Permit CITY TIGARD SITE WORK PERMIT
u;r DEVELOPMENT SERVICES PERMIT # : SIT2002 -00036
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 3/20/03
SITE ADDRESS: 68TH AVE PARCEL : 2S101AA -08700
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING : MUE
BLOCK: `gt.S / LOT: 029 JURISDICTION : TIG
CLASS OF WORK: NEW PAVING ?: Y RESO. NO:
TYPE OF USE: COM GRADING ?: Y VALUE: 15,000.00
EXCV VOLUME: 1,500 cy LANDSCAPING ?: Y
FILL VOLUME: 1,500 cy SITE PREP ?: Y
ENG FILL ?: Y STORM DRAINS ?: Y
SOILS RPT REQD ?: IMPERV SURFACE: 14,930 sf
Remarks: Site work for new 7000 square foot office building.
Owner: FEES
ROTH, J T JR + THERESA Description Date Amount
12600 SW 72ND AVE, STE 200
TIGARD, OR 97223 [BUPPLN] Pln Ck -Valu 12/5/02 $121.75
[FLS] FLS Pln Rv 12/5/02 $74.92
[BUILD] Prmt Fee -Valu 3/20/03 $187.30
Phone: [TAX] 8% St Tax -Valu 3/20/03 $14.99
Contractor: [ERPRMT] Erosion Cntl 3/20/03 $100.00
JT ROTH CONSTRUCTION INC [ERPLN] Ersn Plck - USA 3/20/03 $32.50
12600 SW 72ND AVE STE 200 [EROSN] Ersn Pick-COT 3/20/03 $32.50
TIGARD, OR 97223 Total $563.96
Phone: 639 - 2639
Reg #: LIC 31700
Required Inspections
Erosion Control Insp 846 -8444
Excavation
Fill
Grading
Retaining Wall /Footing
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 through OAR • - -101 -0100. You may obtain copies of these rules or direct questions to OUNC by
calling (503) 246 -6699.
Issued B . '►
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Permittee Signature: ,r �-__
Call (503) 63 • -4175 by 7:00 P.M. for an inspection needed the next business day
Site Work
Building Permit ' - 0 ((al o d -
Date received: / 'S O Penult no.: `a 42, A-0003 6
rs' City of Tigard 1OO2
CiryofTigard
• OR 9722 330 Projecdappl.no.: �redate:
Address: 13125 SW Hall Blvd, Tigard,
Phone: (503) 639 -4171 Date issued: 1EM Receipt no.:
Fax: (503) 598 -1960 p 200 9441303,e1 Case file no.: Payment type:
Land use approval: . P/2.2oo2 r PQ70A 1&2 family: Simple Complex:
TYPE OF PERMIT '
O 1 & 2 family dwelling or accessory gCommercial/industrial O Multi - family O New construction; 0 Demolition V.-
0 Addition/alteration /replacement 0 Tenant improvement ❑ Fire sprinkler /alarm 0 Other.
JOB SITE INFORMATION
Job address: 2 - 8 m ., S •.:, Bldg. no.: Suite no.:
Lot: l i- _ . :lock: 1 Subdivision: d , ,yam Tax map /tax lot/account no.: _ S
Project name: 970a ewe:, _ '
Description and location of work on premises/special conditions: f' /4' //ifi'Q1RL lG.Dt . ((Yrs..)
OWNER FOR SPECIAL INFORA•IATION, USE CHECKLIST l
Name: 7.7: 1a6�r (�D1�1 �i2.1.�C17C�1 I 1.! r^� • ( Floodplain ,septiccapacity,solar,etc.) v im
Mailing address:/2140 Sidi 72 A 1/E �a iT Zoe) 1 & 2 family dwelling:
City: - ri C,, ZIN I StateljQ I ZIP: 9'222.5 Valuation of work $
Phone: 63 f-2,‘ 55 IFax6Zs/- ax,39 E-mail : No. of bedrooms/baths
Owner's representative: Total number of floors
Phone: Fax: E -mail: New dwelling area (sq. ft.)
''- APPLICANT Garage/carport area (sq. ft.)
Name: 54M6 As ai,(/Eg2 Covered porch area (sq. ft.)
Mailing address: / Deck area (sq. ft.)
City: 'State: /1 ZIP: Other structure area (sq. ft.)
Phone: Fax: E7tnail: Commercial/Industrial/multi- family:
CONTRACTOR Valuation of work $ /..5_
Existing bldg. area (sq. ft.)
Business name: 3 a 1, ' 7 f ,aaar ,.i. 7 (N - New bldg. area (sq. ft.) MI
Address: _cam 45 YX4 - Number of stories V
City: I State: 1 ZIP: Type of construction ��
Phone: I Fax: E -mail: Occupancy group(s): Existing:
CCB no.: New:
City /metro lic. no.: Notice: All contractors and subcontractors are required to be
ARCIIITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: Po w provisions of ORS 701 and may be required to be licensed in the
Address: / ?Zap . 5 -- T�4S( » GT• jurisdiction where work is being performed. If the applicant is
City: fi r ' U S te : 02 � Zlp: 17.z 3 exempt from licensing, the following reason applies:
Contact person: fey Plan no.:
Phone: _88/3". Fax: / E -mail:
Name: ,4 'S /67N A0/AVG t lzWeE 57.2Y Fees due upon application $
Address: / 3 9i ' Su/ �is46 l3 #Z M'',0 AO ✓ei SS'rE /oo Date received:
— City: syt/ewore) I State: 02 I ::IW: 97/'1 Amount received $
- Phone: 9Z5- 979 9 J Fax: 925- 9969 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.
attached checklist. All provisions of laws and ordinances governing this Cl Visa ❑ MasterCard
work will be complied with, whether specified herein or not. credit card number: Expires
Authorized signature: Date: Name of cardholder as shown on credit card
$
Print name: Cardholder signature Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (61V0/COM)
• lir
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SITE WORK PERMIT CHECK LIST'"
Commercial, Multi - Family (R -1 occupancY4 and Residential:
Please complete all items below, unlesssQtherwise noted.
Excavation Volume: cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) 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: 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"
attach ed. 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
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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\sitecheddistdoc 09/24/01