Permit CITY TIGARD SITE WORK PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SIT2007 - 00009
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED : 4/2/2007
PARCEL : 2S101AA- 02900A
SITE ADDRESS: 12123 SW 69TH AVE ZONING : MUE
SUBDIVISION: TIGARD CORPORATE CENTER LOT: 00A JURISDICTION : TIG
PROJECT: HOUSEHOLD CREDIT SERVICES
Project Description: (3) ADA curb ramps.
CLASS OF WORK: OTR PAVING ?: RESO. NO:
TYPE OF USE: COM GRADING ?: VALUE: 5,000.00
EXCV VOLUME: cy LANDSCAPING ?:
FILL VOLUME: cy SITE PREP ?:
ENG FILL ?: STORM DRAINS ?:
SOILS RPT REQD ?: IMPERV SURFACE: sf
Owner:
FEES
HOUSEHOLD CREDIT SERVICES Description Date Amount
[BUILD] Prmt Fee -Valu 4/2/2007 �— $91.30
[BUPPLN] Pln Rv -Valu 4/2/2007 $59.35
[TAX] Valu 8% State Surcha 4/2/2007 $7.30
Phone: [FLS] FLS Pln Rv 4/2/2007 $36.52
Total $194.47
Contractor:
BJ CUMMINGS COMPANY
2330 SE CLATSOP ST
PORTLAND, OR 97202
Contact #: PRI 503- 235 -1282
FAX 503 - 235 -0438 REQUIRED ITEMS AND REPORTS
Reg #: LIC 23230
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 952 - 001 -0100. You may obtain copies of these
rule r direct - q -stions to QUNC by calling 503.246.6699 or 1.800.332.2344.
Issu d By: _ I = _ d..1A1 ` Permittee Signature:
X
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.
la 13,3 SW 6 Oft" Het A 020.7, -
' Site Worfi,; / � ) Sud�res
i Building Permit Application J roR Orrlcr; lisl.; ( v•
lig City of Tigard % `: 2007 Received ) ,2� — co? ,...
'
'emit N6) x067 VD 004
° 13125 SW Hall Blvd., Tigard, OR 97 Plan Review Other Permit:
Phone: 503.639.4171 Fax: 503.598. , � DateB . ��
GAR C) ILA Inspection Line: 503.639.4175 � ( i ' j ri Date Ready/By: /�Mi��� RI See Page 2 for
Internet: www.ti g d-or. ov g Notified/metho ��/ o Supplemental Information
1 1 , d •
• TYPE OF WORK p ,' ' / d/ ' EQUIRED 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
O 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 Comercial /industrial Valuation: $
m
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: /2/z3 12 1 2 33c„,..) 6 ,9 y New dwelling area: square feet
• City /State/ZIP: 7/4p 4=44/ e a• Garage /carport ar • . square feet
Suite/bldg. /apt. no.: Project name: A-C'A e..) / /4 fs Covered por area: square feet
Cross street/directions to job site: ,mo 6 eirit eze eLm — 7-- Deck : -:: square feet
Oth - structure area: square feet
6 REQUIRED DATA: COMMERCIAL -USE CHECKLIST
A Subdivision: I Lot no.: Permit fees* are based on the value of the work performed.
Tax map/parcel no.: 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.
�C Valuation: $ 5GLr7O
Colvo -t j of 3 cc�R,3 ,4Am p5 iN
•1 gx /6 -it.J 7 o/oC'At-KS FaZ. I M p/2ov 5.D Existing building area: square feet
J A F' "4 / ' "-' �iv & New building area: square feet
❑ PROPERTY OWNER •f I l• TENANT Number of stories:
Name: HoUl-lot ,tn ce : 4 5a T SER.Vic Type of construction:
Address: / Occupancy groups:
City /State/ZIP: 7'fG_„Iotyr:Z.Oj eig0 Existing:
• Phone: ( ) Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Vtiness name: 5 c.J , � ' l I A ' All contractors and subcontractors are required to be
• Contact name: R cic, mloiciii licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
N Address: Z 3 ?D ,5E C L.A 7750/' jurisdiction in which work is being performed. If the
Z City /State/ZIP: i)f.72 ,dam C3 cf;r C7 7= 1,
p
applicant is exempt from licensing the following reasons
._ Phone: (.3) 235— /Z,5 Z Fa : (503 235 -36
E -mail:
CONTRACTOR
Business name: e u, JMi14,14 co, BUILDING PERMIT FEES*
N' Address: 3� S c cA l (Please fee (or m fie schedule)
I Structural plan review fee (or deposit):
City /State/ZIP: e , R (,A c.—. 9 7Zo Z
N / FLS plan review fee (if applicable):
Phone:(523) 235 - /26Z Fax: (503 ) 235 -0435
Total fees due upon application:
ccB lie;.: Z3 Z30
Amount received:
Authorized signature: y / 0 / ( This permit application expires if a permit is not obtained
/� �' `G within 180 days after it has been accepted as complete.
Print name: / Ait 1 Date: 23/67 * Fee methodology set by Tri-County Building Industry
Service Board
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City of Tigard: Site Work Permit Checklist
Page 2 - Supplemental Information
Commercial, Multi - Familv and One- and Two - Familv Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way, or wetland, the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below, unless otherwise 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 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 One- and Two - family dwellings.
# of Plans
TYPE OF SUBMITTAL Required at
(Includes New, Additions or Alterations) Submittal
Commercial 2
Multi - Family R -1 Occupancy 2
One- & Two - Family Dwelling 2
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