Permit A - tITY O MASTER PERMIT
F TIGARD
PERMIT #: MST2002 -00260
IA DEVELOPMENT BMEN Tigard,
SERVICES
639 -4171 DATE ISSUED: 7/30/02
13125 SW
SITE ADDRESS: 09595 SW LEWIS LN PARCEL: 1S135CD -03600
SUBDIVISION: RUTH ZONING: R -4.5
BLOCK: LOT: 001 JURISDICTION: TIG
REMARKS: Structure modification. changing roof line and adding 1 door and 2 windows
BUILDING
REISSUE: STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ALT HEIGHT: FIRST: sf BASEMENT: sf LEFT: SMOKE DETECTORS:
TYPE OF USE: SF FLOOR LOAD: SECOND: sf GARAGE: sf FRONT: PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: FINBSMENT: sf RIGHT:
VALUE: $ 15.000.00
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 0.00 st REAR:
PLUMBING
SINKS: WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: 1 CATCH BASINS:
TUB /SHOWERS: GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL •
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 - 200 amp: 0 • 200 amp: W /SVC OR FDR: 1 PUMP/IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 • 400 amp: 201 • 400 amp: 1st W/O SVC /FDR: SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EA ADDL BR CIR: SIGNAL/PANEL: 1 IN PLANT:
MANU HM/SVC /FDR: 601 - 1000 amp: 601 +amps- 1000v: MINOR LABEL:
1000+ amp/volt :
PLAN REVIEW SECTION
Reconnect only:
>=4 RES UNITS: SVC /FDR > =225 A.: > 600 V NOMINAL: CLS ARENSPC OCC:
ELECTRICAL • RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO 8 STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR•LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/1RRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL 0 SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 499.94
This permit is subject to the regulations contained in the
LEWIS, SEAN M + JANEL K OWNER Tigard Municipal Code, State of OR. Specialty Codes and
9595 SW LEWIS LN all other applicable laws. All work will be done in
TIGARD, OR 97223 accordance with approved plans. This permit will expire if
work is not started within 180 days of issuance, or if the
work is suspended for more than 180 days. ATTENTION:
Phone: Phone: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set
Reg forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Footing Insp Rain drain Insp
Electrical Service Electrical Final
Electrical Rough In Plumb Final
Framing Insp Final inspection
Insulation Ins° •
Issue By : _ I ! 1 . IL.ALL.. , Permittee Signature :x / 11 1J
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the - t business day
B uild i ng Permit Application ;
,
:;::: l. no.: Expire date:
City of Tigard Address: 13125 SW Hall Biv ' ° '. - ° - , u G
Phone: (503) 639 - 4171 Date issued: B y Q Receipt no.:
Fax: (503) 598 - 1960 l' T i Case file no.: Payment type:
Land use approval: Ct 4 y t9 1' 1. i 1 &2 family: Simple Complex: !j
TYPE OF PERMIT
1 & 2 family dwelling or accessory 0 CommerciaUindustrial 0 Multi - family 0 New construction 0 Demolition O
Additio teration/. 0 Tenant improvement 0 Fire sprinkler /alarm 0 Other: l
JOB SITE INFORMATION _
f,' Job address: 1 S`i 5 SAO . l -M. l►7t 3 1.4.! . - Bldg. no.: Suite no.:
J • N
Lot: I Block: (Subdivision: Tax map /tax lot/account no.:
Project name: � ..\\
o
(n, ' Descripption and location of work on premises/special conditions: tu3T1 - LtYbt4 ?Atli-2E -2E L _ 'b o
1 .4 , -LE ^ 4uAt.4
T .
r; f 8 ,1111 . / c l e.v✓ 4 2 GVIA Jowl / .
OWNER FOR SPECIAL INFORMATION, USE CHECKLIST - rZ
1 blood lain septic acity,solar,etc.
``� Name: �j�,+ -! µ. �tJi5 (� P , P P ) •
�S Mailing address: 1515 5.6.3. 1.Ew1% LA • 1 & 2 family dwelling:
� City: Tt[a41t State: L. I ZIP: 9722_3 Valuation of work $ i S p 0 °
NI Phone: 6.3•1-102-1 (Fax: `443 45011E-mail: No. of bedrooms/baths
'.J
Owner's representative: Total number of floors _
i
Phone: Fax: E -mail: New dwelling area (sq. ft.)
Garage/carport area (sq. ft.)
'* Name: Se.NE prs P-i:NW.ra Covered porch area (sq. ft.)
Mailing address: Deck area (sq. ft.)
City: I State: I ZIP: Other structure area (sq. ft.)
Phone: Fax: E -mail: Commercial /industrial /multi - family:
• - CONTRACTOR Valuation of work $
Existing bldg. area (sq. ft.
Business name: D 1.-u-4:42-. New bldg. area (sq. ft.)
Address:
Number of stories
City: I State: I ZIP:
Type of constructio
Phone: I Fax: I E -mail:
Occupancy group(s): Existing:
_ CCB no.: • New:
City /metro lic. no.: Notice: All contractors and subcontractors are required to be
ARCH ITECI7DESI licensed with the Oregon Construction Contractors Board under
Name: E �µe�tN rj1 provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
City: State: I ZIP: exempt from licensing, the following reason applies:
Contact person: 1 Plan no.:
Phone: Fax: E -mail:
Name: 5Jir (r►.!b , Contact person: t ktcep 4 Jes due upon application - $
_ Address: 3407 ,r, l.i. Gc m r Auer. Date received:
City: Pcsgal- A,a.iD IState:Og, (ZIP: ' 12o% Amount received $
Phone: 221•'1'193 1 Fax: 727- 77Sy -mail: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached checklist. All provisions of laws and ordinances governing this ❑ Visa ❑ MasterCard
— - work will be complied with hether spe • eel herein or not. Credit card -
.Expires
Authorized si ature: Date: t /zZlG 2 Name of cardholder as shown on credit card
Print name:�� . (bwt5 ` $
` Cardholder signature Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (6R00/COM)
, . •
4 ,, One- and Two - Family Dwelling h
Building Permit Application Checklist Reference no.:
Associated permits:
City of Tigard
City of Tigard 0 Electrical 0 Plumbing 0 Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 0 Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 •
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.
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 0 plan 0 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 -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 Five (5) 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 & 22 above.
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will be not 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 & location per approved project street tree plan (if applicable), and COT Street Tree List.
Checklist must be completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 440-064 (6/00/COM)
w .
A Electrical Permit Application • Date received: Permit no. •V ,, —, 1 . o , , 1 .
ac ,.. l ir City of Tigard Project/appl. no.: • Expire date:
Ciry ofTigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 Date issued: By: I Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 - 1960 Case file no.: Payment type:
Land use approval:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Other: ❑ Partial
JOB SITE INFORMATION
Job address: ( S9 S 5.65. Let.. ..i. L... i i t pa. Bldg. no.: Suite no.: Tax map /tax lot/account no.:
Lot: • IBlock: (Subdivision:
Project name: I Description and location of work on premises: ( 4zeur1.1G RI.A 6 S i. 1.t1.0NTS
Estimated date of completion/inspection:
CONTRACTOR APPLICATION FEE SCHEDULE
Job no: Fee Max
Business name: t' J 6-3 },•.NE 4- Description Qty. (ea.) Total no. insp .
Address: New residential - single or multi- family per
dweltingunit. Includes attached garage.
City: I State: I ZIP: Service included:
Phone: I Fax: I E -mail: 1000 sq. ft. or less 4
• Each additional 500 sq. ft. or portion thereof
CCB no.: I Elec. bus. lic. no: Limited energy, residential 2
City /metro lic. no.: Limited energy, non- residential 2
Each manufactured home or modular dwelling
Signature of supervising electrician (required) Date Service and/or feeder 2
Sup. elect, name (print): License no: Services or feeders — installation,
alteration or relocation:
PROPERTY OWNER 200 amps or less 2
Name (print): SEAi.b 1 .-A • t S 201 amps to 400 amps 2
401 amps to 600 amps 2
Mailing address: 1,6 S 4.). Lsw't 5 La. 601 amps to 1000 amps 2
City: 'j'Wp,Rp I State:Qp _ I ZIP: 4:11,/,..t.3 Over 1000 amps or volts 2
Phone: S2Z- S'+ I Fax: I E -mail: Reconnect only 1
Owner installation: The installation is being made on property I own Temporary services or feeders -
which is not intended for sale, lease, rent, or exchange according to installation, alteration, orrelocation:
ORS 447, 455, 479, 670 01. 200 amps or less 2
201 amps to 400 amps 2
y Owner's signature: Date: S f ZZlo2 401 to 600 amps 2
Branch circuits - new, alteration,
or extension per panel:
Name: A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit '2
City: I State: I ZIP: B. Fee for branch circuits without purchase
of service or feeder fee, first branch circuit: 2
Phone: Fax: E-mail: Each additional branch circuit:
('LAN REVIEW (Please check all that apply) Misc. (Service or feeder not included):
❑ Service over 225 amps - commercial ❑ Health -care facility Each pump or irrigation circle 2
❑ Service over 320 amps -rating of l &2 ❑ Hazardous location Each sign or outline lighting 2
family dwellings ❑ Building over 10,000 square feet four or Signal circuit(s) or a limited energy panel,
❑ System over 600 volts nominal more residential units in one structure alteration, or extension* 2
❑ Building over three stories ❑ Feeders, 400 amps or more *Description:
❑ Occupant load over 99 persons ❑ Manufactured structures or RV park Each additional inspection over the allowable in any of the above:
❑ Egress/lightingplan ❑ Other. Per inspection I 1
Submit sets of plans with any of the above. Investigation fee
The above are not applicable to temporary construction service. Other •
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Permit fee $
❑ Visa ❑ MasterCard expires if a permit is not obtained Plan review (at _ %)• $
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $
Expires accepted as complete. TOTAL $
Name of cardholder as shown on credit card
$
Cardholder signature Amount 440 - 4615 (6/00/COM)
le
ELECTRICAL PERMIT FEES: LIMITED ENERGY PERMIT FEES:
•
Complete Fee Schedule Below: TYPE OF WORK INVOLVED - RESIDENTIAL ONLY
p Restricted Energy Fee $75.00
Number of Inspections per permit allowed (FOR ALL SYSTEMS)
Service included: Items Cost Total 4, Check Type of Work Involved:
Residential - per unit
1000 sq. ft or less $145.15 4 ❑ Audio and Stereo Systems
Each additional 500 sq. ft. or
portion thereof $33.40 1 ❑ Burglar Alarm
Limited Energy $75.00
Each Manuf'd Home or Modular ❑
Dwelling Service or Feeder $90.90 2 Garage Door Opener
Services or Feeders 0 Heating, Ventilation and Air Conditioning System*
Installation, alteration, or relocation
200 amps or less $80.30 2
201 amps to 400 amps $106.85 2 ❑ Vacuum Systems
•
401 amps to 600 amps $160.60 2
601 amps to 1000 amps $240.60 2 ❑ Other
Over 1000 amps or volts $454.65 2
Reconnect only $66.85 2
Temporary Services or Feeders TYPE OF WORK INVOLVED - COMMERCIAL ONLY
Installation, alteration, or relocation Fee for each system $75.00
200 amps or less $66.85 2 (SEE OAR 918-260 -260)
201 amps to 400 amps $100.30 2
401 amps to 600 amps $133.75 2 Check Type of Work Involved:
Over 600 amps to 1000 volts,
see "b" above. ❑ Audio and Stereo Systems
Branch Circuits ❑
New, alteration or extension per panel Boiler Controls
a) The fee for branch circuits
with purchase of service or in Clock Systems
feeder fee.
Each branch circuit $6.65 ' 2 ❑ Data Telecommunication Installation
b) The fee for branch circuits
without purchase of service ❑ Fire Alarm Installation
or feeder fee. _
First branch circuit $46.85
Each additional branch circuit $6.65 ❑ HVAC
Miscellaneous ❑ Instrumentation
(Service or feeder not included)
Each pump or irrigation circle $53.40
Each sign or outline lighting $53.40 ❑ Intercom and Paging Systems
Signal circuit(s) or a limited energy
panel, alteration or extension $75.00 ❑ Landscape Irrigation Control
Minor Labels (10) $125.00
Each additional inspection over ❑ Medical ,
the allowable in any of the above
Per inspection $62.50 n Nurse Calls
Per hour $62.50
In Plant $73.75 ❑ Outdoor Landscape Lighting
Fees: ❑ Protective Signaling
Enter total of above fees $ n Other
8% State Surcharge $ Number of Systems
25% Plan Review Fee
See "Plan Review" section on $ * No licenses are required. Licenses are required for all other installations
front of application.
Fees:
Total Balance Due $
Enter total of above fees $
❑ Trust Account # 8% State Surcharge $
Total Balance Due $
All New Commercial Buildings require 2 sets of plans.
i:\dsts \forms\elc - fees.doc 08/30/01
+ Plumbing Permit Application
j 1 pm) -00
'",h1111' y g
City of Tigard , `•r Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City ofTigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 - 1960 Date issued: By: 1 Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
I7 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Food service O Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: 'ISIS S - t.- l.- s L,S- gilt; s M D )p . Description Qty. Fee (ea.) Total
Bldg. no.: I Suite no.: New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: ijkg>a . I ZIP: 5,1 213 Each additional bath/kitchen '
Description and location of work on premises: Site utilities:
t - of irnbr -e o r j Tu1316 t 1. Slat", 1 'Miter Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
—
Manufactured home utilities
Business name: OW 'AMP— Manholes
Address: Rain drain connector
City: I State: I ZIP: Sanitary sewer (no. lin. ft.)
Phone: I Fax: I E -mail:
Storm sewer (no. lin. ft.)
CCB no.: I Plumb. bus. reg. no: Water service (no. lin. ft.)
City/metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve •
Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Floor drains/floor sinks/hub
Name (print): Garbage disposal
Mailing address: Hose bibb
City: I State: I ZIP: Ice maker
/ Phone: I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial) _
_
employee on the property wn as r S Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: S ZL of Sump
Tubs/shower /shower pan -
Urinal
Name: Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $
O Visa O MasterCard expires if a permit is not obtained Plats review (at _ %) $
Credit card number: / / within 180 days State surcharge (8%) .... $
Expires ays after it has been TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6r00/COM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures In PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY lea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" 16.60
3" 16.60 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Urinal
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3"
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device* 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially _ 62.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
**PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee Is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $38.25 + 8% state surcharge.
"All New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
i:ldstslfotmslplm- fees.doc 12/26/01
MechanicalPermit Application
Date received: Permit no.: I gen„2 ----osv 44)
� k% I r
'..��� City of Tigard Project/appt.no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard OR 97223 Date issued: By: I Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: Building permit no.:
TYPE OF PERMIT
l I & 2 family dwelling or accessory 0 Commercial/industrial O Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Other:
JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
Job address: 159 S s. ,.3. LEiJ\ c l a_ \. 1 j(,14Rn, ,g . Indicate equipment quantities in boxes below. Indicate the dollar
Bldg. no.: I Suite no.: value of all mechanical materials, equipment, labor, overhead,
Tax map /tax lot/account no.: profit. Value $ •
Lot: (Block: I Subdivision: 'See checklist for important application information and
Project name: jurisdiction's fee schedule for residential permit fee.
City /county: 4,_.1 . IZIP: 9127_3 1 & 2 FAMILY DWELLING PERMIT FEE SCHEDULE
Description and location of work on premises: AND COMMERICAL /INDUSTRIAL EQUIPM ENT SCR EDULE
Gu (sE ri. DV - T re, 14 bv.ex (Po 5StAL'J)_ Fee(ea.) Total
Est. date of completion/inspection: Description Qty. Res. only Res. only
Tenant improvement or change of use: HVAC:
Air handling unit CFM
Is existing space heated or conditioned? 0 Yes 0 No
Air conditioning (site plan required)
Is existing space insulated? 0 Yes 0 No Alteration of existing HVAC system
MECIIANI(AL CONTRACTOR Boiler /compressors
Business name: l� I.- 54 -se -IL State boiler permit no.:
HP Tons BTU /H
Address: Fire/smoke dampers/duct smoke detectors
City: I State: I ZIP: Heat pump (site plan required)
Phone: I Fax: I E -mail: Install/replacefurnace/burner BTU/H
Including ductwork/vent liner 0 Yes O No
CCB no.: Install/replace/relocate heaters -suspended,
City /metro lic. no.: wall, or floor mounted
Name (please print): Vent for appliance other than furnace
CONTACT' PERSON
Refrigeration:
Absorption units BTU/H
Name: Chillers HP
Address: Compressors HP
Environmental exhaust and ventilation:
City: I State: I ZIP: _ Appliance vent
Phone: Fax: ' E -mail: Dryer exhaust
Hoods, Type U lI/res. kitchen/hazmat
(� hood fire suppression system
Name: Sgi I i . 1...-1 c Exhaust fan with single duct (bath fans)
Mailing address: 5 - A f 3 p -v-S S Exhaust system apart from heating or AC
S Fuel piping and disMbution (up to 4 outlets)
City: State: I ZIP: Type: LPG NG Oil
Phone: Fax: E -mail: Fuel i ing each additional over 4 outlets
P rocess p p g (schematic required)
Number of outlets
Name: Other listed appliance or equipment:
Address: Decorative fireplace
City: I State: I ZIP: Insert - type
Phone: I F I E -mail: Woodstove/pellet stove
f Other:
Applicant signature: , ., Q y . I Date: S1ZZ,!Oi d er:
Name (print): ,$&, MI trw • r •
Permit fee $
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $
Cl Visa Cl MasterCard
Credit card number: / / expires if a permit is not obtained Plan review (at %) $
Expires within 180 days after it has been State surcharge (8%) .... $
Name of cardholder as shown on credit card accepted as complete.
. $ TOTAL $
Cardholder signature Amount 440-4617 (600/COM)
MECHANICAL PERMIT FEES ., ..
COMMERCIAL FEE SCHEDULE: 1 & 2 FAMILY DWELLING FEE SCHEDULE:
TOTAL. VALUATION: PERMIT FEE: Description: . Price Total
$1.00 to $5,000.00 Minimum fee $72.50 Table 1A Mechanical Code Qty (Ea) Amt
$5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and 1) Furnace to 100,000 BTU
$1.52 for each additional $100.00 or including ducts & vents 14.00
fraction thereof, to and including 2) Furnace 100,000 BTU+
$10,000.00. including ducts & vents 17.40
$10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and 3) Floor Furnace
$1.54 for each additional $100.00 or including vent 14.00
fraction thereof, to and including 4) Suspended heater, wall heater
$25,000.00. or floor mounted heater 14.00
$25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and 5) Vent not included in appliance permit
$1.45 for each additional $100.00 or 6.80
fraction thereof, to and including 6) Repair units
$50,000.00. 12.15
$50,001.00 and up $742.00 for the first $50,000.00 and Check all that . Boiler Heat Air •
$1.20 for each additional $100.00 or For items 7 -11, see . or Pump Cond
fraction thereof. footnotes below. Comp •• . .
Minimum Permit Fee $72.50 SUBTOTAL: $ 7) <3HP; absorb unit
to 100K BTU 14.00
8% State Surcharge $ 8) 3 -15 HP; absorb 25.60
unit 100k to 500k BTU
25% Plan Review Fee (of subtotal) $ 9) 15-30 HP; absorb 35.00
Required for ALL commercial permits only unit .5 1 mil BTU
TOTAL COMMERCIAL PERMIT FEE: $ 10) 30 - 50 HP; absorb 52.20
unit 1 -1.75 mil BTU
11) >50HP; absorb
unit >1.75 mil BTU 87.20
ASSUMED VALUATIONS PER APPLIANCE: • 12) Air handling unit to 10,000 CFM
10.00
Value Total 13) Air handling unit 10,000 CFM+
Description: Qty (Ea) Amount 17.20
Furnace to 100,000 BTU, including 955 14) Non - portable evaporate cooler
ducts & vents 10.00
Furnace > 100,000 BTU including 1,170 15) Vent fan connected to a single duct
ducts & vents 6.80
Floor furnace including vent 955 16) Ventilation system not included in
Suspended heater, wall heater or 955 appliance permit 10.00
floor mounted heater -
17) Hood served by mechanical exhaust •
Vent not included in applicance 445 10.00
permit 805 18) Domestic incinerators 17.40
Repair units
< 3 hp; absorb. unit, 955 19) Commercial or industrial type incinerator
to 100k BTU 69.95
3 -15 hp; absorb. unit, ' 1,700 20) Other units, including wood stoves
101kto500kBTU 10.00
15-30 hp; absorb. unit, 501k to 1 2,310 21) Gas piping one to four outlets
mil. BTU 5.40
30-50 hp; absorb. unit, 3,400 22) More than 4 -per outlet (each)
1 -1.75 mil. BTU 1.00
>50 hp; absorb. unit, 5,725 Minimum Permit Fee $72.50 SUBTOTAL: $
>1.75 mil. BTU
Air handling unit to 10,000 cfm 656 8% State Surcharge $
Air handling unit >10,000 cfm 1,170
Non - portable evaporate cooler 656 TOTAL RESIDENTIAL PERMIT FEE: $
Vent fan connected to a single duct 446
Vent system not included in 656 - - - .
appliance permit
Hood served by mechanical exhaust 656 Other Inspections and Fees:
1 170 1. Inspections outside of normal business hours (minimum charge - two hours)
Domestic incinerator $62.50 per hour.
Commercial or industrial incinerator 4,590 2. Inspections for which no fee is specifically indicated (minimum charge - half hour)
Other unit, including wood stoves, 656 • $62.50 per hour
inserts, etc. 3. Additional plan review required by changes, additions or revisions to plans (minimum
Gas piping 1 - 4 outlets 360 charge-one-half hour) $62.50 per hour
Each additional outlet • 63 * State Contractor Boller Certification required for units >200k BTU.
TOTAL COMMERCIAL $ ' A/C requires site plan showing placement of unit.
VALUATION:. " -':'^ '_ All New Commercial Buildings require 2 sets of plans.
i:\dsts \forms\mech- fees.doc 12/26/01
•
Permit #: M br 900.9.- 00.60
F `� 9595 Lt�t L .
/'`' Address:
:.::: ' ,' Issue by: 1 e l,/ iiL" I -Date: ? IS 9---
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
p 1. I own, reside in, or will reside in the completed structure.
P 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
. before or upon completion.
El 3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
ll. 3B. I will be my own general contractor.
iilw
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
.
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form. Di 6 2--
-- 1 • ,y,b0 (Signature of permit applicant) _ (ate)____ _
(White copy to issuing agency permit file,
pink copy to applicant)
Information Notice to Property Owners
About Construction Responsibilities
. Note: This Information Notice to Property Owners about Construction Responsibilities
•
was developed by the Consiruetioh Contractors Board in accordance with ORS 701.055(5).
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent many problems by being aware of the following responsibilities and areas of concern.
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement of a residential structure, you will, in most instances, be ruled to he an employer and the people
you hire will be employees. As the employer, you must comply with the following:
Oregon's withholding tax law: As an employer, you 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 Oregon Dept. of Revenue at 945 -8091.
Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information, call the Oregon Employment Division at the Department of Human Resources
at 378 -3524.
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must
obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject to penalties and will be liable for all claim costs if one of your employees is injured on the job. For more information,
call the Workers' Compensation Division at the Department of Consumer and Business Services at 945 -7888.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wags. You will be
liable for the tax payment even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1 -800- 829 -1040.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections.
Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accident; and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
re -done.
Time to supervise employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough -in and finish
trades, and to notify building officials at the appropriate times so they can perform the required inspections.
If you have additional questions, write or call the Construction Contractors Board (PO Box 14140,'Salem, OR 97309 -5052,
503/378- 4621). The Board is located at 700 Summer St. NE Suite 300, in Salem.
prop- own.pm4
/94
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 . , _ Ov o2 G 0
;
INSPECTION DIVISION , . Business Line: (503) 639 -4171
BUP
Received Date Requested / b — ° Z AM PM BUP
Location ' S ? 5--- Suite MEC
Contact Person Ph ( —5-11 09 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation Access: ELC
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam -
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
PART FAIL
_M CHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE El Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line 1 A7'7,
ADA Approach/Sidewalk Date L l Inspector Est
Other:
Final DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST
INSPECTION DIVISION • " Business Line: (503) 639 -4171
BUP
Received Date Requested / d / ^ �M PM BUP
Location 9. c s C Suite MEC
Contact Person Ph ( ) Ls a - " 5 9 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access: C ��
Ftg Drain � ELR
Crawl Drain -
Slab Inspection Notes: A SIT
Post & Beam � f T_00 /4
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof r: r � , •
AR FAIL
• • ' BING •
Post & Beam J � i
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains -
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL
Post& Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Vol a. -
Fire Al : Q
PASS PART FAIL � Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
SITE 0 Please call for reinspection RE: 0 Unable to inspect — no access
Fire Supply Line
ADA l
Approach/Sidewalk Date / () r Inspect • �L _ — _ Ext
Other:
Final DO NOT REMOVE this Inspection reco d f om the Job site.
PASS PART FAIL