Permit A: 4'CITY OF TFGARD MASTER PERMIT
PERMIT #: MST2005 -00146
ZIP DEVELOPMENT SERVICES DATE ISSUED: 4/27/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 2S104AC 03400
SITE ADDRESS: 12543 SW 134TH AVE ZONING: R -25
SUBDIVISION: MORNING HILL NO. 8 LOT: 178 JURISDICTION: TIG
Project Description: Addition of bonus room. Other mechanical is duct work (fees included in BUP per MAV)
BUILDING
REISSUE: CUSTOM STORIES: 1 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: 11 FIRST: 234 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: 20,000.00
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 234 sf REAR: 15
PLUMBING
SINKS: WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS:
TUB /SHOWERS: GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL /CMP < 3HP: VENT FANS: CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: 1
MAX INP: btu FLOOR FURNANCES: VENTS: 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: 00 SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 • 600 amp: 401 - 600 amp: EA ADDL BR CIR: 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: OTH: BOILER: HVAC: LANDSCAPE /IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
This permit is subject to the regulations contained in the
Owner: Contractor: Tigard Municipal Code, State of OR. Specialty Codes
BARTLETT, KEVIN & STACI OWNER and all other applicable laws. All work will be done.in
12543 SW 134T1-I 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: 503 Phone: 503 - 475 3180 adopted by the Oregon Utility Notification Center. Those
rules are set forth in OAR 952 - 001 -0010 through
952- 001 -0080. You may obtain copies of these rules or
Reg #: direct questions to OUNC by calling 503 - 246 -6699 or
TOTAL FEES: $ 505.67 1 - 800 - 332 - 2344.
REQUIRED ITEMS AND REPORTS
Issued By : :- . Z.,- ,z" Permittee Signature :
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business da
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 Appli eki i I V E D FOR OFFI USE ONLY
City of Tigard Received i 6 ✓' � Permit No : J� - - 6
APR
27 200 , 13125 SW Hall Blvd., Tigard, OR 97223 Dan ate/ By: 7 �
Phone: 503.639.4171 Fax: 503.598.1960 A N I I II Date/By: r 7 \ J Other Permit:
Inspection Line: 503.639.4175 CITY OF TIG ', ! J' "L.. Date Ready /By: Juris: H See Attached Checklist for
Internet: www.ci.tigard.or.us BUILDING DIVISION Notified/Method: i 1( r Supplemental Information
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
' ET Addition/alteration /replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
work indicated on this application.
CATEGORY OF CONSTRUCTION .
•
❑ 1- and 2- family dwelling 111 Commercial /industrial Valuation: $ 2. O D 0 d
❑ Accessory building 1:1 Multi Number of bedrooms:
❑ Master builder III Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 1 2- S -I3 St) I 3Gi +" ftVE New dwelling area: 25 4 square feet
•
City/State /ZIP: "rI (s 4 fZ b 0 9122,3 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: • S (2oM Covered porch area: square feet
Cross street/directions to job site: 135 4H i t.J A l NU f fa (3a0-1 1511 i Deck area: square feet
13 II 1"' RVir: Other structure area: square feet
REQUIRED DATA: COMMERCIAL - USE CHECKLIST
Subdivision: MOtcN inl q h i I 1 Lot no.: Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK �� work indicated on this application.
ADD 1 LI X rl • 3o altos 444^.1 i- t �y+c. le- or nay Valuation: $
14'0°11 Existing building area: square feet
New building area: square feet
li PROPERTY OWNER ❑ TENANT Number of stories:
Name: K 4.3471 Gtr 3 - )"tl cA Type of construction:
Address: 126-43 .Sm.) (3 N #4- <11/4' Occupancy groups:
City/State /ZIP: 7 ', i of R Q 0 In t.3 Existing:
Phone: ( Sa3 ) 3 di •- 1 0 6 Z Fax: ( ) New:
Q APPLICANT ❑ CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
Contact name: KE�10 ( t}(j -��-� 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
applicant is exempt from licensing, the following reasons
City/State /ZIP:
apply:
Phone: ( ) Fax:: ( )
E -mail:
CONTRACTOR
Business name: J!r. /tN 51•zr1e f't'
BUILDING PERMIT FEES*
Address: 115 143 SW 13 y ANC Please refer to fee schedule.
City/State /ZIP: -n G - 44-ED a 2 x/ 7223
Fees due upon application
Phone: (5a/3) 3 0 62 Fax: ( )
Amount received
CCB lie.:
Date received:
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Date: * Fee methodology set by Tri- County Building Industry
Service Board.
i.'Building\Permits\BUP- PermitApp.doc 12/03 440- 4613T(t l /02 /COM/WEB) _
One- and Two - Family Dwelling •
Building Permit Application Checklist a FOR OFFICE-USE ONLY
A ,
City of Tigard R eceived
Permit No.:
Date/13y:
13125 SW Hall Blvd., Tigard, OR 97223 Associated permits:
Phone: 503.639.4171 Fax: 503.598.1960 //x 4 v 11'1'1\
24- Hour Inspection Line: 503.639.4175 ,f I CI Electrical cal ❑Plumbing CI Mechanical
Internet: www.ci.tigard.or.us �- ❑ Other:
THE FOLLOWING ITEMS.ARE.RE FOR PLANREVIEW 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. ❑ ❑ ❑
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 frill -size
and details. be if
Sheet attached to the plans with cross references between plan location anu etaiiail . � nl ii a reVieW cannot ue" completed
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. ❑ ❑ ❑
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.
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 Oregon and shall be shown to be ap i licable to the project under review.
JURISDICTIONAL SPECIFICS
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. ❑ ❑ ❑
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 - - .
• T F OR OFFICE USE ONLY ,
City ot.Tigard
Received Permit No.:A
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
, �� �, r Q Di (../..‘ $ Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 � _,�, r�i�� Date/By: Other Permit:
Inspection Line: 503.639.4175 2 Date Ready /By: inns ® See Page 2 for
Internet: www,ci.tigard.or.us Notihed/Method: Supplemental Information
T YPE OF WORK PLAN REVIEW
❑ New construction El Addition/alteration /replacement Please check all that apply:
Ell Demolition ❑Other: ❑Service over 225 amps, comm'l E] 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
r6 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
['Building over three stories ['Feeders, 400 amps or more
❑ Multi family ❑ Master builder ❑ Other:
['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: 12_593 5.0 i'51 ' A-✓c 1' b-AdZP DQ 7223 The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name: FEE* SCHEDULE **
Description Qty. Fee. Total
Cross street/directions to job site: 1 35 }1 ►iv_ +o k ..,1,,,,,i- Oro NtSk New residential single - or multi - family dwelling unit.
Includes attached garage.
+0 13 q' AAR- • 1,000 sq. ft. or less 145.15 4
Subdivision: r .‘ O 1 ., N `N � ( ,� t I 1 Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 1
Limited energy, residential 75.00 2
Tax map /parcel no.:
Limited energy, non - residential 75.00 /
DESCRIPTION OF WORK Each manufactured or modular
dwelling, service and /or feeder 90.90 2
Services or feeders installation, alteration, and /or relocation
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
Is PROPERTY OWNER ❑ TENANT
401 amps to 600 amps 160.60 2
Name: e I n1 6ARrie. y- 601 amps to 1,000 amps 240.60 2
Address: 1.2/5 d 3 3..a. (314 k Y VQ_ Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City /State /ZIP: 11(r. t Dd '11223 Temporary services or feeders installation, alteration, and /or
relocation
( 5., ) 3 er7... Q G Z 2000 0 amps Fax: ( ) ps
or less 66.85 I
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: y/ Branch circuits - new, alteration, or extension, per panel
❑ APPLICA ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
B. Fee for branch circuits I
Contact name: without service or feeder fee, 46.85 2
each branch circuit
Address: 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
extension. Describe: Page 2 2
Business name:
Address: Each additional inspection over allowable in any of the above
Per inspection 62.50
City /State /ZIP: Investigation per hour (I hr min) 62.50
Phone: ( ) Fax: ( ) Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES*
CCB Lie.: Electrical Lie.: Suprv. Lie.: Subtotal
Suprv. Electrician signature, required: Plan review (25% of permit fee)
Print name: Date: State surcharge (8% of permit fee)
TOTAL PERMIT FEE
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete
Print name: Date: * Fee methodology set by Tri- County Building Industry Service Board
** Number of inspections per permit allowed.
1.1Bmldmg`.PemiitsVELC•PermnApp due 12103 440- 4515T(I 04412/CO01 /WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
•
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined ... $75.00
• Check Type of Work Involved:
n Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
n Heating, Ventilation and Air Conditioning
System*
n Vacuum Systems*
n Other:
COMMERCIAL WORK ONLY:
Fee for each commercial system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved: •
n Audio and Stereo Systems
n Boiler Controls
n Clock Systems
•
n Data Telecommunication Installation
n Fire Alarm Installation
HVAC
I Instrumentation
I Intercom and Paging Systems
I Landscape Irrigation Control*
n Medical
n Nurse Calls
Outdoor Landscape Lighting*
n Protective Signaling
n Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
\Building \Porous \ELC- PennitApp doc 04/03
Mechanical Permit Application !.:-.... , . FOR OFFICE USE ONLY , - 4' ' .: W
I
City Received
y of and @ • g Date /By: Permit No.: /fit. i 15/4
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review !J�
Phone. 503.639.4171 Fax: 503.598.1960 I Other Permit:
�"., µ Date /By:
Inspection Line: 503.639.4175 ��� al 11 • • Date Ready /By: Juns: 0 See Page 2 for
Internet: www.ci.tigard or.us Notified/Method: Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Mechanical permit fees* are based on the value of the work
Ill New construction [g Addition /alte ration /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: S
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
�/ Air conditioning or heat pump
Job site address:
12-5 `4 5 t i3 -1 h AVe_ (requires site plan showing placement) 14.00
City /State /ZIP: — - j . 4/0 , o R. e 1 22 3 Furnace 100.000 BTU (ducts /vents) 14.00
Furnace 100,000+ BTU (ducts /vents) 17.90
Suite/bldg. /apt. no.: Project name: Sops's 12 on Gas heat pump 14.00
Cross street/directions to job site: i •5 tI^ fio il k 4,,\ } LN%sti i'O Duct work I 14 00
Hydronic hot water system 14.00
"3 Li IM h V e. Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended. etc. 10.00
�, f I Flue /vent for any of above 10.00
N
Subdivision: yA 0 t•t Q Lot no.: Other: 10.00
Tax map /parcel no.: J Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
, B N..).5 y, Gas fireplace 10.00
A.D.° x 1 "1 a N.3 •2.00p4 '" L back- Flue vent for water heater or gas
h O✓H fireplace 10.00
ini), Log lighter (gas) 10.00
Wood/pellet stove 10.00
Wood fireplace /insert 10.00
PROPERTY OWNER El TENANT Chimney /liner /flue /vent 10.00
Other: 10.00 _
Name: JCCti1,I 4.1LrIe It Environmental exhaust and ventilation
.5 Range hood /other kitchen
Address: I25 q 3 S 13 q f4- /We. equipment 10.00
City/State /ZIP: 'ri a 44-0 i Q2 ii1zQ'j Clothes dryer exhaust _ 10.00
Single -duct exhaust (bathrooms,
Phone: (5b ) 3 4-100, 7,, Fax: ( ) toilet compartments, utility rooms) 6.80
El 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
Water heater
Fax: Phone: ( ) ( )
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal
Minimum permit fee (872.50)
Phone: ( ) Fax: ( )
Plan review (25% of permit fee)
CCB lic.: State surcharge (8% of permit fee)
TOTAL PERMIT FEE
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: * 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:ABuilding \Permits \iMEC - PermitApp.doc 12/03 2
Apr.26. 2005 8:44AM CLEAN WATER SERVICES 503 6814439 No.6504 P. 2
G4/ L4 /Ludt., lb: bL 50344dWJJJ rL.l,:,Ini. r.�NNI.X HALE 01
<• J tl „ k •
® APP 1 4 2Th35
F ile Number I a 5 , co /6 5 �
CleanWater Service. . v_ -� - - �` F
Our commitment meat is dear. Sensitive Area Pre - Screening Site Assessment
Jurisdiction 7jz,.,i/ Date 41 " O.
. Map & Tax Lot IS/ O q, O3'!QO Owner Vi
Contact . 0'd�1,307 , -5b 6z.
Site Address /2- 6 N3 jt) /.35 fia Company
# Ui' 1213, . Address , 126 .S6-' 131 4
Proposed Activity Go hPrJ1 City State Zip - -n ii 4 00 'ill‘
Phone ) 3a7- gbG Z 1 / jsi eitif 2 i LL
Fax We * Pie up Le -
•
Official use only b9 /ow Mitt !MO
Y N NA Y N NA
r1 �I Sensitive Area Co osite Map i rr Stormwat� frastructure maps
l w i—i I Map # .2-. / ic L. � l L L. _ L-• QS# 41 ...
U 1 I Locally adopted studies or maps El ❑ ri Other
Specify _ Specify
Based on a review of the above information and the requirements of Clean Water Services
Design and Construction Standards Resolution and Order No. 04 -
l i 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. If Sensitive Areas exist on the site or within 200 feet on adjacent •
properties, a Natural Resources Assessment Report may also be required:
•
14 Sensitive areas do not appear to exist on site or within 200' of the site. This pre-
screening site assessment does NOT eliminate the need to evaluate and protect
water quality sensitive areas if they are subsequently discovered. This document
will serve as your Service Provider letter as required by Resolution and Order
04 -9, Section 3.02.1. All required permits and approvals must be obtained and
completed under applicable local, state, and federal law.
Fl The proposed activity does not meet the definition of development. NO SITE
ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED.
Comments:
• rwr /1 w : 'v. .. i - _21 17%12
Reviewed By: — e .oe /(C • Date: _ ._/ .z_ f,OX
•
Returned to Applicant
• Mail Fax Counter . .-
nate__ /��G By
• '.2550 SW Hillsboro Highway • Hillsboro, Oregon 9712:
Phone; (503) 681 -5100 • Fox: (303) 681 -4439 • w
•
CITY OF TIGARD
BUILDING DIVISION PERMIT #: MST2005 -00146
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/27/2005
Phone: (503) 639 -4171 :N4
Inspection Requests (24 Hrs.): (503) 639 -4175 „Jai- II—
INSPECTION WORKSHEET FOR DATE: 7/19/2005 TIME: 7:08AM PAGE: 16
SITE ADDRESS: 12543 SW 134TH AVE CLASS OF WORK:
SUBDIVISION: MORNING HILL NO. 8 LOT #: 178 TYPE OF USE:
PROJECT NAME: BARTLETT
DESCRIPTION: Addition of bonus room. Other mechanical is duct work (fees included in BUP per MAV)
OWNER: BARTLEI i , KEVIN & STACI, PHONE #: 503.307 -9062
CONTRACTOR: OWNER PHONE #: 503 - 475-3180
Inspection Request Scheduled For: Date: 7/19/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
299 Final inspection 011708 -03 503-307-9062 N
Corrections /Comments /Instructions:
C t lE°.....:
X ._ PASS 01 PARTIAL APPROVAL ❑ CANCEL El NO ACCESS
❑ FAIL ji ■ '`' L FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: -�i� Date: 7 / 9_0_s°'
Phone #: (503) 718 -
CITY OF TIGARD
BUILDING DIVISION PERMIT #: MST2005-00146
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/27/2005
Phone: (503) 639 -4171 N1141111'
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 7/19/2005 TIME: 7 :08AM PAGE: 17
SITE ADDRESS: 12543 SW 134TH AVF CLASS OF WORK:
SUBDIVISION: MORNING HILL NO. B LOT #: 178 TYPE OF USE:
PROJECT NAME: BARTLETT
DESCRIPTION: Addition of bonus room. Other mechanical is duct work (fees included in BUP per MAV)
OWNER: BARTLETT, KEVIN & STACI, PHONE #: 503 - 307 -9062
CONTRACTOR: OWNER PHONE #: 503 - 475-3180
Inspection Request Scheduled For: Date: 7/19/2005 Pour .Time:
Code # Inspection Description Confirm # Contact # Message
199 Electrical final 011708-02 503-307-9062 N
Corrections /Comments /Instructions:
Ii PASS al PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL r4 Ci FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: -4_ Date: `' Ir PU hone #: (503) 718 -
CITY OF TIGARD
BUILDING DIVISION PERMIT #: MST2005- 00146
1 3125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4/27/2005
Phone: (503) 639-4171
Requests (24 Hrs.): (503) 639 -4175 __..
INSPECTION WORKSHEET FOR DATE: 7/19170 TIME: 7:08AM PAGE: 18
i1 40
SITE ADDRESS: 12543 SW 134TH AVE CLASS OF WORK:
SUBDIVISION: MORNING HILL NO. 8 LOT #: 178 TYPE OF USE:
PROJECT NAME: BARTLETT
DESCRIPTION: Addition of bonus room. Other mechanical is duct work (fees included in BUP per MAV)
OWNER: BARTLETT, KEVIN & STACI, PHONE #: 503- 307 -9062
CONTRACTOR: OWNER PHONE #: 503 - 475.3180
•
•
Inspection Request Scheduled For: Date: 7/19/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
699 Mechanical final 011708 -01 503- 307 -9062 N
Corrections /Comments /Instructions:
PASS r APPROVAL El CANCEL ❑ NO ACCESS
FFF��� ~
I FAIL CAL ' OR INSPECTION ❑ ADDITIONAL FEES ASSESSED
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Inspector: _ Date: /I 'OK — Phone #: (503) 718-