Permit CITY O F TIGARD
SITE WORK PERMIT
I DEVELOPMENT SERVICES PERMIT # : SIT2003 00013
�I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 6/19/03
SITE ADDRESS: 10215 SW HALL BLVD PARCEL : 1 S135AA 01400
SUBDIVISION: METZGER ACRE TRACTS ZONING : C -
BLOCK: LOT: 037 JURISDICTION : TIG
CLASS OF WORK: NEW PAVING ?: RESO. NO:
TYPE OF USE: COM GRADING ?: Y VALUE: 101,174.00
EXCV VOLUME: 1,318 cy LANDSCAPING ?:
FILL VOLUME: 739 cy SITE PREP ?:
ENG FILL ?: N STORM DRAINS ?:
SOILS RPT REQD ?: N IMPERV SURFACE: 24,200 sf
Remarks: Site work for new 2 - story dermatology clinic.
Owner:
FEES
INTEGUMEND LLC BY SCOTT COLLINS
& MARIA ROSS MD Description Date Amount
9495 SW LOCUST STREET [BUPPLN] Pln Ck -Valu 5/5/03 $488.87
PORTLAND, OR 97223 [FLS] FLS Pin Rv 5/5/03 $300.84
[BUILD] Prmt Fee -Valu 6/19/03 $752.10
Phone: [TAX] 8% St Tax -Valu 6/19/03 $60.17
Contractor: [ERPRMT] Erosion Cntl 6/19/03 $80.00
JOSEPH HUGHES CONSTRUCTION,INC [ERPLN] Ersn Pick 6/19/03 $26.00
7035 SW HAMPTON [EROSN] Ersn Plck - COT 6/19/03 $26.00
TIGARD, OR 97223 Total $1,733.98
Phone: 624 -7100
Reg #: LIC 45645
Required Inspections
Erosion Control Insp 846 -8444
Grading
Paving lnsp
Sprinkler supply lines
Fire system test
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law
requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by
calling (503) 246 -6699.
Issued By:
Permittee Signature: j/ / -.
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
ir
/ D 2/ S�$ t .) / -741 k
Site Work
• • .- . FOR OFFICE USE ONLY.` ` `,.
Building Pert ;Appl ��� ciVE® R eceived s / �y� Building Permit No.: /r I
D � /�
Date/By: 5 /5/ ! (J • 9 p,(� J
City Of Tigard Planning Approval Other
'via . Date /By: Permit No.:
13125 SW Hall Blvd. 1 iik)03 Plan Review Other
Tigard, Oregon 97223 TY �t0 ' Date /By: I. " q -03� Sf Permit No.:
i 'ta Post - Review Land Use
Phone: 503-639-4171 Fax 503-598-1,9 LD j � �1�111gui'�(l � N Date /By: Case No.
Internet: www.ci.tigard.or.us •. , ,_ 2 ° — ` -'*' =-� Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503• - 639=4.175 Name /Method: Supplemental Information
' TYP OFW . ` r � a6
.,� ,. �_ _. a � � � _ � � REQUIRED DATA ,,-
❑ New construction , III Demolition � , ' , _ , 1 A& 2 F DWELLING g,
❑ Addition /alteration/repladeinent 111 Other:
�' ��� ���� ���� f ���
' ,E` 12 r :.4g TEGORY OF CONSTRUCTION: i , , t'i: Note: Permit fees* are based on the total value of the work performed. Indicate
❑ 1 & 2- Family dwelling ❑ Commercial/Industrial the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
❑ Accessory Building ❑ Multi- Family
❑ Master Builder ❑ Other: Valuation $
ffi ° , 1,JOB'SIT,E INEO andlLOC TIO i z t va : _, ` No of bedrooms: No of baths:
Job site address: �J Total number of floors
c`"— New dwelling area (sq. ft.)
Suite #:B /A t. #: Garage /carport area (sq. ft.)
Project Name: /A /7- 7 (/ E j 1. Covered porch area (sq. ft.) •
Cross street/Directions to job site: Deck area (sq. ft.)
Other structure area (sq. ft.)
• r :::' #
REQUIRED DAT , _ ao ,4
;"�
COMMERCIAL : ;USE CHECKLI .
Subdivision: I Lot #:
Tax map /parcel #: Note: Permit fees* are based on the total value of the work performed. Indicate
r '" ,Z :17°" ESCRIJ3TFON .OF WORK `, III M v _ the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
Valuation $ /O / I /74-
Existing building area (sq. ft.)
New building area (sq. ft.) 1111
Number of stories _
', 9' 4`1WPERTYOWNER - -- ``""_ �? Si lTEN:A T„ . :',,,,� Type of construction
ir� �x� � � Yp
ame: 7417 i /n'i�r� /)� L / e Occupancy group(s): Existing:
���� /vas/ v l� New:
Address: 4i' ,o>/.A, _ill G "�.
Cit /State /Zi • : Air I #'l = Phone
' �rfJ 9 ) / NOTICE: All contractors and subcontractors are required to be
y� / ���• ' licensed with the Oregon Construction Contractors Board under
i APPLICAN ,, ,, . t' CON PERSON . F provisions of ORS 701 and may be required to be licensed in the
Business Name: ,% OSEP/( /I() NeJ COIJ$? • jurisdiction where work is being performed. If the applicant is exempt
Contact Name: pi/l7/N /S &A FF/t 5r' from licensing, the following reason applies:
Address: 7.03,g 5 t'rV HAP/PTO/1/4)
City /State /Zip: 77&A.4D, OR, 17 ZZ?
Phone: 62 '#•7 /OO Fax: 6 8 2 -?, t _ � � �� � �
E -mail � 1 4 . BU t PE IT FEES* � ` � � �-
� � � ; y � Please refe� fee sc ; edule ` �� N
V:�.3..'. � L 1.., CONTRAC =TORz ;4k .i t. :` ,. a ....
Business Name: TO$eFW f/Lf4Hdf CONS' Fees due upon application $
Address:
City /State /Zip: Amount received $
Phone: ____.4 F . j Date received:
CCB Lic. #: 't(C '/S /IT
4 Authorized
Notice: This permit application expires if a permit is not obtained within
Signature: / / $ :e. _ I . : D / 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms\BldgPermitApp.doc 01/03
•
' f r
SITE WORK PERMIT CHECK LIST
Commercial, Multi - Family (R -1 occupancy) and Residential:
Please complete all items below, unless otherwise noted.
Excavation Volume: Cu. ds.
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) 73 / cu. yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
❑ Concrete
❑ Other
*Total new impervious area including all buildings, 23 �►2
sidewalks, and paving: / sq. ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
, PlansVRequire`d: See SiteWork PermitApplicatio Plan ;Submittal :Requirements"
=attached The must accompany thi applcation,
Site Plan with Vlcinl ` Ma showin * A
ty p g � Par=king (mc ng AD
ADAcom liance zLigh'ting Plan
I A).and
p
Grading Plan and >details ,' tLandscaping Plan ' ¥ s
-� i .�. "ter � � r .��, �. a ` :, � � 3 r� .�',
t;_f_, ;Erosion Control Plan and, details , :,. : �ESoils Report §ed)
`..'Reta ning S rt uctures . `,.. a
• ; *Does not apply to 1 and 2- family dwellings.
TYPE OF SUB j Req at
(Incl udesNew , Additions or:Alterations ..;.
Commercial
Multi- Family R -1 Occupancy - Vo 4. • d •
•
One- & Two - Family Dwelling 4
NOTE: Plan review is dependent upon submittal of a completed application and plans.
After plan review approval, the Plans Examiner will contact the applicant to request
additional sets of plans for distribution purposes (for Contractor, City of Tigard,
Washington County,. and Tualatin Valley Fire & Rescue).
is \dsts \forms \SIT - checklist.doc 01/29/03