Permit MASTER PERMIT
C ITY OF TIGARD
COMMUNITY DEVELOPMENT Permit #: MST2011 -00090
11G .RD. 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439
Date Issued: 06/09/2011
Parcel: 2S110AB06200
Jurisdiction: Tigard
Site address: 14340 SW 114TH AVE
Subdivision: HELLER PARTITION /MLP2003 -00007 Lot: 2
Project: Roberts
Project Description: Master bedroom and bathroom addition.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 1 First: 120 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front 0 Smoke
Dwelling Units: 0 Third: 0 sf Right 0
Detectors: Yes
Total: 120 sf Value. $24,000.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer. 0
Drains: 0
Tubs /Showers: 1 Garbage Disp: 0 Water Heaters' 0 Water Lines: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Other Fixtures: 0
Drywell- Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types. Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
'Heat Pump: N 'Hoods: 0 Other Units: 0
Furn <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn > =100K: 0
ELECTRICAL
Residential Unit, Service Feeder Temp Srvc /Feeders Branch Circuits
1000 sf or less: 0 ' 0 -200 amp. 0 0 -200 amp: 0 W/ Svc or Fdr 0
Ea add'I 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc /Fdr: 3
Mfd Home /Feeder /Svc: 0 401 -600 amp: 0 401 -600 amp: 0
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +amp /volt: 0
ELECTRICAL - RESTRICTED ENERGY
SF. Residential •
Audio & Stereo: N HVAC: N Security Alarm: N Vaccuu m System: N Garage Opener: N All •
Other: N Other Description:
Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ADD SF VB R -3 120
Owner: Contractor:
ROBERTS, JOHN C OWNER Required Items and Reports (Conditions)
14340 SW 114TH AVE
TIGARD, OR 97224
PHONE: PHONE:
FAX:
Total Fees: $1,254.11
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Code. d all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started, within 180 days of issuan ,, r if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification t =r. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952-.111-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503. / : 98 or 1.800.332.2344.
Issued By: ,-4/ ,-4/ � /� //I��� Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for the next available inspection date. I
This permit card shall be kept in a conspicuous place on the job site until completion • the project.
Approved plans are required on the job site at the time of each inspection.
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Building Permit Application � '
; R e sidential
RECEIVED ,
; ` ,HOR OFF ICE <[ISE ONLY
v
Received W ^ _ n / -0 w _ O
C of Tigard JUN Date/By: • f' ",/ i Permit No.:�^ / •
13125 SW Hall-Blvd., Tigard, OR 97223 JUN 1 7011 Plan Review • ■ ' "
- 6 : °; Phone: 503.718.2439 Fax: 503.598.1960 Date/By: - Iv - [ I Other Permit:
Ti C /t i l Inspection Line: 503.639.4175 CITE OF TIGARD Date Ready/By: tuns la See Page 2 for
I .- Internet: www.tigard- or.gov Notified/Method: Supplemental Information
• BUILDING DIVISION
geri, '4, e u.:;s Z x F , - g ,a - : �ti.c� s Vi a: ,? °.9.u � _.,. ,'r - ..� a,s > <. :, �kaw <rw:n »�.r rx;, °z- , A- >�eti9X.ak �*- - --c - mss:
. . —„,t.„,:.. 4 . 11 ,-, a,Jkli F�'� rip'. E OF WO WA y - .. . l : ..5 «: R E QUIRED DATA _ i ND 2 FAMILYdD,W LUNG l
❑ New construction . ❑ Demolition Permit fees* are based. on the value of the work performed.
Indicate the value (rounded to the nearest dollar) ()fall
® Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and theprofit for the
�' N€ K W - '` i- - 3V M' - - '� �A °t:` =''` "- s s '' >`----. S - �'�; - work indicated on this application.
i. eAt ti .- CATEGORYy OF CONS ..nNs tilt42 - ,h r O , .; a
, ® 1- and 2- family dwelling ❑ Commercial /industrial Valuation`. $24000
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
` JOB SITE INFORMATION ANDS LOCM t : trti g u Total number of floors:
. Job site address: 14340 sw 114 Ave New dwelling area: 120 square feet .
City/State /ZIP: Tigard Oregon 97224 Garage /carport area: square feet
' Suite/bldg. /apt. no.: Project name: Roberts Covered porch area:' square 'feet
Cross street /directions to job site: Deck area: square feet
' Bull Mountain Road 'Other structure area: square feet
>kF.u�;��:b�F^stsaac'?��,`2:9" �x e�3� ,� t
;REQUIRED DMTA COMMERCIAL U CKI,IST
��...�a�:�-�� .>�„ >;:xa, - -ys�. T ;_�� -a ..se_�s` .u^gFS:�sa t ,w - --
Subdivision: Lot no.:' Permit.fees* are based on the value of the.work performed.
Tax maplparcel -no.: 2S110AB06200 Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
x,40 , R, w. v - °k '"Y -a m.. ..h r - - - - ' . tt - -- 3 ti ,
-
M- s i:A.` k +,r .i , DESCRIP,TION . OF WORI�� . ,,..,i A ,, g .r� work indieated on this application. .
- .a.. I I4�' -4..i ` +.., xd d> ,,, ,, M-^,. > >sa> -v. .�, .�:"'m:s l . -,.,- , ,1.F, - �. ., ,' > .,....m& ..« -` ..-
Extending.Master Bedroom and Bathroom Valuation: S
Existing building area: square feet
•
New building area: square, feet
4k m, PROPERTY OWNER � � - -- 4— 4TENANFTt , , Number of stories:
Name: John Roberts Type of construction:
Address: 14340 SW 114' Ave Occupancy groups:
City/State /ZIP: Tigard, OR 97224 Existing:
Phone: ( ) Fax: ( ) New:
. *- < r,v -. LICANz:I .- �:` II t� �:��® CONTACT PERSON Nt - A :. B UILD IN G PE C,, �
Bus iness, name: (,lease re er.to• eeschedxle
• Structural plan:review fee (or deposit):
Contact name: Tim Morris
FLS plan review fee (if applicable):
Address: '11548:'SE 31 Ave
City /State /ZIP: Milwaukie, OR 97222 Total:fees due upon application: n
Phone; 784-6103 Fax: ( ) Amount received: il o2S6 % i g
, T.T. '�a'::} .h'`�3: ' : . = . 9.c.•Fa�J.wok% x3„ �Z`�Y:)F.2:: :- e
a PHOTOVOLTAICSOLARrPANEL SYSTEM>EEES*PS
E-mail: nwframer2@msn.com 1,1,. . ;:'m sx�...s�.vs j- ..-s, *t%,v* '? .as:� ;1�t�> x.w` ..ax- .sv,
:� 'ate ,� ��e;.:K ; P b Commercial and residential prescriptive installation of
i 'c � ` ^. 'z' CONTMQ:: R p � € c Y ¢ a P P
���.����`�..�.�����x -a..� ��.�- ..��,�.- .�,�;;, ����- ��- ���y..,.::- , � ��...- -s. :`�kr_?.�..4i roo - • = itounted Photovoltaic Solar Panel System.
Businessiname: ii (J� I— /` Submit two - s of roof plan with conne _ ' details
v and.fire department a - -- along w • . e 2010 Oregon
Address: Solar Installation Special 00% I ecklist.
City /State /ZIP: Permit Fee (in, •s:plan review $180.00
administrative fees):
Phone: ( ) Fax: ( ) u
S . urcharge (12% of permit fee): $21.60,
CCB lie.:
Total fee due upon application: $201.60
Authorized signatu This permit application expires if a permit is not obtained
0 within 180 days after it has been accepted as complete.
Print name: V W 1� C . 8 e -f_C� Date: 6.. ) , i .Service Board. set by Tri- County Building Industry
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1:\Building \Permits \BUP- RESPermitApp.doc 02/24/2011 440- 4613T(11/02 /COM/WEB)
_ I . .
•
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Electrical Permit Appl ttIVED u , ..4 : ,� -. FOR'OF ICF USFrONL � 4
r R eceived
City of Tigard Permit No.:
t , ° 13125 SW Hall gar
131ll Blvd., Tigard, 223] 7,� DateBy: _�� ������ �� '
�l' Plan Review
- Phone: 503.718.2439 Fax: 50!3 5 98.1960 DateDate/By: Other Permit
Inspection ,Line: Date Ready/By: Ju
y :kids: la See Page 2 for
�TIGARD f 503.639.4175 ' �iG�
i. Internet: www.tigard- or.govCl'l1. Q I ' 1S10N Notified/Method: Supplemental Information
T � )C1 r F' WO RK' • •'PLAN',REVIEW - •
❑ New construction pi Addition/alteration /replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition - ❑ Other: where the available fault current ❑ Marinas and boatyards.
• :CATEGORY OFrCONSTRUCTION . . a exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, orexceeds 14,000 ❑ Commercial -use agricultural
] 1- and.2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
<. , - ; - - ❑ Emergency system. larger separately derived system.
, , JOB SITE 'INFORMATION ,LOCATION 0 Addition of new motor load of ❑ "A " "E " "I -2 " "1 -3 "
Job no.: Job site address: ‘l.‘3 V S W (, � ' t'W t. 100HP or more. occupancy,
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: L c ❑ Ilealth -care facilities. ❑ Supply voltage for more than
��J f2 G tl \ ����` ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: c.4043.E9,... ❑ Service or feeder 600 amps or more.
- , E 'SCHEDULE ".: - -'
Cross.streetldirections to job site:1 V LL "AA ` e 0 q 1 Description 1 OtY, I Fee, I Total
Y 41+ New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential • " 75.00 2
. • • - • � .DESCRIPTION''OF' WORK ' ' •,` (with above sq. ft:)
Limited energy, multi - family 75.00 2
residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
200 amps or less 100.70 2 • , •
PROPERTY `OW.NER ❑ NT
TENA' 201 amps to 400 amps 133.56 2 •
• — " _ �(' 401 amps to 600 amps 200.34 2
Name: . 0, C Q y 601 amps to 1,000 amps 301.04 2
Address: ,..1 4340 SW WAIL AI L P\\I Over 1,000 amps or volts 552.26 , 2
' G fu, (1._,.., �� a Z Temporary services iir feeders installation, alteration, and /or
�
City/State /ZIP: u tr relocation
Phone: (s-;S) f? c k,( G Fax: ( )
200 amps or less 59.36 1 •
201 amps to 400 amps 125:08 2
Owner installation: This inst. a to being made on property that I own which is not
intended for sale, lease rent, o exchan - acco 1•i ing to ORS 447, 449, 670, and 701. 401 ampsao 599 amps 168.54 2
1 Branch circuits - new, alteration, or extension, • er - panel
Owner signature:��- _ 1lk ■ Date: 6 • 1- I 1 A. Fee for branch circuits with
APP LICANT above service or feeder fee
, .❑ •CONTACTE,PERSON, 7.42 2
each branch circuit
Business name: B. Fee for blanch circuits without l
service or feeder fee, first
Contact name: branch circuit 56.18 6 �,pq � l r� ( 2
Each add'l branch circuit 2, 7.42 f . it • Lit 2
Address: Miscellaneous (service or feeder not included)
Cit /State /ZIP: Each,manufactured or modular 67 84 2
y dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail:
Sign or outline lighting 67.84 2
_. CONTRACTOR ",` • - Signal circuit(s) or limited - energy
Business name: 0e..0j ft (e-- panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr,
Industrial plant (1 hr min) 7,8.18/ hr
Phone:.( ) Fax: ( ) Inspections for which no'fee is 90.00 / fir .
specifically listed (%1 hr min)
CCB'<Lie Electrical Lic.: Suprv, Lic,: r . a. ELECTRICAL;PPERMIT . '
Subtotal_ - - I (,, t ' -
Suprv. Electrician signature, required:
_ Plan review (25% of permit fee):: ,
Print name: Date: State surcharge (12% of permit fee): e) , �j'Z
TOTAL PERMIT FEE: ' Ji t •54
Authortzed signature: This permit application expires if a permit is not obtained within X180
Print name: Date: days after it has been accepted as complete. .
Number of inspections allowed per permit.
i.\ Building \Permits\ELC- PermitApp,doc 07/01 /10 440- 4015T(I I /05 /COM/wEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information t
LIMITED ENERGY PERMIT FEES:
•
1RESIaDENThAL'WORK49NI:tY;'
Fee for all residential systems combined $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
•
n Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑
•
Vacuum Systems*
n Other:
p COMMERCIAL WORK :ONI:Y_:
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
❑ Instrumentation
n 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\Permits\ELC- PermitApp.doc 07/01/10
( -•,-- .-.-::-'.... :,:.-"..':.,;`:;-'.',:-..','"..,
Mechanical Permit Application ,,,,c4..,,, - ,, ,,,,, , F011OF FIC r USE
_ ,...- .. .
R .
RECEIVE
,. rc:'' ,i1 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review ° '
11 1114
/ —0•941P
„f Phone: 503.718.2439 Fax: 503.598.1960 • 1 7011 fiEffl gm Permit No.: 8 a
Other Permit: 00
Inspection Line: 503.639.4175 iliN Date/By:
"RIGARD Date Ready/By: Juris: 10 See Page 2 for
Internet: www.tigard TI G RA D Notified/Method: Supplemental Information
CITY OF
ii , niNa DwisION
cit- — - - kl■fEFiCIAUFE* - SCHilitILE USE CHaICLIST::
- Mechanical permit fees* are based on the value of the work
ID New construction i fki Addition/alteration/replacement performed. Indicate the value (rounded to the nearest dollar) of all
0 Demolition 0 Other: mechanical materials, equipment, labor, overhead, and profit.
__ ., Value: $
CATEODRVOF .4".)sISTI2U,gyiON, : L • • - , . . 1 ,
• , RESIDENtIAVEQUIPMEN10,'§YgliEMS FEES'ii ... :
N. I- and 2-family dwelling 0 Commercial/industrial 0 Accessory building For special information use checklist.
0 Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total
-JOB SIT6 INFORMAtI(* AND LotkilION ' ' ' " • - - .. ' Heating/cooling:
Air conditioning
Job site address: pf 3 y 0 ,, /) ' or ve (requires site plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46.75
City/State/ZIP: The Pit 5 72111 Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg./apt. no.: Project name: re,„ 4,0 Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 23.32
Hydronic,hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unitheaters (fuel-type,-not electric),
in-wall, in-duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue/vent for any of above 23.32
Other:. 23.32
Tax map/Oarcel no.: 2 slip 4$ 0 4, zip Otherfuel appliances:
' .‘ . . ' . ' ' .:''': • 'DESCRIPtION,OK4ORK.. ' . ' • . =, ;'." `. ' Water heater 2332
Gas.fireplace 33:39
1 3 /E Dt1_d/P0'■ 44) / nio Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33:39
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Wood fireplace/insert 23.32
. , .., Chimney/liner/flue/vent 23:32
4, • .. XPROPERTY'OWNgR. . ' .. ' ': ■ ' .2 1:1 lEtsaSiT . ' ,- • ,
. . Other: 23.32
Name: :7 IQ ,
Ng-12:73. Environmental exhaust and ventilation:
..---
Address: -
Range hood/other kitchen
‘ LIS, 14 0 0 %.0 k t) t- equipment 33.39
City/State/ZIP: t.--- - I IN a")) "N., (1 .... c:::,1 22 t ( 1 .) — Clothes diyer exhaust
Single-duct &ha (bathrooms, 1 33.39
Phone: (5 Irn 5-4, 4-f.. Fax: ( ) toilet compartments, utility rooms) ( 23.32 22--
APPLICANT : , .;' . ''• . ,.-1: E , ,CONTACT PERSON ,.' . , Attic/crawlspace fans 23.32
Other: 23.32
Business name:
Fuel piping:
Contact name: $14.15 for first four; $4.03 for each additional
Furnace, etc.
Address:
Gas heat pump
City/State/ZIP: Wall/suspended/unit heater .
Phone: ( ) Fax: : ( ) Water heater
Fireplace
E-mail:
Range
.. ,.. .... --.. . • - - , .
2. : . . . .. . , : ' - .'• ',_ ' * ' , :a C.01) '.',.'• : ' !' ' i' . , . - . . ,, Barbecue
Business.natne: O W 16 e/& Clothes dryer (gas)
Other:
Address: : ' ; AECHANleAL-PEiiMif FEES* - ' - " ''
City/State/ZIP: Subtotal 2,73,272.-- __
Minimum permit fee ($90.00) 6 4.,
Phone:( ) Fax: ( )
Plan review (25% of permit fee)
CCBtlie.: State surcharge (12% of permit fee)
• ...1 g G61-1T,t- TOTAL PERMIT FEE icy) ae
This permit application expires if a permit is not obtained within 180
Authorized signature: ....
'4111111k days after it has been accepted as complete. . .
Print name7;,,. lir - Ni Date: C % I / * Fee methodology set by Tri-County Building Industry Seniice
i:\BuiIding\Permits\JiIEC.permitApp doe 09/09/10 ' 440-46I7T (I I/02/COM/WEB)
., .
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Mechanical Permit Application - City of Tigard ..
Page 2 - Supplemental Information
Commercial & Multi- Family Fee Schedule:
Total Valuation; - Permit`Eee: '
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or •
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
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$2.54 for each additional $100.00 or
fraction thereof, to and including •
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
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$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and •
$2.92 for each additional $100.00 or
fraction thereof.
r.
Note: All new commercial buildings require 2 sets of plans.
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I:\ Building \Permits \MEC- PermitApp.doc 09/09/10 2
Plumbing Permit Applicatio CEIVED
'Building Fixtures c „ E OFH us � - n \l l a . ) r . ` ? �'
Cit Of Ti JUN 1 2011 Received • /_
'a Date /By: � P i 1 Permit No.: �m // _�
lig
w 13125 SW 'Hall: Blvd., Tigard, OR 97223 Plan Review / `
9 :.. Phone: 503.718.2439 Fax: 503.5 "tI0511lOF TIGARD Date /By:
lit Other Permit No.:
t G ASR D' d '' Inspection Line: 503.639.4175 BUILDING DIVISION
Date Ready/By: orris: Fa See Page 2 for
°., , , r . '' Internet: www.tigard- or.gov Notified/Method: Supplemental Information
. TYPE, OF WORK • ;FEE *,SCHEDULE ' - - _ • ' ,
❑ New. construction ❑ Demolition For special information use-checklist.
Description I Qty. I Ea.. Total
1, Addition /alteration/replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
' ' ' ' . CATEGORY . :CONSTRUCTION' . • SFR (1) bath 312.70
- and2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
ID Accessory building SFR (3) bath 500.32
ry g ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler (_ sq. ft.) Page 2
° .. JOB' ;SITE IN
2 AND LOCATION.' '9,, • Site utilities:
Job site address: / V tip SW 1 1 y try' Catch basin or area drain 18.76
q 2� Drywell, leach line, or trench drain 18.76
City /State /ZIP:
he of q ? Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: e-.r" / Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
. Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: a $ i I O AO() eavt, Backflow preventer 31.27
..., ac water valve
,' - ,." 'DESCRIPTION OF WOR ° - '_'
° Clothes washer 25.02
Dishwasher 25.02
Drinking,fountain 25.02
Ejectors /sump 25.02
" 0 • Expansion tank 12.51
.. ROPERTY OW � �. �•.. ' . _
Name: e b M1 ss ( `I` e �� Fixture /sewer cap 25.02
Address: C Floor drain/floor sink/hub . 25.02
�y3V G CAA - A I Garbage disposal 25.02
City /State /ZIP: 1 0, 6 (2_ q'N 2 Z t./ Hose bib 25.02
Phone: (51:0 , 8.'7,1 - s Fax: ( ) Ice maker 12.51
,i 1 .❑ ;APPLICANT ❑ ° CONT A C T PER S . Interceptor /grease trap 25.02 •
Business name:
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
' Address: G
Sink/basin / lavatory Q 25.02 ZJiVw
City /State /ZIP: - Solar units (potable water) 62.54,
Phone:.( ) Fax: : ( ) Tub /shower /shower pan i 12 :51 ,Z,1j
E' -mail: Urinal 25.02"
Water closet I _ 25 :02' .2_ -. -
• R CO NTRACTOR,,` _. _ " Water heater • 37:52
• Business name: n(0Pe -(2 Water piping/DWV 5629
Address: . , Other: 25 :02
City/State /ZIP: Subtotal -
Phone:'( ) Fax: ( ) Minimum permit fee: $72.50 t2, __
CCB Lie.: umbing Lie. no.:. Plan review (25% of permit fee) q,. .i% j
State surcharge (12% of permit fee) . a-76
Authorized signature:
C aPy� TOTAL PERMIT FEE ;( 2,C) r
Print name: v k Iv C . 2Ca4^. Date: 6 .. I , II 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\PLMU- PermitApp.doc 10/01/09 • 440- 4616T(10 /02 /COM/WEB) .•
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Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information •
Fee Schedule: Residential Fire Suppression Systems:
Site:Iltilities' . '. ' go' =. `Fee,(ea): Total:, , Sgparel Dotage r,`mit Fee: . •
Footing drain - 1 ' 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Storm & Rain Drain - 1st 100' 62.54 Valuatio n: . Permi ,.. .
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
.:Qty: .F ee (ea) : 'Total each additional $100.00 or fraction thereof, to
Ot �o,r F ,. . . _ _ and including "$10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including, $25,000:00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379'.50 for the first $25,000.00 and $1.45 for
hours (Minimum charge - 2 hours) „ , , each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up' - . ' $742.00 for the first $50,000.00 and $1.20 for
(minimum charge- 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", ' . , , ;
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
,, ° ` ` . . 'Quantityby.FixtureType -" , ' ` : *laiiz"Review forf lunibing ;'I -installathins °.:. ..' '
Fixture Typeifor . Replace) Plan rev i s required for any of the following.
:Cap ped, .. «Ached; - R q y
Work - Performed: Please check all that apply.
Baptistry/Font
Bath Tub /Shower ❑ Any new commercial building with water service 2" and
- Jacuzzi /Whirlpool greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer. _
-Drive Thru ❑ New exterior plumbing,site utilities for anycomplex structure
Cuspidor/Water Aspirator as defined ih OAR918 -. - 0040.
Dishwasher - Commercial ❑ Medical.gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system. . •
Drinking Fountain ❑ Any complex structure as defined in OAR918 780 - 0040. •
Eye Wash
Floor Drain /sink - 2" Submit 2 sets of plans with any of the above.
-3"
4"
. Isomefric ,or Rise°r. Diag ram.
Isometric or riser diagram is uired for new buildings
. . J
Car Wash Drain ❑ Itrii dia re s
Garbage - Domestic- non -food g q g
•
Disposal - Domestic -food related that meet the qualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Statiori
Shower -Gang ,
-Stall ..
Sink/Lav - Non -food related
•
- Bradley
- Commercial -food related
- Service
Swimming Pool Filter *Note: If the fixture.work under this permit results in an
Washer - Clothes
Water Extractor increase of sewer EDUs, a ; sewer permitrwill be issued and
Water Closet- Toilet fees assessed fo.rlhe sewer increase'must be paid before the
Urinal ' . , plumbing permit can be issued.. , ;
Other Fixtures: .
I:\Building\Petmits\PLMF- PermitApp.doc 02/24/2011 2
Clean Water Services File Number
CleanWater Services ( 11— 0 013 9 2
Sensitive Area Pre- Screening Site Assessment
1. Jurisdiction: Washington County
2. Property Information (example 1S234AB01400) 3. Owner Information
Tax lot ID(s): Name: John Roberts
Company:
Address: 14340 SW 114th Ave
Site Address: 14340 SW 114th Ave City, State, Zip: Tigard, OR, 97224
City, State, Zip: Tigard, OR, 97224 Phone /Fax: 503 877 5646 / efax (630) 566 -0905
Nearest Cross Street: Bull Mountain E -Mail: JRinPDX @hotmail.com
4. Development Activity (check all that apply) 5. Applicant Information
IA Addition to Single Family Residence (rooms, deck, garage) Name: John Roberts
❑ Lot Line Adjustment ❑ Minor Land Partition Company:
❑ Residential Condominium ❑ Commercial Condominium 14340 SW 114th Ave
Residential Subdivision Address:
❑ ❑ Commercial Subdivision
❑ Single Lot Commercial ❑ Multi Lot Commercial City, State Zip: Tigard, OR, 97224
Other Phone /Fax: 503 877 5646 / efax (630) 566 -0905
E- Mail: JRinPDX @hotmail.com
6. Will the project involve any off -site work? ❑ Yes El No ❑ Unknown
Location and description of off -site work
7. Additional comments or information that may be needed to understand your project
Project to expand master bedroom & bathroom Eastward by 7 feet for a total of 140 additional sq.ft.
This application does NOT replace Grading and Erosion Control Permits, Connection Permits, Building Permits, Site Development Permits, DEQ
1200 -C Permit or other permits as issued by the Department of Environmental Quality, Department of State Lands and/or Department of the Army
COE. All required permits and approvals must be obtained and completed under applicable local, state, and federal law.
By signing this form, the Owner or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water Services have authority
to enter the projectsite :at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify
that I am familiar with the information contained in this document, and to the best of my knowledge and belief, this information is true, complete, and accurate.
Print/Type Name John Roberts Print/Type Title
ONLINE SUBMITTAL Date 4/12/2011
FOR DISTRICT USE ONLY
❑ Sensitive areas potentially exist on site or within 200' of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties, a Natural Resources Assessment Report
may also be required.
U Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200' of the site. This
Sensitive Area 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 07 -20, Section 3.02.1. All required permits and
approvals must be obtained and completed under applicable local, State, and federal law.
❑ Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially
sensitive area(s) found near the site. This Sensitive Area Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water
quality sensitive areas if they are subsequently discovered. This document will serve as your Service Provider letter as required by Resolution and Order
07 -20, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local, state and federal law.
❑ This Service Provider Letter is not valid unless CWS approved site plan(s) are attached.
LA The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed .by Date e 4/13/2011
2550ESW'Hillsbbro Highway illsbo Ore erh'971;23 Phn (503} 681 - 5 Fax: (503) 68 - www.clea to s ervices , org '
,
( / .'
` Information Notice to Owners About
, _ qv
C_" �`
.,' Construction Responsibilities
\rJ (ORS 701.055 (5))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at.the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503 - 378 -4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503 - 947 -1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to
http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms.
• 'Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503 - 947 -7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as'their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise:. Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough -in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052
Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007
Website Address: www.oregon.gov /ccb
f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant
l
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit::this° statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
•
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners. About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
Ce C • QC)
Print Name of Permit ' ppli ..t
Signature of Permit Applicant
Permit #: H 5i Q.■ l t' - Do090
I I ' /
Address: /'f 40 J // `t µ �f� �'. '• .
t a- rj oa 9 7 4.c( :`�"`.� ";.
Issued by: Date:
This Copy for Permit Offices
°°. t ea '.$'`
krt fi
11111 •
°C y 5
B uil di ng Division
Development Code Provision Review
r t - -aR °` Residential Projects
Building Permit No: H f_ 2C
CWS Service Provider Letter Received: Yes ja No ❑ N/A ❑ 641)
a +P 41 tf 7 '
Iie.f 0 r
Routed Plans:
Original Plan Submittal Date: 61114
1st Revision Submittal Date: ❑ Site Plan Only
2nd Revision Submittal Date: ❑ Site Plan Only
To the Applicant:
Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies to the
Building Division. Only checked (✓) items are approved. Items not approved and those listed in the notes must be
revised prior to re- submittal. For questions please contact the appropriate staff person(s) listed above each section.
Staff: please check items along left only if approved.
Planning Review (contact ,7" lr 62 - 1 -1 at 50 3 - 718 -� L) or ' ' @tigard- or.gov)
Land.Use Case No. / Name P-0 6E/ iS
Er-Zoning 1 4 - 1 . S
ii
❑'! Setbacks: / 7
Front Lc Rear 1 S Side Street Side i° Garage
d Maximum Building Height c - 3 < Actual Building Height
Visual Clearance An fk
Easements /i Pal
lie Sensitive Lands Type: ,U ( a-
- Notes:
Original Plan: Approved l( Not Approved ❑ Date:
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
Engineering Review (contact Mike White at 503 - 718 -2464 or MikeW @tigard - or.gov)
C+ Actual Slope: 9
Notes:
Original Plan: Approved Not Approved ❑ Date: 6 l7 I(
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
r
./
(Review Continues on Page 2) S
Page 1 of 2
City Arborist Review (contact Todd Prager at 503 - 718 -2700 or todd @tigard - or.gov)
��/etreet Trees
IV Protected Trees
Notes:
•
Original Plan: Approved Er Not Approved ❑ Date: 6/,2,9 ,,u1
Revision 1: Approved ❑ . Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
Permit Coordinator Review (contact Albert Shields at 503 - 718 -2426 or albert @tigard- or.gov)
❑ Conditions of Approval Prior to Issuance of Building Permit
Notes :
Original Plan: Date Sent to Applicant:
Revision 1: Date Sent to Applicant
Revision 2: Date Sent to Applicant
Okay to Issue Permit: Yes No ❑
Date Routed to Building: 41i
4
•
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