Permit CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2004 -00344
, �I�� DEVELOPMENT , SERVICES 39 -4171 DATE ISSUED: 12/2/2004
SITE ADDRESS: 11175 SW 119TH AVE PARCEL: 1 S134CA -00505
SUBDIVISION: PANORAMA NO.2 ZONING: R - 4.5
BLOCK: LOT: 016 JURISDICTION: TIG
REMARKS: SF addition, 12' x 22'.
BUILDING
REISSUE: STORIES: 1 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: FIRST: 264 sf BASEMENT: sf LEFT: SMOKE DETECTORS:
TYPE OF USE: SF FLOOR LOAD: SECOND: sf GARAGE: sf FRONT: PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: THRD: sf RIGHT:
VALUE: 10,000.00
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 264 sf REAR:
PLUMBING
SINKS: WATER CLOSETS: 1 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 1 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS:
TUB /SHOWERS: 1 GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: I VENT FANS: 1 CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: 0 WOODSTOVES: GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 . 200 amp: 0 - 200 amp: W /SVC OR FDR: PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/O SVC/FDR: oo SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 • 600 amp: 401 - 600 amp: EA ADDL BR CIR: 2.00 SIGNAL/PANEL: IN PLANT:
MANU HM/SVC /FDR: 601 - 1000 amp: 601 +amps- 1000v: MINOR LABEL:
1000+ amp /volt :
PLAN REVIEW SECTION
Reconnect only:
> =4 RES UNITS: SVC /FDR > =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL - RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: 0TH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 463.15
BRAVERMAN, MARK & CINDY OWNER This permit is subject to the regulations contained in the
BRA
BRA ERMA MARK
CIRC Tigard Municipal Code, State of OR. Specialty Codes
2190 WEST LIEN, OR 97068 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 the
work is suspended for more than 180 days.
Phone: 503 655 - 9711 Phone: ATTENTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those
Reg #: rules are set forth in OAR 952 - 001 -0010 through
952 - 001 -0080. You may obtain copies of these rules or
direct questions to OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Mechanical Insp Framing Insp
Plumb Top Out Electrical Final
Plumb Top Out Plumb Final
Electrical Rough In Building Final
Electrical Ro n
1
Issued y : ai 6i12/ Permittee Signat
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the next business day
Building Permit Apulicatioli) I.OR ()IAA( I I S1.ON1.)
City of Tigard Received Date/B . / /� Mil, Permit No.: r(yr -m 3c/
13125 SW Hall Blvd., Tigard, OR 97223 Loo 4 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date/B . Other Permit:
Inspection Line: 503.639.4175 P�1, 4. '_i_t Date Ready/By: ®See Attached Checklist for
w
Internet: ww.ci.tigard.or.us -AIN OF �� V Notified/Method Supplemental Information
kJ G
g�ll� TYPE OF WORK REQUIRED DATA: I- AND 2- FAMILY DWELU(!IG a
New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
g [ Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
il[ 1- and 2 -family dwelling ❑ Commercial /industrial Valuation: $ /v
❑ Accessory building ❑ Multi- family Number of bedrooms: 3
❑ Master builder ❑ Other: Number of bathrooms: Z
JOB SITE -INFORMATION AND LOCATION Total number of floors:
Job site address: //l 9 5 / / 9 ,i / 4 _ New dwelling area: square feet
v
City /State/ZIP: I l y 4>< GEC e 7 / Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Covered porch area: square feet
Cross street /directions to job site: 1 yQf4 Deck area: square feet
Other structure area: square feet
REQUIRED OAT* COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Al) b b I1-7CSJ td+u'WI 1'64ApC / 2 )` Zi.- Valuation: $
Existing building area: square feet
New building area: square feet
APROPERTY OWNER , Q TENANT Number of stories:
Name: #4,4 /9-R i . izt— C, Nj 4 70 14.4. 2 0 4. t A Type of construction:
Address: Z/ v ie_ I VcQ fl& j5 It is C (ie Occupancy groups:
City /State/ZIP: (N .•rf L, /✓ ,) C .t ' 70b t Existing:
Phone: (50 ) 4, 55 — 9 7 / i Fax: ( ) New:
' > I APPLICANT 0 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
City / State/ZIP: applicant is exempt from licensing, the following reasons
apply:
Phone: ( ) Fax:: ( )
E -mail:
CONTRACTOR
Business name: 5' z r f. /) „,,,,J t'If..„
BUILDING PERMIT MS* `
Address:
Please refer to fee schedule.
City / State/ZIP: l��t) , 5
Fees due upon application
Phone: ) Fax:( )
Amount received
CCB lic.:
Date received:
\6 Autho ' ignature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
P . e:M _ ` - ( ` /e - i ' ,c ' -„1 Date: / i / cf /cy * Fee methodology set by Tri-County Building Industry
Service Board.
i :\ Building \Permlts\BUP- PermitApp.doc 12/03 440 .4613T(11 /02/COM/WEB)
One- and Two - Family Dwelling
Building Permit Application Checklist rolz tlrrr( 1: 1 s l: c1\1.1
City of Tigard Received
13125 SW Hall Blvd., Tigard, OR 97223
Date/By: Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 ,, Associated permits:
24- Hour Inspection Line: 503.639.4175 ti " ",' I ❑ Electrical ❑ Plumbing ❑ Mechanical
Internet: www.ci.tigard.or.us 1" - ❑ Other:
liIE FOt.i.ONv INC; ITFyIS .. RRE REQI. lIRED FOR PLAN RFv II WN
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ■ • •
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- ❑ ❑ ❑
basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑
building 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, roofing, 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. ❑ ❑ —0
Exterior elevations must reflect the actual grade ifthe 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.
23 Five (5) 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 tree protection measures as required by conditions of approval. ❑ ❑ Q
30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, 0 ❑ ❑
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 \Permits\BUP- RES- PermitApp.doc 2
Plumbing Permit Application aG`vE.0 FOR OFFICE USE ONLY
City of Tigard Received �
Permit No.: - � A Date/By:
g an
13125 SW Hall Blvd., Tigard, OR 97223 Q Ll
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 / r +;�, Other Permit No.:
24- Hour Inspection Line: 503.639.4175 �/ O rP all' DateBy: fur ::
GCS i „ -h, Date Ready/By: l0 See Page 2 for
Internet: www.ci.tigard.or.us r ' Notified/Method: Supplemental Information
t
= 0
, . .. � � V V '��4 " � � � .. . F'E� SCFI?EEDULE
-., _ . _mss -. .Me . .'.,s.
❑ New construction ❑ Demolition For special information use checkl
Description I Qty. I Ea. I Total
. Addition/alteration/replacement ❑ Other: , 1- 2- family dwellings (includes 100 ft. for each utility connection)
r I r •9 y
�r:�`�,r��a� ..P�. ,t�,�.,�'r ��"°'.L - �ars ,. °. •� � .. y . ° ° . . �,. � „. . SFR (1) bath 249.20
Al- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder ❑ Other: Each additional bath/kitchen 45.00
Fire sprinkler ( sq. ft) Page 2
ti0 s ;. C 04 r 1 at�a Wa � i0 � a .. a Z.,. s --
. r - : n 3 mss.. ... .- ,., . Site utilities
Job site address: / / / 7 5 ' Cn) ! i 9 v`Zi fq, Catch basin or area drain 16.60
City/State /ZIP: r 7 ff 6Q A G 2 72,3 I Drywell, leach line, or trench drain _ 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site: a_t* t A-k c.) ,44. Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: J Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no
,.. ,,,,„ . , Absorption valve 16.60
m. . , - - ..�a Backflow preventer Page 2
A--,A1) 1.4-7 3 vU Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
n 2 Ejectors /sump 16.60
Name: /��A Q-! C< Ai ' ll 1'i,t � LF1 �
Expansion tank 16.60
Address: Z � / 9v (2_, c f � it.
1 6- e ( , 1 Fixture /sewer cap 16.60
City/State/ZIP: � E f , N A (, A- Cr 7 6E. Floor drain/floor sink/hub 16.60
Phone: (5< 6 5 S Fax: ( ) Garbage disposal 16.60
IL., J r ,� Hose bib 16.60
Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax:: ( )
Sink/basin /lavatory 16.60
Tub /shower /shower pan / 16.60
E-mail:
Urinal 16.60
Psr m i ':" . ` "tee a ,� tin '', '
A , ,
' Water closet 16.60
Business name: 7L) e Water heater 16.60
Address: Other:
City/State/ZIP:
Subtotal
j Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lie.: Plumbing Lic. no.: Plan review (25% of permit fee)
f uthorized signal Ty,ei�y4,- State surcharge (8% of permit fee)
tom TOTAL PERMIT FEE
Print name oft/ Date: l/ /e This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
iABuilding \ Permits \PLM- PetmitApp.doc 12/03 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
. Iermit.Fee:
Footing drain - 1' 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00
7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40 V; Storm & Rain Drain - 1st 100' 55.00
V.ffi�'
$1.00 to $5,000.00 Minimum fee $72.50
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
3'eti*& Ttal o 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 Backflow 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
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
L ,, fi
. t P _ �� �. Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor /Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain /sink - 2"
-3"
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial
Ice Mach. /Refrig. Drains - increase of sewer EDUs, a sewer permit will be issued and
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory
Quantity Total
- Bradley
- Commercial - Isometric or riser diagram is required if fixture quantity
Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
i: \Building\Permits\PLM- PermitApp.doc 3/03
Electrical Permit Applicatio l . V • J C D FOR OFFICE USE ONLY
City of Tigard ,! • L� Received Permit No.: '_''!/ +�
13125 SW Hall Blvd., Tigard, OR 972 Date/By: tl9rdbv 7 � ✓ y*
g Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 i n\ l 0 4 20 3 'h fisit, p y, DDate/By: Other Permit:
, Y
Inspection Line: 503.639.4175 ! Date Ready/13y: jug Fd See Page 2 for
Internet: www.ci.tigard.or.us ✓1 I Y O TI(.. Notified/M Supplemental Information
❑ New construction a Addition /alteration/replacement Please check all that apply:
El Demolition ❑Other ❑ Service over 225 amps, comm'l ❑Hazardous location
_ A „ :l ❑Service over 320 amps — rating ❑ Buildng over 10,000 sq. ft.,
'' i 'it c ' ' ° o f 1 and 2 - famil dwellings 4 or more new residential
te i �. � s_ < �.,... ��M „� � .. r , .M, =�.�� Y g
13. and 2 f dwelling ❑ Commercial/industrial Li Accessory building ❑System over 600 volts nominal u nits in one structure
❑ Multi- family ❑ Master builder ❑ Other: ❑e,
. . _ ❑Occupan❑Building over three stories t load over 99 persons ❑ManFeedrs
ufac tured 400 amps structures or more
or
tl g t i . , ' ® ''' ,. _ ;;mo w!, ;�'"` E ess /li htin lan RV park
. � a., .ti . ❑ g g P
Job no.: Job site address: DHealth-care facility DOther:
1 «� S uJ Submit 2 sets of plans with any of the above.
City/State /ZIP: (!, 42A e 2 5 7 Z--k-/ The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name: ` Y ' -, s l 4, . „„ Description Qty. Fee. To tal
Cross street/directions to job site: „1,0.0_ rite t k- ( A New residential single- or multi- family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 4
Subdivision: I Lot no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no Limited energy, residential 75.00 2
Limited energy, non - residential 75.00 2
' ; ; ;- E manfactud mou
/� t / ,,_
dwelling, service re and /oor d
r feeder 90.90 2
1 u f +7 d" "` �r�s 7 A/c--- Services or feeders installation, alteration, and /or relocation
200 amps or less 80.30 2
+ 201 amps to 400 amps 106.85 2
4 � � 401 amps to 600 amps 160.60 2
Name: / k` / jL Q_ (i ,N 1 U 6 P4A- 1,14 ,) 601 amps to 1,000 amps 240.60 2
Address: Z/ 9 O R._, VL /-�? e h & e c Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State /ZIP:
(,✓a s - ,7 4 L i ,,/ (/✓L F7 m.E,8 Temporary services or feeders installation, alteration, and /or
Phone: (.5 �',) 4.-,51 9 7 ti I Fax: ( ) 2 2000 0 a amps mps
or less 66.85 1 _
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.3 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 2
Owner signature: Date: Branch circuits — new, alteration, or extension, per panel
' l „ . . A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch c
B. Fee for branch circuits
Contact name: without service or feeder fee,
each branch circuit 46.85 2
Address:
Each add'l branch circuit % 6.65 2
City/State /ZIP: Miscellaneous (service or feeder not included)
Phone: ( ) I Fax:: ( ) Pump or irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E -mail: Signal circuit(s) or limited -
_� � n �: �x�• - �*, ,- ;per energy panel, alteration, or
.4 72 . ° -... �t = ,.,.. k.' , - ,r ..,, 4 -a .. 4,,, extension. Describe: Page 2 2
Business name: D 60 /0 erL
Address: Each additional inspection over allowable in any of the above
Per inspection 62.50
City /State /ZIP: Investigation per hour (1 hr min) 62.50
Industrial plant per hour 73.75
Phone: ( ) Fax: ( ) *1„
CCB Lic.: Electrical Lic.: Suprv. Lic.: Subtotal
Suprv. Electrician signature, req re. Plan review (25% of permit fee)
Print name: Date: State surcharge (8% of permit fee)
TOTAL PERMIT FEE
Authorized signal.,• - '
4 / - This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete
Print name I A k Date: _ /� ! • Fee methodology set by Tri County Building Industry Service Board • ''' R� ( " � t ' Number of inspections per permit allowed.
440-4615T 0 /02/
i:\ Building \Permits\ELC- PemutApp.doc 17103 COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
'TOW '.._ VWP.' ®e ms ,, , ,
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
tiP �'_ `T r: '4 WET ti
Fee for each commercial system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
i:\ Building \Pennits\ELC•PennitApp.doc 04/03
Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard
Received Date/B
Permit No.: i y 1 , /
!-
13125 SW Hall Blvd., Tigard, OR 97223 \ G O Review
Phone: 503.639.4171 Fax: 503i4 � /� � Mr Date/By:
Other Permit:
0 0
Inspection Line: 503.639.4175 4 M t ,� Date Ready/By: Juns: ® See Page 2 for
Internet: www.ci.tigard.or.us �`' A � Notified/Method: Supplemental Information
'RQ
TYPE OF WORK -' ' ?" 1{\• COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Mechanical permit fees* are based on the value of the work
❑ New construction ❑ Addition/alteration/replacement
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ 1 - and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building
For special information use checklist.
❑ Multi - family ❑ Master builder ❑ Other:
Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating /cooling
Job site address: I -e' G Air conditioning or heat pump
/ r�� J �( ` (requires site plan showing placement) / 14.00
City/State /ZIP: Furnace 100,000 BTU (ducts/vents) 14.00
�H4 -� Furnace 100,000+ BTU (ducts /vents) 17.90
Suite/bldg. /apt. no.: Project name
Gas heat pump 14.00
Cross street/directions to job site: Duct work 14.00
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 10.00
Subdivision: Lot no.: Flue /vent for any of above 10.00
Other: 10.00
Tax map /parcel no.: Other fuel appliances
lire 0 h DESCRIPTION OF WORK Water heater 10.00
e.7 £X /f � `� A E . eX — Gas fireplace foe gas
10.00
/�/ � Tf Flue vent for water heater or as
�^ / fireplace 10.00
TDe.c L ► N &Li L.Lf 5 7 % O � e �O 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: e6.0 €. ,..(,4.,,,,,_ Environmental exhaust and ventilation
Address: Range hood/other kitchen
equipment 10.00
City/State /ZIP: Clothes dryer exhaust 10.00
Single - duct exhaust (bathrooms,
Phone: ( )3) 65 — F7/ ! Fax: ( ) toilet compartments, utility rooms) 6.80
❑ APPLICANT ! ❑ CONTACT PERSON Attic /crawlspace fans 10.00
Other: 10.00
Business name:
Fuel piping
Contact name: $5.40 for first four; $1.00 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
Clothes dryer (gas)
', 1 1 €Z
Business name: K/ /� C�/C..�. Other:
Address: _ MECHANICAL PERMIT FEES*
City/State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee ($72.50)
Plan review (25% of permit fee)
CCB lie.: / State surcharge (8% of permit fee)
// TOTAL PERMIT FEE
Authorized ignature: ■ ! ' This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: A.A.te Q 4. (.1 , 0,bt/ Date: L / cl t,/ * Fee methodology set by Tri -County Building Industry Service Board
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.
i:\ Building \Permits \MEC- PermitApp.doc 12/03 2
Permit #: 1`tt-r- aQ 4 "U05`f q
•F ��� 75 / / 9 �v�
�, Ad dress:
0
Issued Date: /#7 5
=5
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:
I own, reside in, or will reside in the completed structure. I
n A 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
`' before or upon completion.
ri 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
r i, 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 cer ' 'y that he above information is correct and that I have read and do understand the Information
Notice to P operty 0 . s about Construction Responsibilities on the reverse side of this form.
et ! /L' -
(Signature of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MSTB • ed 3 4 1 /
INSPECTION DIVISION Business Line: (503) 639 -417
BUP
Received Date Requested U AM BUP
Location / 1 / 7 11 Suite MEC
Contact Person Ph ( ) `W q - 5 7 7 PLM
Contra Ph ( ) SWR
ILDIN Tenant/Owner ELC
ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
ap A • FAIL
r IN i
= eam
Under Slab �� �
Rough -In
All Water Service ��
Sanitary Sewer S
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
in-
FAIL
L
Post & Beam
Rough -In /
Gas Line
Smoke Dampers
la PART FAIT( -Z Q
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next in : -. tion. Pay at ity Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE El Please call for einspectio 'E: �% nab - o inspect — n access
Fire Supply Line
ADA �� – 0; �
D — — I ecto 1 � ,` 44
Approach/Sidewalk p �.�
Other:
Final DO • T REMOVE this inspection record from the Job site.
PASS PART FAIL