Permit CITY OF TIGARD MASTER PERMIT
R sr� COMMUNITY DEVELOPMENT Permit # MST2009-00152
TIGARD 13125 SW Hail Blvd Tigard OR 97223 503 639 4171 Date Issued 08/14/2009
Parcel 2S103DD00407
Jurisdiction Tigard
Site address 10865 SW FAIRHAVEN ST
Subdivision Lot 0
Project Crump
Project Description Add 168 sgare feet habitable space and convert carport to garage
BUILDING
Floor Areas Required Setbacks Required
Stories 0 Bedrooms 0 First 168 sf Basement 0 sf Left 0 Parking Spaces 0
Height 0 Bathrooms 0 Second 0 sf Garage 292 sf Front 0 Smoke
Dwelling Units 0 Third 0 sf Right 0 Detectors Yes
Total sf Value $27,12760 Rear 0
PLUMBING
Sinks 0 Water Closets 0 Washing Mach 0 Laundry Trays 0 Rain Drain 2 Catch Basins 0
Lavatories 0 Dishwashers 0 Floor Drains 0 Sewer Lines 0 SF Rain Other Fixtures 0
Tubs /Showers 0 Garbage Disp 0 Water Heaters 0 Water Lines 0 Drains 0
Bckflw Prevntr 0
MECHANICAL
Fuel Types Air Conditioning N Vent Fans 0 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] 500 sf 0 20 1 -400 amp 0 201 -400 amp 0 1st W/O Svc /Fdr
Limited Energy 401 -600 amp 0 401 -600 amp 0 Ea add] Br Cir
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 Vaccuum 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
Owner Contractor Required Items and Reports (Conditions)
PERCY RODNEY W TR 8 OWNER
PERCY, PATRICIA R TR, 10865 SW
FAIRHAVEN ST
TIGARD, OR 97223
PHONE PHONE
FAX
Total Fees $956 28
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR Specialty Codes and all other dpplicable law 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 the 180
days ATTENTION Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center Those rules are set forth in OAR
952 -001 -0010 throug OAR � 9 � 522 -0 001 -0100 /� You � may obtain o acopy of the rules es or direct questions to OUNC by calling 503 246 6699orr 11 800 332 2344
�r
Issued By " cQN-/ r \ Q ` h-Yt N of V'�-' Permlttee Signature W 'tip (-l144-net#--(")
Budding Permit. Application
Residential RECEIVE I :fbR,OFFIC:: uSt ONLY - .
City of Tigard q r Da Received 1 N Permit No 11
13125 SW Hall Blvd , Tigard, OR 97223 JUL 1 7 200 Plan Revie se s. _ Phone 503 639 4171 Fax 503 598 1960 PlaieB P� O MOther Permit
TIOA'HD Inspection Line 503 639 4175 CITY OFTIGAR 1 Dale Read77 M l ` iA turns ® See Page 2 for
Internet www ugard -or gov BUILDING DIVISI! ified /Method Q �] • Supplemental Information
PC aw y � x � t`rk�. '�= 'V -.� a- �:x ^t i3 a rt '., p v-"e xoMrFS��t� _ � mea
'b -s. `t - t ' r TYPE' `sEi a� " Mild U1RED
-vac '" "�';;, .x� ",- ' .�d*. t u'. , .r d �N., ':.�_-+t, -_ w �.�, „sw �t.?v 'S�`, >�„4�._ +, v. s �Q.. �. � >*?- �aa��w;�,,n�%r...,,.. «s.uhDwa Gn
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed
Indicate the value (rounded to the nearest dollar) of all
❑ Addition/alteration/replacement ❑ Other equipment, materials, labor, overhead, and the profit for the
this w
'*m P*''!'.m. °'^= -- - - work indicated on s a lition ca
�Y�x�, �.,- � `���CATEGORY�OT�"CONSTRUCCION ���,o-� PP n
❑ I - and 2 -family dwelling ❑ Commercial /industrial Valuation S ^t ! t 2.7 ,
❑ Accessory building ❑ Multi - family Number of beds ooms V
❑ Master builder ❑ Other Number of bathrooms
` �.i"q - `,,`tr JOB S TE L\'F§1111 ION; AND, WeXr iFfli t ral Total number of doors ) q }:a /�
Job site address I pr�C SW FA I RHAvEm sr New dwelling area I1 square feet
City /State /ZIP in sit 2 h OR 9 72.2.3 Garage /carport area ` � C l square feet
Sune/bldg /apt no Project name F4 /R1 E&f Covered porch area square feet
Cross street/directions to job site I I 0 itt Deck area square feet
". ^ CAR-Po-AT- Other structure area square feet
— r-f /x.J t./x) C.t-O bp_ CAR o AT RE CJII2EDtDAfi1'.xCO MM _E .70 L IJSE`relt, 2.i :1ST
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
A `r at `s`ht,' -`' 'UESCRll'1 TIOti;sg WORK Sy ;� ., ` *; r* -^ t i! work indicated on this application
A-Dl bFr 7v END of House Valuation s
AA.1 b EAJU -o5E CRRPorzr Existing building area square feet
New building area square feet
at
ar, _, �'� Pil20PERTS'a OWNER!' 1' # 5 t❑ TENAN__T \ " ' S Number of stones
Name )MA RC CA I jij 1ypeofconstruction
Address I p 8c S 510 &-f 2 H- f}VSki sr Occupancy groups
City/State /ZIP "l'I ( 4IQN DR 97 2.23 Existing
Phone (93) 2W? - 3968 Fax ( ) New
iiil i`; a'� _ n "y_ `s` >ai - , v *t= ' a e . ".-,c r-,r-: 42, -
ti?. „-.`aa. - ® ..�,e, AP , tr '?` `� h = f 0 . „ . .;, CON ,„-, P ER a ., -,,i ' - °"=.. " -. - , _ - -- s, ya, ,
- �rtx =a" �� a .x r.'. I _u_.r r .,.F�,,.a -xvma .�C ". � Ra - ��tY ..�. �� n v- - 5� ' O . Tm � .I C*'E .� - `�'',
Business name All contractors and subcontractors are required to be
Contact name licensed with the Oregon Construction Contractors Board
wider ORS 701 and may be required to be licensed in the
Address jurisdiction in which work is being performed If the
City /State /ZIP applicant is exempt from licensing, the following reasons
apply
Phone ( ) Fax ( )
E -mail
iiiii -Y't,= ,. � (f„:, r` � `x"�;'fC0\TCRAG7'OR=''7. �' a'r`.��., �.v'' -r�d� �'�" -"
'. ",2'a}*' Y 3z,. - ` r as.' -nom- 5`,3 :..,*s_+br;��"v: .�tb'.r -.. :'.n`.t�.' °. °%��'S7'°
Business name i ' ` - " - 1 ` : PEES *u°,q'r ? er
Address
��. = ='T .(Please re /earn (ee xahedrr/s- gr
Crty /Ste[e/Z1P. Structural plan review fee (or deposit) N 1 sit
( ) Fax ( ) FLS plan review fee (if applicable) C.'
CCB he Total fees due upon application
Amount received
Authorized signature rfrIetA This permit application expires if a permit is not obtained
- V`'f within 180 days after it has been accepted as complete.
Print name /Nl /}(�G. (�.K 1.U (� Date 7- / 7_
* Fee methodology set by T- County Building Industry
/ O `"' !! Service Board
I ABuildingAPemmsVBUP -RES Per mitApp doe 11/6/07 440- 4613T(I1/02 /COM/WEB)
1 i
Building Permit Application Checklist
One- and Two - Family Dwelling FOR OFFICE use. ONLY
City of Tigard Received
•
Dale/BV Penult No
�,• • 13125 SW Hall Blvd, Tigard, OR 97223 Associated peruse
' Phone 503 639 4171 Fax 503 598 1960
TiGAliU 24- Hour Inspection Line 5036394175 ❑Electrical ❑Plumbing ❑ Mechanical
Internet www tigard -or gov ❑ Other
'TH FOLLOWING ITEMS ARE REQUIRED. FOR PLAN REVIE Yes No N/A
I 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 full -size
sheet attached to the plans with cross references between plan location and details Plan review cannot be completed if
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, foists, sub- ❑ ❑ ❑
floor, wall construction, roof construction More than one doss 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 ❑ ❑ Cl
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 aiplicable to the •roject under review
JURISDICTIONAL SPECIFICS
23 Three (3) site plans are required for Item I I above Site plans must be 8 -1/2" x 11" or I1" 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 he 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 trees and tree protection measures as required by conditions of approval Tree locations, rlriplines, ❑ ❑ ❑
and protection measures must be drawn to scale and must Include the project arborist's signature of approval
30 A Clean Water Services' Sensitive Area Pre - Screening Srte 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 i ecord approved prior to September 9, 1995
1 Vimiding\ Permits \BUP- RLS -Permu App doc 03/21/06 440- 4613T(I i /02 /CoMIWLB)
Piuttit+iing- Permit Application �UVL'1)
Building Fixtures JUL 17 2009 ,FOIL OFFICE use. °Nix
City of Tigard CITY OF TIGARD Recened
Permit No
13125 SW Hall Blvd ,Tigard, OR 9 Date/By
0 ING DI VISION Plan Review Other Permit No
Date/Bv:
Inspection Line 503 639 4175
D
'TIGAR Date Ready/Bo tuns See Page 2 for
Internet Ww'W tlgard -or gov Notified/Method Supplemental Information
i 'c .7 .i } . y i ` - S t a t °'it�yx*r 1 . s "a °" it x a- FTiE SCEIEDLfia k4 '"`'3 } �;
<.. yt` �'�....�ib.f= ir"�', ";�TI'PE�OFH �V,012K's '�� ' r.�sS ;:'- �`i,`ea�` # �;'.n3�=''��'. *��,,. 'p`" �ar'� v�a:l'x..��'�1`;t,
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty I Ea I Total
❑ Addition /alteration/replacement ❑ Other New I- 2 -family dwellings (includes 100 ft for each utility connection)
^ /�.,"d,' g b;' CATEGORY= OF2GONST.41411OIVA�; 4„„,,s473".x,' I ' SFR (D bath 24920
❑ I- and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350 00
El Accessory building El Multifamily SFR (3) bath 399 00
Each additional bath/kitchen 45 00
❑ Master builder ❑ Other
Fire sprinkler ( sq ft) Page 2
trf ,+ r . -, r Oi3;: S ITEr 5.'w %'?±. g
- - - Srtc uhhbes
Job site address I 0 E. bs 51.13 pm fo-t-A-vami sr Catch basin or area drain 16 60
City/State/ZIP 77 6M-/Qb OZ 97 223 Dry well, Iteoli line, or trench drain 16 60
Surte/bldg /apt no I Project name F. v c. I
Footing drain (no linear ft _) Page 2
� Manufactuied home utilities 11000
Cross street/directions to job site / j
Manholes 16 60
Rain drain connector Z- 16 60
Sanitary sewer (no linear ft ) Page 2
Storm sewer (no linear ft ) Page 2
Water service (no linear
Subdivision Lot no ( ) Page 2
Tax map /parcel no Fixture or item
„� _ ,..,,, E Absorption valve 16 60
Fa . -s= :,,,., -+, tiles ,= 4AESGRIP_T[ONTOF �W01104+. ." x = 'e "...
y,� p _ Backflow' preventer Page 2
Ali bFC lb ci0 b F Ha asit Backwater valve 1660
l'fNb FA( GtaSa OA-2Pd 2-r Clothes washer 1660
Dishwasher 16 60
" Oi Octifli ;k 'i � ❑tTENAYT f �`V3 Drinking fountain 1660
- -�' « "' - - Ejectors /sump 16 60
Name M t C- C .am P
Expansion tank 16 60
Address f 0 g(os Su) FA-Ht
ftPrU 57 Fixture/sewer cap 16 60
City /State /ZIP 11 642D 02 97 2_2„ 3 Floor drain /floor sink /hub 1660
Phone (S)3) leg- 3q 6g Fax ( ) Garbage disposal 1660
?f , t r >;_ tilii llg1daN tc; 7 -*?? T i `tegYrill eellic_-- T PERSO\= �'#' Flose bib 16 60
,, " „t Ice maker 1660
Business name
Interceptor /grease trap 16 60
Contact name Medical gas (value $ ) Page 2
Address Primer 16 60
City /State /ZIP Roof drain (commercial) 16 60
Phone ( ) 1 Fax ( ) Sink/basin/lavatory 1660
Tub /show et /shower pan 16 60
E-mail
tx _ } Urinal 16 60
" 'sal ..' 'xi 'K€ . -' CONYILACTORtt;<;,r^`:.,� .r ='�-,i a " t Water closet _ _ s. er oset 16 60
Business name Water heater 16 60
Address Other
City /State /ZIP Subtotal
Minimum permit fee $72 50 �--x
Phone ( ) Fax ( ) Residential backflow minimum permit fee $36 25 le
CCB Lie Plumbing Lie no Plan review (25% of permit fee)
State surcharge (12% of permit fee) , 7QQ
Authorized signature ^ �
N^ W pq G(�
- I. ...a." TOTAL PERMIT FEE S�
Punt name I'r ft/? l�uUVI iD Date 7..../1.1-09 This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*lee methodology set by Tn- County Building Industry Service Board
I ApwidmgVerm,¢APLMF- PermaApp doe 12,20/06 410- 46161(10 /02 /CONt/WLB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
�SItC U t1lIt1C" `' `` - ''`s'• • • ° i c4':.� i`"' F_c'e ea 'V FT > , `- 1 - - `<. uscr�„3 ,. �.,su:.s,.. Y a..
5 00 c,
M� .. ° till - Squareoota e: #.'
Footing drain - I 100' 55 00 - 0 to 2,000 g "' "s O' $1 _F,Cf :.,a. r- ,,, � „
Footing drain - each additional 100' 46 40 2,001 to 3,600 $160 00
3,601 to 7,200 $220 00
Sewer - 1st 100' 55 00 7,201 and greater $309 00
Sewer - each additional 100 46 40
Water Service - 1st 100 55 00
Medical Gas Systems:
Water Service - each additional 100' 46 40 x- vs max., :<xnks y ,�.cm..a, r -- �z-- � --_ - rt n E:.v 2,.,, -2„
Storm & Rain Drain - 1st 100 55 00
$1 00 to $5,000 00 Minimum fee $72 50
Storm 8- Rain Drain - each additional 100' 46 40 $5,001 00 to $10,000 00 $72 50 for the first $5,000 00 and $1 52 for each
Fixture or,IteTff; Qty
' " -"' "�°' - ""`f= ' ?A ,- " V i e`t e'a ATo additional $100 00 or fraction thereof, to and
.:, - ,rte( -� tal°
including $10 000 00
Commercial Back Flow Pret,enuon Device 46 40 $10,001 00 10 $25,000 00 $148 50 for the first $10,000 00 and $1 54 for
Residential Backflow Prevention Device each additional $100 00 or fraction thereof, to
(minimum permit fee $36 25) 27 55 and including $25,000 00
Rain Drain, single family dwelling 65 25 $25,001 00 to $50,000 00 5379 50 for the first $25,000 00 and $t 45 for
each additional $100 00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000 00
specially requested inspections - per hour 72 50 $50,001 00 and up $742 00 for the first $50,000 00 and $1 20 for
Subtotal each additional $100 00 or traction thereof
Commercial Fixture Work: PI nEReviektif " stalls "b ons w e
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following
please indicate work performed by fixture. Failure to Please check all that apply
accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building with water service 2" and
¢fa
greater except systems designed and stamped by licensed
x . 5 ' Quaiihtyby `.(Fizture);Wb'r12P.erfoniiedi'.
u Type ' t$ . r.-rc, , en
zit.. item '} 1": 5.,: '• 'r?1x� . s t x i Zki l . d ° . ' C a�clilaee,., engineer
p
�`"_t v < YPrevroas ,Cu "ppex3 �naaea ❑ New exterior plumbing site utilities for any complex structure
Baptistry /Font as defined in OAR918 -780 -0040
Bath - 4ub /Shower ❑ Medical gas and vacuum systems fm health care facilities
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system
Car Wash - Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040
- Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Cuiunier la!
- Domestic. v --••ate -__ = za - sa';s:+' aaccc !.s. `i...
Drinking Fountain t" "r'
IsometrfcorRiser,l ) iagram,-a
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain/sink -2' that meet the qualifications above
-3"
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach /Refrig Drains
Oil Separator (Gas Station)
Rec Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Comincicml increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures
/Boadingd Permu App doc 12127i06
•a ,
Electrical Permit Application RECEIVED - FOR OFFICE LSE ONLY
lan
City of Tigard Date/By SW Hall Blvd, Tigard, OR 97223 1 '� 2009 P Recessed
mi Review 503 639 4171 l'ax 503 598 1960 ' Li DateDate/By Pe ran No Other Permit
® Inspection Line 5 03 639 C ITY O
41 75 OF TIGARD Date Ready /By buns 0 See Page 2 for
Internet www ii 8 and - gov Notified/Method Supplemental Information
TYPE OF' WO PLAN DIVISIO a PLAN REVIEW
Please check all that apply (submit 2 sets of plans Wilms checked below)
El New construction ❑ Addition /alteration /replacement
❑Service or Feeder 400 amps or more ❑ Building over three stones
❑ Demolition El Other where the available fault current ❑ Marinas and boatyards
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ I- 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
JOB SITE INFORMATION AND LOCATION O Emergency system lager separately denved system
❑Addition of new motor load of ❑ "A",' B ",'9- 2 ", "I -3 ",
Job no Job site address ! ° S 1/4°5 50 Fqy &!4AU{�/ 5 r Six or or more occupancy
❑ Six or more residential units ❑ Recreational sehicle parks
City /State /ZIP - r(() Q - 0 e_ 9 7 223 ❑ Health-care facilities ❑ Supply voltage for more than
_- / ❑ Hazardous locations 600 volts nominal
Suite /bldg /apt no Project name f -j ,/V ❑ Service or feeder 600 amps or more
FEE SC
Cross street/directions to job site Jill -fst Description JIQ Qty
Fee I Total I "
New residential single- or multi-family dwelling unit.
Includes attached garage.
Subdivision Lot no 1,000 sq ft or less 145 15 4
Ea add'l 500 sq R or portion 3340 1
Tax map /parcel no Limited energy, residential
DESCRIPTION OF WORK (with above sq ) 75 00 2
0
Prbb 6 a / OP / - 1 , Limited energy, multi - family 75 00 2
7D FJb a5E- residential (with above sq n )
� Services or feeders installation, alteration, and /or relocation
/I Jb &N C't -O 5 C/{ -i2P0 kr" 200 amps or less 8030 r 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106 85 2
Name 401 amps to 600 amps 160 60 2
601 amps to 1,000 amps 240 60 2
Address Over 1,000 amps or volts 454 65 2
City /State /ZIP temporary services or feeders installation, alteration, and /or
relocation _
Phone ( ) Fax ( ) 200 amps or less 66 85 ' 1
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, leas-, ent, or exchan•e, accord i n• o ORS 447, 449, 670. and 701
Owner signature /4 du, 401 amps to 599 amps 133 75 2
Branch circuits- new, alteration, or extension, ei panel
. u a. Date 2 . - ' 5' A Pee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON F above service or feeder fee, b 65 2
each branch circuit
Business name B Fee for branch circuits
Contact name
without service or feeder f� 46 85 ��C 2
first branch circuit
Address Each add] branch circuit ( 6 65 (p, j,' 2
Miscellaneous (service or feeder not included)
City /State /ZIP Each manufactured or modular 90 90 2
dwelling, service and/or feeder
Phone ( ) Fax ( ) Reconnect only 6685 2
E - mail Pump or irrigation circle 53 40 2
CONTRACTOR Sign or outline lighting 53 40 2
Qu.mcss name Signal circuit(s) or limited -
energy panel, alteration, or
Address --..t extension Describe Page 2 2
City /State /ZIP Each additional inspection over allowable in any of the above _
Per inspection r 62 50
Phone ( ) • ( )
Investigation per hour (I hr mm) 6250
CCB Lie Elec .ic Supry Lie Industrial plant per hour 73 75
ELECTRICAL PERMIT FEES
Supry Electrician signature, re red Subtotal 0- 7(')
Print name Date Plan review (25% of permit fee)
- State surcharge (12% of permit fee) J dc
Authorized sit • ure TOTAL PERMIT FEB jt 9 .
'I
Print a Date bis permit application expires if a permit is not obtained within 180
days after it has been accepted as complete
• Number of inspections allowed per permit
1 \Building\PermmtsELC- PermnApp doe 05/23/06 440- 4615T(11 /05 /COMANL13
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:
❑ Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
❑ bleating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
n Other
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
n Clock Systems
n Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
n htstrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
Fl Medical
❑ Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
n Other
Total number of commercial systems
*No licenses are required. Licenses are required
for all other installations
1 \Budding \Permi¢\LLC- PermitApp doc 03/23/06
rQ y 1 1 GA
I LEGAL DESCRIPTION: L.: 6: :...._vi - 1 . 1 7 :-:- fo ,- . In.) -
Property ID,.. - r . i RECEDED _ =
State III: _ 2S103DD00407- ; _= '� �� 1 nr�a ..
- O _ err _ ., r. • -. . lL -
„ CITY OF TIGARD I
-- BUILDINGDIVISION—" I ' --— ;;;.`y-A1
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4. \.,� - -_-_J r , SITE
Q C o - , \21,1=s, � 1/16"
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37-0 � 37 -
CITY OF TIGARD - SITE PLAN REVIEW
BUILDING PERMIT NO: \R SC 7C ( g C7� \S CITY OF TIGARR - SITE PLAN REVIEW
WA proved PERMIT NO.: ---, 7- flq,Q�G�*2
Street Trees: L7 Approved ❑ Not Approved PLANNING DIVISION:
Protected Tt s� �pprov� ❑ Approved Required Setbacks:
BY // : ;Vie; e T Side. 'j ❑ Approved ❑ Not Approved
Street Side
Notes: From &O G age * Rear: 15--
f V isual Clearance: Approved ❑ Not Approved
Maximum Building Height 0 feet
/ CWS Service Provider Letter Required: ❑ Yes No
❑ R ceived
B} ' Date: - 7(aa�c;�t
'ENGINEERING EPARTMENT:
Actual Slope :_,L% 3 Approved ❑ Not Approved
Site PI. : !. - , 'roved ❑ Not App • ved
B : I- ad lPa,/ Date: at. ---4
Notes: a _ q o p-i-c_ ((nauf.44.-cLind swe. c�
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 architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. Thls 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 I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
y 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.
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.
MPt cAzuyvt P
Print Name of PermitApplicant
g �I oq
Signature of Permit Applicant Date
Permit # Tha2CM • M‘ C. ) - 7
Address 10B (.0 S t rli VPn ft e myii,
1 CSC. v4 eyie cir1 Z? � .'rorat
Issued by 9>a Date O (I' \4 • CT'
This Copy for Permit Offices