Permit 6•
Community Development V 0 1
TIGARD Request for Permit Action �`? /' /,
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 08.1960 www.tigard - or.gov
FROM: ❑ Owner ErApplicant ❑ Contractor n City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) owes, s • Sn „ s l c _
Mailing Address: ' "Z5
City /State /Zip: Iolz`Z/� "rte Cm— o 12 1
Phone No.: 5 -- Z3 i — 1 2—
PLEA - TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: FPS - /l—cx i
Site Address or Parcel #: /0300 ' Aif
Project Name: Sdnr) (1$ ,g N c4 4
Subdivision Name: — Lot #:
EXPLANATION: /9 ev , �t ,} f r u i s`e.d .v ao. /
Signature: Date: 0-11(/
Print Name: fdCA/ 72-04 4-- a
Refund P olicy
1. The Director or Building Official may authorise the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date , AT/! B Rte to Bld: Admin: Date jAMIN B - a
Refund Processed: Date Af/ By w1. Invoice Processed: Date By
Permit Canceled: Date / / �f` / By.J$& Parcel Tag Added: Date By
Receipt # Date / Method Amount $
L\ Building \ Forms \RegPernvtAction.doc Rev 04/26/2011
Building Permit Application
Fire Protection System FOR OFFICE USE ONLY
City of Tigard `� Date/By: !) l �� �� Permit No.: J j __op � S
I N 3
41 13125 SW Hall Blvd., Tigard,OR 9722 Plan Review /
• P hone: 503.718.2439 Fax: 503.598.191 ) t \ ' Date/By: Other Permit: L1e /1-00„4- t-f_
Inspection Line: 503.639.4175 Date Ready/By: is: ® See Page 2 for
TIGARD
Internet: www.tigard O�� N otified/Method: / —I ` Supplemental Information
10 `,
TYPE OF WORK CA `® � taG REQUIRED DATA': 1 - AND 2- FAMILY DWELLING
• 11 New construction ❑ Dem a ' on Permit fees* are based on the value of the work performed.
Indicate the value (romded to'the nearest dollar) of all
Er Addition/alteration/replacement ❑ Other: equipment, materials, labor overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on thi . eplication.
❑ 1- and 2- family dwelling 0. ConunercialIindustrial
Valuation: $
❑ Accessory building ❑ Multi- family Number bedrooms:
❑ Master builder ❑ Other: Nu •er of bathrooms:
JOB SITE INFORMATION AND LOCATION otal number of floors:
Job site address: 1 00 Sy,) N cy tn. S New dwelling area: square feet
City /State /ZIP: IMEeSAVvVio an-- Garage /carport area: square feet
Suite/bldg. /apt. no.: r Project name: 'SGFtOU..S SA. s9u S Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
/ Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: 1 Lot n .: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rouided to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
COf�NV� -" PDJME' fa► C:WM°L Ppr�urt_. Valuation: $ �^pr�. °r
,D A-c-cA s Co OL_. TO g ‘ Y •.--- Existing building area square feet
1--. LiukrtV pr. -- New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: / Occupancy groups:
City /State /ZIP: / Existing:
Phone: ( ) lax:( ) New:
❑ APPLICANT / .0 CONTACT PERSON NOTICE'
Business name: / All contractors and subcontractors are required to be
Contact name: � licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be lensed 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: /
CONTRACTOR • BUILDING PERMIT FEES*
Business name: 1"r' ... � ,j'O%A e S'{ Siren - .s (Please refer to fee schedule,
Permit fee:
Address: Q 1 : L s-- fl' v r'
City /State /ZIP: i .v�AW CWL_ eV 1 2 State surcharge (12 % of permit fee):
FLS plan review (40% of permit fee):
Phone: (5O' Z 3 ( — L Q\0\'Z Fax: ( ) (Due upon application.)
CCB lie.: t s G 3.0 Total permit fees:
Authorized signature: Amount received:
This permit application expires if a permit is not obtained
Print name: �Ite1- O t1-- ° W 7 ---"( Date: 1,2_ --1 3 — s \ within 180 days after it has been accepted as complete.
* Fee methodology set by Tri -County Building Industry
Service Board.
I:\Building\Permits\FPS- PermitApp.doc 02/01/2011 440- 4613T(I 1 /02/COM/WEB)
G •
City of Tigard: Fire Protection Permit Checklist
Page 2 - Supplemental Information
Describe work to be done:
1.) ❑ New 2.) Modification to sprinkler heads only:
El Addition ❑ 1 -10 heads: No plan review required.
❑ Alteration ❑ 11+ heads: Plan review required.
El Repair
Number of sprinkler heads:
Additional description of work:
•
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
❑ Wet ❑ Dry ,
Additional Standpipes
Information: Hazard Group
Density •
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood. Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm ; '
Submittal shall Battery Calculations ' • ■ Yes`
include: Individual Component ❑ Yes
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential. Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $ •
FLS Plan Review (40% of permit fee): $ • -
TOTAL: $.
Plan review requires a completed application and three (3) sets of plans at submittal.
Plan review fees are required at submittal.
•
•
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I: \Building \Permits \FPS- PermitApp.doc 02/01/2011 2