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Permit
CITY OF TIGARD MASTER PERMIT I s '- COMMUNITY DEVELOPMENT Permit #: MST2009 -00125 T ( G A O 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/07/2009 Parcel: 2S104AA09000 Jurisdiction: Tigard Site address: 12200 SW 127TH AVE Subdivision: BELLWOOD NO. 2 Lot: 95 Project: Bradford Project Description: Dwelling and garage addition. BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 1 First: 193 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 18 Bathrooms: 1 Second: 0 sf Garage: 370 sf Front: 20 Smoke Dwelling Units: 1 Third: 0 sf Right: 5 Detectors: Yes Total: sf Value: $60,919.15 Rear: 15 PLUMBING Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0 Lavatories: 2 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0 Tubs /Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 0 Bckflw Prevntr: 0 MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 1 Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Fum > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits 1000 sf or less: 0 0 -200 amp: 1 0 -200 amp: 0 W/ Svc or Fdr: 5 Ea add' 500 sf: 0 20 1 -400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr: Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add'I Br Cir: 601 -1000 amp: 0 601 +amp- 1000v: 0 1000 +amp /volt: 0 ELECTRICAL • RESTRICTED ENERGY SF Residential Audio 8 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) BRADFORD, JOHN F AND OWNER L ieo / oft) 6 1 , DONETA L, 12200 SW 127TH /�J TIGARD, OR 97223 PHONE: PHONE: / �! — (1///[[( FAX: C� r TT / Total Fees: $1,705.39 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 do n accordanceith 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 day ATTENTION: Oregly� law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 95 - 001 -0010 through OAR 95 s. 410•. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.22344. A Iss d By: — -Li i# L Permittee Signature: Y/ �r. - ./�J! •GI' , rlee ■ i ill RECEIVFD JUN 0 5 Coop, Property Owner Statement CITY OFTIGARD: Regarding Construction Responsibilities BUILDING DIVISION 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: I 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 ef ' I will 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 I hereby certify that the information on this homeowner statement is true and accurate. 3 0 1-ir, E 64-a4..S.br , Print ■ . e of Permit Applicant fgnature of Permit Ap Date Permit #: M b DO/ A5 Address: /A9c' o°c t) /0q7 'v E • # I 7 'fr,rl4iWyya��, Issued • : J 0 Date: 7/7 /61 \ This Copy for Permit Offices Building Perm Applicatio Residential JUN 0 5 2009 1 OR ( )H ICE USE ONLY City of Tigard Received �� Permit No.: 6 /4•9-4, Irr • 13125 SW Hall Blvd., Tigard, OR OF TIGARD Plan Revs _- M _ _— Phone: 503.639.4171 Fax: 50 ' t Fi/J • Other Permit: } , i► NG DIVISION Date/13 : mil �� r. TIGARD Inspection Line: 503.639.4175 Date Read Mr RI See Page 2 for Internet: www.tigard- or.gov �. A thud: ? (Q 09 ORM Supplemental Information ‘ II , d. . /1 .7!/�I �J. . TYPE OF WORK _ilell RE I IRED DATA: . 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: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. Valuation: 9'� $ i 1- and 2- family dwelling ❑ Commercial/industrial ) ❑ Accessory building El Multi-family Number of bedrooms: I ❑ Master builder ❑ Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: ( 2ZO0 .s .i 1 - z.:74` New dwelling area: square feet City /State /ZIP: "'T' OZ. `l 2 Z3 Garage/carport area: 1 square feet - 370 Suite/bldg. /apt. no.: Project name: giz �� Covered porch area: 1 square feet 1 i p Cross street/directions to job site: 1, p.u.30 -V - 7 - 2.5 (2.13 - L N -TO 1ZZ Deck area: square feet Other structure area: <_ square feet ,. REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: (.ELL LL.30 4:::) p ,r I Lot no.: 9s Permit fees* are based on the value of the work performed. u Indicate the value (rounded to the nearest dollar) of all Tax map /parcel no.: NE .4 set. 4 t 1,. - S . (2 - i V.( LrM , equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. ` Valuation: $ �Gt� Existing building area: square fee New building area: square feet PROPERTY OWNER ` ❑ TENANT Number of stories: Name: J 61-k et 37 o , c) - A" Q f>r a 140 rc' Type of construction: Address: l 22.0 d CA.i t 2 7 -11:1 ' Occupancy groups: City /State/ZIP: (i ..,,,34 . , OR- 97 27_3 Existing: Phone: ('tai) 5 " o - 9 3! Z Fax: (503) Z 13 -20 1 a New: ❑ APPLICANT ❑ CONTACT PERSON NOTICE Business name: " 9 ( 2 j 1� (1 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: ( ) I Fax:: ( ) E -mail: CONTRACTOR Business name: O GL) 0 (L.. BUILDING PERMIT FEES* Address: (Please refer to fee schedule) Structural plan review fee (or deposit): 40-6. I 0- . 1 O City/State /ZIP: Phone: ( ) I Fax: ( ) FLS plan review fee (if applicable): CCB lic.: Total fees due upon application: Amount received: a 5e ' -7C: Authorized signature: x f This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: , vaj Date: 5 "'m G l * Fee methodology set by Tri- County Building Industry Service Board. I: \Building\Permits\BUP -RES PermitApp.doc 11/6/07 440- 4613T(11/02/COM/WEB) Pllaiinbiiig Permit Application Building Fixtures RECEIVED FOR OFFICE USE ONLY : City of Tigard Received Date/By: Permit No. A9� -reyaS II - ■ 13125 SW Hall Blvd. Tigard OR 97223 I Phone: 503.639.4171 Fax: 503.598.1960) UN Q 5 2049 Plan Review Date/By: Other Permit No.: TIGARD Inspection Line: 503.639.4175 ReadyBy: Juni,: 0 See Page 2 for Date Internet: www.tigard CITY OF TIGARD Notifie Supplemental Information TYPE OF woSUlLDING DIVISION FEE* SCHEDULE ❑ New construction Ifi; bemolition For special information use checklist. Description I Qty. I Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 ' 1- and 2- family dwelling 0 Commercial /industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi - family SFR (3) bath 399.00 El Master builder Each additional bath/kitchen 45.00 ❑ Other: Fire sprinkler ( , sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: t Z 2,p p u„s 1 Catch basin or area drain 16.60 City/State /ZIP: '' G„.f, OJf, X22• Drywell, leach line, or trench drain 1 16.60 \ , Suite/bldg. /apt. no.: I Project name: -a,, V 9._c_.1. Footing drain (no. linear ft.: ) Page 2 Cross street/directions to job site: Manufactured home utilities 110.00 Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: (1.7) Page 2 5s,co Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2 Tax map /parcel no.: Fixture or item ♦e /Esrt6 Absorption valve 16.60 DESCRIPTION OF WORK Backflow preventer Page 2 Backwater valve 16.60 Clothes washer 16.60 Dishwasher 16.60 �, PROPERTY OWNER El TENANT Drinking fountain 16.60 Name: Q R+i�.�JFo Ejectors /sump 16.60 R9 Expansion tank 16.60 Address: Fixture/sewer cap 16.60 City/State /ZIP: Floor drain/floor sink/hub 16.60 Phone: ( ) Fax: ( ) Garbage disposal 16.60 ❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60 Ice maker 16.60 Business name: Interceptor /grease trap 16.60 Contact name: Medical gas (value: $ ) Page 2 Address: Primer 16.60 City /State /ZIP: Roof drain (commercial) 16.60 Phone: ( ) F es:: ( ) Sink/basin/lavatory 1... 16.60 'n ,20 Tub /shower /shower pan l 16.60 ( ( E -mail: Urinal 16.60 CONTRACTOR Water closet ( 16.60 t Business name: C.--) �._ Water heater 16.60 , try Address: Other: City/State/ZIP: Subtotal 1 Wi.Cr Minimum permit fee: $72.50 Phone: ( ) Fax: ( Residential backflow minimum permit fee: $36.25 CCB Lic.: i i umb�.�: . no.: Plan review (25% of permit fee) k* 2t State surcharge o of permit fee) 16 , Authorized signature: TOTAL PERMIT FEE (9 .' r/ .� Print name: 011.1 'r / !'as - t- Date: C.,,,-Alr■of This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. 1:\Building\Permits\PLMF- PermitApp.doc 12/27/06 440- 4616T(10 /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' r 55.00 0 to 2,000 $115.00 Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00 3,601 to 7,200 $220.00 Sewer - 1st 100' 55.00 7,201 and greater $309.00 Sewer - each additional 100' 46.40 Water Service - 1st 100' 55.00 Medical Gas Systems: Water Service - each additional 100' 46.40 Valuation: Permit Fee: Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and including $10,000.00. Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to (minimum permit fee $36.25) 27.55 and including $25,000.00. Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for each additional $100.00 or fraction thereof, to Inspection of existing plumbing or and including $50,000.00. specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for Subtotal: each additional $100.00 or fraction thereof Fixture Work: Plan Review for Plumbing Installations Are you capping, adding or replacing fixtures? If "yes", Plan review is required for any of the following. please indicate work performed by future. Failure to Please check all that apply. accurately report futures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed Fixture Type: Replace engineer. Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure Baptistry/Font as defined in OAR918- 780 -0040. Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities. - Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system. Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040. -Drive Thru Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher - Commercial -Domestic Isometric or Riser Diagram Drinking Fountain g Eye Wash ❑ Isometric or riser diagram is required for new buildings Floor Drain/sink - 2" that meet the qualifications above. -3" -4" Car Wash Drain Garbage - Domestic Comments regarding fixture work: Disposal - Commercial - Industrial Ice Mach./Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley *Note: If the fixture work under this permit results in an - Commercial increase of sewer EDUs, a sewer permit will be issued and - Service fees assessed for the sewer increase must be paid before the Swimming Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet - Toilet Urinal Other Fixtures: \ Building \Permits\PLM- PermitApp.doc 12/27/06 'Mechanical Permit Application FOR OFFICE USE ONLY ` City of Tigard Date/By: : Permit No.yi �.,, '" GO /2 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.639.4171 Fax: 503.5 EIVED 1 ` Plan Review Other Permit: 11 4 Date By T I G A R D Inspection Line: 503.639 Date Ready /By: orris: 65 See Page 2 for Internet: www.tigard or.gov Notified/Method: Supplemental Information JUN 4 S 2009 TYPE OF WORK � I COMMERCIAL FEE* SCHEDULE — USE CHECKLIST ❑ New construction jeAddition/clt� is r re ald� Mechanical permit fees* arc based on the value of the work BUILDING DIVISN performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit. CATEGORY OF CONSTRUCTION Value: $ RESIDENTIAL EQUIPMENT / SYSTEMS FEES* Igi 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist. ❑ Multi- family ❑ Master builder ❑ Other: Description Qty. Ea. I Total JOB SITE INFORMATION AND LOCATION Heating/cooling Job site address: 1 2.2 0 o S1�.1 1-z./ '4'1' Air conditioning or heat pump (requires site plan showing placement) 14.00 City /State /ZIP: --r" 1 G,...32..P ok. el-77_23 Furnace 100,000 BTU (ducts/vents) 14.00 Furnace 100,000+ BTU (ducts/vents) 17.90 Suite/bldg. /apt. no.: Project name: 13(2, A.F'OlLZ) Res Gas heat pump 14.00 Cross street/directions to job site: L `.,y"V T — t 2, a1"'"' Duct work 10.00 Hydronic hot water system 14,00 Residential boiler (radiator or hydronic) 14.00 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 14.00 Flue /vent for any of above 6.80 Subdivision: 1 l..: p c Lot no.: . Other: 10.00 Tax map /parcel no.: Other fuel appliances DESCRIPTION OF WORK Water heater 10.00 Gas fireplace 10.00 Flue vent for water heater or gas fireplace 10.00 Log lighter (gas) 10.00 Wood/pellet stove 10.00 Wood fireplace /insert 10.00 -PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 10.00 Other: 10.00 _ Name: S,5I UILS> Environmental exhaust and ventilation Address: Range hood/other kitchen equipment , 10.00 City /State /ZIP: Clothes dryer exhaust 10.00 Single -duct exhaust (bathrooms, Phone: ( ) Fax: ( ) toilet compartments, utility rooms) 6.80 ❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans I 10.00 Other: 10.00 Business name: Fuel piping Contact name: $5.40 for first four; $1.00 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: � L...) Nom^ Ot dryer (gas) Other: Address: MECHANICAL PERMIT FEES* City /State /ZIP: Subtotal ,s, Phone: ( ) Fax: ( ) Minimum permit fee ($72.50) ` 4.3So Plan review (25% of permit fee) CCB lic.: State surcharge (12% of permit fee) 0,-, TOTAL PERMIT FEE 8 I, Z C Authorized signature: This permit application expires if a permit is not obtained within 180 n ` days after it has been accepted as complete. Print name: ...1 � 1 e w r 13 re I. J Date: (... el, * Fee methodology set by Tri- County Building Industry Service Board I:\ Building \Permits\MEC- PermitApp.doe 01/19/07 440 -4617T (t t /02/COM/WEB) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial Fee Schedule: Total Valuation: Permit Fee: $1.00 to $2,000.00 Minimum fee $72.50 $2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and $1.80 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and $1.35 for each additional $100.00 or fraction thereof, to and including $50,000.00. $50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and $1.25 for each additional $100.00 or fraction thereof, to and including $100,000.00. $100,000.01 and up $1,396.50 for the first $100,000.00 and $1.10 for each additional $100.00 or fraction thereof. Note: All new commercial buildings require 2 sets of plans. I:\ Building \Permits \MEC- PermitApp.doc 01/19/07 2 Electrical Permit A licat' FOR OFFICE USE ONLY City Tigard DateB 1 � �oo4 ,0e to?‹ of Ti and ENED Permit No.: • 13125 SW Hall Blvd., Tigard, OR 97223 y g Plan Review . Il Phone: 503.639.4171 Fax: 503.591.10 0 5 2 009 Date/By: Other Permit: T I G A R D Inspection Line: 503.639.4175 Date Ready/By: Juris: 0 See Page 2 for Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information TYPEBOIMING DIVISION PLAN REVIEW ❑ New construction ig 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: 12 Z O 0 S W 12 El Six or more. occupancy. Six or more residential units. ❑ Recreational vehicle parks. City /State /ZIP: ; G_, , O Q G, 2Z3 ❑Health -care facilities. CI Supply voltage for more than El Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: a ca ..,,lt.04,50 0j ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: description I Qty. I Fee. I Total I ' New residential single- or multi- family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4 Ea. add'l 500 sq. ft. or portion 33.40 1 Tax map /parcel no.: Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) Limited energy, multi - family 75.00 2 residential (with above sq. ft.) Services or feeders installation, alteration, and/or relocation 200 amps or less 1 80.30 lit ,2 2 L:PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2 Name: Z r D 'Is:. 401 amps to 600 amps 160.60 2 601 amps to 1,000 amps 240.60 2 Address: Over 1,000 amps or volts 454.65 2 City/State /ZIP: Temporary services or feeders installation, alteration, and/or relocation Phone: ( ) Fax: ( ) 200 amps or less 66.85 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2 Owner signature: Date: Branch circuits — new, alteration, or extension, per panel A. Fee for branch circuits with ❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee, to each branch circuit 6.65 •3; 2 Business name: B. Fee for branch circuits Contact name: without service or feeder fee, 46.85 2 first branch circuit Address: Each add'I branch circuit 6.65 2 Miscellaneous (service or feeder not included) City/State /ZIP: Each manufactured or modular dwelling, service and/or feeder 90.90 2 Phone: ( ) Fax: : ( ) Reconnect only 66.85 2 E -mail: Pump or irrigation circle 53.40 2 CONTRACTOR Sign or outline lighting 53.40 2 Business name: Signal circuit(s) or limited - d(.o Kb Q energy panel, alteration, or Address: extension. Describe: Page 2 2 City/State /ZIP: Each additional inspection over allowable in any of the above Per inspection 62.50 Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50 CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: 11 '2 7 ,. -j'5 Print name: at Plan review (25% of permit fee): Win^ State surcharge (12% of permit fee): I Z, (, 3 Authorized signat TOTAL PERMIT FEE: (•z 7. ( 8 2 2 I This permit application expires if a permit is not obtained within 180 Print name: O K . , 4 moo d - j Date: Cs —7,-07 days after it has been accepted as complete. ' Number of inspections allowed per permit. I:\ Building \Permits\ELC- PermitApp.doe sS /23/06 440-4615T( 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: ❑ Audio and Stereo Systems* ❑ Burglar Alarm n Garage Door Opener* n Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* n 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 n Data Telecommunication Installation n Fire Alarm Installation ❑ HVAC n Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls n Outdoor Landscape Lighting* n Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations t\ Building \Permits\ELC- PermitApp.doc 03/23/06 l' s q‘ t, 11 S \\ V MAC / g 2 049 � Clean Water Services File N C1eanWater \ Services O -6O p9 0 5 ,-° ensitive Area Pre - Screening Site Assessment 0 � 1y vo 1. urisdiction: Tigard 0 1�1 S�0 2. Property Information (example 1S234041301400) 3. Owner Information � 1ti� 1 Tax lot OD(s) :, Lot 95, Reiiwood 1 2S 16 AA 0`iit' Name: John & Donets Bradford B Company: Address : SW 127111 - Site Address: 122005W 127th City, State, zip: r9ard,. OR 97223 City, State, Zip: Tigard, OR 97223, Phone/Pax: ¢O3- 590 -9312 Mt,. 503- 21372013 wk. Nearest Cross Street lnut .. ... _ . E -Mail: John :biadfordQbccenglneefing.rAm 4. Development Activity (check all that apply) 8. Applicant iriorniation ta Addition to Single Family Residen'ce_(rocina, deck, garage) Name: same C] Lot Line Adjustment 0 Minor Land Partition Company: • CI Residential Condominium Cj Commercial Corxiotrinium " " " "" °' • Address: la Residential Subdivision ❑ Commercial Subdivision ❑ Single Lot Commercial ❑ Multi Lot c oamerciai City, State, Zip: Other Phone/Fax . E -Mail: 6. WIII the project Involve any off-site work? 12) Yes U No 0 Unknown Location and description of off -site work Widen. driveway curb cut 7. AdditiOnal comments or Information that may be needed to understand your project A drywell is. planned for new roof surface runnoff This application does NOT replace Grading and Erosion Centre! 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 andfor Department of the Army COB, 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 ail reasonable times for the purpose of inspecting project she conditions and gathering information related to the project site. I certify that i am fanliliarlyith the information contained in this document an ■ to the best of my knowledge and belief, this information Is true, complete, and accurate. Print►Type N n ad ord ® . '/ Print/Type Title Owner Signature /4- � • _ Date 5 -29 -09 FO: 6 (STRICT VSE .e LY • ED Sensitive areas potentittyr Oust on site or within 200' of ilia site, THE AAPLIOANT MUST PERFORM ANTE 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 may also be required. X Based oft review pf 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 PreScreeping Site.kssessment does N01 ell 111110 a the need to evaluate and protect water quality sensitive areas If they are subsequently disqovered. This document will sere as your Service Provider letter as required by Resolutionend Order 07-20, Section 3,02.1. All required permits and approvals must 0000410d grid completed underappllcable 100x1, State, and federal law 1] Based on teview of the submitted materials and best available information the above referenced project will not sgniftcantly impact the existing or potentially sensitive area(s) found near the site This Sensidvekea Pre- Srxeening 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 reAuired by Resolution and Order 07.20, Section 3.021, All required permits and approvals must be obtained and completed under applicable local, state and federal law. ❑ This Service Provider Letter is not valid unless CWS approved site plan(s) are attached. I]i The proposed activity does not meet the definition of development or the lot was platted after 9 /9195 ORS 02 040(2), NO SITE ASSES MENT OR SERVICE PROVIDE - LETTER IS REQUIRED. Reviewed by —, -- - •—:----) Date 10 Q MILK 2550 SW Hillsboro 1lighway • Hillsboro Oregon 97123 • Phone. (5031 681-5100 • Fax: (503) 681 -4439 • w,rnv.cleanwaterservices.ovg 17 t Building Permit Application Checklist One- and Two - Family Dwelling FOR OFFICE USE ONLY City of Tigard R eceived Permit No 11111 .: 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: Phone: 503.639.4171 Fax: 503.598.1960 Associated permits: I II,ARI) 24- Hour Inspection Line: 503.639.4175 El Electrical ❑ Plumbing ❑ Mechanical Internet: www.tigard- or.gov ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW 1 es No N/A 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. ❑ ❑ I 4 Fire district approval required. Name of district: . ❑ ❑ ❑ 5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ 2 6 Sewer permit. ❑ ❑ MI 7 Water district approval. ❑ ❑ 2 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 VI ❑ ❑ 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 I ❑ ❑ there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -ft. 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 g ❑ El 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- IN ❑ ❑ 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 N ❑ ❑ locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ Fl 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 load. 20 Manufactured floor /roof truss design details. ❑ ❑ 10 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 13 ❑ ❑ architect licensed in Ore Ion and shall be shown to be applicable to the .ro'ect under review. it IZIsI)I (.' IiONAL sI'I.( III('- 23 Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". tZt ❑ ❑ 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. ❑ ❑ J' 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 accompanied by 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. I:\Building\Pe mits\BUP- RES- PumitApp.doc 03 /21/06 440- 4613T(11 /02/COM/WEB) RECEIVED A~ AT CORNER OF RATNERNE — AND ' g1z j �\� JUN 0 5 2009 PROVIDE INLET PROTECTOR MST WATER METER i11•E (0..; STO OwO SITE S ATA • • I NE // ECTION 4, T-25, R -1W, W.M. i Q � ! ---- - - - - -- - - - - - -- -� BUILDING-DIVISION - N I WASNING}ON COUNTY, OREGON J - - --- --- -- --- --- -- --- -- — (900X 32, PG 17) ' ( y - TREE TER NE (1• COPPER) I, 0� I W E $FFOR DATA AFFORF R BED ROOMS PRO% i .�.��, 2 BATH - - - I I�'' GARAGE ✓�, 1 I 4 G2 SF 1ST RR I i._ ____ __ j I M93 SF 2ND Fl . [r- -� r - _ �_r ___ "-- --Ti li 111P 115 SF TOTAL �. II L _1 I I AFTER �OOYS ' II - 1 BATH I ■ GARAGE . JJ 1 22 98 SF 1ST I R 1 \�� 8 SS 1N0 Fl R /( 2089 SF TOTAL EMT MT NCI TREE . - I I DRAWING 'INDEX ~ _yl • I � • m I I `Ex SEWER UNE 1 1020 -01I SITE PLAN I 3020 -02 FIRST FLOOR PLAN �� • • I I I I 3020 -03. EXISTING 2ND FLR - /-( )) ' NEW ATM FLOOR PLAN 1 - ■ I I 3020 -0 ROOF PLAN / \ I 11 4020 -OSS' FOUNDATION PLAN k DETAILS I I 5020 -06I FIRST FLOOR FRAMING PLAN 1@ OL ROTC TREE I I i L__ ;1 ` I I EMT OM PATIO I 5020 -07: ATTIC FLOOR NAMING PLAN `f - _. I I 5020 -08 ROOF FRAMING PLAN I I LL �- �__ J � 5030 -091 WEST EL I 5030 -10, SOUTH ELEVATION k SECTION • I I I -- I • 5030 -11 EAST ELEVATOIN k SECTION "T�I 5030 -12, NORTH ELEVATION AND SECTION '—� I. 1 I I1/4',- � 15030 -13. SECTIONS ' �1 ` h 5050 -141 STRUCTURAL NOTES ' _ ' UT ! - I 3020 -I5. ELECTRICAL - FIRST FLOOR ' 3020 -18i ELECTRICAL - ATTIC - I EXISTING HOUSE j ® I, w l I I /1' I I 1 ..... uNE J I \ I ( 2/ j EMT NOW.. I rt k -N EXISTING 2 CAR °6004 �� GARAGE I i M. , SETBACK LP. / I \ I I ■ -I Art HORNBEAM OOSTCN CONCRETE !AMMAN I i / EMT EUROPEAN j yF EMT ELECT METER TO EE NOOG \ ,` \ � C / EMS, GAS METER' TO RE REE00900 \ /'t HORNBEAM TREE -. =WORgit EXIST WATER I `` \,. \ \ \ \Je %.:r Arr. • -- I/ �' SETBACK LAZE �' \ \ \ \ \ \ \ \ \ \ \ \ \\ \ \v% ' r It P GARAGC PROPOSEO BEDROOM / ROOF OVER 4 ADDITION EXTENSION EW CONCRETE L MST STONE WALLOW/ - °tRi i Lim \ E . \ \ \ \ \ \� \` \ \�\% � /; . NEW . . ��! ` t. _ . E C . Lwasf IxD I� >. \ - Ind. BMW( ,MW( NCB Roo. LNE -- - 9ENBAEIL UME = �_-- Tr_'`� - -- ------ __- __ -__ - . ) I Tai^ er w :7 - -J , -REPLACE EMT S/w TON AREA I NEW GAS METER NN / _ y-I --- __— __ —__— roes /e• CD.. TE J FEW ELECTRIC METER "j"j���'��R�_.. ' ,; NMN,�.,L ENe.RNR,,� 4. AL BRADFORD John & Donato Bradford °y -^3 °�j"L,k, � S��in. , CONRAD 11200 S.W. 11. Awns N I... .6P6 nxa] i PO .w m " s o WO 4 1 8 " O. a `N ,e �X p G CROW ENGINEERING C 10 w ,:1»r `. w. V cwo Vr "MI I � aNN • .1.uc1,w.L • ,EUMxNr BIN�N 12200 SW 127th ADDITION AVE TICARD, OR 1h AV ,",g', 1741T $fJ.'fok M ,dfJ., °P"` ^""„""e "M •"^ "E.w"m N 000 i l�w° I W NO'1'i.I'':'"".°.. . ml. SITE PLAN WRITTEN CONSEXT Of N.I a.... LIP: 1M'Oaw INB IS - NI .NB CNFfxm Rua O .rz O 9 l fi «N .n '":'�'"R,f9p." 3:�.o n ° S.sN"D fi'w '175'M'"3 ENO... K PROMrrE ^°T °S/'V rz wm x[ B EN. 00E vncR'Trox BR RCN. °ATC NEKR.mN .. _ a rer.A 5-29 -09 vAi1 :Vtl,All si XS - OW S -0I -0I�MAX.NIBN DS/nrv1 I,:1R.iV1l a owwr I I 1 / R' `1 ' I' I S - 2 - 09 1 99217- 1020 —DT I CITY OF TIGARD • SITE PLAN REVIEW BUILDING PERMIT NO.: 4 7 f ..PV — 2 14! >J Pr ► .M I mo- --`� PLANNING DIVISION: Required Setb).cks: (XApproved/. ❑ Not Approved V � �� Side: b Street Side: � � � `' Garage: Rear: l.S Visual Clearance: 2 ❑ Not Approvedw� -t Maximum Buildi. _ He ' teet CWS Service Provider Letter Required: ❑ Yes ❑ No ❑ ' eceived B : - cktO Date: c k i ENGINEERING, • EPARTMENT: Actual Slope: _j_% Approved ❑ Not Approved Site PI : Approved ❑ Not A 'proved B / Date: Notcs: CITY OF TIGARD - SITE PLAN REVIEW BUILDING PERMIT NO: Street Trees:El ppooved ❑ Not Approved Approvcd Protected Trees: Ap proved ❑ BY: �� rr Date: 07/ Notes: ro ( /(o addael C - (tc;vcc 1 CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: MST2009 -00125 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/07/2009 Parcel: 2S104AA09000 Jurisdiction: Tigard Site address: 12200 SW 127TH AVE Subdivision: BELLWOOD NO. 2 Lot: 95 Project: Bradford Project Description: Dwelling and garage addition. 10/6/10 added (3) services or feeders and (15) branch circuits B.T. Owner: FEES BRADFORD, JOHN F AND Quantity Description Date Amount DONETA L, 12200 SW 127TH TIGARD, OR 97223 1 ea Building Permit 07/07/2009 $582.74 1 Plan Review 06/05/2009 $256.10 PHONE: 1 ea Build 12% State Surchrge 07/07/2009 $69.93 0 Plan Review 07/07/2009 $122.68 Contractor: 1 ea CDC Plan Review, RES 07/07/2009 $46.00 OWNER 1 ea CDC Plan Review, RES - 07/07/2009 $6.00 LRP 1 ea Tig -Tual School CET - 07/07/2009 $193.00 Residential PHONE: 1 ea Erosion Control 07/07/2009 $40.00 FAX: 1 ea Erosion Plan Review CWS 07/07/2009 $13.00 1 ea Erosion Plan Review COT 07/07/2009 $13.00 1 ea Services or Feeders - 200 07/07/2009 $80.30 amps or less Type of Use: SF 5 crt Branch Circuits w /Purchase 07/07/2009 $33.25 Class of Work: ADD Type of Const: VB Service or Feeder Occupancy Grp: R -3 1 ea 12% State Surcharge - 07/07/2009 $13.63 Electrical 1 ea Single Duct Exhaust 07/07/2009 $6.80 (Bathrooms, Toilet, Utility Rooms) 1 ea Attic/Crawlspace Fans 07/07/2009 $10.00 Total $2,293.40 Required Items and Reports (Conditions) 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 - - • • - - —y of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: Permittee Signature: 7 41 IL t1M OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR. ELEC' Date: LICENSE NO. 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. Electrical Permit Application roll O F F I C I: Hsi.: ()MA .l ° rsc Received City of Tigard a 4 Date/B fin : Permit No.: �� It_ U9 —vo I �S 13125 SW Hall Blvd., Tigard, OR 97223 -0 / -Q 0,0 : \') II Plan Review '� C Phone: 503.639.4171 Fax: 503.598. ti 4\ -, `, . rs" Date/B : Other Permit: TIGARD Inspection Line: 503.639.4175 '' qO Date Ready/By: dlMeth : See Page 2 for Internet: www.tigard or.gov 1 2 Q 1 Notified/Method: Supplemental upplemental Information TYPE OF WORK �� QRp PLAN REVIEW ❑ New construction ❑ Addition /alterationeNc & �E t�Z ,•v1Sl 10' Please check all that apply (submit a sets of plans w /items checked below): (��l? V , ❑ Service or feeder 400 amps or more ❑ Building over three stories. ❑ Demolition ❑ Other: 0.01t ` 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 ", "t -3 ", Job no.: Job site address: 1001-11" or more. occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State /ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description 1 Qty. I 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' 1 500 sq. ft. or portion 33.92 1 Tax map /parcel no.: Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) 1 Limited energy, multi - family 75.00 2 6wdpi C S � ✓U�2c5 /'�-� t'wd C �) Cr krt,t., i 13 residential (with above sq. ft.) _ Services or feeders installation, alteration, and/or relocation "0 0 S j��J -C t ^} 200 amps or less 3 100.70 33, )Q 2 ❑ PROPERTY OWNER v I ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: 601 amps to 1,000 amps 301.04 2 Address: Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation, alteration, and/or City/State /ZIP: relocation _ Phone: ( ) Fax: ( ) 200 amps or less 59.36 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2 Branch circuits — new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with ❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, f S 7.42 / 3i 2 each branch circuit , Business name: B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact name: branch circuit Each add'l branch circuit 7.42 _ 2 Address: Miscellaneous (service or feeder not included) City/State/ZIP: Each manufactured or modular 67.84 2 tY dwelling, service and/or feeder Phone:( ) 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 Each additional inspection over allowable in any of the above Address: Additional inspection (1 hr min) 66.25/ hr City/State /ZIP: Investigation (1 hr min) 66.25/ hr Industrial plant (1 hr min) 78.18/ hr Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr specifically listed (V2 hr min) - - CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: s-f/ 3, yv Plan review (25% of permit fee): Print name: Date: State surcharge (12% of permit fee): ley, ( TOTAL PERMIT FEE: L, 3, /9 ► Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: Date: • Number of inspections allowed per permit. I:\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: ❑ Audio and Stereo Systems* ❑ 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 111 Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ 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 Location: Record Type: Inspection Type: Comments: Inspection Date: Record ID: Result: City of Tigard 13125 SW Hal Blvd. Tigard, OR 97223 Tel: 503.718.2439 12200 SW 127TH AVE, TIGARD, OR, 97223 Residential - Master Permit 699 Mechanical final 06/12/2013 00:00 MST2009-00125 PASS Violation Summary: Inspector Contractor