Permit CITY TIGARD SITE WORK PERMIT
I DEVELOPMENT SERVICES PERMIT # : SIT2004 -00017
DATE ISSUED : 6/18/2004
1 3125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 15762 SW 79TH AVE PARCEL : 2S112CD 07200
SUBDIVISION: PP1991 -063 ZONING : R -12
BLOCK: LOT: OOA JURISDICTION : TIG
CLASS OF WORK: NEW PAVING ?: RESO. NO:
TYPE OF USE: SF GRADING ?: VALUE: 3,000.00
EXCV VOLUME: cy LANDSCAPING ?:
FILL VOLUME: cy SITE PREP ?:
ENG FILL ?: STORM DRAINS ?:
SOILS RPT READ ?: IMPERV SURFACE: 5,000 sf
Remarks: Site work for required fire department turn around and access to flag lots.
Owner:
FEES
DANIEL SLIMICK
11345 SW 97TH CT Description Date Amount
TIGARD, OR 97223 [BUILD] Prmt Fee - Valu 6/18/2004 $72.10
[BUPPLN] Pln Ck -Valu 6/18/2004 $46.87
[TAX] Valu 8% State Stu 6/18/2004 $5.77
Phone: [FLS] FLS Pln Rv 6/18/2004 $28.84
Contractor: [ERPRMT] Erosion Cntl 6/18/2004 $80.00
DANIEL R. SLIMICK [ERPLN] Ersn Plck - CWT 6/18/2004 $26.00
11344 SW 97TH CT [EROSN] Ersn Plck - COT 6/18/2004 $26.00
TIGARD, OR 97223 Total $285.58
Phone: 503 - 684 -6496
Reg #: LIC 107487
Required Inspections
Ersn Cntrl 681 -4444
Driveway surfacing
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and
all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not
started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires
you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010
through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
246 -6699.
Issued By: .' //
Permittee Signature:
•
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Site Work" ®� �®
Building Permit � �V 1. , FOR OFFICE U S E ONLY
'i Received
City of Tigard i1 11 A\ a� ��
Date : c e 6 7] Permit No.: <,,, -4? f
13125 SW Hall Blvd., Tigard, OR 97223,V f�p° Plan Review / J� (jay �^
O C PR , 1i a1s% r 1 I A\ Da n Re 6 � ' N Ot her Permit:pp�! / I '�'a 3
Phone: 503.639.4171 Fax: 503,598.1960 C t G 7 s
Inspection Line: 503.639.4175 CV O1v` - „ a' I Date Ready/By: Juris: ® See Page 2 for
Internet: www.ci.tigard.or.us e0.-‘,1
� � Notified/Method: Supplemental Info��ti� ni
Plat, Pool/ (oet6,"141- J4�LPSg x1 l` , >fte
A
tom, , ?i a3 y ». ti s ?n, t . o w s :. , : r 4r g 4 E 1 n ,, .x e ; ” ' rt r ,; , fif xa , a . € ;
m i:
�s��1t � � ,�, , � "" 1 AND FAMILY�DtWELL y
totzEwg �: , Nil ;„ I S _fbegi R� EE OF WORK, .:ON -t4:i �a a , I x, REQU IIiED:`DATA i : F
� ... -. �^ ��, ,�>E.�.�� , , ��c .., err. �a,�rr.��eaR.��r � az« �.�.�.a,. r�.r, .. : s ..� ,..''P's &,
❑ New construction ❑ Demolition Permit fees* are based on the value of the work perform
Indicate the value (rounded to the nearest dollar) of all
❑ Addition/alteration/replacement ❑ Other: equipment, mat- - : , a.or, over - . • , : • I - . rofit for the 1•
3441 5 s 3 " ,YF, C4AT1 ORY CONS
Ggg xi� r TRUC TION ii , ° e UCF1ON � e- vu „ ", w. . . ea on t is application. .,■)
i' .i �,. ,, 1 t �,;64ArLs, �O , t![ te'
Valuation: $ /�� ��
❑ 1- and 2- family dwelling ❑ Commercial /industrial
❑ Accessory building 111 Multi-family Numbero .ei-.•
❑ Master builder ❑ Other: Number of bathrooms:
} { kr ":r4F 'ix ,, :. ."P'd'#LT a& a'k F a'a A ✓ N 4 fr v€, wig.z N §{ ^r +.� q
� `
i glint' JOB SITE 'INFORMATIdgZi LOCATI �".t ` . a „`I Total number of floors:
k w, A ° ,io . -. 1;� ,o °, �, 4 , er u:as a >a2r;t .r.,q u i . & ^ ..c, . P:i : . T-u �. ir
Job site address: � e fb5 1-2,461— r0A' rl New dwelling area: square feet
City/State /ZIP: Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet '-,�
Other structure area: square feet
RE DA C OM ME R CI AL US - C H ECK L I S T
Subdivision: kit /2.&e x ) PR An T70# Lot no.: i 4d7 4 Permit fees* are based on the value of the work performed.
�1 Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: AS, j 7p�C ^ 0 79,00 . equipment, materials, labor, overhead, and the profit for the
�, rr as V 5 *'s 'b 4 tay..au O 8 z"" r a :.t= as rx , .� ' s
3 x i " r d $ work indicated on this application.
."a -. i !: � }E .$ , *F., , „feD CRIPcTION OF t,WORK. €' ,:S;r '� .,. . . v' // ` e v. t
.._...1,.. Q 2 F-4. S 0.... tle '5 4- tt 5 0 II VAC Valuation: $
` .(0�� ` 0 p C - ,6�� � ®..t-� Existing building area: square feet
/ New building area: • square feet
4 X' , 3' , 1
^a .,, z r a�. W N E rx si 'r : ( jw'�:_. 61 t� "r' a r' a ERA# Number of stories:
P ROPERTY O U, r - -1: ,T w i �: .,t , V, :-.
-a, v� -ate z... -��;N , .a+,�ss� mss. t, ,, r. �� rP � .
Name: > c. > : ,, , ,,.......,,, , , > ,, S' ( t `� . . Type of construction:
Address: / / 7s Y s c,t) q 7 tt■ G f----- Occupancy groups:
City/State/ZIP: '—
ty Z I t tAVf/ d� q > 1 �-- '3 Existing:
Phone: ( 7) G 9 qv- 6 4 4 c, Fax: (0 9 6 g c C vg G New:
,, ' ,, w, ^ rya . C g � PLI I w, ,,, a,� F g{' �, - 0 e � N F . E "ISON .,, ,,',e14-.. }fit 5= " d `E ' r r /6r, `ta . wx °, . ».: i' z a �
® APPLICANT vi CONTACT, ''
m„ ` . ',v , i� ..,..a . a ,o- ..,.. r , ,, r ". � 'tea, i . g:6 .° ” : 2� ,.v,'z4 ,6irw_,?.^ , m.:56wry,:;e + X -a6 ®"fi „ , :tea ; _ _ ' s e ` e _. . NOTICE' s a 6 , , . .,• 1 „ 3
Business name: 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
applicant is exempt from licensing, the following reasons
City/State /ZIP: apply:
Phone: ( ) • Fax:: ( )
E -mail:
MP, 6t9 r f.R, t rrF to rs ' m .S_ , r�' , „. t p J^a{.re W �° , p ° S � u , `mp
;agiOa ° ` ;. , c , , � n <. - L ,
C ONT RAC OR , " " - a�" ti u J" `; ,V a � - - �.. g is t,V
j, Business name: 7) cw. t ` ( ( t t� t� x ic'" i I l�� )�DINGI:PERMI G -R. > T FEES * FEES " '` ,
A ` ti,BI7 }i °
Address: ,/ (''S T s ) �— e Please refer to fee schedule.
City/State /ZIP: TO a , 0 1,
Fees due upon application
Phone: ($b3 )6 gy - rq C Fax: (. 3) 6 g —( T4 c Amount received
CCB lic.: % 7 `( 7 Date received:
„,.........,.....-.-4-- Authorized signature: This permit application expires if a permit is not obtained
4.. within 180 days after it has been accepted as complete.
J Print name: (A. ,'@ 51, G Date: /q /0(� * Fee methodology set by Tri- County Building Industry
1 Service Board.
i:\ Building \Permits\S1T- PermitApp.doc 12/03 440- 4613T(I I /02/COM/WEB) •
• R r.
City of Tigard: Site Work Permit Checklist
Page 2 - Supplemental Information
•
Commercial, Multi - Family and One- and Two - Family 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.
` S , f, V V #offiPlans#
c �` ti� 1< } "r , H�r'.. T' t�`Zi
deg New, Additionnsorr Alt pr ati o n so, 4 Sub mi t tal
Commercial 2
Multi- Family R -1 Occupancy 2
One- & Two - Family Dwelling 2
i:\Building\Forms \SIT- Checklist.doc 12/29/03
•
CITY OF TIGARD
BUILDING DIVISION - PERMIT #:2-604 1
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 m�puiigl� °��h�
Inspection Requests (24 Hrs.): (503) 639 -4175 ■ tl ••
INSPECTION WORKSHEET FOR DATE: tjP/ / (� TIME: PAGE:
SITE ADDRESS: 61(e2... 6i CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: I) 1/V't I e/1.-' . VIA \ C/ PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: Pour Time:
Code # Inspection Description Confirm # Contact # Message
4:-Et Vio t2
1/� Ldfs — U4-4
Corrections /Comments /Instructions:
k -- vut___Q}PJA.3-aa,
1
SL.) c2__-r
PASS n PARTIAL APPROVAL ❑ CANCEL n NO ACCESS
n FAIL I I CALL FOR INSPECTION ADDITIONAL FEES ASSESSED
1 � ,, c
Inspector: v ' A Date: Phone #: (503) 718 -