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Permit C ITY OF TIGARD SITE WORK PERMIT l DEVELOPMENT SERVICES PERMIT # : SIT2004 -00012 � 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 4/30/2004 SITE ADDRESS: 16260 SW 108TH AVE PARCEL : 2S115AA-00400 SUBDIVISION: WILLOWBROOK FARM ZONING : R -25 BLOCK: LOT: 035 JURISDICTION : TIG CLASS OF WORK: NEW PAVING ?: RESO. NO: TYPE OF USE: SF GRADING ?: VALUE: 6,500.00 EXCV VOLUME: cy LANDSCAPING ?: FILL VOLUME: cy SITE PREP ?: ENG FILL ?: STORM DRAINS ?: SOILS RPT REQD ?: IMPERV SURFACE: 8,490 sf Remarks: Site work, grading & road construction for new minor land partition. Owner: FEES SWARTWOOD, JACK A GRACE E Description Date Amount 16260 SW 108 TIGARD, OR 97223 [BUPPLN] Pln Ck -Valu 4/2/2004 $71.83 [BUILD] Prmt Fee -Valu 4/30/2004 $110.50 Phone: [TAX] Valu 8% State Sui 4/30/2004 $9.61 [ERPRMT] Erosion Cntl 4/30/2004 $80.00 Contractor: [ERPLN] Ersn Plck - USA 4/30/2004 $26.00 OWNER [EROSN] ErsnPlck -COZ 4/30/2004 $26.00 [WQUAL] Wtr Qual % 4/30/2004 $225.00 [WQUANT] Wtr Quant ° 4/30/2004 $275.00 Total $823.94 Phone: Reg #: Required Inspections Ersn Cntrl 681 -4444 Driveway surfacing Final Inspection Fill This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -6699. Issued By: / . ti Permittee Signature: \ t // 1--tvi 0 n Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day ' i6 5N /08 Site Work — Building Permit Application FOR OFFICE USE ONLY 4 Received City of Tigard Ge , Date /B : g/ffjcm� Permit No./7 13125 SW Hall Blvd., Tigard, OR 97223 ` Plan Review a _ / _ 1 cit te Other Permit: [ f�a �j'3' L�7 � O Phone: 503.639.4171 Fax: 503.598.1960 , ° I � '( Date/B : / V" 135 S ,m // / Inspection Line: 503.639.4175 P R % ;,,,.. i I-. Date Ready/By: Az / `�� � 0 See Page 2 for rnet www.ci.tigard.or.u�/) O Notified/Method I s 0 .1 Ci tfe : 11 11M Supplemental Information V KO aoA)ST O ro, ' a r re: ^t .an. a4 ' 7* _ g �. W° 5 t 'f° S 1 y$ iu , F, ' � 7 44 - aA - . �a , " . #; , .. " 1 4 .( ` r , � mil, . � ,,� . REQUIRED DATAt 1- AND 2- FAMILY DWELLING E'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 °p � rr work indicated on this application. E '- and 2- family dwelling Valuation: $ 5V V ❑ C ommercial /industrial ❑ Accessory building ❑ Multi- family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: 2_ f/ L Total no .er of floors: Job site address: / ( ,3 (0 0 S.) 1 0 1 rQ� New dwelling • ea: ?....,? square feet City/State /ZIP: I 1 a. 1 C J q 7 i. j — Garage /carport a • .: 66 7 square feet / Suite/bldg. /apt. no.: I Project name: t Covered p. h area: • ,: square feet Cross street/directions to job site: T ks 1., R d c4- J 0 8 r' 1 De area: p ri + ,' 0 2,, o s. - .re feet Other structure area: _ __ square feet • REQUIRED DATA COMMERCIAL -USE CHECKLIST Subdivision: • I Lot no.: Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all Tax map /parcel no s) Si • 6 0 O gt equipment, materials, labor, overhead, and the profit for the 04.; ' d ® ® ®_ �f w work indi - ed on this application. p Valuation: $ �LUt1L �..7.af a.m.. , • 71>• _ CM s Existing building .. - a: square feet New building area: square feet '77.7" rA 4 : a � 0 �,. � . 4. �. t+= ' r- , ;. ,� >�.., ,.`. ii4 , Number of s . es: Name: — 3 ' 0..C,K o, G d"a Ce, S wJ Ck r ' V� 0 d , Type o onstruction: Address: i 4 Z Go S tti) lo in, A 0 upancy grou s s: City/State/ZIP: 'r . a , ti k Q k 91 a. `i Existing: Phone: (5 10) (• 3 , _ 0 Fax: (5'03 ) G 3 - 9 • . 0 3 New: l I. , ,, dg " ` . l ,, g i a - ` ,, ; ' .4.4,& € 4 t N OTICE - ^v e, p'm^7.*. .a` -.c ,r `. ,'.�, - �r a '' . , :.. ? " ter ' .9 4 Business name: All contractors and subcontractors are required to be licensed with the Oregon Construction Contractors Board Contact name: 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: : ( ) 1.7(...k.; f IO W 71 e r I t(4 r E -mail: WI ' .. Business name: � ., il l 1q 1 s. a 1 k t ' T iA444 4 .,';._ ;. - ,...k�.` .. 4�: i, :; b,, Address: prefer to fee sc e• u e. City/State /ZIP: 4 V'3 Fees due upon application ?! Phone: ( ) Fax: ( ) Amount received CCB lie.: Date received: r This Authorized signature: permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: Gra ce ' Z ac ©, Date: y� �Q Y * Fee methodology set by Tri County Building Industry Service Board. i:l Building \ Penults \S1T- PemutApp.doc 12/03 440- 4613T(I1 /02/COM/WEB) 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: 9 / f *Total new impervious area including all OO 77 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. # of Plans TYPE OF SUBMITTAL Required at (Includes New, Additions or Alterations) Submittal Commercial 2 Multi - Family R -1 Occupancy 2 One- & Two - Family Dwelling 2 i:\Building\Forms \SIT- Checklist.doc 12/29/03 FILE JDPY _: , . -. ; FEB 1 a 2003 CleanWater Services BY - -- __ File Number - c./ 7 thi It; i- i / Sensitive Area Pre - Screening Site Assessment ZS1 LCa 4- Jurisdiction r i f t' o f / - 9 r , ' Date Feb /0 C'. Map & Tax Loly/Fr 2S_ -!Z 1,1) 5 t „ c is— ._ . 6wier S'a at I i i t S s.ar.cL.ttt,,, S Site Address / p ___ Contact R RattcL. . Proposed Activity 1 a ( rt-;?'1 _ Address 16 /Si S BA4 f)* 40 Phone s Official use only below this line Y N NA Y N NA I �I I n Sensitive Area Composite Map n i f ® Stormwater Infrastructure maps Map# 5/W4 QS# 47/8 Y N NA Y N NA III I IN Locally adopted studies or maps FJ n F I Other Specify Specify Based on a review of the above information and the requirements of Clean Water Services Design and Construction Standards Resolution and Order No. 00 -7: n Sensitive areas potentially exist on site or within 200' of the site. THE APPLICANT MUST PERFORM A SITE CERTIFICATION PRIOR TO ISSUANCE OF A SERVICE PROVIDER LETTER OR STORMWATER CONNECTION PERMIT. If Sensitive Areas exist on the site or within 200 feet on adjacent properties, a Natural Resources Assessment Report may also be required. Sensitive areas do not appear to exist on site or within 200' of the site. This pre- screening site assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered on your property. NO FURTHER SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED. THIS FORM WILL SERVE AS AUTHORIZATION TO ISSUE A STORMWATER CONNECTION PERMIT. n The proposed activity does not meet the definition of development. NO SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED. Comments: f i c.sect oft r ty; tw a 7 2-000 Cc'e,; . a r ra 9-..,;7; - r`e vo i o - - w • _ - 7 0 -Tr Reviewed By: Date: 2h/o3 Returned to Applicant Mail Fax Counter x 155 N First Avenue, Suite 270 • Hillsboro, Oregon 97124 Date ,'Z / /0/p D►,... • /Gfl)t 0 AC Ocn4 _ r ... Irnn% non nrnr CITY OF TIGARD BUILDING DIVISION PERMIT #: 5rt 7-034-- " Iz- I 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: Phone: (503) 639 -4171 Atti c 0 11i��ypu�h ll �l : Inspection Requests (24 Hrs.): (503) 639 -4175 .' INSPECTION WORKSHEET FOR DATE: ( IVS106 TIME: PAGE: SITE ADDRESS: ( E tc(3 ( CB AZJ. CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: DESCRIPTION: E 4 16- !b OWNER: PHONE #: CONTRACTOR: PHONE #: Inspection Request Scheduled For: Date: Pour Time: Code # Inspection Description Confirm # Contact # Message Corrections /Comments /Instructions: R AlAt- n ErEr---- '' ' ib 4 .-----------7 .r j' g/F V k PASS El PARTIAL APPROVAL ❑CANCEL ❑ NO ACCESS ❑ FAIL op CA L FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: 0'4'1 Date: i 4 O )6 Phone #: (503) 718-