Permit A . ' CITY OF TIGARD SITE WORK PERMIT
I DEVELOPMENT SERVICES PERMIT # : SIT2003 -00007
_.J 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 4/21/03
SITE ADDRESS: 14894 SW 116TH PL PARCEL : 2S110BD - 03100
SUBDIVISION: HELM HEIGHTS ZONING : R - 4.5
BLOCK: LOT: 008 JURISDICTION : TIG
CLASS OF WORK: OTR PAVING ?: RESO. NO:
TYPE OF USE: SF GRADING ?: VALUE: 18,000.00
EXCV VOLUME: cy LANDSCAPING ?:
FILL VOLUME: cy SITE PREP ?:
ENG FILL ?: STORM DRAINS ?:
SOILS RPT REQD ?: IMPERV SURFACE: sf
Remarks: Sports court & fence.
Owner:
FEES
KELLER, MICHAEL R + LORI J Description Date Amount
14894 SW 116TH PL
TIGARD, OR 97224 [BUPPLN] Pln Ck 4/1/03 $140.47
[BUILD] Prmt Fee -Valu 4/21/03 $216.10
Phone: [TAX] 8% St Tax -Valu 4/21/03 $17.29
Contractor: Total $373.86
OWNER
h one:
peg #:
Required Inspections
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:4 1ic-a ,
Permittee Signature: f /2 �ei(2,0
Call (503) 639 175 by 7:00 P.M. for an inspection needed the next business day
Site Work
7i FOR OFFICE USE ONLY
Building'e11on Received lll.����� 7 CIt of Tigard Other
Cit pDD 01 2003 Date/By: Permit No
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 CITY OF TIGARD Date/By: Permit No.:
Phone: 503 -639 -4171 t u. ;.' u1 N /i"' lit ''' "" Post - Review Land Use
$UTCD� , ki �I ` " .' Date /By: Case No. Nk
Internet: www.ci.tigard.or.us Contact ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name/Method: �/G Supplemental Information
p O
TYPE OF WORK r`
��� DAT�y
❑ New construction ❑ Demolition = 1:& ZEAMitirEiNitat$G,
❑ Addition/alteration/replacement ❑ Other:
CATEGORY OF CONSTRUCTION Note: Permit fees* are based on the total value of the work performed. Indicate ,
❑ 1 & 2- Family dwelling ❑ Commercial/Industrial the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
❑ Accessory Building ❑ Multi-Family .-4.
ov
❑ Master Builder ❑ Other: Valuation $ /8) O2 —
JOB SITE INFORMATION and LOCAIIO No of bedrooms: No of baths:
Job site address: /4/g 9 4 / 5) //b - / - Total number of floors
New dwelling area (sq. ft.)
Suite #: Bldg. /Apt. #: Garage /carport area (sq. ft.)
Project Name: Covered porch area (sq. ft.)
Cross street/Directions to job site: Deck area (sq. ft.)
Other structure area (sq. ft.)
t F EDD A '
C ekI Ia< IA' E a fi
Subdivision: Lot #:
Tax map /parcel #: Note: Permit fees* are based on the total value of the work performed. Indicate
;'. s DFrCRIPTIQN OF WORK the value (rounded to the nearest dollar) of all equipment, materials, labor,
/ 5 « overhead and profit for the work indicated on this application.
� ) � U11�T — c.5 (bv
,g,� 1. , Valuation $
Existing building area (sq. ft.)
New building area (sq. ft.)
Number of stories
PROPERTY OWNER tTj / NTV. ,, - ,., 1 p ..` : Type of construction
Name: M 1C H V EL q- L 1 K C .1-e - Occupancy group(s): Existing:
Ne
Address: /4,9W SW / /l/o PI
City /State /Zip: 9 0 r se ,,e Q Az ,z 4/
Phone: 503 (24/- 9115 Fax NOTICE: All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board under
13 APPLI , r. , , , - 0 CONTACT provisions of ORS 701 and may be required to be licensed in the
Business Name: jurisdiction where work is being performed. If the applicant is exempt
Contact Name: from licensing, the following reason applies:
Address:
City /State /Zip:
Phone: Fax: i,
E-mail: .: l ea<sere � � '
CONTRACT ' .._,�. .,.e __
Business Name: 00 ) ME 2 Fees due upon application $ / YI , 4 / 7
Address:
City /State /Zip: Amount received $
Phone: I Fax: Date received:
CCB Lic. #:
Authorized n Notice: This permit application expires if a permit is not obtained within
Signature: e�/� / Date: 3 •e2 180 days after it has been accepted as complete.
i)'? / ck .,Q / /. [t. e// el- *Fee met odology set by Tri- ounty Building Industry Service Board.
(Please print name) P ate(' k-0-4 t— ,A..... 6 0, /� -2.d
,i:\Ds Forms\BldgPermitApp.doc 01/03 ....41.02....e0 C� ✓L� —[� • � �. n
T�X
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SITE WORK PERMIT CHECK LIST
Commercial, Multi - Family (R -1 occupancy) and Residential:
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
C' CMU
`� Concrete
❑ Other
*Total new impervious area including all buildings,
sidewalks, and paving: sq. ft.
Site Utilities Plumbing Work:
Complete the "TAN" 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 1 and 2- family dwellings.
b _
r �o
TYPE O! SUBMITTAL f Plans
Required at
i C q t_ ( I ncludes New, Additions or Alterations) Submittal
Comm- a 4
Mul • amity R -1 Occupancy 4
0 -- & Two - Family Dwelling 4
WA' N TE: Plan review is dependent upon submittal of a completed application and plans.
After plan review approval, the Plans Examiner will contact the applicant to request
additional sets of plans for distribution purposes (for Contractor, City of Tigard,
Washington County, and Tualatin Valley Fire & Rescue).
is \dsts \forms\sitechecklist.doc 09/24/01
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Permit #: ./ 77,Q DO .3 D DO 7
Address: /Yer 9 V ,52.t.) //6 /e 4.
Issued by:gilg Date: L 1-0
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
'1,, 1. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
1 3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
E l 3B. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form. /-...2/-613
S ig n at re of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
W
Information Notice to Property Owners
About Construction Responsibilities
Note: This Information Notice to Property Owners about Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 70./.055(5).
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent many problems by being aware of the following responsibilities and areas of concern.
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement of a residential structure. you will, in most instances, be ruled to be an employer and the people
you hire will be employees. As the employer, you must comply with the fol lowing:
Oregon's withholding tax law: As an employer, you must withhold income taxes from employee wages at thetime employees
are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more
information, call the Oregon Dept. of Revenue at 945 -8091.
Unemployment insurance tax: As an employer. you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information, call the Oregon Employment Department at 378 - 3524.
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must
obtain workers' compensation insurance for your employees. Ifyou fail to obtain workers' compensation insurance, you may
be subject to penalties and will be liable for all claim costs ifone ofyour employees is injured on the job. For more information,
call the Workers' Compensation Division at the Department of Consumer and Business Services at 945 -7888.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be
liable for the tax payment even if you didn't actually withhold the tax. For more information, call the internal Revenue Service
at 1- 800 - 829 -1040.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the perm it holder for th is project, you are responsible for resolving any fai lureto meet code requirements
that may be brought to your attention through inspections.
Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
re -done.
Time to supervise employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work ofrough -in and finish
trades, and to notify building officials at the appropriate times so they can perform the required inspections.
If you have additional questions, write or call the Construction Contractors Board (PO Box 14140, Salem, OR 97309 -5052.
503/378 - 4621). The Board is located at 700 Summer St. NE Suite 300, in Salem.
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APR 01 2003
't 44 CITY OF TIGARD
000' oO ' y, BUILDING DIVISION
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CITY OF TIGARD
Approved
Conditionally Approved ..........(
O - Q }.. For only the work asdescxibed in:
..Q PERMIT NO, Si }'a T
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Attac t s
Job Alen: /4/9qt/ 541 ,/(40-Th ,r/
0 - BY: e, Date: - 7-
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