Permit CITY TIGARD SITE WORK PERMIT
I
A " A DEVELOPMENT SERVICES PERMIT # : SIT2002 -00013
" • I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED : 8/4!03
SITE ADDRESS: 16875 SW PACIFIC HWY PARCEL : 2S115BD -02600
SUBDIVISION: ZONING :
BLOCK: LOT: JURISDICTION : KIN
CLASS OF WORK: NEW PAVING ?: Y RESO. NO:
TYPE OF USE: COM GRADING ?: Y VALUE: 250,000.00
EXCV VOLUME: 1,200 cy LANDSCAPING ?: Y
FILL VOLUME: 2,900 cy SITE PREP ?: Y
ENG FILL ?: Y STORM DRAINS ?: Y
SOILS RPT REQD ?: IMPERV SURFACE: 56,640 sf
Remarks: Site work for new 4,243 sq.ft. gas station /convenience store
Owner:
FEES
SPACE AGE FUEL INC
PO BOX 607 Description Date Amount
GRESHAM, OR 97030 [BUPPLN] Pln Ck -Valu 5/31/02 $866.55
[BUILD] Prmt Fee -Valu 8/4/03 $1,333.15
Phone: 503 - 665 -5693 [TAX] 8% St Tax -Valu 8/4/03 $106.65
[FLS] FLS Pln Rv 8/4/03 $533.26
Contractor: Total $2,839.61
PLISKA CONSTRUCTION
PO BOX 607
GRESHAM, OR 97030
Phone: 503 - 665 -5693
Reg #: LIC 75494
Required Inspections
Erosion Control Insp 846 -8444
Excavation
Fill
Paving Insp
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 ATTENTION: Oregon law
requires you to follow rules .e : =tea by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through P • R 952 -001 -4' 00. You m y obt.'n copies of these rules or direct questions to OUNC by
calling (503) 246 -669:.
Iss ed By: . t LISA
Permittee Signature: � �e
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
•
. tom .... ...._ ... . .
E r 24 b32 12:26 .. SPAS AGE FUEL 9 S NO.562 DOO2
✓nEd to Z.5"
Bull ding e'er mat Application
Date receive4$ /3/ /b 9. Permit r ono /3
,Mi. City of Tigard pro; eet/appi.no.: Expire date:
% CiryofTgarC
Phon es: 13125 SW Nall Blvd, Tigard, OR 97V3 Datei; sued: By:. , Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 - 1960 Oise file no.: _ Payment type:
• 1.0 family: Simple Complex:
Land use approval: 4.t /tf i v
TITS OF PERMIT. `:
O
Cl 1 & 2 family dwelling oc accessory z'' Commercial/industrial 0 Multi - family XNew construction O Demolition
O Addition/alteration/replacement • Tenant improvement 0 Fire spriaklerlalarm 0 Other. •
JOB SITE 1A'FORMATION .
llill Bldg. no.: Suite no.:
Job address: •r _ r u_ • k ■a *i r
Lo . Block; Subdivision: Tax ma • tax lot/account no.: ?rj • C dr%: % P t `�
Project name: _ , - . ,. +7 Description and location of work on premixs'speclal conditions:
j 'h2e t D . 17 ?A l - ` 7.-. 1 -
0wn]i : - - FOR SPECI IR`TORMATION, USE CIIECKLIST
(Flo ad plain, septic ca pa city, solar,ctc.)
Name: .' 2L._..•
Mailing address: rQ �� ?{ & 2 family dwelling: . glop
Win" 44 '4 Y3 �,� ZIP: 030 Valuation of worst $ — O
_
Phone: G�o • .`)a Fax:e r,� f E -mail: No. of bcdroo _
- Ownees.re. . _• . ve: , ,_.� Total number of floors
Phone: J ,3 -r . • E- : New dwelling area. (sq. ft.)
APPLICANT Gar area (sq, ft) (fl
'--1.-- Covered porch area (sq. ft.)
- `'�
Name: 1 ` 4 Deck area (sq. ft.) —
Mailing address: a t' , a Other structure area 's • . ft.) —
P b o o ,•' ,,, Stated CommercisVmdustrial /multi - family:
• Phone r� e e ) _ Fax ► : / &m ail: s 025 �'r) \
s Valuation of work _
CONTRACTOR Existing bl area ( sq. ft ) • Business name: _ v � - New bldg. area (sq. ft.) -
.
Address: O �_ • Number of stories
r--:4113 . rc.. j ZIP: _ 0 • TYPc of construction
Phone: , , _ 0. . • r / E- l Occupancy group(s): Exi New: \
CCB no.:
City /metro lie. no.: Notice: All contractors and subcontractors ace required to be
ARCH ITECT/DESIGNER ` , ` licensed with the Oregon Consmtctioa Contractors Beard under ,
Name: 'I provisions of ORS 701 and may be required to be licensed in the
• � jurisdiction where work is being performed. If the applicant is
City: Addtess: Z55 i2�}1 ? 5C.27 Kl 'T • exempt from licensing, the following reason applies:
City: n AI 'State.: iffrizzr: 6418 I _
Contact • •rv. ,1 , / N Plan no.: . -
Phone' •§_e •75 -7- Fax -may . ; .. L'
L7Gli�EI3i
Contact person•. .r l j . Fees due upon application ._ $
Name:' PL. �., • , z . .
Address: Date received: _
State:. ZIP:. Amount received $
City: Please refer to fee schedule. • •
Phone:, Fax< E _
1 hereby certify I have read and examined this application and the ' prat &Otitis:Da:1ms amcpt watt , p can ju a foe :nom eafamv+ce.
anached checklist All provisions of laws and ordinances governing this 0 Visa 0 MasterCard / /
work will be comp!' •with, ere spe. ifi in or not canter cd °O° ,ice: •
Authorized sly : % .1 � -- Date: t✓2 Now or ar4Mtie u � m cecd:e c.rd
$
��°°°`
Print name: , a is ..sariFtj"_ Carebolder si art
Notice: This permit application expires if a permit is net obtained within 180 days after it has been accepted es complete. 444146t3 (F4
•
•
•
•
05/242[102 ` 12:26 SPACE AGE FUEL 4 9503525925E N0.562 D003
•
SITE WORK PERMIT CHECK LIST
Commercial, Multi - Family (R -1 occupancy) and Residential:
Please complete all items below, unless otherwise noted.
_Excavation Volume: 1 Z.,01:" cu. yds. J
Grading Volume:
Soils re. • rt re• uired for >5,000 cu. ds.) '4 I 00 cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) _ Z 9 0 cu.yds.
Retaining structure? (Check one) , ❑ Rock
• ❑ CMU
IV 0 ❑ Concrete
CJ Other
*Total new impervious area including all buildings, � 6y p sq ft.
sidewalks, andpaving:
Site Utilities Plumbing Work:
Complete the "TAN" Plumbing Permit Application for site utilities plumbing work.
• :pions Requireti:..$ee S Site WOrkPei tApplication -Plan Submittal
• Regirements attached, the :o1Iovwutg. must accompany this application:
din FDA and
•�: - Sife�? ,lar�:�nnttib/igiri'l�Map�w�' � "Paricing'('iriclu g )
i s
' iY
#. �$ -�� •.. Lig ht;ng-:Plen . � --
+ '.. h ` d" taiCs ?p • � � � tEehdtcap Plan
.
«.....;. ctlire
• ii Eros�or Coittrot`i?Ia' ;' rid ?details` . - t :Retaining SrU
q ui "reci) .
vi o. _ appro *ed
(s�iowmg`ionneCion fo:,
..�'°
• System) •
*Does not apply to 9 and 2- family dwellings.
•
•
i:\dstsVcrms\sitechecklist.dO 05131/01
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received `' 7 : Requeste M9 /a AM PM BUP
Location ! ,� Suite MEC
Contact Person Ph (_ 5. l7 2Z PLM
Contractor 424�4! Ph ( ) SWR
BUILDING Tenant/Owner .1t? ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain �
Slab Inspection Notes: SIT -- '0)6/ 0�O
C t 3
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
1 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:
Final
PASS PART FAIL
MECHANICAL -
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.
• —` PART FAIL
❑ Please call for reinspection RE: Unable to inspect – no access
re upply Line
ADA Date / 7 Th ' i.i Approach/Sidewalk ate 2 / 6 L ' / Inspector Ext
O' - - . -
;'''�'�� DO NOT REMOVE this inspection record from the Job site.
%1% PART FAIL