires site plan showing placement) 46.75
City /State /ZIP: 1 Ar n 1 Z � Furnace 100,000 BTU (ducts/vents) 46.75
1 Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg. /apt. no.: Project name: � t JS.0 1--' Heat pump 61.06
Cross street/directions to job site: Duct work 1 23.32
Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32 _
Tax map /parcel no.: Other fuel appliances
1DESCRIPTIONOF WORK • Water heater 23.32
1 A tt P ` p Gas fireplace 33.39
t :tte S\ 0-vW a deA e Vl, Flue vent for water heater or gas
�� / (3 fireplace 23.32
'C h pv'�Q Z Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
Chimney/liner /flue /vent 23.32
�PROPERTY''OWNER I ❑TENANT
Other: 23.32
Name: \il L8 ` \ S Environmental exhaust and ventilation '
CA Range hood/other kitchen
Address: 11 lrjy2 ' � ` f,001,.. , A equipment i 33.39
City /State /Z1P: / '+� of 722"3 Clothes dryer exhaust 33.39
f 1 Q 1� 1 -_ Single -duct exhaust (bathrooms,
Phone: (SQL) 52 t V d'1 I 0 Fax: ( ) toilet compartments, utility rooms) 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Other: 23.32
Business name:
Fuel piping
Contact name: $14.15 for first four; 84.03 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax:: ( ) Water heater
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: Clothes dryer (gas) -
Other:
Address: 0 W , I - MECHANICAL PERMIT•FEES* e City /State /ZIP: N Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00)
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee)
� / TOTAL PERMIT FEE
/ // This permit application expires if a permit is not obtained within 180
Authorized signature: . . I days after it has been accepted as complete.
Print name:, / Date: Q ?�� d * Fee methodology set by Tri- County Building Industry Service Board
I:\ Building \Permits\MEC- PermitApp.doc 10/01/09 440- 4.17T(1I /02 /COM/WEB)
I
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi- Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and .
$2.54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
I: \Building\Permits \NEC- PermitApp.doc 10/01/09 2
Plumbing Permit Application
Building Fixtures .
ixtures I o of l• Icl um.: ()NIA
•
City of Tigard Received
IN Date/By: Permit No.:
n 13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Other Permit No.:
Date/By:
I I t:; A I: t Inspection Line: 503.639 Date Ready/By: Juris: El See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
building SFR (3) bath 500.32
❑ Accessory g ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: Hs ( 4 ®0k�o Catch basin or area drain 18.76
�� "/ ^ w l /1 � k ' Drywell, leach line, or trench drain 18.76
City /State /ZIP:
yf q 72
2 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: ( Sp 1^ Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
`DESCRIPTION OF; WORK Backwater valve 12.51
Clothes washer 25.02
lK ` k- r - , •' Dishwasher 25.02
l't r Q J , I
kin OD 'Z *- 3 Drinking fountain 25.02
Ejectors /sump 25.02
PROP RTY _OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap 25.02
Ll, e' 1 S � Floor drain/floor sink/hub 25.02
Address: 1 GJ'l �- � � �� Al� h �� •
�'' Garbage disposal 25.02
City /State /ZIP: Y t Uf r 0 a di 727 3 Hose bib 25.02
Phone: ( 503) 520 O t{ O Fax: ( ) Ice maker 1 12.51
• ' ❑ APPLICANT ❑ . CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory ` 25.02
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: Water piping/DWV • 56.29
Address: 1 CPV Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) ax: ,' ) Minimum permit fee: $72.50
1 7 Plan review (25% of permit fee)
CCB Lic.: / ' 1 , bing Lic. no.:
State surcharge (12% of permit fee)
Authorized signature: / / l` TOTAL PERMIT FEE
Print name: B / ` L ker � $011 Date: O Thi perm app lication expires if a permit is not obtained within 180 days
yyy �, after it has been accepted as complete.
"Fee methodology set by Tri- County Building Industry Service Board.
I:\Building\Permits\PI,MU- PermitApp.doc 10/01/09 440- 4616T00 /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' 50.03 0 to 2,000 $121.90 •
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $t.52 for
Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
I� and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up • $742.00 for the first $50,000.00 and $1.20 for
(minimum charge 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", Plan Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees * . Please check all that apply.
Quantity_ by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: Replace greater, except systems designed and stamped by licensed
Previous Capped Added Existing engineer.
Baptistry/Font
Tub /Sowr ❑ New exterior plumbing site utilities for any complex structure
Bath - hower
Tub /S erlpool as defined in OAR918- 780 -0040.
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive tall ❑ Any multipurpose fire sprinkler system.
Cuspidor/Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash Isometric or Riser Diagram .
Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings
that meet the qualifications above.
- 4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial
- Industrial Comments regarding fixture work:
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial *Note: If the fixture work under this permit results in an
- Service increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be paid before the
Washer - Clothes
Water Extractor plumbing permit can be issued.
Water Closet - Toilet
Urinal
Other Fixtures:
I:\Building\Permits\PLMF- PermitApp.doc 2
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
O P • I wll 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 1 hereby certify that the information on this homeowner statement is true and accurate.
•
Print Na - of Permit Applica
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ArALWil "'AL.
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Signature of Permit Applicant Date
Permit #: 4 � CAD 1 2•"
Address: 115-4 9. tw
off. 47a9-3 1, ry ,;
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Issued b Date: 8" fog4 I (0 t_L-i
This Copy for Permit Offices