Permit CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
' COMMUNITY DEVELOPMENT Permit#: FPS2012 -00035
TI CARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/08/2012
Parcel: 1 S 1260000300
Jurisdiction: Tigard
Site address: 9573 SW WASHINGTON SQUARE RD B06
Project: The Limited Subdivision:VASHINGTON SQUARE ESTATES NO. Lot: 108
Project Description: Fire alarm
Contractor: SIEMENS INDUSTRY INC Owner: PPR WASHINGTON SQUARE LLC
15201 NW GREENBRIER PKWY BY THOMSON PROPERTY TAX SERVICES
SUITE A4 ATTN HILARY RAYMOND
BEAVERTON, OR 97006 2235 FARADY AVE, STE 0
CARLSBAD, CA 92008
PHONE: 503 -234 -9995 PHONE:
FAX: 503 - 234 -8030
FEES
Description Date Amount
Spe Permit Fee - COM 03/08/2012 $112.96
12% State Surcharge - Building 03/08/2012 $13.56
Type of Use: COM Plan Review - Fire Life Safety - COM 03/08/2012 $45.18
Class of Work: ALT Type of Const: Info Process /Archiving - Lg $2.00 (over 03/08/2012 $4.00
Occupancy Grp: Height: ft 11x17)
Stories: Info Process/Archiving - Sm $0.50 (up to 03/08/2012 $5.00
11x17)
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard:
Density: 0 Design Area: 0
K Factor: 0
Commercial Fire Alarm System:
Fire Alarm Required: Alarm Type:
Pull Station Required: Smoke Detectors Req:
Battery Calcs Provided: Cut Sheets Required:
Total $180.70
Valuations: Required Items and Reports (Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $3,673.00
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 suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the s adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952- 001 -0090. You m:. in a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. ''
Issued By: Permittee Signature: ''I11, "
IF Ca . 9.4175 by 7:00 a.m. for the next available inspection date.
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 Permit Application
Fire Protection System B ECEWED FOR OFFICE USE ONLY
City of Tigard � .Q� P ermit No.: aPf
13125 SW Hall Blvd., Tigard, OR 97223 pp pp
Phone: 503.718.2439 Fax: 503.598.1960 NI 2 RI 2 patte/ / 1�� Od'�Permit: 49e)11-Qa l
TIGARD
Inspection Line: 503.639.4175 /� Date Ready : Juris: ® See Page 2 for
Internet: www.tigard - or.gov V! 1 1 OF TIGARD Notified/Method: Supplemental Information
TYPE OF NAIVIr N G DIVISION
REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ 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
CATEGORY OF CONSTRUCTION work indicated on this application.
El 1- and 2- family dwelling ® Commercial/industrial Valuation: $
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder - ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 9573 SW WASHINGTON SQUARE ROAD New dwelling area: square feet
City/State/ZIP: TIGARD, OR Garage/carport area: square feet
Suite/bldg. /apt. no.: STE B06 I Project name: The Limited Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
WASHINGTON SQUARE MALL Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: 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
DESCRIPTION OF WORK work indicated on this application.
ADDITION OF SMOKE DETECTION IN RETAIL SPACE Valuation: $83,673.00
Existing building area: square feet
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name: ROGER OTT Type of construction:
Address: 9585 SW WASHINGTON SQUARE ROAD Occupancy groups:
City/ State/ZIP: TIGARD, OR Existing:
Phone: (503)639 -8860 Fax: ( ) New:
® APPLICANT ❑ CONTACT PERSON
NOTICE
Business name: SIEMENS INDUSTRY, INC. All contractors and subcontractors are required to be
Contact name: CHARLES HUGHES licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 15201 GREENBRIER PARKWAY jurisdiction in which work is being performed. If the
City/State/ZIP: BEAVERTON, OR 97006 applicant is exempt from licensing, the following reasons
apply:
Phone: (503) 207 -1839 I Fax: : (503) 207 -1901
E -mail: charles.hughes@siemens.com
CONTRACTOR BUILDING PERMIT FEES*
(Please refer to fee schedule)
Business name: SIEMENS INDUSTRY, INC.
Permit fee:
Address: 15201 GREENBRIER PARKWAY
City/State/ZIP: BEAVERTON, OR 97006 State surcharge (12% of permit fee):
Phone: (503) 207 -1839 I F ax: (503) 207 -1901 FLS plan review (40% of permit fee):
( ) ( ) (Due upon application.)
CCB lic.: 133041 / Total permit fees:
Authorized si _ Amount received:
:
This permit application expires If a permit is not obtained
Print name: CHARLES ' UGHES I Date: 01/24 /2012 within 180 days after it has been accepted as complete.
• Fee methodology set by Tri -County Building Industry
Service Board.
I:\ Building\Pamits\FPS- PamitApp.doc 02/01/11 440-4613T(I I /02/COMIWIB)
V
i
TIGARD
City of Tigard
August 22, 2012
Siemens Industry Inc.
Attn: Charles Hughes
15201 NW Greenbrier Pkwy, A -4
Beaverton, OR 97006
Re: Permit No. FPS2012 -00035
Dear Mr. Hughes:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 9573 SW Washington Square Rd.
Project Name: The Limited
Job No.: N/A
Refund: n Check # in the amount of $ .
® Credit card "return" receipt in the amount of $201.60.
Note: Please allow 2 -5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of $ .
Comments: Per applicant's request, refund 100% of early morning inspection fees as
inspection was done in conjunction with other permit for the same date /time.
If you have any questions please contact me at 503.718.2430.
Sincerely,
ii/ .% '4
Dianna Howse
Building Division Services Supervisor
Enc.
is \ Building \Refunal4 ,S 1° It lit efelcT , 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Siemens Industry Inc. DATE: 07/26/2012
Attn: Charles Hughes
15201 NW Greenbrier Pkwy, A -4 REQUESTED BY: Dianna Howse
Beaverton, OR 97006
TRANSACTION INFORMATION:
Receipt #: 186068 Case #: FPS2012 -00035
Date: 03/27/2012 Address /Parcel: 9573 SW Washington Sq Rd
Pay Method: CreditCard Project Name: The Limited
EXPLANATION: Refund 100% per applicant's request as early morning inspection for this permit was
done in conjunction with other permit for the same time; OK per Chip Barnett.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Hourly Building Rate 230- 0000 -43104 $180.00
12% State Surcharge 100- 0000 - 24001 21.60
TOTAL REFUND: $201.60 t.i
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: P / �/ / /�- By: 4
I: \Buil ding\ Refunds \RefundRequest.doc z 09/01 /2010
CC/
' City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENRECEI ED
I a . Request Permit Action
q JUN 2 1 2012
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www. ' a -or.. ' ,,r
8 I L N G D V I O N
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant V1 Contractor p City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) ( e1Y00 <_k...14-1 1 ,17AC_
w
Mailing Address: I 5 ( G rea.lprter- Rd. ci. A y
City/State /Zip: Sewer r4-0v OR- ?70x
Phone No.: OM 3103 - ?0 7 - i c l Ca
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑ CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). `
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ___ fPs av a - a00 35
Site Address or Parcel #: 1 S7,3 ,S G>uS 5 D (2.00. 13 V L
Project Name: - rN.t (A'Srvt f'ked
C-S
Subdivision Name: 0) OS LN.15 Sy4_t ( Lot #: / 0 el
EXPLANATION: 0•e ea .i , , ,_ _ r u'a C , _../
i • / 1 " . . ) - u r f;IN, a v r 4 1 FP5 a-oia- t Z 3Y. R1av e4/1 MQ,n ilk i
-rep c (e P (1.02_&? b �e- te n *, -(=d)
�, Signature: A Date: - p�� -�
`► e�
Print Name: e h 4des l
Refund Policy
1. The Director or Building Official may authorize 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 he 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 Sys Adenin: Date By Rte to Bldg Admin: Date .2.//2- By 4.1•-,
Refund Processed: Date )/2 . /Z By 4/v Invoice Processed: Date By
Permit Canceled: Date B _ - Parcel Tag Added: Date By
Receipt # /fr604,er Date ,3 /a /-Z Methocj Amount $
1:\ Building \ Forms \RegPermitAction.doc Rev 05/25/2012
FT'Szi:DIL-Pcsr>
Certificate of Completion
Name of Protected Property: WASINGTON SQUARE MALL
Address: 4 SW WASHINGTON SQUARE DRIVE — Suite B06 The Limited
TIGARD, OR •
Rep. of Protected Prop. (name /phone):ROGER OTT (bldg engineer) 503 -639 -8860
Authority Having Jurisdiction:CITY OF TIGARD — FIRE AND RESCUE
Address: 13125 SW HALL BLVD
TIGARD, OR 97223
Phone Number:503- 718 -2439
1. Type(s) of System or Service:
X NFPA 72, Chapter 3 - Local
If alarm is transmitted to location(s) off premise, list where received:
NFPA 72, Chapter 3 - Emergency Voice /Alarm Service
Quantity of voice /alarm channels: Single: Multiple:
Quantity of speakers installed: Quantity of speaker zones:
Quantity of telephones or telephone jacks included in system:
NFPA 72, Chapter 4 - Auxiliary
Indicate type of connection:
Local energy, Shunt, Parallel telephone
Location and telephone number for receipt of signals:
NFPA 72, Chapter 4 - Remote Station
Alarm:
Supervisory:
NFPA 72, Chapter 4 - Proprietary
If alarms are retransmitted to public fire service communications center or others, indicate
location and telephone number of the organization receiving alarm:
Indicate how alarm is retransmitted:
•
Updated: 4/30/2012 Page 1
X NFPA 72, Chapter 4 - Central Station
The Prime Contractor:SIEMENS INDUSTRY, INC.
Central Station Location: Dallas Call Center 1- 866 - 552 -7823
Means of transmission of signals from the protected premise to the central station:
McCulloh Multiplex One -Way Radio
X Digital Alarm Communicator Two -Way Radio Others
Means of transmission of alarms to the public fire service communications center:
•
1. Telephone
2.
System Location: 9585 SW WASHINGTON SQUARE DRIVE TIGARD, OR
Organization Name /Phone Representative Name /Phone
Installer
Supplier SIEMENS INDUSTRY CHARLES HUGHES 503 - 207 -1900
Service Organization SIEMENS INDUSTRY SERVICE DEPT 503 - 207 -1900
Location of Record (As- Built) Drawings:
WASHINGTON SQUARE MALL FACILITIES DEPT
Location of Owners Manuals:
WASHINGTON SQUARE MALL FACILITIES DEPT •
Location of Test Reports:
WASHINGTON SQUARE MALL FACILITIES DEPT
A contract, dated for test and inspection in accordance with NFPA standard(s)
No.(s) dated • is in effect.
2. Certification of System Installation
This system has been installed in accordance with the NFPA standards as listed below, was
inspected by on , includes the devices
listed below and has been in service since
X NFPA 72, Chapters X 4 X 5 X 6 X 7 X 10
X NFPA 70, National Electrical Code, Article 760
X Manufacturer's Instructions
Other (specify):
Signed: Date:
Organization:
•
•
Updated: 4/30/2012 Page 2
•
3. Certification of System Operation
All operational features and functions of this partial system were tested by SAM CORRELL
on April 24 2012 and found to be operating properly in accordance with the
requirements of:
X NFPA 72, Chapters X 4 X 5 X 6 X 7 X 10
X NFPA 70, National Electrical Code, Article 760
X Manufacturer's Instructions
Other (specify):
Signed: Date:
Organization:SIEMENS INDUSTRY, INC.
4. Alarm Initiating Devices and Circuits
MANUAL
a) Manual Stations Noncoded, Activating Transmitters Coded
b) Combination Manual Fire Alarm and Guard's Tour Coded Stations
AUTOMATIC
Coverage: Complete NO Partial YES
a) 4 Smoke Detectors: Ion 4 Photo
b) Duct Detectors: Ion Photo
c) Heat Detectors: FT RR FT /RR RC
d) Sprinkler Water Flow Switches: Noncoded, Activating
Transmitters Coded •
e) Other (list): •
5. Supervisory Signal Initiating Devices and Circuits
GUARD'S TOUR
a) 0 Coded Stations
b) _ 0 Noncoded Stations Activating 0 Transmitters
c) _ 0 Compulsory Guard Tour System Comprised of 0 Transmitter Stations •
and 0 Intermediate Stations
Note: Combination devices recorded under 4(b) and 5(a).
SPRINKLER SYSTEM
•
a) 0 Coded Valve Supervisory Signaling Attachments
Valve Supervisory Switches Activating Transmitters
b) 0 Building Temperature Points
c) 0 Site Water Temperature Points
d) 0 Site Water Supply Level Points •
•
•
•
Updated: 4/30/2012 Page 3
•
Electric Fire Pump:
e) 0 Fire Pump Power
f) 0 Fire Pump Running
g) 0 Phase Reversal
Engine- Driven Fire Pump:
h) 0 Selector in Auto Position
i) 0 Engine or Control Panel Trouble
j) 0 Fire Pump Running
Engine- Driven Generator:
k) 0 Selector in Auto Position
I) 0 Control Panel Trouble
m) 0 Transfer Switches
n) 0 Engine Running
Other Supervisory Function(s) (specify):
6. Alarm Notification Appliances and Circuits
Quantity of indicating appliance circuits connected to the system:
Types and quantities of alarm indicating appliances installed: •
•
a) 0 Bells Inch
0 Speakers
b) Horns
c) Chimes •
d) 0 Other:
e) Visual Signals Type:
with audible w/o audible
f) 0 Local Annunciator
7. Signaling Line Circuits:
Quantity and Style of signaling line circuits connected to system:
Quantity: Style:
•
8. System Power Supplies •
a) Primary (Main): Nominal Voltage: Current Rating:
Overcurrent Protection: Type: Current Rating:
Location:
b) Secondary (Standby):
Storage Battery: Amp -Hour Rating •
Calculated capacity to drive system, in hours:
Engine- driven generator dedicated to fire alarm system:
Location of fuel storage:
Updated: 4/30/2012 Page:4
c) Emergency or Standby System used as backup to Primary Power Supply, instead of using a
Secondary Power Supply:
0 Emergency System described in NFPA 70, Article 700
0 Legally Required Standby System described in NFPA 70, Article 701
0 Optional Standby System described in NFPA 70, Article 702, which also meets the
performance requirements of Article 700 or 701
9. System Software
a) Operating System Software Revision Level(s):
b) Application Software Revision Level(s):
c) Revision Completed by: SAM CORRELL SIEMENS
(name) (firm)
10. Comments:
This project was for the purpose of a remodel space only, it involved the addition of 4 smoke
detector in the retail area of the space.
IDOL
- .� PROJECT MANAGER 04/24/2012
(signed or Alarm e e Company (title) (date)
Frequency of routine tests and inspections, if other than in accordance with the referenced NFPA
standard(s):
System deviations from the referenced NFPA standard(s) are: None •
4 .11 ,11 k PROJECT MANAER 04/24/2012
(signe'' f• r Alar Company (title) (date)
Up ' �m,pletion of the system(s) satisfactory test(s) witnessed (if required by the authority
h. n jurisdiction: •
- S..
signed) repre>A'.`e of the authority having jurisdiction (title) ( te)
Updated: 4/30/2012 Page 5