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Permit
-Lt,o0q, ; . CITY OF TIGARD . COMMUNITY DEVELOPMENT 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 Plumbing Signature Form IMPORTANT PERMIT NOTICE Permit #: MST a,00 — bodOy Date Issued: Z(g( (cov Parcel: Site Address: (13$5 �w �R�►'t; �'t Subdivision: Lot: Jurisdiction: -1744 Lb Zoning: Project Name: Cu�.4EL 4' Description: Ftvb e , 0 3 • Your company has been indicated as the plumbing contractor for the permit referenced above. In order for the plumbing permit to be valid, please have the appropriate individual from your company sign below and return this Plumbing Signature Form prior to the start of the work. Please mail the form to: City of Tigard, Building Division, 13125 SW Hall Blvd., Tigard, OR 97223, or you may fax the form to: 503.624.3681. If you have any questions please call 503.7182431, No plumbing inspections will be authorized until this completed form is received OWNER: ,. ) LA. LE.t2T' A PLUMBING CONTRACTOR: 3 85° `,�to C25� T ('L $41 L1 -S - aDeO H 6e Nar QO -'► X44 4-72.$ H, oL 47 /P., Phone #: 6 Loa 1° 93 ' g Phone #: Reg #: $5$5 AN INK SIGNATURE IS REQUIRED ON THIS FORM � , • iii er r5 r p Yh P.r jr- Pr. Si.natur of Authorized Plumber Name (pante � jp r d +© Qcldl fteh torltrac or CITY OF TIGARD � Q-- co \-trtA MECHANICAL PERMIT COMMUNITY DEVELOPMENT 1 f Ue t Permit# MST2009 -00004 � Date Issued 03/31/2009 .T:IGf[RD 13125 SW Hall Blvd , Tigard OR 97223 503 639 4171 �eY parcel 2S103DB09600 Jurisdiction TIG Site address 11385 SW ERSTE PL Subdivision Lot Project CULBERTSON Project Description Addition ADDED (1) furnace, (1) a /c, (1) gas line, and ductwork in addition 6/24/09 Owner FEES JON CULBERTSON Description Date Amount 11385 SW ERSTE PL TIGARD, OR 97223 [BUPPLN] Pin Rv Deposit 01/20/2009 $336 54 PHONE 503 -681 -9338 [CDCPLN] CDC Pln Rev 03/31/2009 $46 00 ]LRPF] LR Planning Surcharge 03/31/2009 $6 00 [BUPPLN] Pln Rv Balance 03/31/2009 $134 28 Contractor [BUILD] Bldg Permit 03/31/2009 $724 34 JOHN DOCTOR INC [TAX] Build 12% State Surchrge 03/31/2009 $86 92 1163 NE 3RD AVENUE [TIGCET] Tig -Tual School CET 03/31/2009 $846 00 HILLSBORO, OR 97123 [MECH] MEC Permit 03/31/2009 $72 50 PHONE 503 - 681 -2079 [TAX] MEC 12% State Surcharge 03/31/2009 $8 70 FAX 503 - 357 -2696 [PLUMB] PLM Permit 03/31/2009 $72 50 [TAX] PLM 12% State Surcharge 03/31/2009 $8 70 (ELPRMT] ELC Permit 03/31/2009 $60 15 [TAX] ELC 12% State Surcharge 03/31/2009 $7 22 Type of Use SF [ERPRMT] Erosion Control 03/31/2009 $40 00 Class of Work ADD Type of Const 5N [ERPLN] Erosn Pln Rv CWS 03/31/2009 $13 00 Occupancy Grp R3 [EROSN] Erosn Pln Rv COT 03/31/2009 $13 00 Stories 2 Fuel Fuel Types Gas Pressue Total $2,475 85 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 may obtain a copy of the rules or direct questions to OUNC by calling 503 246 6699 or 1 800 332 2344 Issued By No da Y it , 4 ( I Permittee Signature 1' ' L 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 Mechanical Permit Application RECEIV 1 .. FOR oF FI C E LISEIU Ini City of Tigard Permit No 13125 SW Hall Blvd , f igard,OR 97223 Phone 503 639 4171 Fax 503 598 1960 JUN 2 4 Zp 1 tIatan e/By Rewew Other Permit ® Inspection Line 503 639 4175 Date Ready/By June WI See Page 2 for Internet www tigard - or goy CITY OF TIGA Ianeed/Methea Supplemental Information BUILDING DIVI • 1 TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST q ew construction gAddamn/alteration /replacement Mechanical permit fees* are based on the value of the work performed Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other mechanical materials, equipment, labor, overhead, and profit CATEGORY OF CONST RUCTION Value $ RESIDENTIAL EQUIPMENT / SYSTEMS FEES* - and 2 -family dwelling ❑ Com mercial /industrial ❑ Accessory building M uIU - family ❑Master builder ❑Other Por special information use checklist Description I Qty Ea focal JOB(] SITE INFORMATION AND LOCATION Heating/cooling Job site address { 1 395 SW 2s 4 e pi. Air conditioning or heat pump (requires site plan showing placement) 4 14 00 City /State / "LIP• t i , r Vs Ai O Z g 7 22-3 Furnace 100,000 BTU (ducts /vents) ► 14 00 Swte / bldg /apt no J Project name Furnace 100,000+ BTU (ducts /vents) 17 90 Gas heat pump 14 00 Cross street/directions to Job site Duct work 10 00 Ilydronic hot water system 14 00 Residential boiler (radiator or hydromc) 14 00 Una heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc 14 00 Subdivision Lot no Flue /vent for any of above 6 80 Other 10 00 Tax map /parcel no Other fuel appliances DESCRIPTION OF WORK Water heater 1000 p [� /fll f Gas fireplace 10 00 � WS �-C(k T•IJ.0 YVt rye �� /ls-� � 1 S ` � ' Flue vent for water heater or gas 0V G1- • v A- dOfubd'� fireplace 1000 Log lighter (gas) 10 00 Wood/pellet stove 10 00 Wood fireplace/msert 10 00 A-- PROPERTY OWNER I ❑ TENANT Chimney /liner /flue /vent 1000 ( Other 10 00 Name 7%0 fn C 4 I bV /4lp Other exhaust and ventilation / 13 8 s s Er i V n i . - 9 Range hood/other kitchen Address 9 equipment 10 00 City /State/ZIP -e-„( G. k B R. 9? 2.1. 3 Clothes dryer exhaust 10 00 / ` Single -duct exhaust (bathrooms, Phone 3 ) V ec /. ¶ 339-- Fax ( ) toilet compartments, utility rooms) 6 80 ❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 1000 Other 10 00 Business name Fuel piping Contact name $5 40 for first four; $1.00 for each additional Address Furnace, etc I Gas heat pump City /State /ZIP Wall /suspended/unit heater Phone ( ) 11'ax ( ) Water heater Fireplace E-mail Range CONTRACTOR Barbecue Business name 01 Afec I.( l / ► Clothes dryer (gas) Address f . D f a e / 62,1 MECHANICAL PERMIT FEES* City /State/ZIP 8 re, del l C y 1).y% 9 ft 9 2 0v Subtotal l Minimum permit fee ($72 50) Phone (T 0) )z SQ t (9 c y, '' Fax ( ) Plan review (25% of permit fee) CCB he 1 Z 6 l/9 1 tt ■ State surcharge (12% of permit fee) TOTAL. PERMIT FEE = This permit application expires if a permit is not obtained within 180 Auihonzed sig / j days after it has been accepted as complete. f / Print name ejel40 SiCee(tuf Date 6 e.2 it -2 r Fee methodology set by To County Building Industry Service Board I ,Bwidmg\Permns' MEC- PermitApp doe 01/19/07 490-1617T (I I /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. 11Hwiding \Permrts\MEC- PcnmtApp doc 01/19/07 2 i on CVIbv4sson • I 13&s s w ERs PC ? t5 -. oR ?7223 Co3 - r - f &.v4 -rwc L .r — 131s C 94-his &C £03 2 $'o ;rS 13 fL,a40 S c o` I N zO CITY OF TIGARD MASTER PERMIT COMMUNITY DEVELOPMENT Permit# MST2009 -00004 TIGARD 13125 SW Hall Blvd . Tigard OR 97223 503 639 4171 Date Issued 03/31/2009 Parcel 2S103DB09600 Jurisdiction TIG Site address 11385 SW ERSTE PL Subdivision Lot Project CULBERTSON Project Description Addition BUILDING Floor Areas Required Setbacks Required Stories 2 Bedrooms 1 First 423 sf Basement sf Left Parking Spaces Height 24 Bathrooms 1 Second 423 sf Garage sf Front Smoke Dwelling Units 1 Third sf Right Detectors Yes Total sf Value 50 00 Rear PLUMBING Sinks Water Closets 1 Washing Mach Laundry Trays Rain Drain Catch Basins Lavatories 2 Dishwashers Floor Drains Sewer Lines SF Rain Drains Other Fixtures Tubs /Showers 1 Garbage Disp Water Heaters 1 Water Lines Bckflw Prevntr MECHANICAL Fuel Types Air Conditioning Vent Fans 1 Clothes Dryers Heat Pump Hoods Other Units Furn <100K Vents Woodstoves Gas Outlets Furn > =100K ELECTRICAL Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits 1000 sf or less 0 -200 amp 0 -200 amp W/ Svc or Fdr Ea add'I 500 sf 20 1 -400 amp 201 -400 amp 1st WIG SvclFdr Limited Energy 401 -600 amp 401 -600 amp Ea add'I Br Cr 601 -1000 amp 601 +amp -1000v 1000 +emp /volt ELECTRICAL - RESTRICTED ENERGY SF Residential Audio & Stereo HVAC Secunty Alarm Vaccuum System Garage Opener All Other Other Description Ecompasing BUILDING INFO Class of Work Type of Use Type of Constr Occupancy Group Square Feet Owner Contractor Required Items and Reports (Conditions) JON CULBERTSON JOHN DOCTOR INC 11385 SW ERSTE PL 1163 NE 3RD AVENUE TIGARD, OR 97223 HILLSBORO, OR 97123 PHONE 503- 681 -9338 PHONE 503- 681 -2079 FAX 503- 357 -2696 Total Fees $2,475 85 T permit is iii ed\ublect to the regulations contained in the Tigard Municipal Code, State of OR Specialty Codes and all other applicable law All work ill be done in accordance with approved plans This permit will expire if work is not started within 180 days of issuance, or d work is suspended for more the 180 days ATTENTION g 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 • • i-40 -0100 You may obtain a copy of the rules or direct questions to OUNC by calling 50 46 6699 or 1 800 33 144 slued By /i Perm ittee Signature i i�� c_ I I 7_8/5 49 EC=sTG EL- Building Permit Application Residential li�gl FOR OFFICE USE.ONLY { t. a - Pon City of Tigard 9 1J�iM+ �+1 V Lill// Re e; `e<I Awn Pelmn fr e7/ �oe9._oe r 1 SW 1 SW Hall Blvd Tigard OR 972 A qq p plan Re � • t la� ©�� m 503 639 4171 Fax 5D3 3 9 j i 60�' 2U1f7 pp Date /R Other Pen� I fs. 'TIGA'RD Inspection Line 503 639 4175 Date R �� � hire 0 See Pane 2 for Internet sswss a and -or goy Notified/method g C ON ` • ( .12 q �� Supplemental ...._C----1/4" ' oi matron I • • w � • - Ci - s "- s 4 s n', ° F'W 7' T}• - ,, T-A ;-- ' REQUIRED DA - 1= AND'2'FA MILY,DWILLUNG, : ❑ New construction ❑ Demolition Permit tees* are based on the value of the wot k performed Indicate the value (rounded to the nearest dollar) of all gAddibon /alteration /replacement ❑ Other equipment materials labor, overhead and the profit Mt the s4 r ;t' m'' ' 'h:fc• t CATEGORY ,0F CONSTRUCTION : t ! 1 , 'sort. indicated on this application I- and 2- family dwelling ❑ Commercial /industrial Valuation S 0 ❑ Accessory building ❑ NItillrfamily Number of bedrooms ❑ Master butldei ❑ Other Number of bathrooms ( ,' ,» . -..f4 `, , ; i "`d013j SI CE;INEQRN4"I ION AND 1 OCATION a 7 ' Total number of floors 8 - lob site address ) / 3 8 5' S L1/ 2.....> (� pC i1 C C � New dwelling area square feet - C ny /State/ZIP 776 nit 0 R Garage/carpoit area LX square feet Suue/bld g /apt no Protect name '..,_... ` t / 6 I I C UG(j��/ X/7/ AD/ 77Q4 Cove] ed porch m ea s squat e feet Cross street /directions to lob site Deck area I 2.0 square feel Othei structure area square feet `REQUIRED DAFA:,CO51i1FiRCIAI IJSE,CHECKLIS7.;,q Subdivision I of no Permit fees* are based on the value of the work performed Indicate the value (sounded to the nearest dollar ) of all ax map /parcel no equipment matei mss litho' overhead and the profit Lot the eS 4 1 ; - " :. • ° DFSGRII'11I0A0I'' N'ORK ";, ' "" I: . A '_ law indicated on this application .12 cm c✓c Co. verse. -N) )-r< 14? o cC/=l — rx,2 -at,!� Valuation S / 1 0, t D xL F_vsVna b udding area square feet C /I. /Yt-� ��01� rX ��L/�'a i c"02E.YJ»^ ✓n l ;A1 Pt 00 /1.4 el. 5 TYL IiF Oat A 547>A,L pargyn. New building at ea square feel , k4 j,ili ." ('_., ;,s <-:- • .. x _ . 0 . 4 tENA_l,g341: 3,, 14 Number of stories :Jame 'i7 not cI)c- )2,r7273C9/L/ Type of construction Address i /.3 `rte �7 5 5 W 0 / S�Z= � -g � CJ Occupancy groups City /State /ZIP 77Ukty � n/`2 Existing Phone (SO3) 4.1 / - / '3 38 has ( ) New -es ' [ 2' u 41P 'LIG�4NTv;, tic • � C PERSON». "r- _z, ,d _ r '' <, °r ,ONTAC"I !' - .. I T ,," 1II''NOFICE.:1._ ^ii f ._ -�P Business name do L Coni ztie /7 fit r k/ C. All contractors and subcontractors are required to be Contact name �� LL f r / / r A c 4 � in licensed with the Oregon Construction Contractors Board I- under ORS 701 and may be required to be licensed in the Addre 75 5' 1 L , i 4 • / . . L L R� jurisdiction in which work is being perforated If the Cits /State /ZIP _ f' applicant is exempt from licensing the following reasons C��� / z.v� n � ��, 3 aapply Phone (q)/ ) / /(J 5 Z JS y P I Fax (3 5C7 Z6 / q F -mad JO///l./TC ct!L ``D ^ (o /LK'L T, &Vt m_)t,s,'':.`,v. _ c • sxr n,., • s._ ' 'CONTRAC;I0R , ,. . - /N,f T _ <', . -, Business name ge L (CJ /L /)2Li ;- _ -- ) }_'ic" "y*.g`,13OWDIN'G,PERA7IT FEE5 ', ' ;;;;;E .v Address 7 5-30 cI L �-' c-') }�fC 7;` 0; ',y'`,_ _.. %(Plense,rel✓✓ i'ofee seGe %ej .R .. ;A'":,:,."' lay/State/ill' > Structural plan teview fee (oi deposit) /55 C. JT �,,rn, rLC/S fl q s - 7/ / 3 _ �• �r1 FLS plan review fee (it applicable) y Phone (S L ) f ax 6 3 - Zte/ Q � CCB he 1 otal fees due upon application d e'C.P , 5 7 Amount received 33 , :1 u0soi tied signature / t or I his permit application expo es if a pet mit w not obtained Pant name 1Z-ZL /31/4-c5 �� Date / � 76- n me ISO days sties it has been accepted as complete L t ce methodology set by I n-Comny Building Industq So vice Board I', Budding s Pernuts \BtIP -R LS Perm itApp doe 11/6/07 440- 1613T( I1 /02 /COM /WFR) Mechanical Permit Application FOR OFFICE USE ONLY , Irk City of Tigard Received Er • 13125 S W Hal 61vd , Ti aril OR 97223 DateBy / r 0 /l //i'/' € Plan Review C Phone 503 639 4171 Fax 503 598 1960 Other Peu nit RECEIVED DateBy T I G ARD Inspection Line 503 639 4175 Date Ready /By 0 See Page 2 for Internet WWW tigard -or gov Notified/Method Supplemental Information TYPE OF WORK JAN 20 2(//19 COMMERCIAL FEE* SCHEDULE — USE CHECKLIST Mechanical piece fees* are based on the value of the work ❑ New construction ❑ Addition /alteratitcir aOEM L DING DIVISION performed Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑Other BUILDING mechanical materials, equipment, labor, overhead, and profit CATEGORY OF CONSTRUCTION Value $ RESIDENTIAL EQUIPMENT / SYSTEMS FEES* gj I- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist ❑ Multi-family ❑ Master builder ❑ Other Description Qty Ea I 1 otal JOB SITE INFORMATION AND LOCATION Heating/cooling Job site address ' l 38 5 $ (• l� 5 pt IA C e - Air conditioning or heat pump (mgmies site pla showing placement) 14 00 City /State /ZIP 77 pgrj-6 012 Furnace 100,000 BTU (ducts /vents) 1400 I Furnace 100,000+ BTU (ducts /vents) 17 90 Surte/bldg /apt no Project name C irZ%SD/U JA 17O' Gas heat pump 1400 Cross street/directions to lob site Duct work / 10 00 I lydronic hot water s\stem 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 am of above 6 80 Subdivision Lot no Other 10 00 Tax map /parcel no Other fuel appliances DESCRIPTION OF WORK Water heater 10 00 Gas fireplace 10 00 e XT[a'l/T 17 044 / W ire /✓EN.t✓ e mimic marns Flue vent for water heater or gas fireplace 10 00 nlL-7✓ (34 -3}/ jar FAA. e DU/ /7 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 JON C U L , C-)2 77c04.) Environmental exhaust and ventilation Address _ _ _ Range hood /other kitchen ddress 3 5 C s W e- rz.S pew e c equipment 1000 City/State/LIP 77 C 4 2 is 02 Clothes dryer exhaust 10 00 CI -� /q Single -duct exhaust (bathrooms, Phone (4 0 J 3 ) 6 , / ' /If Fax ( ) toilet compartments, utility rooms) 1 6 80 ❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 10 00 Business name C L (Ovj) UC "O"t% I n/ C Other 10 00 Fuel piping g i Contact name pr i L 1114 C 5 6 /'" k $5.40 for first four; $1.00 for each additional Address 75 fro S r.0 v W di/ tl n heat etc / _ vN Gas as heat pump City /State /ZIP ( 7 1 2 / 2 ica, U S () t 7/i 3 Wall /suspended/unit heater Phone. en I) y L - 9 b If g Fax (,5 - 03) 3 s —2696 Water heater Fireplace E-mail 4 IM) T)1 tr CC C- 9 (Dr ic- 7 N t) Range CONTRACTOR Barbecue Business name 67 C L_ (b.v5TnaucT ) i 141 Clothes dryer (gas) Other Address -7 5'30 5 u.) 1 o /y4 N LL R MECHANICAL PERMIT FEES" 2 City /Slate /ZIP (U/VEC I c' L 0 p y 7// / Subtotal Plan review (25 5% permit of permit Phone (5D3) 706 r8 �3 Fax (C 3S 7 —2 b/ e Minimum pfeer - ?Z.`7 fee) CCB lie I 35 - ,- State surcharge (12% of permit fee) TOTAL PERMIT FEE a .20 Authorized signature This permit application expires if a permit is not obtained within 180 € days after it has been accepted as complete Print name De -«_ y p 6 j , O 1 Date 20 f(�/ Zaj, ' lice methodology set by Tn- County Building Industry Service Board 1 Aamidingwermns \MEC- PermuApp doe 01/19/07 440-4617T 1/02 /CO W WEn) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial Fee Schedule: Total Valuation: Permit Fee: $I 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 \Budding \Pernms \MEC- PernutApp doc 01/19/07 2 . Plumbing Permit Application Building Fixtures ,TIC _' FOR, OFFICE USE, ONLY I RECEIVED R eceived / City of Tigard / An 0 C/ Penn No /7 !� Date /By ( ' ui ! IIIII • 13125 SW Hall Blvd ,Tigard, OR 97223 Plan Review 9 Phone 503 639 4171 Fax 503 598 19� 1.2 ,0 2009 Date /Bv Other Permit No TIGARD Inspection Line 503 639 4175 Date Ready /By ^� ® See Page 2 for Internet www tigard-or gov CITY OFTIGARD Notified/Method (L.! Supplemental Information TYPE OF W Ojfgq DING DIVISION FEE* SCHEDULE ❑ New construction 0 Demolition For special information use checklist Description I Qty 1 Ea I Total I:a:Addition/alteration /replacement ❑ Other New 1 -2 -family dwellings (Includes 100 ft for each utility connection) CATEGORY OF CONSTRUCTION SFR (I) bath 249 20 - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350 00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399 00 Each additional bath/kitchen 45 00 ❑ Master builder El Other Fire sprinkler ( sq ft ) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address / 13 g S 5 w I7Lt 7 / JL�C C — Catch basin or area drain 16 60 City/State /ZIP / /. nab A l C[_ Dryw ell, leach line, or trench dram 16 60 Suite/bldg /apt no Protect name p l3 t- a t arson& 4 (,y) m, Footing dram (no linear ft Page 2 Manufactured home utilities 110 00 Cross street/directions to job site Manholes 16 60 Rain drain connector 16 60 Sanitary sewer (no linear ft ) Page 2 Storm sewer (no linear ft ) Page 2 Subdivision Lot no Water service (no linear ft _) Page 2 Fixture or item Tax map /parcel no Absorption valve 16 60 DESCRIPTION OF WORK Backflow preventer Page 2 A/ /,Zit./ [ V 4i71g691.'\ t,g- /Mt 2- 6 .4t. / n/ Backwater valve 16 60 ! 5 Di S _ ac/t7L Clothes washer 16 60 Dishwasher 16 60 ❑ PROPERTY OWNER l ❑ TENANT Drinking fountain IG 60 /� Ejectors/sump 16 60 Name JUN `z- �aNYL�O Expansion tank 16 60 Address / )3Rs.----- 5 t<-i 6:72s) Pt /Z\CG- Fixture /sewer cap 16 60 Cit4/Statc/Z1P 7 <-ie, C I7 Floor drain /floor sink/hub 16 60 Phone ( 68 / - .9 338 Fax ( ) Garbage disposal 16 60 El APPLICANT ❑ CONTACT PERSON I lose bib 16 60 lee maker 16 60 Business name Gr. L rozi Jet ,, )4t' Inlerceptol /gl ease trap 1660 Contact name - ptZ L km /Ci- S -bens Medical gas (value $ ) Page 2 Address 7 S' 30 SI-c. 1700- /1/2 LC lG /N) Primer 1660 City /Stale / (be / Z. 0 2 9 7. /3 Roof drain (commercial) 16 60 Sink/basin/lavatory Z 16 60 Phone (IN ) 909 ( Fax (sTV3) 3,57 -769 Tub /shower /shower pan 1660 E-mail .7 ppp j r GC L. e CO/h C .iye r Urinal 16 60 CONTRACTOR Water closet I 16 60 Business name 741 U_- 4 t g-C..I Pi »/ /PJC. Water heater 16 60 Address. P6 t R2- 3 Other Crty /State /ZIP ( Ice a -j Subtotal � ki l \ 3 11 �J V o e J C 123 _ Minimum permit fee $72 50 72 .r Phone 90 ) Fax Resid ential backflow minimum permit fee $3625 Gr `fa • 2 5 2 5 p CCB Lie 35 85 ( 3 ( (/ 27 Lb Plumbing Lie no 3l{. -' pR Plan review (25% of permit fee) (I State surcharge (12% of permit fee) a 70 Authorized signature 7 TOTAL PERMIT FEE at ,7!") Print name Date This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by 1n -County Building Industry Service Board I \ Budding \PermasiPI.MF- PermItApp doe 12/27/06 440- 4616T( I O /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 - I' 100 55 00 0 to 2 000 $115 00 Footing drain - each additional 100 46 40 2,001 to 3,600 $160 00 Sewer 3 601 m 7 200 $220 00 ewer - 1st 100 55 00 7,201 and greater $309 00 Sower - each additional 100 46 40 Water Service - I st 100' 55 00 Medical Gas Systems: Water Service - each additional 100' 46 40 Valuation: Permit Fee: Storm & Rain Dram - Ist 100 5500 $1 00 to $5,000 00 Minimum fee $7250 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 Backllow 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 Commercial 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 fixture. Failure to Please check all that apply accurately report fixtures could result in increased sewer fees*. ❑ Any new commercial building with water service T 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 OAR9I8- 780 -0040 Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities - ]actwavi/Whirlpool ❑ Any multipurpose lire sprinkler system Car Wash - Each Stall ❑ Any complex structure as defined in OAR918 780 - 0040 - Drive I hru Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher - Commercial - Domestic Drinking Fountain Isometric or Riser Diagram 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 /Refng 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 Swimnng Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet - toilet Urinal Other Fixtures VBuilding'PermmV'LM- PermitApp doe 12/27/06 Electrical Permit Application FOR OFFI USE.ONLY III q City of Tigard RECEIVE 1 oa;mBed /i /� Q I 13125 SW Hall Blvd , Tigard, OR 97223 g Plan Review Phone 503 639 4171 Fax 503 598 1960 Date /By Other Pet nit TI D . Inspection Line 503 639 4175 SAN 2,0 2009 Date Ready /B} lull ® See Page 2 for Internet w tigard -or gov Notified /Method ((.(a Supplemental Information TYPE OF' WORKCITY OP I1tiAKO PLAN REVIEW } ,��11'tI _� r • Please check all that apply (submit 2 sets of plans whtems checked below) ❑ New construction gi Addition /alterattoa ❑ Sen Ice or feeder 400 amps or more 0 Building ocer three stories ❑ Demolition ❑ Other when. the avatlable fault current ❑ Manias and boatyards CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings less to ground or exceeds 14 000 ❑ Commercial -use agncultm at ig I- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations buildings ❑ Multi- family ❑ Master builder ❑ Other ❑ Pore pump ❑ Installation of KVA or JOB SITE INFORMATION AND LOCATION ❑Emergency system larger separaieh i‘ed system zp C J � ❑ Addition of new motor load of - ❑ "A' "B' "I- 2 "'I -3', Job no Job site address / / /8 S� C 12 5j - PL 100HP or more occupancy ❑ Six or more residential units ❑ Recreational vehicle parks City /State /ZIP , J( 2 o Y n ` ❑ Health -rare facilities ❑ Supply voltage for more than ❑ttaeardons locations 600 colts nominal Suite /bldg /apt no Protect name e✓,_;gza A/7),04.) /[04.) ❑ Service or feeder 600 amps or more FEE SCHEDULE Cross street/directions to job site Denenptioo I Qty [ tee. I Toms I • New residential single - or multi-family dwelling unit. Includes attached garage. Subdivision Lot no 1 000 sq ft or less 145 IS 4 Tax map /parcel no Ea add'I 500 sq ft or portion 33 40 I 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 80 30 2 ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106 85 2 Name U oN (� v s &-ye 73 401 amps to 600 amps 160 60 2 601 amps to 1,000 amps 240 60 2 Address 9 / 3 es _ 4 lf-, Ere 37 F Over 1,000 amps or volts 45465 2' i City /State /ZIP / Temporary services or feeders installation, alteration, and/or / 7 /40:2.,b p � � relocation Phone ( 93) 6 6 /_ 9 3 3 l7 Fax ( ) 200 amps or less 66 85 1 Owner installation: Ihis 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 I 2 Branch circuits — new, alteration, or extension, per panel Ow nci signature Date A fee for branch circuits a nth ❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee, 6 65 2 each branch circuit Business name B Fee tor branch circuits / Contact name 1t /shout service or feeder fee, S 46 85 2 first branch circuit Address Each add I branch circuit de 6 65 2 Miscellaneous (service or feeder not included) City /State /ZIP Each manufactured or modular 90 90 2 dwelling service and /or feeder Phone ( ) Fax ( ) Reconnect only 66 85 2 E-mail Pump or irrigation circle 53 40 2 CONTRA CTOR Sign or outline hahting 53 40 2 Business name panel, (260 Signal (s) er or d- ( i 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 (I hr mini 62 50 CCB Lie Electrical Lie Supry Lie Industrial plant per hour 73 75 ELECTRICAL PERMIT FEES Supry Electrician signature. required Subtotal ((', (-j Print name Date Plan review (25% of permit fee) State surcharge (12% of pennit fee) 7 , 2.72_ Authorized signature TOTAL PERMIT I EE b7 3 - 7 This permit apphcanon expires if a permit is not obtained within 180 Print name Date days after it has been accepted as complete ' Number of inspections allowed prr permit I dlmldmgWermits,Fl C- PermttApp doe 05/21/06 440- 4615T( I I /05 /CObi/w'EB 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: n Audio and Stereo Systems* n Burglar Alarm n Garage Door Opener* n Heating, Ventilation and Air Conditioning System* ❑ Vacuum Sl stems* n Other [ COMMERCIAL WORKK ONLY: Fee for each commercial $75.00 system (SEE OAR 918 309 - 0000) Check Type of Work Involved: n Audio and Stereo Systems n Boiler Controls ❑ Clock Systems n Data Telecommunication Installation n Fire Alarm Installation n I-IVAC ❑ Instrumentation n Intercom and Paging Systems n Landscape Irrigation Control* n Medical n Nurse Calls ❑ Outdoor Landscape Lighting* n Protective Signaling n Other Total number of commercial systems *No licenses are required. Licenses are required for all other installations I \auddm6 \PCrmns\LLGPermuApp doc 03/23/05 Building Division One & Two - Family Dwelling rlcnKD Fees Checklist ' PERMIT INFORMATION: - Permit #- 'tt(t1- ?&9 - Or Plan # Date. 2/2- Site Address ( ( 7-,c,:, x.25 (� Parcel # Subdivision C:0C.e21 �y cyR1 At c77 S CiaLi ,#-3) Lot #. - Zoning Junsdicnon 116 Setbacks Front Rear. Left Right - Class of Work i\TD7 Stories First Floor , 4'z"rt- Type of Use i 5 Height . Second Floor k 2? Construction (?-7' Floor Load "� Third Floor Occupancy Group - Dwelling Units I Bonus Room Valuation • -a�� I Bedrooms 1 Total Floors Est ( eI , . Bathrooms \ Basement Decks f 71j I — Garage. Porches Other. FEES: Description: Fee Amount: • Amount Paid: ' Balance Due: Plan Check Budding 470 , Er .. -3 .`54k- ( '✓4 Extra Set Permit Building 7 -ZA , 2 Tax. e Co , o Metro CET School CET PA-( ' Cxm Mechanical - 72- '50 Tax. a ?0 Plumbing 72, Tax 8 nG Electrical 4 l Tax ! . _z__2- Lou Voltage Tax — CDC CDC Plug Rev C Lo CDC LRP Fee 1 CO SDC Parks TIF Res _ TIFMT — Erosion Permit 16k(),o0 Erosion CWS ‘92. , 00 Erosion COT ( , CO Water Quality Water Quantity ---_- SUB TOTAL: Sewer Permit Inspection SUB - TOTAL: TOTAL MST & SWR: I A Building \ Forme APr.PIanCheckPet. doc 01 /19/07 Page 1 PLUMBING FEES (for special information use checklist) MECHANICAL FEES (residential equipment/systems) Description Qty I Fee(ea ) I Total Description Qty Fee(ea.) 1 Total New 1 -'& 2- family dwellings Hearing, /Cooling (includes 100 ft. for each utility connection) Air conditioning or heat pump* 14 00 SFR (1) bath 249 20 Furnace 100,000 BTU (ducts /vents) 14 00 SFR (2) bath 350 00 Furnace 100,000+ BTU (ducts /vents) 17 90 SFR (3) bath 399 00 Gas heal pump 14 00 Each additional bath /kitchen 45 00 Duct work _ 10 00 Ram Drain single family dwelling 65 25 Hydromc hot water system 14 00 Fire sprinkler - sq ft 0 to 2,000 115 00 Residential boiler Fire sprinkler - sq ft 2,001 to 3,600 160 00 (for radiator or hydronic system) 14 00 Fire sprinkler - sq ft 3,601 to 7,200 220 00 Unit heaters (fuel, not electric) Fire sprinkler - sq ft 7,200 and greater 309 00 On wall. rn -duct, suspended, etc) 14 00 Site Utilities Flue /vent (for any of above) 6 80 _ Catch basin /area drain 16 60 Repair units 12 15 _ Drywell /leach line /trench drain 16 60 Other Fuel Appliances Footing drain - 1" 100' 55 00 Water heater 10 00 Footing drain - each additional 100' 46 40 Gas fireplace 10 00 Flue vent (water heater /gas fireplace) 10 00 Manufactured home utilities 110 00 Log lighter (gas) 10 00 Manholes 16 60 Wood/Pellet stove 10 00 Rain diem connector 16 60 Wood fireplace /Insert 10 00 Sanitary sewer - I' 100' 55 00 Chimney /liner /flue/vent 10 00 Sanitary sewer - each additional 100' 46 40 Other 10 00 Storm sewer - 1 100' 55 00 Environmental Exhaust & Ventilation Storm sewer - each additional 100' 46 40 Range hood /other kitchen equipment 10 00 Water service - 1" 100' _ 55 00 Clothes dryer exhaust 10 00 Water service - each additional 100' 4640 Fixture or Item Single duct exhaust Absorption valve 16 60 (bathrooms, toilet compartments, Backflow preventer 27 55 . utility rooms) 6 80 Attic /crawl space fans 10 00 Backwater valve 16 60 Other I 10 00 Clothes washer 16 60 Fuel Piping Dishwasher _ 16 60 * *($5.40 for first 4, SI 00 each additional) Drinking fountain 16 60 Furnace etc ** Ejectors /sump 16 60 Gas heat pump ** Expansion tank 16 60 Wall /suspended /unit heater ** Fixture /sewer cap 16 60 Water heater *4 Floor drain /floor smk/hub 16 60 Fireplace ** Garbage disposal 16 60 Range * Hose bib 16 60 BBQ ** Ice maker 16 60 Clothes dryer (gas) ** Interceptor /grease trap 16 60 Other ** Primer 16 60 Total Roof drain (commercial) 16 60 Mechanical Permit Fees Sink /basin /lavatory 16 60 Subtotal $ Tub /shower /shower pan 16 60 Minimum Permit Fee $72 50 $ Urinal 16 60 Plan Review Fee (25% of Permit Fee) $ Water closet 16 60 State Surcharge (12% of Permit Fee) $ Water heater 16 60 TOTAL PERMIT FEE $ Other - Other Plumbing Permit Fees ELECTRICAL FEES (residential single - or multi - family) Subtotal $ Description Qty Fee Total Lisp Minimum Permit Fee $72 50 $ 1,000 sq ft or less 145 15 4 Plan Review (25% of Permit Fee) $ Ea add'1 500 sq ft or portion 33 40 1 State Surcharge (12% of Permit Fee) $ Limited energy, residential 75 00 2 TOTAL PERMIT FEE $ Each manufactured or modular dwelling. service and /or feeder 90 90 2 Electncal Permit Fees Subtotal $ Plan review (25% of permit fee) $ State surcharge (12% of permit fee) $ TOTAL PERMIT FEE $ 1 \ Building \ Forms \ResPlanCheckFrea doc 01/19/07 Page 2 REC 1 n ] 5 I AN 2 0 2009 DEC • 0 2 2008 �}(OPTIG ean Water ServicesFile Number _ ❑ DING DIVI C1eanWat Sp ervices FS-00367-7 By — Sent Area Pre - Screening Site Assessment 1 Jurisdiction: J 1G��1l�i) 2, Property Information (example 1S234AB01400) 3. Owner Information _ Tax lot ID(s) i., 2 2 5 10 3 D B Name C 2754vv, •.I tin) co-7- `36 !Y4(' Company Address 5 h vvi r Site Address I ) 38 5 S U'✓ ,T11 S7 icisc City, State, Zip City, State, Zip T17c <72h O Phone /Fax Nearest Cross Street E-Mail 4. Development Activity (check all that apply) 5 Applicant Information j� 2 Addition to Single Family Residence (rooms, deck, garage) Name D L /1'))4C ‘109- 1 0C,- /g q la Lot Line Adjustment 21 Minor Land Partition Company C e i o.c712_ cfc iiat. © Residential Condominium Commercial Condominium Address 75 S RJ Pb o Residential Subdivision 0 Commercial Subdivision / al Single Lot Commercial 0 Multi Lot Commercial City, State, Zip ( { 5 5 7/ x Other 1 /F_a„ (CZ) '3 S 7 26 J E -Mail jo /ieVi T H - L; L�.- (� ['0 r- r'F)5 Ale 7 6. Will the project involve any off -site works Yes , No © Unknown Location and description of off -site work 7 Additional comments or information that may be needed to understand your project iv, Cd t c')c /7 /t,C /)ccvC Z=X LJvs 72 Z L i0 P AbD recAI3Li rCA✓ L 2 c; "Fr- r - NA) ) i✓ '' j This application does NOT replace Grading and Erosion Control 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 andlor Department of the Army COE 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 protect site at all reasonable times for the purpose of inspecting protect site conditions and gathering information related to the project site I certify that I am familiar with the information contained in this document, and to the best of my knowledge and belief, this information is true, complete, and accurate Print/Type Naarna De- - - / 1 /a C S7 J1- Print/Type Title I c1�=Z/ )10 Is' rte /� Signature (� /, /.7; 1 `/ = _ Date Z>r 2 i l FOR DISTRICT USE ONLY U Sensitive areas potentially exist on site or within 200' of the site THE APPLICANT MUST PERFORM A SITE 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. 1S Based on review of 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 Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas rf they are subsequently discovered This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3 02 1 All required permits and approvals must be obtained and completed under applicable local, State, and federal law U Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s) found near the site Tnis Sensitive Area Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas if they are subsequently discovered Tnis document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3 02 1 All required permits and approvals must be obtained and completed under applicable local, state and federal law U This Service Provider Letter is not valid unless CWS approved site plan(s) are attached U The proposed activity does not meet the definition of development or the lot was platted after 919/95 ORS 92 040(2) NO SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS�REQUIR D Reviewed by Date La/ CVO Sf 2550 SW Hillsboro Highway a Hillsboro, Oregon 97123 • Phone: (503) 681 =5100 • Fax (5D3) 681 -4439 • www.cleanwaterservices:org CITY OF TIGARD - SITE PLAN REVIEW ' 0 s.) 2009 BUILDING PERMIT NO.: - i -.SA* IP PLANNING DIVISION: CP) QF ►G 0 C Required Setbacks: ❑ Approved ❑ Not Approved p4C DIVIS�QN z Side: S Street Side: 8 Front. ;o Garage- aT Rear: ` s PROPERTY LINE n Visual Clearance: ❑ Approved ❑ Not Approved z Maximum Building Height 3_ feet I \ SET ®ACK LINE CWS Service Provider Letter Required: ❑ Yes ❑ No � � �� c ❑ Received By I Date: I I a 1 (O I N i� ENGINEERIN DEPARTMENT: I \ '7• i. Actual SI pe: % IS Approved 0 Not Approved 4 Site PI [,Approved ❑ Not pproved \ rl BY:Datec O% X n ,,, � 4 Notes: c� { / cv c c G `------________L / w O% 5 �� W :� / ti al 24.94' I w / r 7,6. , w z ` �!1 e o tn C) II 1 w I� n ea � II !� s� CITY OF TIGARD - SITE PLAN REVIEW r I ' I 01 2 BUILDING PERMIT NO: I , e v p, g j ' r Street Trees: App roved ❑ Not Approved L - - - - b $ W c pproved i m m Protected Trees: / ❑Approved 0 Not Approved — — — — f m it By: o N( J ( Qcycr' Date: /�d �� �� I ooX ED NOTE " Not s: VERIFY LOOATION TA)QMAP 2S103OB '. "' i NO ti , TR< ,}Sat ) SITE PLAN OF UTILITIES. LOT 85600 ASI SCALE: 1' • 30-0' OF N.