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Permit it d i^ C ITY 0 F t° IGARD MASTER PERMIT c��ii, DEVELOPMENT SERVICES DATE PERMIT ISSUED: 3/9/20055 00041 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 - 4171 PARCEL: 2S 103BA -01000 SITE ADDRESS: 12400 SW 121ST AVE ZONING: R -4.5 SUBDIVISION: LOT: JURISDICTION: TIG REMARKS: Addition of (3) bedrooms & (1) bath. BUILDING REISSUE: CUSTOM STORIES: 0 FLOOR AREAS REQUIRED SETBACKS REQUIRED CLASS OF WORK: ADD HEIGHT: 12 FIRST: 976 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y TYPE OF USE: SF FLOOR LOAD: 40 SECOND: sf GARAGE: sf FRONT: 15 PARKING SPACES : 2 TYPE OF CONST: 5N DWELLING UNITS: THRD: sf RIGHT: 5 VALUE: 90,182.00 OCCUPANCY GRP: R3 BDRM: 3 BATH: 1 TOTAL: 976 sf REAR: 15 PLUMBING SINKS: WATER CLOSETS: 1 WASHING MACH: 1 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: VENT FANS: CLOTHES DRYER: 1 FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: 1 MAX INP: btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: GAS OUTLETS: ELECTRICAL RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS 1000 SF OR LESS: 0 • 200 amp: 1 0 - 200 amp: W /SVC OR FDR: 00 PUMP /IRRIGATION: PER INSPECTION: EA ADM_ 500SF: 201 - 400 amp: 201 - 400 amp: 1st W /OSVC1FDR: SIGN /OUT LIN LT: PER HOUR: LIMITED ENERGY: 401 • 600 amp: 401 - 600 amp: EA ADDL BR CIR: SIGNAL /PANEL: IN PLANT: MANU HWSVC /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: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL: GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR: HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS: Owner: Contractor: This permit is subject to the regulations contained in the AUSBIE, DONNA D M HUMPHREY ROSEWOOD Tigard Municipal Code, State of OR. Specialty Codes 12400 SW 121 ST AVE DEVELOPMENT CO and all other applicable laws. All work will be done in TIGARD, OR 97223 12385 SW 121 ST AVE accordance with approved plans. This permit will expire TIGARD, OR 97223 if work is not started within 180 days of issuance, or if the work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules Phone: Phone: 503 329 - 6461 adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through Reg #: LIC 46568 952- 001 -0080. You may obtain copies of these rules or TOTAL FEES: $ 1,617.26 direct questions to OUNC by calling (503) 246 -6699. REQUIRED ITEMS AND REPORTS Ersn Cntrl 681 -4444 Issued By : __:_ Permittee Signature : ..tc..e . Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the next business day. 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 Ap , l F - ' FOR OFFICE ICE USE ONLY City of Tigard F ED 5 20 Datei B s .. ' D3 Permit No., y , f�Bot,, / 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Phone: 503.639.4171 Fax: 503.598.1960 / / + ff,ir - , +` Other Permit: Inspection Line: 503.639.4175 . ?��� �,� Date Ready/By: 10 See Attached Checklist for Internet: www.ci.tigard.or.us CITY �I- _ • ' Notified/Method: ? ” 1` Supplemental Information 131JTLD OC � 5 ,? o1G,e \\ o c\. o-t)\--- TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING ❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all I4 Addition /alteration /replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. CO 1- and 2-family dwelling Valuation: S 9 /?0Z , y g ❑ Commercial /industrial ❑ Accessory building ❑ Multi- family Number of bedrooms: ❑ Master builder El Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION • Total number of floors: Job site address: 12 L ib o j L J e? 1 p t., New dwelling area: square feet City /State /ZIP: ' � jj 3 ,,..1 J 6 iZ c1 72 Z 7 Garage /carport area: square feet Suite/bldg. /apt. no.: Project name: Covered porch area: square feet t Cross street /directions to job site: i / .1. �o r J 1 G or /2/ S-- f t Deck area: . square feet ii- Lk) G / to ti t? i/t J� ocs 4- S i l _ a —T 54 ../-- Other structure area: square feet REQUIRED DATA: 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 - DE SCRIPTION .OF WORK / work indicated on this application. 7 r e �e� r o° v^ / het,-/ A Valuation: S Qd i lc-"A Existing building area: square feet New building area: square feet VI PROPERTY OWNER - . - ❑ TENANT Number of stories: Name: fly, A vk. 5 N u s hie Type of construction: Address: ) . 6 - ) 2 I P V Occupancy groups: City /State /ZIP: J t:\ H d J 0 9 7 223 Existing: Phone: (3 Si 3) 7 / al j Fax: ( ) New: a APPLICANT gr CONTACT PERSON NOTICE Business name: Z c _,3 c_ t_.-3 G o Oe v C ; All contractors and subcontractors are required to be Contact name: l G K ( r e ` licensed with the Oregon Construction Contractors Board � under ORS 701 and may be required to be licensed in the Address: f a S• .j sscLi ) 21 h v jurisdiction in which work is being performed. If the City /State /ZIP: C a G � 2 2) applicant is exempt from licensing, the following reasons l H apply: Phone: (3 J 3)\ 3 2 9 G L/ 4 Fax:: (6b)) s 7 Y- 3 Z `I E-mail: I- o d e., C. v Q /le 7 cs c c ; n c I _ CONTRACTOR /� Business name: iZ L SG Ca, 3 De,), C - • 'BUILDING PERMIT FEES* Address: /2 3 J' S c-5- 4-, ) 2/ v Please refer to fee schedule. City /State/ZIP: G w- �x ! t'J )L 9 7 2.Z Fees due upon application Phone: (5 (; 3) 3 c . 6 c/ E i Fax: (50 3 ) 1 7 ? - 3,2 cc 9 CCB lic.: z--) l' 5 4, ,,,9 Amount received Date received: Authorized signature: //G %� ,(/ This permit application expires if a permit is not obtained "��(/ / / within 180 days after it has been accepted as complete. Print name: Q7i ti a .. / NN b 4 A r v Date: Z ,) " * Fee methodology set by Tri- County Building Industry r/ f // _s j /C} Service Board. i:\ Building \Permits\BUP- PermitApp.doc 12/03 440 -4613T(1 l /02/COM/WEB) I One- and Two - Family Dwelling <, i Building Permit Application Checklist 'FOR OFFICE USE ONLY City of Tigard Received Date/By. Permit No.: 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.639.4171 Fax: 503.598.1960 Atr-i Ka i r 1 . ive Associated permits: \ 1 24- Hour Inspection Line: 503.639.4175 a ,' j ❑ Electrical ❑Plumbing ❑ Mechanical Internet: www.ci.tigard.or.us " " "I - ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW es No N/A 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. I I it. 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. ❑ ❑ ❑ 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 ap plicable to the .ro"ect under review. JURFSDICTIONAL SP[CI[IC.S . 23 Five 5) sit- . ans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑ 24 _.:._ 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. ❑ ❑ ❑ 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 \Permits\BUP- RES= PermitApp.doc 2 Electrical Permit Application FOR OFFICE USE ONLY City of Tigard k Received Permit No l Q O 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Phone: 503.639.4171 Fax: 503.598.1960 Gar i " ` Other Permit: M1(''li� Date/By. Inspection Line: 503.639.4175 7 44111. ":_,. Date Ready/By: lads ® See Page 2 for Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information TYPE OF WORK PLAN REVIEW ❑ New construction j Addition /alteration/replacement Please check all that apply: El Demolition ❑Other: ❑Service over 225 amps, comm'I ❑ Hazardous location ❑Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft., CATEGORY OF CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential c ycr 1- and 2 family dwelling ❑ Commercial /industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure ❑ Multi family ❑Master builder ❑Other' ['Building over three stories ❑Feeders, 400 amps or more ❑Occupant load over 99 persons ❑Manufactured structures or JOB SITE INFORMATION AND LOCATION ❑Egress/lighting plan RV park Job no.: Job site address: ❑Health -care facility ['Other: Submit 2 sets of plans with any of the above. City/State/ZIP: The above are not applicable to temporary construction service. Suite/bldg./apt. no.: Project name: FEE* SCHEDULE Description I Qty. I Fee. I Total I ** Cross street/directions to job site: New residential single- or multi - family dwelling unit. Includes attached garage. 1,000 sq. ft. or less 145.15 4 Subdivision: Lot no.: Ea. add'I 500 sq. ft. or portion 33.40 1 Limited energy, residential 75.00 2 Tax map/parcel no.: Limited energy, non - residential 75.00 2 DESCRIPTION OF WORK Each manufactured or modular / J c / t dwelling, service and/or feeder 90.90 2 J`J ) .4 ¢i Services or feeders installation, alteration, and/or relocation • 200 amps or less / 80.30 FG? 3D 2 • ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2 401 amps to 600 amps 160.60 2 Name: 601 amps to 1,000 amps 240.60 2 Address: Over 1,000 amps or volts 454.65 2 Reconnect only 66.85 2 City/State/ZIP: Temporary services or feeders installation, alteration, and/or relocation Phone: ( ) Fax: ( ) 200 amps 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 100.30 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 ❑ APPLICANT • ❑ CONTACT PERSON A. Fee for branch circuits with �r service or feeder fee, each 8 6.65 .3 T 26 2 Business name: branch circuit B. Fee for branch circuits Contact name: • without service or feeder fee, 46.85 2 Address: each branch circuit • Each add'I branch circuit 6.65 2 City/ State/ZIP: Miscellaneous (service or feeder not included) Pump or irrigation circle 53.40 2 Phone: ( ) Fax :: ( ) Sign or outline lighting 53.40 2 E -mail: Signal circuit(s) or limited - CONTRACTOR energy panel, alteration, or Business name: A c4ri7c / extension. Describe: Page 2 2 Address: ( - - q ��X 75— / Each additional inspection over allowable in any of the above Per inspection 62.50 City / State/ZIP: "14itJ.‘+2T QM ? 7/.32- Investigation per hour (1 hr min) 62.50 Phone: V d3) „-3 3- g�)3 Fax: (S233) 53 g- go 73 Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES *, CCB Lic.: / ill 2 y/ Electrical Lic.: .76 - /02C. Suprv. Lic.: lit 7/, S - Subtotal /33, -5 Suprv. Electrician signature, required: W4 ee 4 4 f Plan review (25% of permit fee) - p Print name: /0a,r -k 4) ST d ' 4 -y Date: 2 7/,',..sr— State surcharge (8% of permit fee) /0, p TOTAL PERMIT FEE PH, r /e Authorized signature: G` e:61 ` � � y , This permit application expires if a permit is not obtained within 180 / /� days after it has been accepted as complete AA Print name: . /v(,u K/ S,,a„, ciri Date: 2 /7 o .S * Fee methodology set by 'Fri-County Building Industry Service Board / •• Number of inspections per permit allowed. i:\ BuildingWermits \ELC- PermitApp.doc 12/03 440-4615T(10 /02/COM/WFB • Electrical= Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK "ONLY: w ° • 1 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: rCOMN1l IRCIAIL- WORK,:ONLY: 1 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\EL.C- PennitApp.doc 04/03 Plumbing Permit Applicatibn . FOR OFFICE USE ONLY City of Tigard Da teBed Permit No.� 3.1" � r 13125 SW Hall Blvd., Tigard, OR 97223 y' Plan Review Phone: 503.639.4171 Fax: 503.598.1960 /a� N 0 p;\ Date/By: Other Permit No.: 24- Hour Inspection Line: 503.639.4175 t!I Date Ready/By: Juris 0 See Page 2 for Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information 'lY.; �' k ` :s'�- - ' �;� 's. ..+f ",�`; =+t' =ash: i -;T'z -°a•^ �;:y?"re:r.Fcgs:,,� ay ,:z•:,z g c sw w•,;: n,� [:.Y < .er;...; .•,rr�,e �. ,- _ - , .. - .. .i u . _ .'. T OF WORK t - , :' - *, ° ,S'GA --.. �' @ld�#«�' -r� §, °'.`,i:� i emsW.' a°:^. "�wa+ax&:- `a;'- E -.,,. n. h,:.:.....s::;i5 , s:,,,...:a�:.:i wa..: • -. ..'.'�- ,a:sFKrs'?o-.,., ...... ... -. For special information use checklist. ❑New construction ❑ Demolition Description Qty. 1 Ea. Total IA Addition/alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) ` � '�ti °'r: `". s� ; a,cx � r< " ��sx.eoa� }::�,a: :, ;.�, =:�tl ,,_,ir.' ° �:zTM i 7"`�`K.a,3,�^ :.r�,.r±- tv:Y�+ b C AT E OR ' OF CONSTRUCT , s � . . .1 SFR (1) bath 249.20 . , 14 1 - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi - family SFR (3) bath 399.00 1=1 Master budder Each additional bath/kitchen 45.00 ❑ Other _ Fire sprinkler (. sq. ft.) Page 2 '.x"34 r ;sr}^� ' mow' � --'x �. sd l-t t ' ' , JO S IT `I R Mr�• =I g jAN I) � IaO CATION , II ' � Site utilities Job site address: ; 2 LI C . o v 12- ( A v Catch basin or area drain 16.60 City/State /ZIP: Ti .5 r'" Ai / O f� y �z2 3 Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2 job t h Manufactured home utilities 110.00 10.00 Cross street/directions to ob site: I e •, t3) y• v Manholes 16.60 1 2- tt ) Ct 1 in tA. +- (;) VI ) cl a -- 45 t i e Rain drain connector 16.60 0 3 / 4-r -e. e Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2 Fixture or item Tax map /parcel no.: • i w , _ :... _ "," 4 4a Absorption valve 16.60 l 4 Jl . �. f 9« I D QF / _ WOJ � i � x 1 ° ' Backflow preventer Page 2 3 bee. .-Uri M ) JO w .7 �n Ci d A i l t . 1.4 Backwater valve 16.60 Clothes washer 16.60 Dishwasher 16.60 • ;.�r.t.; >,,:..wL; a : �,.p.: -::F -- ,c :,:E Drinking fountain 16.60 • ' p RO,, O H. &g -4 , - aid 4 w a T:E14A a4 - ,t� ��tr r t ., � k� nv . �, . _ _. . . '- Ejectors /sump 16.60 Name: D I: Yl Yv Ct 0 (.1 } i / Expansion tank 16.60 Address: /.2 17 o t') .5 / .2 l a v Fixture /sewer cap 16.60 City/State /ZIP: '7- vi u f. i 6 12 9 7 2z 6 Floor drain /floor sink/hub 16.60 / Phone: (go 3) S q - ,i L j e Fax: ( ) Garbage disposal 16.60 t A ` a . r ` Cb i PE BSQN - , 3 ,, ` Hose bi 16.60 : ;16: '. t r a,,, _ %�,�W 4 ` , 1 . , ,. = tG- . ' Y> - ( /o ff.. a Ice maker 16.60 e. Business name: 2 OvL u+ OO De,,,, ( o I J V e v�•T (0 , Interceptor /grease trap 16.60 I ! Contact name: ` 1 C ,. I @ e. I I -1 U. 0-. p In r e i Medical gas (value: $ ) Page 2 Address: Jf:,2 3 Er 5- S (.4 / 2 ( t4 ✓ Primer 16.60 City/ State/ZIP: "T y r . D �Z 7 7 22 3 Roof drain (commercial) 16.60 Sink/basin /lavatory 16.60 Phone: (56 3) 1 z y " 6`16 ( Fax:: C,co3) S ly - 32,p7 // �� Tub /shower /shower pan 16.60 E -mail: !' D d e c a l) 7/ cc, 1 0 e , h e-7 Urinal 16.60 ` x '' t IR ; . RdbNTRA @TOR "' 4 i ,14 , rte - ,...,.:., 4e, .1... -. -. r I,^ . . V.3 � i . ..t ., � j a €grii , . , - %' Water closet 16.60 Business name: i ; _ j_�. . A.t✓ [ PLA Water heater 16.60 Address: j- / 0 - X 3 6 X S C, 7 Other: � Subtotal City/State/ZIP: Z .ct G L4. / C /2 7 ? 0 2 3 Minimum permit fee: $72.50 Phone: (g 0 3) c V s - Li 3 S Fax: ( ) Residential backflow minimum permit fee: $36.25 CCB Lic.: ®, , 7 9 Plumbing Lic. no.:3C3 k ; Plan review (25% of permit fee) � State surcharge (8% of permit fee) ` Authorized signature: X J 4 ;4 //� '[ -iccC TOTAL PERMIT FEE Print name: h Li Date: � J ; 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. i:\ Building \Permits\PLM- PermitApp.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: :wsx a °� ~<Pr'.;; S1tGVt111tTe.S s Fee ( TofaC .q g ... . ' $ ,. . %;* __ .� S ua?re F,0 a Perm><t 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 iqialuatioriW? , y° P.er:mi:F E . s Storm & Rain Drain - 1st 100' 55.00 $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 woo ;x ,. „ x < - re:7 , . n - additional $100.00 or fraction thereof, to and ><xtureorItem... Qc >Fee (eat ..._ "'. ,= 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 * . ,F +' < Quantity" Sy (Fi fifr) WorkP,erformed ` �Fixture � � c i<Kepla�, fi ,, �, _v , , m avQd misting Capper 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" -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 \Pemilts\PLM -Pere itApp.doc 3/03- Mechanical Permit Application FOR OFFICE USE O - i. A City of Tigard Date/By: Permit No.:� C T 13125 SW Hall Blvd., Tigard, OR 97223 Y• \' I de s �UQ� 9// Plan Review Other Permit: Phone: 503.639.4171 Fax: 503.598.1960 /�dl Date/By: Inspection Line: 503.639.4175 t• Date Ready/By: Juris: El See Page 2 for �.. g Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST ❑ New construction NI Addition/alteration/replacement Mechanical permit fees* are based on the value of the work 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* IN 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 Air conditioning or heat pump Job site address: 1 2_1( b 0 `5 W 1 y 2 1 A V (requires site plan showing placement) 14.00 u City/State /ZIP: "jt , r ` J 6 12... 12... 1 2. 2 3 Furnace 100,000 BTU (ducts /vents) 14.00 Z i 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: 1 h .� 4Jd r.J„l e .* /2/ ? Duct work 14.00 / I Hydronic hot water system 14.00 CJ 0.' Yt w al" L - d J 4 �1 t et e of <S Jt `z e /- 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 DESCRIPTION OF WORK Water heater 10.00 n t w + Gas fireplace 10.00 l -eki -! , Y v. a. c e,.2 r A e.- •1-r ✓ Flue vent for water heater or gas / fireplace 10.00 C G v . y , -1 ra v7„ a > I 'i - 1 - ..Er-c4. 0 J✓ f (� b 5 Log lighter (gas) 10.00 aJ Wood/pellet stove 10.00 Wood fireplace /insert 10.00 Chimney /liner /flue /vent 10.00 [Z PROPERTY OWNER ❑ TENANT Other: 10.00 Name: 0 C H u 4 ids Li Environmental exhaust and ventilation Address: Range hood /other kitchen f 2 y7 © ,s 1 2 / equipment 10.00 City/State /ZIP: 77,..1 6 le Clothes dryer exhaust 10.00 �' / Single -duct exhaust (bathrooms, Phone: (5b 1) s 7 t. — / ' S ' Fax: ( ) toilet compartments, utility rooms) 6.80 A APPLICANT I CONTACT PERSON Attic /crawlspace fans 10.00 Business name: l I ther: 10.00 2 f I lit e / b e ,„ �h' co L- Fuel piping Contact name: m 1 / h P_ t lit lA Y✓� k r e '-/ $5.40 for first four; $1.00 for each additional f p Furnace, etc. Address: / t J O S L-1 / 2/ , U Gas heat pump City/State /ZIP: .T, J 0,v,1 ) a � / 7 2 2 3 Wall /suspended /unit heater Phone: (56 3) 3 z y _ 6, ,.. j Fax: : (,, ) L s - '7? -- 3 2s q Water heater Fireplace E -mail: re J e C' o CO iie1 ,sG& Je • vi e-1 Range CONTRACTOR Barbecue ( Clothes dryer (gas) Business name: C 1 G JS ea� J J CU, ( � Other: Address: 2 7 S , 5' i--)u y 2/ MECHANICAL PERMIT FEES* City/State /ZIP: X30 r t vt qq ei )Z / 9 760 y Subtotal J / Minimum permit fee ($72.50) Phone: (5- 3) t✓' t` _ -2 / f L Fax: ( 5 - °, 3 ) 6 ? - O � P Plan review (25% of permit fee) CCB lic.: 1 / b 3 q State surcharge (8% of permit fee) TOTAL PERMIT FEE Authorized signature: days permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: Do� S ) 4 < .$ Date: Z// /o * 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 ago , - EEC 2 21105., , >5PV ,; ; ,CLE..N WATER SERVICES 503 6314434 N:i 5156 P. 1_ ei r IV .. e' 1) I I [ i.I File Number o0 5 - ° 305 � U { 1eanWater Services F 1 � JAN 2 6 2005 r!; I i FEB � � � [)'ur cainmihr��an� it clear. Sensitive a Alea* e- $ereening Site Assessment CITY li •i° , �Sdietibn Date ` - .2. (o BUILDING Dt Map & Tax Lot '9,.. 5 3'5 , F1 .. - '.(. vcs___o - - Owner r7 n /41..1 Site Address Contact .1 .2 4 D O SC i D. 1.41. Proposed Activity a ', . 3c Z ri u m I t3yi in Address T i.5 u, , d / d R- n ►� - 9 71 Phony .7 0 3 327 - 6.`1 6 / ttP 5 79 ., 32 g 9� / O'ArJal use only below this Me V N NA Y N NA !Ai r Sensitive Area Composite Map F Stormwater Infrastructure maps LL L.--) Map # 25/641 . r— ' - OS # 3J7 LL_j r Locally adopted studies or maps n E r1, Specify Based on a review of the above Information and the requirements of Clean Water 3tlrvlces Design and Construction Standards Resolution and Order No. 04 -9: 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 ad)scent 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 pro - 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. The proposed activity does not meet the definition of development. NO SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED. Comments: Reviewed By; ��'�"_ Date: T� - -- Returned to Applicant Post -it" Fax Note 7671 rate oZ h o ► / — Mai! lax Counter Qj (�� papc f / Date 7 . Q5 By - TO From rj �C ti ed � ji f 44, cp ./Dept, Co e (4. 5 Pone • P 10114 fi F:ix A�7_ . CITY OF TIGARD BUILDING DIVISION PERMIT #: MST2005.00041 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/9/2005 Phone: (503) 639 -4171 v'm��� i • Inspection Requests (24 Hrs.): (503) 639 -4175 INSPECTION WORKSHEET FOR DATE: 7/13/2005 TIME: 7:10AM PAGE: 4 SITE ADDRESS: 12400 SW 121ST AVE CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: AUSBIE DESCRIPTION: Addition of (3) bedrooms & (1) bath. OWNER: AUSBIE, DONNA D, PHONE #: CONTRACTOR: ROSEWOOD DEVELOPMENT CO, M HUMPHREY PHONE #: 503 - 3236461 Inspection Request Scheduled For: Date: 7/13/2005 Pour Time: Code # Inspection Description Confirm # Contact # Message 199 Electrical final 011326-01 503-329-6461 N Corrections /Comments / Instructions: • • N . PASS ❑ PARTIAL APPROVAL ❑ CANCEL n NO ACCESS ❑ FAIL ❑ C LL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: 1/4' , Date: 7.-13/-O_SS Phone #: (503) 718- CITY OF .TIGARD BUILDING DIVISION r • PERMIT #: MST20050004'l 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/9/2005 Phone: (503) 639 -4171 ��m�m I 1 v Inspection Requests (24 Hrs.): (503) 639 -4175 :,.:- INSPECTION WORKSHEET FOR DATE: 7118/2005 TIME: 7 : 07AM PAGE: 39 SITE ADDRESS: 12400 SW 121ST AVE CLASS OF WORK: . SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: AUSDIE DESCRIPTION: Addition of (3) bedrooms & (1) bath. OWNER: AUSSIE, DONNA D, PHONE #: CONTRACTOR: ROSEWOOD DEVELOPMENT CO, M HUMPHREY PHONE #: 503. 329-6461 Inspection Request Scheduled For: Date: 7/18/2005 Pour Time: ! Code # Inspection Description Confirm # Contact # Message 699 Mechanical final 011609-01 503-329-6461 N Corrections /Comments /Instructions: I k PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS I I FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: Date: Phone #: (503) 718- CITY OF TIGARD `i ,. BUILDING DIVISION PERMIT #: MST2005 -00041 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/9/2005 Phone: (503) 639 - 4171 40th N�iN Inspection Requests (24 Hrs.): (503) 639 -4175 . INSPECTION WORKSHEET FOR DATE: 7/18/2005 TIME: 7:07AM PAGE: 38 SITE ADDRESS: 12400 SW 121ST AVE CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: AUSBIE DESCRIPTION: Addition of (3) bedrooms & (1) bath, OWNER: AUSBIE, DONNA D, PHONE #: CONTRACTOR: ROSEWOOD DEVELOPMENT CO, M HUMPHREY PHONE #: 503 - 329- -5461 Inspection Request Scheduled For: Date: 7/18/2005 Pour Time: Code # Inspection Description Confirm # Contact # Message 399 Plumbing final 011609-02 503-329-6461 N Corrections /Comments /Instructions: • !; - ASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS II FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: itrn Date: - " Phone #: (503) 718 - . CITY OF TIGARD . t. BUILDING DIVISION PERMIT #: MST2005- 00041 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/9/2005 Phone: (503) 639 -4171 i liV��ypitpl"ICI Inspection Requests (24 Hrs.): (503) 639 -4175 �..' � INSPECTION WORKSHEET FOR • DATE: 7/20/2005 TIME: 7 :11AM PAGE: 36 ' SITE ADDRESS: 12400 SW 121ST AVE CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: 'PROJECT NAME: AUSBIE DESCRIPTION: Addition of (3) bedrooms & (1) bath. OWNER: AUSBIE, DONNA 0, PHONE #: CONTRACTOR: ROSEWOOD DEVELOPMENT CO, M HUMPHREY PHONE #: 503-329-6461 Inspection Request Scheduled For: Date: 7/20/2005 Pour Time: Code # Inspection Description Confirm # Contact # Message 299 Final inspection 011789-01 503. 329 -6461 N Corrections /Comments /Instructions: • /1/// • PASS ' n PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS ❑ . FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: Date: /- C) Phone #: (503) 718- •