Permit CITY TIGARD SITE WORK PERMIT
COMMUNITY DEVELOPMENT PERMIT # : SIT2008 - 00016
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED : 1/13/2009
PARCEL : 25111 BA - 02104
SITE ADDRESS: 09895 SW INEZ ST ZONING : R - 3.5
SUBDIVISION: INGEBRAND HEIGHTS LOT: 011 JURISDICTION : TIG
PROJECT: SCOTT
Project Description: Retaining wall.
CLASS OF WORK: OTR PAVING ?: RESO. NO:
TYPE OF USE: SF GRADING ?: VALUE: 3,000.00
EXCV VOLUME: cy LANDSCAPING ?:
FILL VOLUME: cy SITE PREP ?:
ENG FILL ?: STORM DRAINS ?: Y
SOILS RPT REQD ?: Y IMPERV SURFACE: sf
Owner: FEES
ROBERT SCOTT Description Date Amount
9895 SW INEZ ST [BUPPLN] Pln Rv -Valu 7/29/2008 $47.66
TIGARD, OR 97223 [BUILD] Prmt Fee -Valu 1/13/2009 $73.33
[TAX] Valu 12% State Surcha 1/13/2009 $8.80
Phone: 503 - 577 -1542 Total $129.79
Contractor:
OWNER
Contact #:
REQUIRED ITEMS AND REPORTS
Engineered soils
Reg #:
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- 1 -0100. You may obtain copies of these
rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
I
Issue By: / # / 4�� Permittee Signature: I 3c
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.
Building rer>rmii Applicat of n
-Site-Work Work FOR OFFICE USE ONLY
..• ei ,, .
(.. K Received ' ��� .... •
City of Tigard Date /B : i Permit No.: /_
13125 SW Hall Blvd., Tigard, OR 972 ) a q ® ®� Plan Revie
• Phone: 503.639.4171 Fax: 503.598.1960 b DateB : Other Permit:
A RD Inspection Line: 503.639.4175 �� / Date Ready /By: ® See Page 2 for
Internet: www.tigard- or.gov �� 1� �� N..stified/Method: 1 )—� 3 ry � Supplemental Information
/NItak� cA/I 5-.. Ref4e7f
,.T-
, -
TYPF O ° REQUIRED DATA 2- FAMILY DWELLING , ELLIN
❑ New construction TYPE O .,.Wi��
❑ 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
,. - .. -, - - -- . : ' T E = ;' "; . ,,,� work indicated on this application.
,, CATEGORY OF- CONSTRUCTION, f -1 „; ;, : ',` x, , , .,,v,,
❑ 1- and 2- family dwelling ❑ Commercial /industrial 3 00
Valuation: $
111 Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
"•` Total number of floors:
s.. w ,. "JOB' SITE INFORMATION'. AND • LOCATION; ', 4 _, -
Job site address: q t g l ) S---- 4_J ne Z New dwelling area: square feet
City /State /ZIP: 1 , t!Yr e)\---) Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: dgr Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED, -DATA: COMMERCIAL- USEtHECKLIST
Subdivision: I 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
'Z' a : '
DESCRIPTION OF WORKS ° 1, - work indicated on this application.
Valuation: $
Existing building area: square feet
New building area: square feet
' ' P TY° O - `❑' TENANT,,.., ','',,',_ - Number of stories:
'''Name: � t , 3 R'° Type of construction:
Address: Cl «c� ( neZ e Occupancy groups:
City /State /ZIP: T CA ,, e?1 a01--,`I'f Existing:
Phone: (f S —15114._ Fax: ( ) New:
❑ APPLICANT ' a , U CONTACT PERSON ' N
Business name: All contractors and subcontractors are required to be
Contact name: a � ��(� licensed with the Oregon Construction Contractors Board
under 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:
,,. i'' CO CTOR b
Business name: BUILDING;PERMIT'FEES*
Address: ; :. ” , •.. _ `, (PWserejer'io jeeschedule)` • '
Cn , ?...-FL Structural plan review fee (or deposit): cp.
City /State /ZIP: C �o
Phone: ( ) I Fax: ( ) FLS plan review fee (if applicable): --
CCB lic.: Total fees due upon application: !'7. a, 0
Amount received: ", 4, G
Authorized si r' ' This permit application expires if a permit is not obtained
S within 180 days after it has been accepted as complete.
Print name: 1* �a Date :��, * Fee methodology set by Tri- County Building Industry
Service Board.
I:\ Building \Permits \SIT- PermitApp.doc 12/27/06 440- 4613T(11 /02 /COMIWEB)
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
El 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
❑ Grading Plan and details Cl *Landscaping Plan
❑ Erosion Control Plan and details ❑ Soils Report (if required)
❑ Retaining Structures
*Does not apply to One- and Two- family dwellings.
#. of Plans. ". ...
'ti TYPE. OF SUBMITTAL: Re q uire d':at'
(Includes" New; Additions . orNAlterations) . ' Submittal
Commercial 2
Multi- Family R -1 Occupancy 2
One- & Two - Family Dwelling 2
1: \ Building \Permits \SIT - PermitApp.doc 12/27/06 2
•
RECEIVED
Property Owner Statement JAN 1 3 2009
Regarding Construction Responsibilitie CM( OFTIGARD
UILDING DIVISION
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. 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.
s �
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Print ■a f Permit Applicant _ Se ....,( 7 0 T --
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1/1.54
Signature of Permit Applicant Date
Permit #: • F
Address: ' 9 `T 5 be-t) /g., "7-- ,r,-
�� 4 r ®g 97 ??- 0rti.vF
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Issue by: Date: IA 5/D ?
af:
This Copy for Permit Offices
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CITY OF TIGARD - SITE PLAN REVIEW
BUILDING PERMIT NO.: "irrJ ..2MI i Z :�
PLANNING DIVISION: Not Approved
Required Setbcks: a Approved ❑ pP
Side: Street Side:
(;a ya�e: Rear: _�
Front. � Not Approved
Visual Clearance: ' Appro' ed ❑ p•
2 3• Maximum Building Height . Feet 0 No
CWS Service Provider Letter I2.Nq fired: eseived
4M-121- t t :►te: "iis-gIUX
ENG NEERING 10 EPARTMEN'T':
Actual SI pe: % Approved Cl Not Approved
/ (,Approved ❑ Not Awed
B Site : Pla 3 Date: d
Notes:
CITY OF TIGARD • SITE PLAN REVIEW
BUILDING PERMIT NO: '7" U%'' c2-0/L0
met Trees: wt Approved ❑ Not Approved
;Arotected r e : Vif Approved ❑ Not pproved ot
11_ .40_04_P_Te- Date: r,,