Permit CITY T I G A R D SITE WORK PERMIT
"r DEVELOPMENT SERVICES PERMIT # : SIT2002 -00022
� I� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 2/18/03
SITE ADDRESS: 10998 SW 68TH PKWY PARCEL : 1S136AD -06505
SUBDIVISION: WAY LEE ZONING : C -G
BLOCK: LOT: 003 JURISDICTION : TIG
CLASS OF WORK: NEW PAVING ?: N RESO. NO:
TYPE OF USE: COM GRADING ?: N VALUE: 50,000.00
EXCV VOLUME: 1 cy LANDSCAPING ?: N
FILL VOLUME: 1 cy SITE PREP ?: Y
ENG FILL ?: N STORM DRAINS ?: Y
SOILS RPT REQD ?: N IMPERV SURFACE: 6,040 sf
Remarks: S. r- � ) i -u� 3—
Owner: (� � FEES
BANK OF SALEM
PO BOX 847 Description Date Amount
SALEM, OR 97308 [BUPPLN] Pln Ck -Valu 9/11/02 $306.02
[FLS] FLS Pln Rv 9/11/02 $188.32
Phone: 503 - 585 -5290 [BUILD] Prmt Fee -Valu 2/18/03 $470.80
[BUPPLN] Pln Ck -Valu 2/18/03 $306.02
Contractor: [TAX] 8% St Tax -Valu 2/18/03 $37.66
PHOENIX CONTRACTORS [FLS] FLS Pln Rv 2/18/03 $188.32
5360 LANDON STREET SE [ERPRMT] Erosion Cntl 2/18/03 $40.00
SALEM, OR 97306 [ERPLN] Ersn Plck -USA 2/18/03 $13.00
[EROSN] Ersn Pick -COT 2/18/03 $13.00
Phone: 503 - 589 -1268 Total $1,563.14
Reg #: LIC 107161
Required Inspections
Paving Insp
Strm Drain Insp
Culvert/Catch Basin
Culvert/Catch Basin
San Sewer Insp •
Manhole /Cleanout - PVT
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. 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 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 throug e ° ' e 101 -0100. You obtain copies of these rules or direct questions to OUNC by
calling (503) 246 -6" 9.
O
I- ued By: 44,
Permittee Signature: ( K Aqa,i.g.k. t- )q-s�
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
-1 ` - Site Work 4 L 1 - ? '� 1 , .. ,
Building Permit Application
Date received: 9 // 0 Permit no.: ,5 i f' a -0p0A2
',y" City of Tigard
-- Project/appl. no.: Expire date:
City ofTigard Address: 13125 SW Hall Blvd, Tigard, OR 972
Phone: (503) 639 - 4171 Date issued: By: Receipt no.: cP
Fax: (503) 598 ID.' q r Case file no.: Payment type:
Land use approval: 199Q -otao A( p 1 &2 family: Simple Complex:
• • "!' TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ New construction ❑ Demolition
❑ Addition/alteration/replacement ❑ Tenant improvement ❑ Fire sprinkler /alarm ❑ Other:
JOB SITE INFORMATION
Job address: 0' ' 6 W • j 71 ' l ,J-f VI Bldg. no.: Suite no.:
Lot: I : lock: Subdivision: I Tax map /tax lot/account no.: b`
Project name:
ifil-
Description and location of work on premises/special conditions:
2 ,
..:..,...,,.....:.„.::J.,.,..,,, ,, QwTIER' . FOR SPECIAL INFORMATION, USE CHECKLIST
Name: TA-lo (}F 4�K1/ /�/� (Floodplain, septic capacity, solar, etc) 1
Mailing address: € ?0 V743)( -1 7., 1 & 2 family dwelling: ril
City: �� I State: bP I ZIP: n-308 Valuation of work $ _.
Phon54 4 92' I Fax: IE-mail: No. of bedrooms/baths
Owner's representative: Total number of floors
Phone: Fax: E -mail: New dwelling area (sq. ft.)
' ' i'' ;APPLICANT YY Garage/carport area (sq. ft.)
Name: KotA ftl�) F4 i ft∎ ip;�(.�1l'6C�1 'T, C Covered porch area (sq. ft.)
Mailing address M 1.r 2j ''{ 1 511 Deck area (sq. ft.)
City: � M State(j'� ZIP: 34 �jp Other structure area (sq. ft.)
`J 's""
�, r E -mail C mercial/industr al/multi- family /4 / 5-1° 046
Phone: rp �{ _ Fax o . j ri r - ' V uation of work. . 4A 7 - b 1 7 � s $
.. , ..;:.,.; -' , :: : , ., : . ,.,, , CONTRACTOR
' '' ( Existing bldg. area (sq. ft.) C --
Business name: 1•••\0 N \x WA Vi e I R,> New bldg. area (sq. ft.) f
Address: Cj'1j(o LA NIP.) S Number of stories
City: f1/1 f Statelt I ZIP: 0.3-46 Type of construction
Phone% V 36q4 I Fax: I E -mail: Occupancy group(s): Existing:
CCB no.: 101-1 Sol New:
�ti� City /metro lic. no.: Notice: All contractors and subcontractors are required to be
. ARCHITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: L\ (A 14r provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is \
City: State: I ZIP:
exempt from licensing, the following reason applies:
Contact person: Plan no.:
Phone: Fax: E -mail:
G J \V
Nam ANY l Contact person: ‘M & Fees due upon application $ '-'
Address: ( ,(.., j) 6 (4 Zw� i eofi) Date received: p,
City: �) . � IState:5 IZIP: ' »9.ti 6t. Amount received $
Phone: rjp?, t 5 i I Fax: $.)6 11141 I E -mail: . Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information. to
attached checklist. All provisions of laws and ordinances governing this ❑ Visa ❑ MasterCard
work will be complied 'th, w 'ether specified herein or not. Credit card number: / /
s Expires r
.,\
Authorized signature: 1 � , \ _,. c:.---.: e D / ate: i o9, Name of cardholder as shown on credit card \ 4V
Print name: +T -7� Q %�74t Cardholder signature $ Amount 3
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (6ro0/COM)
- -
SITE WORK PERMIT CHECK LIST •
Commercial, Multi - Family (R -1 occupancy) and Residential:
Please complete all items below, unless otherwise noted.
Excavation Volume: cu. yds.
Grading Volume: ^
(Soils report required for >5,000 cu. yds.) 1\1 Pc cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to 90% of
maximum density) cu. yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
❑ Concrete
❑ Other
*Total new impervious area including all buildings,
sidewalks, and paving: N -� sq. ft.
Site Utilities Plumbing Work:
Complete the "TAN" 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 *Parking (including ADA) and
ADA compliance Lighting Plan
Grading Plan and details *Landscaping Plan
Erosion Control Plan and details Soils Report (if required)
Retaining Structures
*Does not apply to 1 and 2- family dwellings.
# of Plans
TYPE OF SUBMITTAL Required at
(Includes New, Additions or Alterations) Submittal
Commercial 4
Multi - Family R -1 Occupancy 4
One- & Two - Family Dwelling 4
NOTE: Plan review is dependent upon submittal of a completed application and plans.
After plan review approval, the Plans Examiner will contact the applicant to request
additional sets of plans for distribution purposes (for Contractor, City of Tigard,
Washington County, and Tualatin Valley Fire & Rescue).
is \dsts\forms\sitechecklist.doc 09/24/01