Permit r
,.
= n • CITY OF TIGARD
SITE WORK PERMIT
I I I s COMMUNITY DEVELOPMENT 'Permit #: SIT2009 -00020
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/28/2009
Parcel: 1 S 135BC01200
Jurisdiction: Tigard
Site address: 10225 SW NORTH DAKOTA ST
Subdivision: Lot: 0
Project: Harrell
Project Description: Erosion control for temporary gravel stockpile.
Owner: FEES
MBM HOLDING COMPANY LLC Description Date Amount
659 NW PACIFIC GROVE DR
BEAVERTON, OR 97006 Erosion Control 10/28/2009 $80.00
Erosion Plan Review CWS 10/28/2009 $26.00
PHONE: Erosion Plan Review COT 10/28/2009 $26.00
Contractor:
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT
Site Specifics:
Excavation Volume: cu. yd.
Fill Volume: Cu. yd.
Impervious Surface: sq. ft.
Engineered Fill: Soil Report Required:
Paving: Grading:
Landscaping: Site Prep: •
Storn Drains: Retaining Wall:
Fire Underground: Accessible Parking:
Fence:
•
Total $132.00
Required Items and Reports (Conditions)
1 BUP Ersn Cntrl 681 -4444
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 rules adopted by the Oregon
Utility Notification Center. Those rules are set forth 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 503.246.6699 or 1.800.332.2344.
Issued By: � (1 n � \ (j u Permittee Signature:
�► �!► 'C
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 Permit Application
Site Work REC I \ �IED FOR OFFICE USE ONI.V
City of Tigard Received Date/B : A Permit No.: "NI 2(04.G 20
° 13125 SW Hall Blvd., Tigard, OR 97223 OCT 2 8 2009
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit:
TIGARD Inspection Line: 503.639 CITY OF TIGARD Date Ready/By: S See Page for
Internet: www.tigard - or.gov Notified/Method: Supplemeatallnformadoa
BUILDNG DIVISION
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
El New construction El 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: Grading equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1- and 2- family dwelling Valuation: $0
El
❑ Accessory building El Multi-family Number of bedrooms: 0
El Master builder El Other: Number of bathrooms: 0
JOB SITE INFORMATION AND LOCATION Total number of floors: 0
Job site address: 10225 SW North Dakota New dwelling area: 0 square feet
City/ State/ZIP: Tigard, OR. 97223 Garage/carport area: 0 square feet
Suite/bldg./apt. no.: 0 Project name: Refuge at Fanno Creek Covered porch area: 0 square feet
Cross street/directions to job site: Enter in off North Dakota Deck area: 0 square feet
Other structure area: 0 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.: 1s135BC -1200 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.
Stockpile of 90cyds of gravel for future use of driveway construction Valuation: $$0.00
Existing building area: 0 square feet
New building area: 0 square feet
® PROPERTY OWNER ❑ TENANT Number of stories: 0
Name: Matthew Harrell Type of construction: 0
Address: 659 NW Pacific Grove Dr Occupancy groups:
City/State/ZIP: Beaverton, OR 97006 Existing: 0
Phone: (503)645-4872 Fax: ( ) New: 0
❑ APPLICANT ® CONTACT PERSON NOTICE
Business name: n/a 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:
CONTRACTOR
Business name: n/a BUILDING PERMIT FEES*
Address: (Please refer lo fee schedule)
City/ State/ZIP: Structural plan review fee (or deposit):
Phone: ( ) Fax: ( ) FLS plan review fee (if applicable):
CCB lic.: Total fees due upon application:
/ Amount received: (32 • GO
Authorized signature: /A This permit application expires if a permit is not obtained
!!!"` within 180 days after it has been accepted as complete.
Print name: 074.771/0d/ 1,4 , Date: /0_. 2 @ O q I • Fee methodology set by Tri -County Building Industry
Service Board.
I:\Building \Permits \SIT - PermitApp.doc 10 /01/09 440- 4613T(11 /02/COM/WEB)
It.
TRANSMISSION VERIFICATION REPORT
TIME : 10/28/2009 10:35
NAME :
FAX .
TEL .
SER.# : BR0H7J690762
DATE,TIME 10/28 10:34
FAX NO. /NAME CWS
DURATION 00:00:26
PAGE (S) 02
RESULT OK
MODE STANDARD
ECM
CITY OF TIGARD SITE WORK PERMIT
' COMMUNITY DEVELOPMENT P ormlt>g•
T S1T2009 -00020
T f rs :1 P, D 13125 SW Half Blvd., Tigard OR 97223 503.639,4171 Date issued: 10/28/2009
Parcel: 1S13513C01200
Jurisdiction: Tigard
Site address: 10225 SW NORTH DAKOTA ST
Subdivision: Lot: 0
Project: Harrell
Project Description: Erosion control for temporary gravel stockpile.
owner.
MBM HOLDING COMPANY LLC FEES
Description Date Amount
659 NW PACIFIC GROVE DR
BEAVERTpN, OR 97006 Erosion Control 10/28/2009 $80.00
PHONE: Erosion Plan Review MS 10/28/2009 526.00
Erosion Pin Review COT 10/28/2009 $26.00
Contractor:
PHONE;
FAX:
Type of Use: COM
Class of Work: ALT
SJjg Specifics;
Excavation Volume: cu. yd,
Fill Volume; cu. yd.
Impervious Surface: sq. fl.
Erigineered'Flll: Soil Report Required:
Paving: Grading:
Landscaping: Site Prep:
Stem Drains: Retaining Wall: .
Fire Underground: Accessible Perking:
Fence:
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