Permit CITY OF TIGARD MASTER PERMIT
''. COMMUNITY DEVELOPMENT Permit #: MST2009 -00143
,TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/07/2009
Parcel: 2S 109BA01900
Jurisdiction: Tigard
Site address: 13969 SW LEAH TER
Subdivision: Lot: 0
Project: Wiebe
Project Description: Interior remodel.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 1 Third. 0 sf Right: 0 Detectors: Yes
Total: sf Value: $5,100.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach' 0 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0
Lavatories. 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0
Tubs /Showers: 2 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0
Drains: 0
Bckflw Prevntr: 0
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 1
Furn <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
F u rn> =100 K: 0
ELECTRICAL
Residential Unit Service Feeder Temp SrvctFeeders Branch Circuits
1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea add'I 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)
WIEBE, THOMAS ALLEN & OWNER
CYNTHIA EL
13969 SW LEAH TERR
TIGARD, OR 97224
PHONE: PHONE:
FAX:
Total Fees: $428.21
This permit is issued subject to the regulations contained in the Tigard Municipal. Code, State of OR Specialty Codes and all other applicable 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 suspende• for mor he 180
days. ATTENTION' Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are et 1o' in OAR
952- 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.669 or 1.800.332.234'.
Issued By: M !(R AZ) Permittee Signature:
Building Permit Application
Re RECE FOR OFFICE USE ONLY
,- Re ceived
IN City of Tigard DateB i J Permit No.: c .C� A t I i 3
° 1 31 25 SW Hall Blvd., Tigard, OR 97223 JUL 0 7 2 009 Plan Revi' � �� Oth er Permit.
M ' Phone: 503.639.4171 Fax: 503.598.1960 NG DIVISION Date/F3 .45,,,,,, T °I CARD Inspection Line: 503.639.4175 CIT O F T IGARD Date Rea. 1 ''•. El See Page 2 for •
Internet: www.tigard -or gov
BUILDING Notified/Method. Supplemental Information
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❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
q l , Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
r art work indicated on this application.
�' ' CATEG IiT', OF GONSTRUGIIIO v _ �� x pp
1- and 2-family dwelling ❑ Commercial /industrial Valuation: $ J I 0 t Y UO
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
: ;. , 4 ", J IJ i — IVIA ND ;LOCATIONs '' ` r '. - t o a, 1 Total number of floors:
! a,.. x ..... . _.. .4,11 rs aaxa. .. -., ,_,- , r , , / - , .
Job site address: / 3 q67 9 s �J H c t�� l'' R New dwelling area: square feet
City /State /ZIP: ' & Iq o) ® q71-24-7 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: [V l 1 �� Q ��n i k 6101 Covered porch area: square feet
Cross street/directions to job site: Y ` �✓, Deck area: square feet
Other structure area: square feet
f I2EQ . b DATA 654 - Eif USE CHE6&g ~,`
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
;..:, -;;.- ,, ,.. ;;. # ,, ;m , :. ,,; ., ,,t.. ;,,;. ;" ,r equipment, materials, labor, overhead, and the profit for the
;' "' 11 , t i ` f - r R .,. .4 a ( ' ` t ` " ' z' work indicated on this application.
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Affi.f� OrVialmOr Ii1 S ``' h.1114Vel,h1)194f1^1' Valuation: $
Existing building area: square feet
New building area: square feet
R.s �..EI2 - ""5 .;. - -; , _;A : ,.. b CI -a r 0 ..0 . . "
;�; = °, ' - :.� x t ®= ,�Nt1`T� „'N ^> ;, -:>.: Number of stories:
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Name: ' WP GC Type of construction:
Address: s 7 Occupancy groups:
City /State /ZIP: /'UE ". Existing:
Phone: (6`-',03) �j ” L c, Fax ( ) New:
ti `" E , I'I,ICAN'I�� rs � ❑OON�I' ACT�"PERSON�'�"S�'� '�� o OPP��x, �f i
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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 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: ( ) I Fax:: ( )
E -mail:
, ,,, de {#�' Sy A`. ..� w+ x e Y'a�. ,nC.YS'^ W OS I AC l. 'ki ,t
Business name: OW
,, � 4 :>r ' 00x'CIiLDtNxiBFiR' ` +EES* � � .. �,
Address: : ,utiv . x' tf�'feaseietawecheduf ° ', „ 6.0..;
City /State /ZIP: Structural plan review fee (or deposit):
Phone: ( ) Fax: ( ) FLS plan review fee (if applicable):
CCB lie.:
Total fees due upon application:
- /J - - - - - - - - Amount -
Authorized signature. if '-
This permit application expires if a permit is not obtained
` (,� within 180 days after it has been accepted as complete.
7 Print name: LO$44 C l g.0 Date: 7 - 0 o I * Fee methodology set by Tri- County Building Industry
��`"'�� 6 � Service Board.
I: \Building\Permits \BUP -RES PermitApp.doc 11/6/07 440- 4613T(I1/02/COM /WEB)
Building Permit Application Checklist , '
One- and Two - Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received
`r' Date /By Permit No.:
W 13125 SW Hall Blvd , Tigard, OR 97223 Associated ermits:
C • Phone: 503.639.4171 Fax: 503.598.1960 P
rIGARD 24- Hour Inspection Line: 503.639.4175 ❑Electrical ❑Plumbing ❑Mechanical
Internet: www.tigard - or.gov ❑ Other:
•.THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No ,.N /A
1 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 CI CI
6 Sewer permit. ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. El ❑ ❑
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, joists, sub- ❑ ❑ Cl
floor, wall construction, roof construction. More than one cross 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 ❑ ❑ ❑
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 applicable to the project under review.
JURISDICTIONAL SPECIFICS
23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" 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 be 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 Cl ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
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 Site 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 record approved prior to September 9, 1995.
1.\ Building \Permits\BUP- RES- PermitApp doc 03/21/06 440- 4613T(11 /02 /COM/WEB)
Plumbing Permit Application
Building'Fix.tu'res tit REJE FOR OFFICE USE ONLY
City of Tigard Received p ermit ?1�/
II
v 13125 SW Hall Blvd., Tigard, OR 97223 JUL 0 7 2009 Date 5 11% - t�/�/
Phone: 503.639.4171 Fax: 503.598.1960 Plan Revi
ew
- Other Permit No.:
C ITY OF TIGARD Date By:
T 1 CARD Inspection Line: 503.639.4175 �+ nA� Date ReadyBy • runs Pi See Page 2 for
Internet www.tigard-or.gov BUILDING DIVISION, Notified/Method Supple Information
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❑ New construction ❑ Demolition For special information use checklist
Description Qty. Ea. Total
Ri Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
� . riliA . CATEGORY Q rCONS UCTTON° •1 ¢ ti :' SFR (1) bath 249.20
54 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
.,,t ,,: _ :, :. ,. Fire sprinkler ( sq. ft.) Page 2
;',„r *`v . JOB $ITE INkORMA`[f0 �?iND LjO'GATION -V t � ; t Si ut ilities
Job site address: t3 96q Sew LEAN' TEA Catch basin or area drain 16.60
City /State /ZIP: "7'16 1kb ®P. x`712.4 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: l Project name: �/4� ii4 DwL u2Dm Footing drain (no. linear ft.: ) Page 2
Cross street/directions to job site:
Manufactured home utilities 110.00
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.• _) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: Lot no.: g
Fixture or item
Tax map /parcel no.: 16.60
r,e _ , ��; z�.., , ,;,, Absorption valve
4 W , , D E S CR , WTIO O, ,' WQ c.. + „ r i ,x ' Backflow preventer Page 2
Reill / / extsfif'U bR.Arocon Backwater valve 16.60
eatWerf b OM ball/49'0N Clothes washer 16.60
Dishwasher 16.60
;7 , „.<:n�- :r.r�.. r�:.. ;; Drinking fountain 1 6.60
. >. -. - ,
* , PRQPEft . - .° OWNER, ` „ , -, . , s ,:.: :. ❑ °:TENA 4 1 . . , r :,,;. . 4, ,
< , > . : ..r..a�;: , , ...,n.....;, �a�.i����;.. - ..... -..... { -:... � ,:�i;:���. -,� ,..;:�:, g 16.60
Ejectors /sump
Name: `THp 1PE t r 4r, Expansion tank 16.60
Address: n P Fixture /sewer cap 16.60
56,44' A's I zi .. (.17.1:-
Cit /State /ZIP: Floor drain /floor sink/hub 16.60
Phone: (S03) 0 - 5-S5' Fax: ( ) Garbage disposal 16 60
:''rk - ° >.; x>,;ry : >, e„ ,.. :, <.. n
.r .. & -Q 47.1 itt•li , U 4- V ` n . CONTACTtirl SON 6.60
�`r .am,. <. r.4 r .<, .. , :. ,..r.<?a,.,.xi.mac .,,,'A. .r:•, -* 4r. .4a:�,, Hose bib lee maker
16.60
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: ( ) Fax:: ( ) Sink/basin /lavatory 1 16.60 1 4, .(j)
E -mail: Tub /shower /shower pan a 16.60 33 20
Urinal 16.60
n -.. ;t ., l a. CONTR . ` ` , �w & .a., ' Water c 16.60
Business name: era t! � I114 dersavtr Water heater 16.60
Address: 2T7 '3 ( sE 1 Ava, Other.
City /State /ZIP: �-0 AZ'Li) AID op_ q7 2.! t i �
Subtotal
Minimum permit fee: $72.50
Phone: (563) 2 32 - 1066 Fax: ( ) Residential backflow minimum permit fee• $36.25 12_,m
CCB Lic.: 16®L53 6/28/' / Plumbing Lie. no.: .5L1 PE) Plan review (25% of permit fee)
/7� / State surcharge- (12 %- of- permit fee) a- '
Authorized signature: --. "� 1 / , ill
l
dt � 7" ` TOTAL PERMIT FEE r .
Print name: °re/ 0044.5 1 r 1„ 7 ,.. �/ . Date: I_ D 7 This permit application expires if a permit is not obtaine 6
180 days after it has been accepted as complete. �h1.4
*Fee methodology set by Tn- County Building Industry Service Board.
1 its\PLMF- PermitApp.doc 12/27/06 440- 46t6T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Sltte li iest >, ee ea)" `Total;
Q r , ; Squar...e, _ tit
Footing drain - l' 100' 55.00 0 to 2,000 $115.00
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
Perm><tFee ��
Storm & Rain Drain - 1st 100' 55.00 u
-
$1.00 to $5,000.00 Minimum fee $72.50
Storm & 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
FllXture Or ItEitl - „ n. QtY , F ee (ea) ` ufTotal additional $100.00 or fraction thereof to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $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 $379.50 for the first $25,000.00 and $1,45 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 fraction thereof
Commercial Fixture Work: r Pia`: .. ,, ,.g. t � -r. s: k -: , 43
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 *. El Any new commercial building with water service 2" and
T., - =`7 ` Quan`ti ti i fure 4,610erformed i greater, except systems designed and stamped by licensed
aFixture *TYPQ o .4, %
engineer.
" z1 Replape��� g
• €? „ 's :.A, ._, -, - �:.;. ax.-..,y -.� ` -� xp ;r. a ? a q �r , .
::,Gapped .�r,.ABaed��� fExshii ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower Cl Medical gas and vacuum systems for 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 - Commercial
- Domestic .: r -. ;, . ><. - .,. „, , s:a .. .r
:. � }zr:�&as:t:,. >: ", �,�'_� F:a_:,, :� -- ;:,:•`:
Drinking Fountain; „f5:0llletrlGOIRISCr , la2'm < =rts
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
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
- Commercial 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:
is\ Building \'ermits\PLM- PermitApp.doc 12/27/06
Electrical Permit Application REcE 1 FOR OFFICE USE ONLY
Ell City of Tigard V i I el1 i ate/By: Permit N CJ7-aQZ)e7_ C.730 / y3
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review /
Phone: 503.639.4171 Fax: 503.598.1960 JUL 0 7 2009 Date /By: Other Permit:
inspection Line: 503.639.4175 Date Ready/By: Juris. ® See Page 2 for
Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information
TYPE OF WO 'L‘ ILDING DIVISION ' PLAN REVIEW
❑ New construction ❑ Addition/alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ 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
1- 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 ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
Job no.: Job site address: 1 6n, su.) LEA t -FE R 100HP or more. occupancy.
❑
❑ Six or more residential units. Recreational vehicle parks.
City /State /ZIP: 1 C'k. 71:2-q ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: tii I ta O p m bda ,e 2 ❑ Service or feeder 600 amps or more.
J FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I 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'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.:
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
lit fz t L LbL v 4 , osier, p, t, �I 4 1 residential (with above sq. ft.)
rr rs Ge Services or feeders installation, alteration, and /or relocation
room s 4- 6 @ •Pevik 200 amps or less 80.30 2
10 PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: - o 5 L4) 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: cfayvo 0s�rb h ck Over 1,000 amps or volts 454.65 2
City /State /ZIP: ti"‹.) Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( - fJ -s-via Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being ' ade property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease o Chang accc�rdin o ORS 447, 449,..670, and 701. 401 amps to 599 amps 133.75 2
/� Dater ti Branch circuits new, alteration, or extension, ser panel
Owner signature: }6 A. Fee for branch circuits with
❑ / APPLICANT ❑ CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit •
Business name: B. Fee for branch circuits
without service or feeder fee, I
Contact name: first branch circuit 46.85 r. J 2
Address: Each add'l branch circuit ! 6.65 C., .60, 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 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR • Sign or outline lighting 53.40 2
Business name: 0 ti) /j /.6Q Signal circuit(s) or limited -
b e „ energy panel, alteration, or
Address: extension. Describe: Page 2 2
City/State /ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( )
Investigation per hour (1 hr min) 62.50
CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: Z, t
- Date:
Print name: / -- -- -- Plan - review - (25 %of- permit - fee): —
- -- - - - --
11 .----I State surcharge (12% of permit fee): 4 Z Authorized signature: 4---V / ALg TOTAL PERMIT FEE: . 9 , „ This permit application expires if a permit is not obtained within 180
Print name: 'r D ll� 4 t ,
Lc Q Date: 1p, o -0 days after it has been accepted as complete.
• Number of inspections allowed per permit.
I: \Building\Permits\ELC- PermitApp doe 05/23/06 440- 4615T(l 1/05 /COM/WEB
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*
❑ Burglar Alarm
❑ Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
❑ 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
❑ Clock Systems
n Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
n 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
I: \Building\Permits\ELC- PermitApp.doc 03/23/06
Mechanic .1 Permit A s 1lic ::,: -< FOR OFFICE USE ONLY
Tigard
of Ti
City Received y
I:9
City g U
Date/By: Permit No: 5 '�/T��— J
13125 SW Hall Blvd., Tigard, OR 97223 ro
Phone: 503.639.4171 Fax: 503.598. l9 Plan Review
.>�L 0 7 2009 DatDate/By: i N Other Permit:
/
Inspection Line: 503.639.4175 Date Ready/By: runs: El See Page 2 for
Internet: www.tigard- or.gov CITY OF TIGARD Notified/Method: Supplemental Information
TYPE &G DIVISION COMMERCIAL FEE* SCHEDULE — USE CHECKLIST'
Mechanical permit fees* are based on the value of the work
❑ New construction 151 Addition/alteration/replacement performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
AI_ and 2-family dwelling RESIDENTIAL EQUIPMENT./ SYSTEMS FEES*
y g ❑ CommerciaUindustrial ❑ Accessory building
For special information use checklist.
❑ Multi - family ❑ Master builder ❑ Other: Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Job site address: 21q,/ A / J� Air conditioning or heat pump
6� Il tY/� � �� I. C ►t� ��� (requires site plan showing placement) 14.00
City /State /ZIP: --- nc, 0 f, q 72. A_ L/ Furnace 100,000 BTU (ducts /vents) 14.00
�� Furnace 100,000+ BTU (ducts/vents) 17.90
Suite/bldg. /apt. no.: Project name: l� a �g ail Gas heat pump 14.00
Cross street/directions to job site: Duct work it 10.00 l
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 14.00
Flue /vent for any of above 6.80
Subdivision: Lot no.:
Other: 10.00
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
Gas fireplace 10.00
M n 1n L4 0 et. Flue vent for water heater or gas
Add, t roots gel 10.00
� n Log lighter (gas) 10.00
Wood/pellet stove 10.00
Wood fireplace /insert 10.00
Chimney /liner /flue /vent 10.00
gt PROPERTY OWNER ❑ TENANT
Other: 10.00
Name: 111ni AS J) /,e.hZ Environmental exhaust and ventilation
Address: Range hood/other kitchen
SAS 1. A j S h equipment 10.00
City /State /ZIP: ' Clothes dryer exhaust 10.00
Single -duct exhaust (bathrooms, /
Phone: (5h3) 5 —'5 � Fax: ( ) toilet compartments, utility rooms) I 6.80 6.
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 10.00
Other: 10.00
Business name:
Fuel piping
Contact name: $5.40 for first four; $1.00 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax:: ( ) Water heater
Fireplace
E -mail:
Range
CONTRACTOR Barbecue
Business name: ( t Clothes dryer (gas)
`�/ Other:
Address: MECHANICAL PERMIT,FEES*
City /State /ZIP: Subtotal
Phone: ( ) F es: ( ) Minimum permit fee ($72.50) T Z,
Plan .review _(25 % -of permit -fee)_
CCB lic.: State surcharge (12% of permit fee) Et ,
TOTAL PERMIT FEE n (, G
Authorized signature: This permit application expires if a permit is not obtained 180
days after it has been accepted as complete.
Print name: 71400.,44 ti CAE Date: 7- 3 - 2_00 ¶ * Fee methodology set by Tri- County Building Industry Service Board
C\ Building\Permits\MEC- PermitApp.doc 01/19/07 440 -4617T (11 /02/COM/WEB)
Mechanical Permit Application - City of Tigard •
Page 2 - Supplemental Information
Commercial Fee Schedule:
Total Valuation: Permit Fee:
$1.00 to $2,000.00 Minimum fee $72.50
$2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30
for each additional $100.00 or fraction
thereof, to and including $5,000.00.
$5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and
$1.80 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and
$1.35 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and
$1.25 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $1,396.50 for the first $100,000.00 and
$1.10 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
I:\ Building \Permits\MEC - PermitApp.doc 01/19/07 2
f� �,7
Information Notice to Owners About
, Construction Responsibilities
ca. (ORS 701.055 (5))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503 - 378 -4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503 - 947 -1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to
http: / /www.oregon.gov /DOR /BUS /dots /211- 055.pdf for the appropriate forms.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503 - 947 -7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough -in and finish trades.
CONSTRUCTION
700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052
Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007
Website Address: www.oregon.gov /ccb
f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant
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. 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.
I H OM43 L');c
Print Name of Pe Applicant
• ✓ V -IL 9 o q
Signature of Permit Applicant Date
Permit #: 1 k 2co9'W' 2 o f \.
Address: Z___9._44' (Q is 1,e4 tf'rraKS •; �ul!�� ',. •
•
Utlick Cif
• Issued by: Date: �1 MCA / ` 5
This Copy for Permit Offices