Permit N
Community Development
Request for Permit Action
TIGARD
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner. ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
M CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Peria#: A P 2 0\ 0 Z (p
ite Address or Parcel #: \ 22.10 S (A S C Q . l3 PC. ✓r I�GI •
\'D Project Name: 0 Q T l ce € �/l ,YTh
l b � , . ! Subdivision Name: Lot #:
EXPLANATION: 1 poi i Carl* l ✓V Or V2 CA in
40 v Irv\ ; r\ s* DSc c-') i n --q_ -rz d { 8 r) rls2 c.,0
,p.Q f na k_-- ()AA Pn bkr - . S-E #7,20 o 9 ev go 3 -- .
Signature: ■ , / • 0. ._ L • _ � .. ♦ a Date: ' \ V k 0
Print Name:
Lorne n Q S.-C. `‘S fr.
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date /6 /She By el,
Refund Processed: Date /1/ //9'" By Invoice Processed: Date By
Permit Canceled: Date /d /(o //p Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
Baildin� Permit Aaalication
Commercial RECEIVED I. t) IR O I. I: I c i : t i S E:; (), I.1
CI of Ti and Received , ) Permit No.:
`.1 g DateB lit • 41 • 0 — (P
13125 SW HaII Blvd., Tigard, OR 97223 FEB 0 4 2010 Plan Review
■ ' Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit:
f 1 ., \ k I) Inspection Line: 503.639.4175 CITY OF TIGARD Nolifie ®pp ementat f l o n r fo
Internet: www.tigard-or.gov BUILDING DIVISIO
TYPE OF WORK REQUIRED 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
❑ Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application. ��J
❑ 1- and 2- family dwelling ❑ Commercial/industrial � �ll "'�— $ � /
❑ Accessory building ❑ Multi- family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFO T f TION AND TION Total number of floors:
c �e addr� ,l %�/ • �J 5 .!/ � LO , New dwelling area: square feet
� � Ali/ s L°
City /State /ZIP: � ! Garage /carport area: square feet
Suite/bldg. /apt. n 4 Project name: 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.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
Am ' E$ eRPTION_OF- -WORK , i work indicated on this application.
. ir Valuation: S
� � � Existing building area: square feet
New building area: square feet
❑ PROPERTY OWNER I ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City /State /ZIP: Existing:
Phone: ( ) Fax: ( )
New:
❑ er
A CONTACT PERSON NOTICE
Business name: // l All contractors and subcontractors are required to be
Contact name: licensed wit h 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
..a apply:
one: (S 7) 91 D - tot/(f I Fax:: ( )
ail:
CSC -0N_FRe1,GT R.
�ti f
r
4
ess name: �� ��,,� f Km / /.... BUILDING PERMIT FEES*
y /ease refer fee schedu
s:
/ (P eler to! k�
Structural plan review fee (or deposit):
to /ZIP:
FLS plan review fee (if applicable):
Fax: ( )
Total fees due upon application:
Amount received:
d srgrratureJ This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
e: Date: * Fee methodology set by Tri -County Building Industry
Service Board.
ermits\BUP -COM PermitApp.doc 2 /23/07 440- 4613T(11 /02 /COM/WEB)
. - , ,
mu
I
e,.
Building Division
- Accessibility: Barrier Removal Improvement Plan
TIGi \RD
REQUIREMENT: OREGON REVISED STATUTE (ORS) 447.241.
(1) Every proje for renovation, alteration or modification to affected buildings and related
facilities shall be made to insure that the path of travel to the altered area and the restroom,
telephones and drinking fountains are readily accessible to individuals with disabilities unless
such alterations are disproportionate to the overall alterations in terms of cost and scope.
(2) Alterations made to the path of travel to an altered area may be deemed disproportionate to
the overall alteration when the cost exceeds twenty-five per -cent (25 %).
VALUATION: Total of all renovation, alteration or modification being done,
excluding painting and wallpapering: [1] $
MULTIPLIER (25% barrier removal requirement): x .25
TOTAL BUDGET FOR BARRIER REMOVAL: [2] $
ELEMENTS: In choosing which accessible elements to provide under this section, priority shall be given
to those elements that will provide the greatest access. Elements shall be provided in the
following order:
(a) Parking $
(b) An accessible entrance: $
(c) An accessible route to the altered area: $
(d) At least one accessible restroom for each sex or a single unisex
restroom: $
(e) Accessible telephones: $ •
(f) Accessible drinking fountains: and, $
(g) When possible, additional accessible elements such as storage and
alarms: $
TOTAL (shall equal line [2] of Valuation Computation): , . - $
I: \Building \Permits \BUP -COM PermitApp.doc 06/25/08