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Permit C ITY OF TIGARD SITE WORK PERMIT DEVELOPMENT SERVICES PERMIT # : S1T2005 - 00015 c l l l 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED : 9/28/2005 PARCEL : 2S110BC -00900 SITE ADDRESS: 12475 SW BULL MOUNTAIN RD ZONING : R -1 SUBDIVISION: LOT: JURISDICTION : TIG Project Description: Well house. CLASS OF WORK: NEW PAVING ?: U RESO. NO: TYPE OF USE: COM GRADING ?: Y VALUE: 41,900.00 EXCV VOLUME: 293 cy LANDSCAPING ?: Y FILL VOLUME: 51 cy SITE PREP ?: Y ENG FILL ?: N STORM DRAINS ?: Y SOILS RPT REQD ?: N IMPERV SURFACE: 2,653 sf Owner: FEES TIGARD WATER DEPT. Description Date Amount 8777 SW BURNHAM ST [ERPRMT] Erosion Control 9/28/2005 $80.00 TIGARD, OR 97223 [ERPLN] Erosn Pln Rv CWS 9/28/2005 $26.00 [EROSN] Erosn Pln Rv COT 9/28/2005 $26.00 Phone: 639 - 4171 395 [TAX] Valu 8% State Surcharg 9/28/2005 $32.86 [BUPPLN] Pln Rv -Valu 9/28/2005 $267.02 [BUILD] Prmt Fee - Valu 9/28/2005 $410.80 Contractor: [WQUAL] Water Quality 9/28/2005 $225.00 SCHNEIDER EQUIPMENT INC [WQUANT] Water Quantity 9/28/2005 $275.00 21881 RIVER ROAD NE SAINT PAUL, OR 97137 Total $1,342.68 Phone: 503 - 633 -2666 REQUIRED ITEMS AND REPORTS Reg #: LIC 39265 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 -0100. You may obtain copies of these rules or direct questions to 0 NC by " g 503 - 246 -6699 or 1- 800 -332 -2 Issued By: , , ia ��� Permittee Signature (eW.1..72 - r Call 503 -639 -4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Site Word] +j 4 Building Permit Application - - -- _ - - - - - - -- „ - FOR OFFICE usI oNLY� < r City of Tigard �j E CE VE .,d D R a , ' �1 PermitNo.:S j�. C705" o ©/ / 13125 SW Hall Blvd., Tigard, OR 97223' Plan Revie � Other ennit:j �- ,i �»;tr( �,' 7 - 04 Phone: 503.639.4171 Fax: 503.598.1960 Date/B . � I (l�(� ,.� JUL Inspection Line: 503.639.4175 UL 2 2 200C I j,i � ' _ `�__., Date W' Jutis ® See Internet: www.ci.tigard.or.us Notified/Method: Gi Supplemental Information CITY OF TI(3ARD atitiONAC REQUIRED DATA 1- AND 2 FAMILY DWELLING 4-New construction ❑ Demolition Permit fees* are based on the value of the work performed. 1 ' Indicate the value (rounded to the nearest dollar) of all • ❑ Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. El ' i 1- and 2- family dwelling Commercial /industrial Valuation: $ ❑ Accessory building ❑ Multi- family Number of bedrooms. ❑ Master builder ❑ Other: Number of bathrooms: . JOB SITE INFORMATION AND LOCATION. Total number of floors: 1 Job site address: / Z y 2 5' S J 4.,z_ Nt au 4)r,4-y,‘ (-, New dwelling area: square feet City /State /ZIP: 7.J'!r R- e, 2 9 7 z y,I. UP l , r Garage /carport area: square feet Suite/bldg. /apt. no.: Project name: T q dam L �� , , u Covered porch area: square feet \1 • ti Cross street /directions to job site: / -L "�- ,¢ � - T j fr,o,,,,,Ygq S7'Ol'" cm Deck area: square feet --s- A / 70 4 4, Other structure area: square feet • REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: Lot no.: Permit fees* are based on the value of the work performed. Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the , "DESCRIPTION OF WORK work indicated on this application. /� Co Sr P../ C1 0 a9 c� c taBc.) SST eqv n C - ..csr -- -20 < t.) c - r L Valuation: $ l ` `7 U 0 ,c9 Existing building area: square feet New building area: (l f square feet 0(PROPERTY OWNER ❑ TENANT Number of stories: Name: C =-,--- ,{ 0 r � - 7 4 Type of construction: S Address: l a ( e - S S13.3 f- iA-LC L yj) Occupancy groups: 4,4n - b 6 a_ 7 Z3 Existing: � City /State /ZIP: 7' g: ' Phone: (5 C o 31 - LI / 71 Fax: (5 0 6 Z ` e5 7 S Z New: ❑ APPLICANT ❑ CONTACT PERSON NOTICE Business name: sc. (,e.Dt�- Ac -/2 €0 , 3 - p r N T - C All contractors and subcontractors are required to be Contact name: a � N €1, it._ licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: Z f % g / /g3ii-ei ,2;,4b_ !J L- jurisdiction in which work is being performed. If the City /State /ZIP: �f} I! L t� �- q 3 7 applicant is exempt from licensing, the following reasons �i apply: Phone: (,}`n3) (3 5 ..7-6 6 ( Fax: : (5%3 ) 633 - z (, e. a E -mail: 1,_,.... p t C_ , co CONTRACTOR Business name: S' c /._(,,,, ez i7L� €e J. ,)0. pJe.-- BUILDING PERMIT . FEES* . Address: 2 ( ( 6 ? ( (zd v�tc- 12,9,q.b N c Please refer to fee schedule. City /State /ZIP: 5 r - RA - J L o ti.- 7 700 7 • ,-, 3 z-6' 6 G Fax: (c1:::5 6 3 Fees due upon application Phone: ( � 3 J - I ) j - Z 6 (9 Amount received CCB lie.: 3 g z G ,S - 5 It / 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.. C at L ej , a Date: 7 " - 2 - as - * Fee methodology set by Tri County Building Industry Service Board. is \Building \Permits \SIT- PermitApp doe 12/03 440- 4613T(11/02/COM /WEB) City of Tigard: Site Work Permit Checklist Page 2 - Supplemental Information • Commercial, Multi - Family and One- and Two - Family Dwellings: No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If fill is in a flood plain, drainage way, or wetland, the applicant must apply for a sensitive lands review • (SLR). Please complete all items below, unless otherwise noted. Excavation Volume: cu. yds. Grading Volume: (Soils report required for >5,000 cu. yds.) cu. yds. Fill Volume: (Fill exceeding 12" in depth shall be compacted to 90% of maximum density) • cu. yds. Retaining structure? (Check one) ❑ Rock ❑CMU ❑ Concrete ❑ Other: *Total new impervious area including all buildings; sidewalks, and paving: sq. ft. Site Utilities Plumbing Work: Complete the Plumbing Permit Application for site utilities plumbing work. Plans Required: See "Site Work Permit Application - Plan Submittal Requirements" attached. The following must accompany this application: ❑ Site Plan with Vicinity Map showing ❑ *Parking (including ADA) and ADA compliance Lighting Plan El Grading Plan and details ❑ *Landscaping Plan ❑ Erosion Control Plan and details ❑ Soils Report (if required) Retaining Structures *Does not apply to One- and Two - family dwellings. # of Plans TYPE OF SUBMITTAL Required at (Includes New, Additions or Alterations) Submittal Commercial 2 Multi- Family R -1 Occupancy 2 One- & Two - Family Dwelling 2 i:\Building \Forms \SIT- PermitApp.doc 1/13/04 2 CITY OF TIGARD BUILDING DIVISION PERMIT #: S IT a oOS - o p o is 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: Phone: (503) 639 - 4171 il "rN�nP til 9 / Inspection Requests (24 Hrs.): (503) 639 -4175 111. INSPECTION WORKSHEET FOR DATE: 9-06 /06 TIME: PAGE: SITE ADDRESS: ! 02 97 5 Stu 130/ M c u k4 A , e-. R i CLASS OF WORK: SUBDIVISION: ^ LOT #: TYPE OF USE: • PROJECT NAME: ci). I G4 T■' SG ra DESCRIPTION: ,- vn 54,4ic koh 0 -1 LA.)p ii /notice OWNER: PHONE #: CONTRACTOR: PHONE #: Inspection Request Scheduled For: Date: Pour Time: Code # Inspection Description Confirm # Contact # Message Corrections /Comments/ Instructions: 5 ___---- I i) r , 1 ,-- - 4 ‘//-, I PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS ❑ FAIL I I CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED po Inspector: 4 Date: �j Phone #: (503) 718-