Permit CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2003 -00415
•
i DEVELOPMENT SERVICES DATE ISSUED: 8/29/03
. - 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 13790 SW 124TH AVE PARCEL: 2S103CC - 06500
SUBDIVISION: WHISTLER'S WALK ZONING: R -4.5
BLOCK: LOT: 012 JURISDICTION: TIG
REMARKS: New SF detached.
BUILDING
REISSUE: CUSTOM STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: NEW HEIGHT: 24 FIRST: 1,420 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 1,530 sf GARAGE: 711 sf FRONT: 20 PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: 1 THIRD: sf RIGHT: 5
VALUE: 290
OCCUPANCY GRP: R3 BDRM: 4 BATH: 3 TOTAL: 2,950 sf REAR: 15
PLUMBING
SINKS: 1 WATER CLOSETS: 3 WASHING MACH: 1 LAUNDRY TRAYS: 1 RAIN DRAIN: 100 TRAPS:
LAVATORIES: 4 DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: 100 SF RAIN DRAINS: 1 CATCH BASINS:
TUB /SHOWERS: 2 GARBAGE DISP: 1 WATER HEATERS: 1 WATER LINES: 100 BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIUCMP < 3HP: VENT FANS: 3 CLOTHES DRYER: 1
GAS FURN > =100K: 1 UNIT HEATERS: HOODS: 1 OTHER UNITS: 1
MAX INP: btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: 0 GAS OUTLETS: 4
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 1 0 - 200 amp: 0 - 200 amp: W /SVC OR FDR: PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 6 201 • 400 amp: 201 - 400 amp: 1st W/O SVC/F DR: SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 • 600 amp: 401 - 600 amp: EAADDL BR CIR: SIGNAUPANEL: 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: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 5,461.98
This permit is subject to the regulations contained in the
DON MORISSETTE HOMES DON MORISSETTE HOMES INC Tigard Municipal Code, State of OR. Specialty Codes and
4230 GALEWOOD ST 4230 GALE WOOD ST, STE 100 all other applicable laws. All work will be done in
STE 100 LAKE OSWEGO, OR 97035 accordance with approved plans. This permit will expire if
LAKE OSWEGO, OR 97035 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 adopted by the
Phone: 503 387 - 7538 Phone: Oregon Utility Notification Center. Those rules are set
forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
Reg #: .9 38737 may obtain copies of these rules or direct questions to
1 OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Erosion Control lnsp 84 Post/Beam Structural Mechanical Insp Shear Wall Insp Insulation Insp Water Service Insp
Grading Inspection Post/Beam Mechanical Plumb Top Out Exterior Sheathing Ins[ Gyp Board Insp Appr /Sdwlk Insp
Sewer Inspection Underfloor insulation Electrical Service Low Voltage Rain drain Insp Electrical Final
Footing Insp Crawl Drain /Backwater Electrical Rough In Gas Line lnsp Storm drain Insp Mechanical Final
Foundation Insp PLM /Underfloor Framing Insp Gas Fireplace Water Line Insp Plumb Final
�!! , I -
,,�
Issued By : Permittee Signature \ �I Al = I • -
Call (5 ) 639 -4175 by 7:00 p.m. for an inspection needed the next business day
To ?r g'- ,),e -03 ~ .t/ kaoo 5 - DO
Building Permit Application .. , �, ._.s. «F r �
' Date receive L - 0 6 Permit no : jet. j ro3 -pO E// '
.,
jli City of Tigard Project/appl.no.: Expire date:
Cirynf7igard Address: 13125 SW Hall Blvd, Tigard OR 97223
Pck
Phone: (503) 639 -4171 Date issued: By: € iI Receipt no.:
Fax: (503) 598 -1960
Case file no.: Payment type: Q
Land use approval: 1 &2 family: Simple Complex: o,
T1 PE OF PERMIT'
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ,,CNew construction ❑ Demolition
l] Addition/alteration/replacement l] Tenant improvement l] Fire sprinkler /alarm ❑ Other.
.: s , A L �, 4 ir,, ±:_, . ' <, �. x��•C1'� .a� + OIt1�1 ,,. : ��� . .f , , , e 1- _ ,., . „4.,
: � �
Job address: j TV { � " �� • ' , Bldg. no.: Suite no.:
Lot: ( Block: 'Subdivision: \AA.r , ' fa, lA (4 I Tax map/tax lot/account no.: ,, (. 3CC _ abc,
Project name: K. S'
Description and location of work on premises/special conditions: Ai ea.) S l% 41.r - ,.,.t....)
ONY NIX FOR SPECIAL INFORMATION, USE CHECKLIST
_LM �_ _,,I (1:lo septic capacity, solar, etc.)
Mailing address: 'eraf a l R if 1 & 2 family dwelling: C,
City: , , , State4 ZIP: / ' , - 2 Valuation of work $ 1
Phone:. - Ar� Fax:2, )• -740, -mail: No. of bedrooms/baths
Owner's representative: , War j if C vej Total number of floors 1 1;
Phone: Fax: E -mail: New dwelling area (sq. ft.) ,w4 ■ ~ V
APPLICANT Garage/carport area (sq. ft.)
Name: V CY\ 1ri� _ . S Covered porch area (sq. ft.)
Mailing address: , ,,,e_, a a - Deck area (sq. ft.)
City: I State: I ZIP: Other structure area (sq. ft.)
Phone: Fax: E -mail: Commercial/industrial/multi- family:
CONTRACTOR Valuation of work $
Existing bldg. area (sq. ft.)
�= f1� �'- New bldg. area (sq. ft.)
Address: -& v�r �jZi. Number of stories
City: State: ZIP:
Type of construction
Phone: I Fax: I E -mail: Occupancy group(s): Existing:
CCB no.: 7j ? 5 �j" New:
City /metro he. no.: Notice: All contractors and subcontractors are required to be
ARCHITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: � -la i,{ �--� provisions of ORS 701 and may be required to be licensed in the
Address: ) Cis ( �3VO jurisdiction where work is being performed. If the applicant is
City: State: I ZIP:
exempt from licensing, the following reason applies:
Contact person: Plan no.:
Phone: Fax: E -mail:
ENGINEER
Name: Contact person: Fees due upon application $
Address: Date received:
City: (State: (ZIP: Amount received $
Phone: I Fax: I E -mail: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached checklist. A t rovisions of 1 ws and o dinances governing this ❑ Visa ❑ MasterCard
work will be compli - a WI a, , whether ifie 1 iierein t. Credit card number: / /
1 A . Expires
Authorized si a atu � =' � // _ - � .,f e % Name of Cadholder as shown on credit card
Print name: 1111 -1... �� 4 t (
$
� Cardholder signature Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (6r'X0ICOM)
One- and Two - Family Dwelling
Building Permit Application Checklist Reference no.:
Associated permits:
City of Tigard City of Tigard O Electrical 0 Plumbing 0 Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 0 Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes 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. 4
3 Verification of approved plat/lot.
4 Fire district approval required.
5 Septic system permit or authorization for remodel. Existing system capacity
6 Sewer permit.
7 Water district approval. k
8 Soils report. Must carry original applicable stamp and signature on file or with application.
9 Erosion control 0 plan 0 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 r/
if copyright violations exist. J�
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. n
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, J
fireplace construction, thermal insulation, etc. J�
15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels.
Exterior elevations must reflect the actual grade if the 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. x
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered
systems, see item 22, "Engineer's calculations." `'X\
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 Oregon and shall be shown to be applicable to the project under review.
JURISDICTIONAL SPECIFICS �r
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 & 22 above.
25 Building plans shall not contain red lines or tape -ons.
26 No rolled, reversed or mirrored building plans will be accepted.
27
28 •
Checklist must be completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 440 -4614 (6,00/COM)
.
Mechanical Permit Application `"° rt ''�"�"
Date received: Permit no.: ,l ; , 4,2, abl,//^
ma y, •� . City of Ti ar �LD Project/appl. no.: Expire date:
City ofTigard Address: 13125 U.; T Ti a nti, OR 97223 Date issued: By: Receipt no.:
Phone: (503) 639-4 71
Fax: (503) 598 -1960 A 11G O Cj 2003 Case file no.: Payment type:
Land use approval: AD Building permit no.:
•F TIUA
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial 0 Multi - family ❑ Tenant improvement
few construction 0 Addition/alteration/replacement ❑ Other:
JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
Job address: ( 0 5 L e . Indicate equipment quantities in boxes below. Indicate the dollar
Bldg. no.: Suite no.: value of all mechanical materials, equipment, labor, overhead,
Tax map /tax lot/account no.: profit. Value $ .
Lot: l Block: Subdivision: K./ *See checklist for important application information and
Project name: a g jurisdiction's fee schedule for residential permit fee.
City/county: [ ZIP: I & 2 FAMILY DWELLING PERMIT FEE SCHEDULE
Description and location of work on premises: AM) COMMERICAL/INDUSTRIAL EQUIPMENTSCIIEDULE
Fee(ea.) Total
Est. date of completion/inspection: Description Qty. Res. only Res. only
Tenant improvement or change of use: 13YAC:
•
Is existing space heated or conditioned? ❑ Yes ❑ No Air handling unit CFM
Air conditioning (site plan required)
Is existing space insulated? 0 Yes ❑ No Alteration of existing HVAC system
MECHANICAL CONTRACTOR Boiler /compressors
State boiler permit no.:
Business name: �,t [ + _ i 1 i eA ► / _ - HP Tons BTU/H
Address: Fire/smoke dampers/duct smoke detectors
City: - LI�\\ State:(1�' ZIP: . �j Heat pump (site plan required)
Phone: � .1j � ax: E -mail: Install/replace furnace/burner BTU /H
�
y � Including ductwork/vent liner CI Yes El No
CCB no.: ' i ,r9 '5�,r) Install/replace/relocate heaters — suspended,
City/metro lic. no.: N/A wall, or floor mounted
i Vent for appliance other than furnace
Name (please print): � I t7 .�j�1 (�,��(_
CONTAC "f PERSON Refrigeration:
Absorption units BTU/H
Name: 0 Cf`A--k 0.1, Chillers HP
Compressors HP
Address:
-- V— ') -A (' 4t Environmental exhaust and ventilation:
City: State: ZIP: Appliance vent ,
Phone: Fax: E -mail: ' Dryer exhaust
OWNER Hoods, Type I/ II/res. kitchen/hazmat
hood fire suppression system
Name: � al�' alp 46 Exhaust fan with single duct (bath fans)
Mailing address: g „� / m ��_ir!,eoI Exhaust system apart from heating or AC
City: A , , State '4 ZIPR` i , 5 Fuel piping and distribution (up to 4 outlets)
Type: LPG NG Oil
Phone:. —2— �� Fax: E - mail: Fuel piping each additional over 4 outlets
ENGINEER Process piping (schematic required)
Name: Number of outlets
Other listed appliance or equipment:
Address: Decorative fireplace
City: I State: I ZIP: Insert — type
Phone: Fax: E -mail: Woodstove/pelletstove
Other: _
. , Applicant's signatu" � `� , I Date: Other:
Name (print): (.'c i - I. f 1 rli t / I
Not all jurisdictions accept credit cards, please call jurisdiction for more information.
c infoation. Mini Permit fee $
ac
Notice: This permit application Minimum fee $
0 Visa ❑ MasterCard expires if a permit is not obtained
Credit card number: - E Expires w i t hin 180 days after it has been Plan review (at _ %) $
x •
p State surcharge (8 %) .... $
Name of cardholder as shown on credit card accepted as complete.
S TOTAL $
Cardholder signature Amount 440 -1617 (MXVCOM)
Plumbing '
b Date received: Permit no.: •, _
�i� City of Tigard AA 11 O Ip 200 Sewer permit no.: Building permit no.:
'#'+�' Address: 13125 SW Hall BI*VVigard, OR 97223 ire date:
City ofTigard Phone: (503) 6394171 �1GAR� Project/appl.no.: P
Fax: (503) 598-1960 G lri O G p► Date issued: By: Receipt no::
BV��,Q1M Case file no.: Payment type:
Land use approval:
TYPE OF PERMIT
0 I & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
►: New construction 0 Addition/alteration/replacement 0 Food service 0 Other.
.108 SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: t e • Description Qty Fee(en.) Total
New 1- and 2- family dwellings only:
Bldg. no.: Suite no.: (includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (I) bath
Lot: t 0 Block: Subdivision: L,1 SFR (2) bath
Project name: CIA r SFR (3) bath
City /county: [ ZIP: Each additional bath/kitchen
_ Description and location of work on premises: Site utilities:
Catch basin/area drain
Est- date of completion/inspection: Drywells/leach line/trench drain
-- Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR RACTOR Manufactured home utilities
Business name: p., ` 7 ‘ L . Manholes
Address: 0 Rain drain connector
' Sanitary sewer (no. lin. ft.)
��!" �" —"� Storm sewer (no. lin. ft.)
Phone: y ,-.1- .t Water service (no. lin. ft.)
: no.: or; "7 l.- I Pl g D.11 •• II. V Fixture or item:
City/metro lac. no.: NSA , Absorption valve
Contractor's representative signature ! ' . ^ Back flow preventer
I Print name: , 1 t " ` / U' - I) Backwater valve 1
CONTACT PERSON Basins/lavatory =_
i • Clothes washer
Name ::\ `'� , � ��Di N e Dishwasher Address: • / 0 ti, A/ — Drinking fountain(s)
City: I State: ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
OWNER Fixture/sewer cap
Floor drains/floor sinks/hub
Name (print): • , Alt b` Garbage disposal
Mailing address: A -{�.'} L� . •
PINT • Hose bibb
Cif•,: L _n State ZIP : 0 - 2C� ) Ice maker
-�_7 ? E -mail: Interce for /grease trap
Owner installation /residential maintenance only: The actual installation Pnmer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial) ,
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s). lays(s)
Owner's signature: Date: Sump - 11111
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: State: ZIP: Other.
—
Phone: Fax: E -mail: Total
Minimum fee ................ $
Ntx all l unsdictions accept credit cards, please call lunsdicuon for more infomuuon. Notice: This permit application %) $ �
C Visa 0 MasterCard Plan review (at / ` expires if a permit is not obtained
_ )
C.edit card number. w ithin 1 80 days after it has be State surcharge (8%) .... $ �
Expires TOTAL $ --- --
accepted as complete.
Name of cardholder u shown co credit cant
S Amount 440 - 461 6 (6 OM)
�_ Cardholder signature �
A Electrical Permit A 'cation ,w
- . SG 1 Date received: Permit no.: ...r -0
_a City of Tigard `- Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW Hall Bl1\1)0 v ,Tt, Q10223 Date issued: By: Receipt no.:
Phone: (503) 639 - 4171
Fax: (503) 598 - 1960 116p,AD Case file no.: Payment type:
Land use approval: U1 . NG 0 N1S ) G N
TYPE OF PERMIT
0 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi - family 0 Tenant improvement
v New construction 0 Addition/alteration /replacement 0 Other. 0 Partial
JOB SITE INFORMATION
Job address: I, 0 4- , Av Ni A Bldg. no.: Suite no.: Tax map /tax lot/account no.:
Lot: I r Block: ISubdivision: 1 fMV ?b'- W�(A
Project name: I Description and location of work on premises:
Estimated date of completion/inspection:
CON I RAC' OR ;\hhl.l(',\ I ION FEE SCHEDULE
Job no: �'"") - Fee Max
_ Business name: ELELX--g' c, Description Qty. (ea.) Total no. hasp
New residential - single or multi- family per
Address: ro • 1, I st a t • E dwelling tmiL Includes attached garage.
City: (-Akg-- State: 19 ZIP: ct '2 - 2„ Service included:
Phone:L J2- , 1 Fax: E -mail: 1000 sq. ft. or less 4
1 I ^ Each additional 500 sq. ft. or portion thereof
CCB no.: . ,�,�, Elec. bus. lic. no: 1 p (_. L energy, residential 2
c' r) ................D Limited energy, non- residential 2
Each manufactured home or modular dwelling
nature of electrician (required) Date Service and/or feeder 2
License no: q Services or feeders— installation,
Sup. elect. name (print): 9 I alteration or relocation:
200 amps or less 2
201 amps to 400 amps 2
Name (print): ` tit.. • Il,(tl IlLi /1 401 amps to 600 amps 2
Mailing address: �� /, jlb 601 amps to 1000 amps 2
City: ____.il , State 111 ZIP: 7( Over 1000 amps or volts 2
Phone:)? --- j1 Fax: }7- "7615E -mail: Reconnect only �
Owner installation: The installation is being made on property I own Temporary services or feeders -
which is not intended for sale, lease, rent, or exchange according to dilation, alteration,orrelocation:
200 amps or less 2
ORS 447, 455, 479, 670, 701. 201 amps to 400 amps 2
Owner's signature: Date: 401 to 600 amps 2
ENGINEER Branch circuits - new, alteration,
or extension per panel:
Name: A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 2
City: I State: I ZIP: B. Fee for branch circuits without purchase
of service or feeder fee, first branch circuit: 2
Phone: Fax: E Each additional branch circuit:
PLAN REVIEW (Please check all that apply) Misc. (Service or feeder not included):
O Service over 225 amps-commercial 0 Health -care facility Each pump or irrigation circle 2
O Service over 320 amps- rating of I &2 0 Hazardous location Each sign or outline lighting 2
family dwellings ❑ Building over 10,000 square feet four or Signal circuit(s) or a limited energy panel,
O System over 600 volts nominal more residential units in one structure alteration, or extensions 2
❑ Building over three stories ❑ Feeders, 400 amps or more *Description:
❑ Occupant load over 99 persons 0 Manufactured structures or RV park Each additional inspection over the allowable in any of the above:
❑ Egress/lightingplan 0 Other. Per inspection r I I (
Submit sets of plans with any of the above. Investigation fee
The above are not applicable to temporary construction service. Other
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Permit fee $
O Visa ❑ MasterCard expires if a permit is not obtained Plan review (at _ %) $
Credit card number. _ / / within 180 days after it has been State surcharge (8%) .... $
Expires accepted as complete. TOTAL $
Name of cardholder as shown on credit card
S
Cardholder signature Amount 440 -4615 (6A0uCOM)
Electrical PerRton FOR OFFICE USE ONLY
Received Electrical /"
Date/B : Permit No.: fir. / _ „0 03 - 00 * •
City of Tigard OCT 1 2003 Planning Approval Sign
Y Tigard Date /B Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 2 � Date/B : Permit No.:
Phone: 503-639-4171 F Ci1 C fCIV� l lllfSi D Post- Review Land Use
�N �/rrr 13, � Date /B Case No.:
UBI.,
Internet: www.ci.tigard.or.us • ' I i Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 '”
P q Name/Method: Su I I lemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
Addition/alteration /replacement ❑ Other: ❑ Service over 320 amps- rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
El 1 & 2- Family dwelling n Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building ❑ Multi - Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE 7 5 t f INFORMATION and LOCATION Submit sets of plans with any of the above.
1 / 2 LI itU The above are not applicable I SCHEDULE construction service.
7
Job site address: i
Suite #: Bld. /Apt. #: Number of inspections per permit allowed
Project Name: oN 0-455 - M f/p De Qty Fee (ea.) Total
Cross street/Directions to job site: New residential- single or multi - family per •
l dwelling unit. Includes attached garage.
Service included:
1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Subdivision: ttJ}}/$J ,4S kJ// K Lot #: 12 Limited energy, residential 75.00 2
Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
Services or feeders - installation,
alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTY OWNER 1 ❑ TENANT 601 amps to 1000 amps 240.60 2
Over 1000 amps or volts 454.65 2
Name: D 6A) / /f C? 5,-)1--t.-- Reconnect only 66.85 2
Address: t/7 36 (;ALIL W Si ., sari( /04 Temporary services or feeders - installation,
alteration, or relocation:
Cit /State /Zi.: Li(/(mb „V" ,As 6 / ) .1 200 amps or less 66.85 I
Phone: 3. _ 75 g Fax: 3 ,57--7&/5----- 201 amps to 400 amps 100.30 2
❑ APPLICANT ❑CONTACT PERSON
401 n 600
ch amps 133.75 2
c
Branch circuits - new, alteration, or
Name: extension per panel:
Address: A Fee for branch circuits with purchase of
service or feeder fee, each branch circuit 6.65 2
City /State /Zip: B. Fee for branch circuits without purchase of
service or feeder fee, first branch circuit 46.85 2
Phone: I Fax: Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR - Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: 2 73 2 Signal circuit(s) or a limited energy panel,
Business Name: 11 , ,,, �-E - e , i l „C _ Description:
extension Page 2 2
D + ' Desc ription:
9' Address: UU/ 59 6,`i
City /State /Zip: AL6H 4 bR T700-7 Each additional inspection over the allowable in any of the above: —
Per inspection per hour (min. I hour) 62.50
Phone: 3'51 -S74. 28" Fax: (o1 3 - `fig/'/ 5 Investigation fee:
CCB Lic. #: 13 2222 Lic. #: 3zi _ ff3 Other:
Electrical Permit Fees*
Supervising electrician Subtotal I $
Si: ature re • uired: __� AI 11i / , .,..L...: Plan Review (25% of Permit Fee) $
Print Name: L ,a iri State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Authorized / Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
(Please print name)
is \Dsts\Permit Forms \ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
El Audio and Stereo Systems
0 Burglar Alarm
El Garage Door Opener
Heating, Ventilation and Air Conditioning System
n Vacuum Systems
El Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
PI Clock Systems
El Data Telecommunication Installation
Fire Alarm Installation
n HVAC
n Instrumentation
O Intercom and Paging Systems
n Landscape Irrigation Control
❑ Medical
❑ Nurse Calls
Outdoor Landscape Lighting
n Protective Signaling
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
is \Dsts\Permit Forms\ElcPermitAppPg2.doc 01/03
1
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land use and development standards for street tree installation. ■
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CITY OF TIGARD 24 -Hour
BUILDING Inspection Life: (503) 639 -4175 3 (S' /LS S
INSPECTION DIVISION Business Line: (503) 639 -4171
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Received Received lel 3 53 Date Requested 1 Z1( 2 79 'SAM PM BUP
Location 1 3 7 9 0 /2 ei Suite MEC
Contact Person s Ph ( ) ;Z-b9 3 7 3 _ c 0 S43
Contractor 4/7 Ph ( ) SWR
UILD Tenant/Owner ELC
Footing
Foundation ELC
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:
1 �
PART FAIL
UMBIN
Posra, eam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
inaF
RT FAIL
RAMC ' L
ost & Beam
Rough -In
Gas Line
S39.0 Dampers
allk PART FAIL
z -
S- ' -
Rough-In
UG /Slab
Low Voltage
■1Y 11
Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
a' :it1 PART FAIL
r ❑ Please call for reinspection RE: 0 Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date /2 / /a? /0 3 Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL