Permit CITY OF TIGARD BUILDING PERMIT
PERMIT #: BUP2003 -00478
A SW i
IN DEVELO PMEN Tigard, o
SERV (503) 6 -4171 ACES DATE ISSUED: 8/5/03
SITE ADDRESS: 11990 SW 121ST AVE PARCEL: 1 S134CD 03800
SUBDIVISION: LERON HEIGHTS NO.3 ZONING: R -4.5
BLOCK: LOT: 070 JURISDICTION: TIG
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: OTR FIRST: 2,625 sf N: S: E: W:
TYPE OF USE: SF SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 5N : sf N: S: E: W:
OCCUPANCY GRP: SR3.3 TOTAL AREA: 2,625 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED:
STOR: 1 HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED
FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET:Y
DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC:
BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING:
VALUE:
Remarks: Change of use from R -3 to SR -3.3
Owner: Contractor:
LUKE -DORF
10313 SWE 69TH AVE
TIGARD, OR 97223
Phone:
Phone:
Reg #:
FEES REQUIRED INSPECTIONS
Description Date Amount
[BUPPLN] Pln Rv 8/5/03 $62.50
Total $62.50
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law
requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of these rules or direct questions to OUNC by
calling (503) 246 -6699 or 1- 800 - 332 -2344.
Issued By: L Q1//_,6
Pemiittee / / 0
Signature: ky-∎ -/
Call 639 -4175 by 7 p.m. for an inspection the next business day
Building Permit Application FOR OFFICE USE ()NIX Received �L Building
Date/By: Permit No. 11,1 l 7 o Q.2V 7$
City f Tigard Planning Approval Other
y g Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 I / " % j � % 1 ;A Post - Review Land Use
Internet: www.ci.tigard.or.us a4191 " I Date/By: Case No.
Contact Juris.: [E] See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name/Method: Supplemental Information
§ ., 4
❑ New construction ❑ Demolition
❑ Addition/alteration/re.lacement 2 Other: 1 °
4 = Note: Permit fees* are based on the total value of the work performed. Indicate
❑ 1 & 2 -Famil dwellin El Commercial/Industrial the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
❑ Accesso Buildin: ❑ Multi -Famil
❑ Master Builder ❑ Other: Valuation $
No of bedrooms: No of baths:
Job site address: f • P .5. ( ► tie • Total number of floors
New dwelling area (sq. ft.)
Suite #: Bld :. /A.t. #: Garage /carport area (sq. ft.)
Pro*ect Name: � , _ e - 11 e Covered porch area (sq. ft.)
Cross street/Directions to job site: Deck area (sq. ft.)
Other structure area (sq. ft.)
` y
Subdivision: Lot #:
Tax ma. /. arcel #: Note: Permit fees* are based on the total value of the work performed. Indicate
_; + � i r o E the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
Valuation $
Existing building area (sq. ft.) 2 6 2 S
New building area (sq. ft.) 2 , 6 2
Number of stories / / S
D PROPERTY OWNS ` °"" °7 Type of construction V —
Occupancy group(s): Existing: - 3
New: 5/2- 3, 3
Address: p i a • fh ' v e
Ci /State /Zi.: -'", a rd Dk q 7 a a 3
Phone: - 0,3 - S ; - Fax SD3 ' • - ' NOTICE: All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board under
r 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:
Ci /State /Zi.:
Phone: Fax: e,
E
Business Name: N � Fees due
upon application
$
Address: B111111111111111•11111 p
EgliMENEMINIMEMEIMMENIM Amount received $
Phone: Fax: Date received:
CCB Lic. #:
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: .SE . r /tom.. Date:
180 days after it has been accepted as complete.
�u 8/i /I EZ
*Fee methodology set by Tri -County Building Industry Service Board.
(Please print name)
i: \Dsts\Permit Forms \BldgPermitApp.doc 01/03
Plan Submittal Requirement Matrix
•� �l Commercial & Multi- Family
City of Tigard New, Additions or Alterations
Site Work 4
(must include location of all accessible parking)
Plumbing - Site Utilities 2
Building 1*
Fire Protection System 3 **
Mechanical 2
Plumbing - Building Fixtures 2
Electrical 2
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).
*For over - the - counter commercial tenant improvements, submit 2 sets of plans.
** "New" fire protection systems require that plans bear the original seal of an
Oregon licensed fire suppression engineer, or NICET level "3" technicians.
is \Building \Forms \PlanSubMatrix.doc 04/03
OREGON OFFICE OF STATE FIRE MARSHAL LICENSED FACILITIES REFERRAL
4760 Portland Road NE, Salem, OR 97305 FOR FIRE SAFETY INSPECTION
ALL INFORMATION MUST BE COMPLETED FOR FORM TO BE PROCESSED
Date: 7/14/2003 Licensing Contact Name: Belinda Sauer /Lisa Richards
Licensing Agency Name: Office of Mental Health and Addiction Services )
Agency Address: PO Box 14250-2575 Bittern Street NE
City /Zip: Salem 97009 Phone #:( 503 945- 9724/945 -9705
(Occupancy Type Defined on Reverse)
Residential Care /Assisted Living Facility: ® Adult Foster Home (R -3): **
Please indicate the number of clients 5 Date of Licensing Agency On -Site Inspection of Adult
Foster Home * *:
(* *Describe the area(s) of concern
Health Care Facility (I)
SCF Children's Residential School (L): 0 ** *FOR CHILD CARE FACILITIES * **
Day Care Center (E -3):
Increase # of Occupants
Original ft of children # increased to
Name of Facility: Luke Dorf Respite Facility
Street Address: 11990 SW 121st City: Tigard
Zip: 97223 Co Washington Nearest Cross St. (If known):
David Sones 503-524 -2612 CO i — 49-1 4 1 - 5 I &
Provider /Manager: Mona Knapp Phone # ( 503 ) 598 - 1186 x19
License Expiration Date: # Residents /Children/Capacity:
Reason for Referral:
al New Facility /New License 0 Renewal of Licensed Facility
0 Other (Explain):
To / Be Completed By DEPUTY/INS CTOR:
Name of Deputy /Inspector kt) ut Wilk— - -L) - i" i
/ ' (Please ' t ' S 03
Inspecting Agency: AA-7A e . � � „I ` . / ��
Y � _ ' • pection Date:
Phone #. ) . '1/17‘9<- Fire Inspection #: /-5
APPROVED for occupancy (no deficiencies noted).
® APPROVED with corrections listed on fire inspection notice.
® NOT APPROVED ti . all deficiencies are ci ec ,I Ref i fire spection notice. ��
C'
..
Deputy /Inspector Signature: � at./ a.�l it 1 ' i d L�`� D
Distribution: White- Provider Ye, ow -OSFM, Salem Green -Distri II, �4ty/Local nspeetor Pink- Licensin G
NOTE: All previous copies of this form are invali , Y ■ It •rmsdisk/inspregP00100(l2 /96) v U `� 2003
FIRE MARSHAL'S OFFICE
To SFM 7/14/2003 / 17 i
1
r
11990 S.W. 121st St., Tigard, OR 97223 2000 sq ft.
2625 sq ft. with garage X = Smoke Alarm
FX= Fire extinguisher
0 Living Room
15x23
(345 sq ft)
• FIRE
• EXIT
r 0
7 Entrance
FIRE (50 sq ft) Office
10x12
EXIT
Ir (120 sq ft)
[
X
0 X r
Kitchen FIRE
10x20 EXIT
(200 sq ft)
LI Dining Area
13x17
El (221 sq ft)
i i
• FIRE FIRE
Laundry • EXIT EXIT
7x9 Fx .,
(63 sq ft) Bathroom I
58
(40
Bedroom
Bathroom 12x15
7x11 (180sgft)
(77 sq ft) 0
Garage
25x25 I
r (625 sq ft) l�
x 1 x X Bedroom
Bedroom Bedroom 10x20
10x12 0 x12 (120 sq ft)
(120 sq ft) ( 120 s q ft)
r =I., , o -=
..,
GARAGE x,, i2 eq 6
FIRE 1
EXIT cm 0it f' V e fect-cvs.