Permit CITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit #: MST2011 -00030
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03!10/2011
Parcel: 2S109DD00200
Jurisdiction: TIGARD
Site address: 12615 SW BEEF BEND RD
Subdivision: CROSS PARTITION - WACO Lot: 0
Project: Cross Partition
Project Description: Kitchen remodel.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors:
Total: 0 sf Value: $8,700.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Drains: 0
Tubs /Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Drywell- Trench Drain: 0 Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Natural Gas Heat Pump: N Hoods: 1 Other Units: 0
Furn <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits
1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea add! 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 5
Mfd Home /Feeder /Svc: 0 401 -600 amp: 0 401 -600 amp: 0
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +amp /volt: 0
ELECTRICAL - RESTRICTED ENERGY
SF Residential
Audio & 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:
ALT SF 0
Owner: Contractor:
CROSS, DONALD L & DEBORA LEE OWNER Required Items and Reports (Conditions)
12615 SW BEEF BEND RD
TIGARD, OR 97224
PHONE: PHONE:
FAX:
Total Fees: $524.14
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 a = • - 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. AT • NTION: Oreg• law , uires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -001 -' 010 through OAR 9. .11 -0090. •u may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued = : • � / s_�` Permittee Signature: C . Call 503.639.4175 503.639.4175 by 7:00 a.m. for the next available inspecti n date.
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.
Building Permit Application .
Residential FOR OFFICE USE ONLY
City Tigard e I a 673 IY' -vu ' vac
Ci of Ti and Received Permit No.:
1111111 ' ° 13125 SW Hall Blvd., Tigard, OR 97223 I D Plan Review h
Phone: 503.639.4171 Fax: 503.598.1960 . S iy I Date/By: / 1/ Other Permit:
I I Ci A K D Inspection Line: 503.639.4175 Date Ready/By: --- Juris: ® See Page 2 for
Internet: www.tigard or.gov Notified/Method: 0 Ida A M , Supplemental Information
1
TYPE OF WORK ry � l� ' i� l' REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Denkolttialt 13 N \' Permit fees* are based on the value of the work performed.
) Indicate the value (rounded to the nearest dollar) of all
js Addition /alteration/replacement ❑ Ott4}l\ `�� equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
1- and 2- family dwelling ❑ Commercial/industrial Valuation: $
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
t ,
Job site address: / Is S W $ e e 4 13e/. fed New dwelling area: square feet
City/State/ZIP: T a rd D it 9') 2 21 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Covered porch area: square feet
Cross street/directions to job site: 13 QC,•?` 13 eHI To ( , e e Al . 9 ;e /S Deck area: square feet
a A/ e b/ k R G4 1- O a, in 12 r w a 1/ f , ea S S Other structure area: square feet
-the{ h o tx s - +c4 r At r 1 , f REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
no.: Indicate the value (rounded to the nearest dollar) of all
Tax map/parcel
-2 .$/O 9 /DID L e .� / G o equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
V` i P nl tern Valuation: $ ' ' d :)
Existing building area: square feet
New building area: square feet
45 PROPERTY OWNER ❑ TENANT Number of stories:
Name: 0 C. r 0 Type of construction:
Address: / 2 L /s _5' to (, e - f Sabi a i Q el' Occupancy groups:
City/State/ZIP: 17 a cc / O n q t) 2 2 if Existing:
Phone: (.6 — o3) 9'. — ‘>c, t 9 Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
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: ap
Phone:( ) Fax::( )
E -mail:
CONTRACTOR
Business name: diVevCi BUILDING PERMIT FEES*
Address: (Please refer to fee schedule)
Structural plan review fee (or deposit):
City/State/ZIP:
Phone: ( ) Fax: ( ) FLS plan review fee (if applicable):
CCB lic.: Total fees due upon application: y 136 ,
Amount received: jta 6
Authorized signature: • uti► e._,-d4. This permit application expires if a permit is not obtained
Print name: p ithin 180 days after it has been accepted as complete.
k Cr C o.SS Date: ( — )) . // * Fee methodology set by Tri-County Building Industry
Service Board.
I: \Building\Pennits\BUP -RES PennitApp.doc 10/01/09 440-4613T(11/02/COM/WEB)
Building Permit Application Checklist
One- and Two - Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received Permit No.:
13125 SW Hall Blvd., Tigard, OR 97223 Date/By:
I Phone: 503.639.4171 Fax: 503.598.1960 Associated permits:
24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
T 1 C: A R D Internet: www.tigard - or.gov ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW es No N/A
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ 0
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑
3 Verification of approved plat/lot. ❑ ❑ ❑
4 Fire district approval required. Name of district: ❑ , ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity ❑ ❑ ❑
6 Sewer permit. ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
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- ❑ ❑ ❑
r tection, etc.
10 M I plete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑
• mg 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 ❑ ❑ ❑
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 ❑ ❑ ❑
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, roofmg, 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 ❑ ❑ ❑
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 ❑ ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑
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. ❑ ❑ ❑
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 ❑ ❑ ❑
architect licensed in Ore:on and shall be shown to be a, .licable to the .ro'ect under review.
JURISDIC I IONAL SPECIFICS
23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
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. ❑ ❑ ❑
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 must include 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 \Pennits\BUP- RES- PermitApp.doc 03 /21/06 440.4613T(1I/02/COM/WEB)
Electrical Permit Application FOR OFFICE USE ONLY
City of Tig Date/By: t No.:
1111
• 1 S W H all Blv Tigard, OR 97223 plan Rev rew
Other Permit.
Phone: 503.639.4171 Fax: 503.598.1960 D ate/By:
. 1 . 1(i A 1: I ., Inspection Line: 503.639.4175 C�')�� Date Ready/By: Saris: VI See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
TYPE OF WORK ��� \ i ' PLAN REVIEW
• C , 0 A � Please check all that apply (submit 2 sets of plans w /items checked below):
El New construction ®Addition /alteration replace
O \ ` S\ p� ❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: �. where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONST) M exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
j .1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: 0 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: 100HP or more. occupancy.
l2 , As S w 6 e. 42 6, Na/ ( d' ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: 'T�' Q rd 0 !Z 9 2 2 ❑ Health -care facilities. ❑ Supply voltage for more than
y ❑ 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: Qe e. f 6e Na/ to G,r e e iv Pie/o/ Description I Qty. I Fee. I Total I "
New residential single- or multi- family dwelling unit.
cite 'ilk Ti i t o A, R. 0 7rt b to,va/f . Pass 3 Ao i p s fare tQ r Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft, or less 168.54 4
Z. S' JO 9 D 0 + 2 D D
Tax map /parcel no.: "2 S' Limited 500 y, es ft. or portion 33.92 1
Limited energy, residential 75.00 7
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
A residential (with above sq. ft.)
Add /.) r c - Pe Cu Ad,/ 2
a a pl do a o x is r Services or feeders installation, alteration, and/or relocation
Guile 1 C i (Cat i , (Z a /ocaie 2 �x 3'4+ N� O k >i/4 71 ems /i,t, l ; �o0 ampsorless 100.70 2
®- PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
C 401 amps to 600 amps 200.34 2
Name: Do H C ress 601 amps to 1,000 amps 301.04 2
Address: 12 L /s S to e e e -P 6, ho/ Rd Over 1,000 amps or volts 552.26 2
City/State /ZIP: Temporary services or feeders installation, alteration, and /or
T j et ed art Q'' ? 2 y relocation
Phone: (5'03) q /y _' O G 7 Fax: ( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature: )- oes t o �en�r1 Date: 2 - i r) - II A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 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'1 branch circuit L 7.42 3.f. t 2
Address: Miscellaneous (service or feeder no ( included) V t
Each manufactured or modular 67 84 2
City/State /ZIP: dwelling, service and/or feeder
Phone: ( ) Fax: : ( )
Reconnect only 67.84 2
E - mail: Pump or irrigation circle 67.84 2
Sign or outline lighting 67.84 2
.1k CONTRACTOR Signal circuits) or limited- energy
Business name: panel, alteration, or extension. Page 2 2
GrIA..0!C'j- 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 (%2 hr min)
CCB Lie.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: 15
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): 10. 3 6
TOTAL PERMIT FEE: vl 6 ,
Authorized signature:
e•rr 6Z.6.44..„ This permit application expires if a permit is not obtained within 180
Print name: //�� Date: days after it has been accepted as complete.
�� / al,/ C V C -CS '2 - / / Number of inspections allowed per permit.
I:\Building\Permits\ELC- PennitApp.doc 07/01/10 4404615T(11/05/COMM1VEB
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:
n Audio and Stereo Systems
n Boiler Controls
n Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
n HVAC
❑ Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
n Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I: \ Building \Permits\ELC- PermitApp,doc 07/01/10
Mechanical Permit Application Folz of ncE: i F. ON 1.)
City of Tigard Received
0 Date/By Permit No.:
41 13125 SW Hall Blvd., Tigard, OR 97223
Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 (, Date/By: Other Permit:
(WARE)
Inspection Line: 503.639 Date Ready/By: Juris: 53 See Page 2 for
Internet: www.tigard - or.gov 1 . • Notified/Method: Supplemental Information
���
‘� COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
TYPE OF WORK (* � S
i Mechanical permit fees* are based on the value of the work
❑ New construction g Addition/alterationktlayt performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition 0 Other: :A * ' mechanical materials, equipment, labor, overhead, and profit.
Value: $
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
is 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: / .2 ( . S w Al p Q e N '/ Rd (requires site plan showing placement) 46.75
City /State /ZIP: ; u {� q ' ? Z e Furnace 100,000 BTU ( ducts/vents) 46.75
/ Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg. /apt. no.: Project name: Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Q e..p J3.e iv le, G { 4 eN -e, „/d Duct work 23.32
Hydronic hot water system 23.32
O N e b/ h // f ►( 1 1- a N i> ` n .,rt •19.” a No� f PASS Residential boiler (radiator or
} +e-ee 1 7t9uS`eS }&rN r h heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: ? S'20 9 D D Z.- co f 2 a a Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
Gas fireplace 33.39
ate+ e . Gars -Pe r III ' « /1 ; 4-01 we ve '/ro e / Eachiqs4 Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
Et PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32
Other: 23.32
Name: / G Xi e e o Si' Environmental exhaust and ventilation:
Address: / 2 ( (s-- S 4) is e c .2 6e' N N quipment� other kitchen 33.39 13 3
City /State /ZIP: - a f j 0 n `t'' 2 q el Clothes dryer exhaust 33.39
`i Single -duct exhaust (bathrooms,
Phone: (5 q / - / . - > o 6 7 Fax: ( ) toilet compartments, utility rooms) 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name:
Other: 23.32
. Fuel piping:
Contact name: $14.15 for first four; $4.03 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: I/ Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal L'
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) q ti. CA)
Plan review (25% of permit fee)
CCB lie.: State surcharge (12% of permit fee) 10 , �j
TOTAL PERMIT FEE ) fir) , k()
Authorized signature: This permit application expires if a permit is not obtained within 180
04 days after it has been accepted as complete.
Print name: / O N C O f F Date: . -/r) — / / * Fee methodology set by Tri- County Building Industry Service Board
I:\ Building \Permits\MEC- PermitApp.doc 09/09/10 4404617T (11 /02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi - Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
$2.54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
I:\ Building \Permits\MEC - PermitApp.doc 09/09/10 2
Property Owner Statement
Regarding Construction Responsibilities
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
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.
1� N C r S
Print Name of Permit Applicant
(, Cam--' 2 - i 7 - / 1
Signature of Permit Applicant Date
Permit #: msY l l— OF
0
Address: ` I S St L
s: � �� i.l. ��( �
1 yv � ` l 7c4Y
Issued by: 6 .7'. Date: 9 •
This Copy for Permit Offices