Permit CITY TIGARD SITE WORK PERMIT
.1N COMMUNITY DEVELOPMENT PERMIT #: SIT2009 -00001
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED : 1/16/2009
PARCEL : 1S136CC -02100
SITE ADDRESS: 11746 SW PACIFIC HWY ZONING : C -G
SUBDIVISION: DUTCH BROTHERS COFFEE LOT: JURISDICTION : TIG
PROJECT: DUTCH BROS. COFFEE
Project Description: Site work for new coffee drive - thru.
CLASS OF WORK: NEW PAVING ?: U RESO. NO:
TYPE OF USE: COM GRADING ?: Y VALUE: 75,000.00
EXCV VOLUME: 350 cy LANDSCAPING ?: Y
FILL VOLUME: 2,400 cy SITE PREP ?: Y
ENG FILL ?: Y STORM DRAINS ?: Y
SOILS RPT READ ?: Y IMPERV SURFACE: 13,921 sf
Owner: FEES
RYAN HAWKINS Description Date Amount
18216 SW MCCONNELL CT [FLS] FLS Pln Rv 1/12/2009 $194.68
SHERWOOD, OR 97140 [BUPPLN] Pln Rv -Valu 1/12/2009 $316.36
[BUILD] Print Fee -Valu 1/16/2009 $486.70
Phone: 503 - 349 -6245 [TAX] Valu 12% State Surcha 1/16/2009 $58.40
[ERPRMT] Erosion Control 1/16/2009 $80.00
Contractor: [ERPLN] Erosn Pln Rv CWS 1/16/2009 $26.00
[EROSN] Erosn Pln Rv COT 1/16/2009 $26.00
DALKE CONSTRUCTION CO INC
2180 16TH ST NE Total $1,188.14
SALEM, OR 97301
Contact #: PRl 503 585 - 7403
FAX 503 - 585 -1978 REQUIRED ITEMS AND REPORTS
U,05 do -
Reg #: LIC 63080
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 9 - 1 -010 You may obtain copies of these
rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: J\ Kx& Permittee Signature:
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.
.J l TA(, 5u k ci c. cw
Building Permit Application
Site Work RECEIVED FOR OFFICE USE ONLY
J AN 08 Date:_. .. ��•�I
City of Tigard 8 2009 Dater _ ` • f Permit No.: &%
13125 SW Hall Blvd., Tigard, OR 97223 Plan Rev'< • 1/
• �`ik�� Other Permit: S Z Q `1
Phone: 503.639.4171 Fax: 503.598. �`y �p� Date /B
TI G A R D Inspection Line: 503.639.4175 �' + + OF T Date Rea. y :y: iris. n ® See Page 2 for
Internet: www.tigard - or.gov BUILDING DIVISION Notified/Method: l • Z • (39 y, T 1`' Supplemental Information
L.ry 3c 4■1-1.c,r. 91G- L.ieZLI I. lS•oq
TYPE OF WORK 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.
Valuation: '`,
❑ I- and 2- family dwelling Commercial /industrial $ ' 7s 04t7
❑ Accessory building ❑ Multi- family
Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors: I
Job site address: 11-744 sw Ac IFI C. Hi.,././ New dwelling area: square feet
City/ State/ZIP: -- 17, d ptQ � ZZ 3 lfz Lo6�f Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: CuitL� ` Covered porch area: square feet
Cross street/directions to job site: Sv.J 71 r' Are. 0fF of f(Luy 9'1 Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: ..-4 Lot no.: 2 too Permit fees* are based on the value of the work performed.
i Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: , 1 5I 3 6 C-C: equipment, materials, labor, overhead, and the profit for the
/ DESCRIPTION OF WORK ��//�� work indicated on this application.
C_o if fu �es j. 1 Q f✓fIZ ;� I ].. Valuation: $
- . Existing building area: square feet
J C New building area: 311 square feet
B PROPERTY OWNER ❑ TENANT Number of stories:
Name: e 7QN Kam le. n,c • Type of construction: T V— i •
Address: 1 QZI (O .w H Co��G I 1 �u! t Occupancy groups:
City /State/ZIP: S 4 (1t J 0P-, C1 7140. 8 79f. Existing:
Phone: ( »3) 341— Ca. 4S Fax: ( )
New:
❑ APPLICANT CONTACT PERSON NOTICE
Business name: •I o I t1/-Tt rL., E ., AIc All contractors and subcontractors are required to be
Contact name: I�,�/ licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: II S 13' S'-f SE jurisdiction in which work is being performed. If the
City /State/ZIP: o 2 1-73-1Z_ applicant is exempt from licensing, the following reasons
,// applly
Phone: (S.3 3() 3 ZL7 Fax: : (,�3) �J(o4')Lbfl ', L,...4 Eke .4 �••,: Wee. •••
E -mail: ` G1, L° n'•t „I 4 •5 • n..., S'
CONTRACTOR
Business name: • Co, l tee. Ct sivs.•.,4\ •- C D • BUILDING PERMIT FEES*
Address: P. 0. 0.5e, S f ° (Please refer to fee schedule)
City /State /ZIP: S. Q� 4 Structural plan review fee (or deposit): , \
t - tO
�13 « LI . (0
Phone: ( .503) se.c..• - 7 4 o3 Fax: ( . 3 SSS... hie FLS plan review fee (if applicable):
CCB lic.: b 3,,6o Total fees due upon application: 5 \ . 0
Amount received:
Authorized signature: 1 This permit application expires if a permit is not obtained
/ 0 ' within 180 days after it has been accepted as complete.
Print name: SE fF t, Dae: I
F Date: ,• • Fee methodology set by Tri-County Building Industry
Service Board.
I: \Building \Permits \SIT - PermitApp.doc 12/27/06 4404613T(II/02/COM /WEB)
City of Tigard: Site Work Permit Checklist
Page 2 - Supplemental Information
Commercial, Multi- Family and One- and Two - Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep
and will not be supporting a structure. If a building will be constructed on the fill, it must be
engineered fill. If fill is in a flood plain, drainage way, or wetland, the applicant must apply for
a sensitive lands review (SLR).
Please complete all items below, unless otherwise noted.
Excavation Volume: 3 SO cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) j 2-0 cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be
compacted to 90% of maximum density) Zoo cu. yds.
Retaining structure? (Check one) El Rock
❑ CMU
❑ Concrete
❑ Other:
*Total new impervious area including all
buildings, sidewalks, and paving: I''j sq. ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See "Site Work Permit Application - Plan Submittal Requirements"
attached. The following must accompany this application:
El Site Plan with Vicinity Map showing El *Parking (including ADA) and
ADA compliance Lighting Plan
El Grading Plan and details ❑ *Landscaping Plan
❑ Erosion Control Plan and details El Soils Report (if required)
El Retaining Structures
*Does not apply to One- and Two - family dwellings.
# of Plans
TYPE OF SUBMITTAL Required at
(Includes New, Additions or Alterations) Submittal
Commercial 2
Multi - Family R -1 Occupancy 2
One- & Two - Family Dwelling 2
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