Permit A - CITY OF TIGARD SITE WORK PERMIT
I�� DEVELOPMENT SERVICES PERMIT # : SIT2001 -00001
I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED : 7/30/01
SITE ADDRESS: 5 u.) i - PARCEL : 2S114A0 -01500
� �
SUBDIVISION: 11 ZONING : R -12
BLOCK: LOT: JURISDICTION : TIG
CLASS OF WORK: OTR PAVING ?: Y RESO. NO:
TYPE OF USE: COM GRADING ?: Y VALUE:
EXCV VOLUME: cy LANDSCAPING ?:
FILL VOLUME: cy SITE PREP ?: Y
ENG FILL ?: STORM DRAINS ?: Y
SOILS- RP -T- REQD ?: IMPERV SURFACE: 100.000 sf
Remarks: Site work permit for Cook Park pathway from 85th Ave to 92nd Ave. Work consists of Parking Lot, installation of
utilities, and emerngency access /Sidewalks
Owner: FEES
TIGARD, CITY OF Type By Date Amount Receipt
13125 SW HALL
TIGARD, OR 97223 EROS DEB 4/20/01 $100.00 JE #291
ERPU DEB 4/20/01 $32.50 JE #291
Phone: Total $132.50
Contractor:
NORTHWEST EARTHMOVERS INC
PO BOX 1467
TUALATIN, OR 97062
Phone:
Reg #: LIC 00062761
Required Inspections
Retaining Wall /Footing
Paving Insp
Strm Drain Insp
Culvert/Catch Basin
Domestic water line inspect.
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law
requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952-001-Is ; i. Yo ay obtain copies of these rules or direct questions to OUNC by
calling (503) 246 -1987.
Permittee Sign. • re: t;� 1 1 ',f
Issu : d B , 0 � -� • 0//i
V
Call (503) 639 -4 75 by 7:00 P.M. for an inspection needed the next business day
Building Permit Application
( ,\�l Date received: D / - / '/.0t Permitno.:. ,-( /eac cow/
..,, , th City of Tigard
l,I. Project/appl. no.: Expire date:
City ojTigard Address: 13125 SW Hall Blvd, Tigard, OR 97223
Phone: (503) 639 -4171 Date issued: By: Receipt no.:
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: CcPaC<Z) 0000 / 1 &2 family: Simple Complex:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family ❑ New construction ❑ Demolition
❑ Addition/alteration/replacement ❑ Tenant improvement ❑ Fire sprinkler /alarm ❑ Other:
JOB SITE INFORMATION
Job address: Cie. ftip.G - a G Bldg. no.: Suite no.:
Lot: Block: Subdivision: Tax map /tax lot/account no.:
Project name: t =00%c, (1 ' • _ G
Description and location of work on premises/special conditions: e• 1.0 ° -e - •,12.tOSAAJPets L PAQ�i ^1Gs
.b. L, .
OWNER ER , . FOR SPECIAL _INFORMATION, USE CHECKLIST
Name: C.... , , ■ T6, - P42 ` (Flood plain, septic capacity, solar, etc.)
Mailing addles : l C La i r _, z. b 1 & 2 family dwelling:
City: - r-re.N,qo2„3) State:Oa_ ZIP: ' 2,2,3 Valuation of work $
Phone: Co S _ ., 71 Fax: E -mail: No. of bedrooms/baths
Owner's representative: p+J tJ t. Fi t\)6, -.A Total number of floors
• Phone: Fax: E -mail: New dwelling area (sq. ft.)
APPLICANT = . Garage/carport area (sq. ft.)
Name: `,, 60,--J e Covered porch area (sq. ft.)
Mailing address: Deck area (sq. ft.)
City: State: ZIP: Other structure area (sq. ft.)
Phone: Fax: E -mail: Commercial/industrial/multi-family:
CONTRACTOR Valuation of work $
�- 1 . ��/ Existing bldg. area (sq. ft.)
Business name: ' _ ` _ New bldg. area (sq. ft.)
Address:
Number of stories
City: State: ZIP: Type of construction
Phone: Fax: E -mail:
Occupancy group(s): Existing:
CCB no.: New:
City/metro lic. no.: Notice: All contractors and subcontractors are required to be
ARCIIITECT/DESIGNER licensed with the Oregon Construction Contractors Board under
Name: provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
_State: ZIP: exempt from licensing, the following reason applies:
11311 Contact person: Plan no.:
Phone: Fax: E -mail:
ENGINEER •
IIIMININI person: . :• Fees due upon application $
Address: Issrp, S c 6 • . P-4. 1 .5Da Date received:
City: 64 We-6.--o . te: d e ZIP:. . 03,c Amount received $
Phone: ,g_ ( Fax: 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. All provisions of laws and ordinances governing this 0 Visa ❑ MasterCard
4 work will be complied with, hether s. - 'fled herein or not. Credit card number: Exp / s
Authorized signature: / a�ri Date: $0 3 /a/ Name of cardholder as shown on credit card $
Print name: r GO - , 4 • 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 ( M)
SITE WORK P ERMIT CHECK LIST
Commercial
cu. yds.
idPntial: Co areas only.
Excavation Complete ENTIRE form.
Residential: s mrcial and
. me y.
S HADED
cu. yds.
Grading Volu
Gra omluem:
>5,000 Cu
(Soils
. . -
. cu. yds.
Retaining structure? (Check one),
(Soils report requir for
Fill Volume:
(Fill exceeding
U Rock
( ceeding 12" in depth shall be compacted to
,. maximum density)
CMU
90% at a
1:3 Concrete
Li Other
.:,
•
D
0
• '
sq. ft.
Total new 1m
• pervious area including all buildings,
sidewa lk s, and paving: .• Loot° °
Plum Work:
Utilities Plum
L.., Permit App lication Site i
N- Plumbing
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iAdsts\forms\sitechecklist.doc 12/21/00