Permit ,l, `( MASTER PERMIT
C I T OF T rG A R D PERMIT #: MST2004 -00063
rr* DEVELOPMENT SERVICES DATE ISSUED: 6/1/2004
I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639.4171
SITE ADDRESS: 09580 SW PIHAS ST PARCEL: 1S135CD-14100
SUBDIVISION: GREENBURG PINES ZONING: R
BLOCK: LOT: 012 JURISDICTION: TIG
REMARKS: New SF detached. .
BUILDING
REISSUE: M -2760 STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED '
CLASS OF WORK: NEW HEIGHT: 24 FIRST: 1,409 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 1,381 sf GARAGE: 420 sf FRONT: 20 PARKING SPACES : 2
TYPE OF CONST: 5N DWELLING UNITS: 1 THRD: sf RIGHT: 5
VALUE: 269
OCCUPANCY GRP: R3 BDRM: 3 BATH: 3 TOTAL: 2,790 sf REAR: 15
PLUMBING
SINKS: 1 WATER CLOSETS: 3 WASHING MACH: 1 LAUNDRY TRAYS: 1 RAIN DRAIN: 100 TRAPS:
LAVATORIES: 5 DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: 100 SF RAIN DRAINS: 1 CATCH BASINS:
TUB /SHOWERS: 2 GARBAGE DISP: 1 WATER HEATERS: 1 WATER LINES: 100 BCKFLW PREVNTR: GREASE TRAPS:
• OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: 4 CLOTHES DRYER: 1
GAS FURN > =100K: 1 UNIT HEATERS: HOODS: 1 OTHER UNITS: 1
MAX INP: btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: GAS OUTLETS: 4
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 1 0 - 200 amp: 0 - 200 amp: W/SVC OR FDR: PUMP/IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 5 201 - 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: IN PLANT:
MANU HM/SVC /FDR: 601 - 1000 amp: 601 +amp3- 1000v. MINOR LABEL:
1000+ amp/volt : '
PLAN REVIEW SECTION
Reconnect only:
>=4 RES UNITS: SVC /FDR > =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL - RESTRICTED ENERGY -
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO &'STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE.SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 7,865.88
VISTA NORTHWEST VISTA NORTHWEST INC This permit is subject to the regulations contained in the
VI I RTH BOX NORTHWEST
P BOX 91459 Tigard Municipal Code, State of OR. Specialty Codes
V
PORTLAND, OR 97291 PORTLAND„ OR 97291 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 the
work is suspended for more than 180 days.
Phone: 503 0531 - 0505 Phone: 503 - 531 - 0505 ATTENTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those
Reg #: LIC 75507 rules are set 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
Ersn Cntrl 681 -4444 Post/Beam Mechanical . Plumb Top Out Exterior Sheathing Insr Gyp Board Insp Appr /Sdwlk Insp
Sewer Inspection Underfloor insulation Electrical Service Low Voltage Rain drain Insp Electrical Final
Footing Insp Crawl Drain /Backwater Electrical Rough In Gas Line Insp Storm drain Insp Mechanical Final
Foundation Insp PLM /Underfloor Framing Insp Gas Fireplace Water Line Insp Plumb Final
Post/B- - -- - . - _ ral Mechanical Insp Shear Wall Insp Insulation Insp Water Service Ins! Building Final
C
Is . ued By : 11110 ° AO _L. _i • Permittee Signature :. i ( �1
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the next business day
FOR OFFICE USE ONLY
B� Per . -� i' . 17, 1 Received ®�� Building
Date/B : ! Permit No.: vr„#'/r /I d /
/
City of Tigard FEB 18 2004 Planning Approval Other
Date/By: Permit N it 60
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 CITY OF TIGARD
Date/By: Permit No.:
Phone: 503 - 639 - 4171 / i r� Post- Review Land Use
I#�fl�dg+l�l''�I Date/By: Case No.
Internet: www.ci.tigard.or.us Contact .1i_jac.i ® See Page 2 for
24 - hour Inspection Request: 503 639 - 4175 Name/Method: / /gp Supplemental Information
TYPE OF WORK REQUIRED DATA:
-e'ew construction ❑ Demolition 1 & 2 FAMILY DWELLING
❑ Addition/alteration/replacement ❑ Other:
f
CATEGORY OF CONSTRUCTION , Note: Permit fees* are based on the total value of the work performed. Indicate
& 2- Family dwelling ❑ Commercial/Industrial the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
❑ Accessory Building ❑ Multi - Family
❑ Master Builder ❑ Other: Valuation $
JOB SITE INFORMATION and LOCATION No. of bedrooms: No. of baths: cZ
,......- ,,,, J—
Job site address: / Total number of floors
f.
Q �� /� /��9 �'e' New dwelling area (sq. ft .) 7 . O
Suite #: 1 Bldg. /Apt. #: Garage /carport area (sq. ft.) 7...A ......
Project Name: Covered porch area (sq. ft.) / 420
Cross street/Directions to job site: Deck area (sq. ft.)
Other structure area (sq. ft.)
REQUIRED DATA:
- COMMERCIAL - USE CHECKLIST
Subdivision , 13c/ RAM Lot #: /,2
Tax map /parcel #: Note: Permit fees* are based on the total value of the work performed. Indicate
DESCRIPTION OF WORK the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
Valuation $
— Existing building area (sq. ft.)
New building area (sq. ft.)
Number of stories
❑ PROPERTY OWNER - ( ❑ TENANT Type of construction
Name: ,s ,4/22m Occupancy group(s): Existing:
New:
Address: P.�x 9/ y�
City/State/Zip/722 ' a 2/
Phone: f �� Fax: NOTICE: All contractors and subcontractors are required to be
❑ APPLICANT El CONTACT PERSON licensed with the Oregon Construction Contractors Board under
provisions of ORS 701 and may be required to be licensed in the
Business Name: 9� jurisdiction where work is being performed. If the applicant is exempt
Contact Name: from licensing, the following reason applies:
Address:
City /State /Zip:
Phone: I Fax:
BUILDING PERMIT FEES*
E -mail Please refer to fee schedule.
CONTRACTOR
Business Name:
5�� Fees due upon application $
Address:
City /State /Zip: Amount received $
Phone: I Fax: • Date received:
CCB Lic. #: 7
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: /�_ ate;��� 180 days after it has been accepted as complete.
*Fee methodology set by Trl -County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms\B1dgPermitApp.doc 01/03
l
One- and Two - Family Dwelling
• ; ,y
Building Permit Application Checklist Reference no.:
City of Tigard City of Tigard Associated permits:
b ❑ Electrical U Plumbing O Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 ❑ 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 ❑ plan ❑ 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 revi .
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. 440.4614 (6/00/COM)
• FOR OFFICE USE ONLY
Mechanical Permit Application Received Mechanical ,!
RECEIVED P anning PermitNo.:N�r0�7' e63 ate/By:
Building
Planning Approval
City of Tigard Date/By: Permit No.:
13125 SW Hall Blvd. FEB 1 8 2004 Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503 -639 -4171 tit-14160§0 Post- Review land Use
(FAY / /dmit 1� ' ( Date/By: Case No.:
Internet: www.ci.tigar ING QI�/ : ION - e Contact _furls.: ® See Page 2 for •
24 -hour Inspection Request: 03- b39-41 /5 Name/Method: Supplemental Information.
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST .
.New construction ❑ Demolition Mechanical permit fees* are based on the total value of the work
❑ Addition/alteration/replacement ❑ Other: performed. Indicate the value (rounded to the nearest dollar) of all
CATEGORY OF CONSTRUCTION mechanical materials, equipment, labor, overhead and profit.
& 2- Family dwelling ❑ Commercial/Industrial Value: $ See Page 2 for Fee Schedule
❑ Accessory Building ❑ Multi- Family _ RESIDENTIAL EQUIPMENT /SYSTEMS FEE* SCHEDULE
Description I Qty I Fee(ea.) I Total
❑ Master Builder ❑ Other: Heating/Cooling
JOB SITE INFORMATION and LOCATION Furnace - add -on air conditioning ** 14.00
Job site address: ,',5'7,■:::, `� /' / J ./ 2: , / fi _ Gas heat pump 14.00
Suite #: Bldg. /Apt. #: Duct work 14.00
Project Name: Hydronic hot water system 14.00
Residential boiler
Cross street/Directions to job site: (for radiator or hydronic system) 14.00
Unit heaters (fuel, not electric)
(in wall, in -duct, suspended, etc.) 14.00
Flue /vent (for any of above) 10.00
Repair units _ 12.15
Subdivision: _ i r ., _Ai_ Ot #: _ Other Fuel Appliances
_ _ - _ Tax map /parcel #: _ Water heater 10.00
DESCRIPTION OF WORK Gas fireplace 10.00
Flue vent (water heater /gas fireplace) 10.00
Log lighter (gas) 10.00
Wood/Pellet stove 10.00
Wood fireplace/insert 10.00
Chimney/liner /flue/vent 10.00
❑ PROPERTY OWNER I 0 TENANT Other: 10.00
Name: Environmental Exhaust & Ventilation •
�4 S� — �� Range hood/other kitchen equipment 10.00
Address: /3 7/ )'S? Clothes dryer exhaust 10.00
City /State /Zip: F 99,/ Single duct exhaust
Phone: ,57T/ -OSC:,-5 Fax: (bathrooms, toilet compartments,
0 APPLICANT ❑ CONTACT PERSON utility rooms) 6.80
Name: ---CB- Attic/crawl space fans 10.00
Other: 10.00
Address: • Fuel Piping
City /State /Zip: * *($5.40 for first 4, $1.00 each additional)
Phone: I Fax: Furnace, etc. **
Gas heat pump **
E -mail: Wall/suspended/unit heater **
CONTRACTOR Water heater **
Business Name:5i /A,��<.) Fireplace **
Address: Z1'2y. .5' / Range **
City /State /Zip: ) 7Z 7 72"6 Clothes dryer (gas) **
Phone:75 — 77>?9I Fax: Other: **
CCB Lic. #: yg . Total:
Authorized Mechanical Permit Fees* •
Signature: Date: / �� Subtotal: $
`� Minimum Permit Fee $72.50 $
�e /.� , . / �2_ l � Plan Review Fee (25% of Permit Fee) $
/ (Please print name) State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Notice: This permit application expires if a permit is not obtained within *Fee methodology set by Tri -County Building Industry Service Board.
180 days after It has been accepted as complete. * *Site plan required for exterior A/C units.
i:\Dsts\Permit Forms\MecPermitApp.doc 01/03
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial Fee Schedule:
Total Valuation: Permit Fee:
$1.00 to $5,000.00 Minimum fee $72.50
$5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52
for each additional $100.00 or fraction
thereof, to and including $10,000.00.
$10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and
$1.54 for each additional $100.00 or
fraction thereof, to and including
$25,000.00.
$25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and
$1.45 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,001.00 and up $742.00 for the first $50,000.00 and
$1.20 for each additional $100.00 or
•
fraction thereof.
Assumed Valuations Per Appliance:
Value Total
Description: Qty (Ea) Amount
Furnace to 100,000 BTU, including 955
ducts & vents
Furnace > 100,000 BTU including ducts 1,170
& vents
Floor furnace including vent 955
Suspended heater, wall heater or floor 955
mounted heater
Vent not included in appliance permit 445
Repair units 805
< 3 hp; absorb. unit, 955
to 100k BTU
3 -15 hp; absorb. unit, 1,700
101k to 500k BTU
15 -30 hp; absorb. unit, 501k to 1 mil. 2,310
BTU
30 -50 hp; absorb. unit, 3,400
1 -1.75 mil. BTU
>50 hp; absorb. unit, 5,725
>1.75 mil. BTU
Air handling unit to 10,000 cfm 656
Air handling unit >10,000 cfm 1,170
Non - portable evaporate cooler 656
Vent fan connected to a single duct 446
Vent system not included in appliance 656
permit
Hood served by mechanical exhaust 656
Domestic incinerator 1,170
Commercial or industrial incinerator 4,590
Other unit, including wood stoves, 656
inserts, etc.
Gas piping 1-4 outlets 360
Each additional outlet 63
TOTAL COMMERCIAL $
VALUATION:
is \Dsts\Permit Forms\MecPermitAppPg2.doc 01/03
• FOR OFFICE USE ONLY
• Electrical Permit Application Received Electrical
Date/By: Permit No.. ° / "' AV 63
City of Tiga . G CE` V r ED • Planning Approval Sign
Ir Date/By: Permit No.:
13125 SW Hall Bl Plan Review Other
Tigard, Oregon 97223 . rQ 1 8 2004 Date/By:
Phone: 503- 639 -4171 Permit No.: -
1? S03 598-
A � 0 Oaeo,di�� (ti\ Post - Review Land Use
Date/By: Case No.:
Internet: www.ci.tigar 16 pF T IO ,I I I ® See Page 2 for
[� ■ e . Contact Jur
24 -hour Inspection Reg tp�g�,��JJd Name/Method: Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
❑ Addition/alteration/replacement ❑ Other: ❑ Service over 320 amps - rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
�& 2- Family dwelling ❑ Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit _ sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: 9, g€ LIJ,,iff}S. 5'i FEE* SCHEDULE
Suite #: I B ldg. /Apt. #: Number of inspections per permit allowed
Project Name: Description Qty Fee (ea.) Total !
Cross street/Directions to job site: New residential-single i t.a nc ln d e or multi-family per
dwelling unit. Includes attached garage.
Service included:
• 1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Limited energy, residential 75.00 2
SubdivisiOn: ,t/ /3zi, e; /i?yt/ I Lot #:/ Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
Services or feeders - installation,
alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTY OWNER 1 ❑ TENANT 601 amps to 1000 amps 240.60 2
f .,..57-:,4 1 - /t/ , /� Over amps or volts 454.65 2
Name: Reconnect nnect ect only 66.85 2
Address: /3 , 5' /ye_ Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: p 9l.Z,V 200 amps or less 66.85 I
"
Phone: • Fax: • 201 amps to 400 amps 100.30 2
❑ APPLICANT ❑ CONTACT PERSON Branch n h circuits amps 133.75 2
Branch circuits -new, alteration, or
Name: /7 5 , j_i AI E--- extension per panel:
A. Fee for branch circuits with purchase of
Address: 2j ?/Q sl/J /'9,4 1// service or feeder fee, each branch circuit 6.65 2
City/State /Zip: - 1,41&, S zE: ,d7,e -7/z -3 B. Fee for branch circuits without purchase of
service or feeder fee, first branch circuit 46.85 2
Phone :14/2 -- Z gee 25) I Fax: Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: Signal circuit(s) or a limited energy panel,
Business Name: alteration, or extension Page 2 2
���SS �_. ., -- ° /(' Description:
Address: 2,3 g/4:::, ,�,i9, ,C,(,/
/y Each additional inspection over the allowable in any of the above:
City/State /Zip: 4/� C7 9%Z 3 Per inspection per hour (min. 1 hour) 62.50
Phone: e 44/2 —2 Fax: Investigation fee:
CCB Lic. #: //1 � // , Lic. y_ t�3�'t� Other: *
Electrical Permit Fees
Supervising electr Subtotal $
signature required: - " Plan Review (25% of Permit Fee) $
Print Name; ,,: L #:
ic. , z ,. 5' State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: . — �_, -- / Date 180 days after It has been accepted as complete.
*Fee methodology set.by Tri -County Building Industry Service Board.
(Please print name)
i:\Dsts\Petmmit Forms\ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems , $75.00
Check Type of Work Involved:
E] Audio and Stereo Systems
▪ Burglar Alarm
Garage Door Opener
❑ Heating, Ventilation and Air Conditioning System
Vacuum Systems
• Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918- 260 -260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
Boiler Controls
Li Clock Systems
❑ Data Telecommunication Installation
El Fire Alarm Installation
HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
• Landscape Irrigation Control
• Medical
El Nurse Calls
• Outdoor Landscape Lighting
El Protective Signaling
Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
i:\Dsts\Permit Forms \ElcPermitAppPg2.doc 01/03
. Building Fix CElv E D .,
Plumbing Pea Xpplication ' FOR OFFICE USE ONLY
City of Tigard 1. 8 2004 Received qg
h' g ca Date/By: - (p 61 Permit No.: N..4, n 43
13125 SW Hall Blvd., Tigard, (�i 9 OR 97223 (GARS Plan Review
QZ
Phone: 503.639.4171 Fax ((� .-- / /pr
■ ri c.�l y �� � + I Date/By: Other Permit No.:
24 Hour Inspection Line:A�l�( pIViSIO N Date Ready/By: Sara:
5 � JJ'"` o Supplemental See Page for
Internet: www.ci.tigard.o . Notified/Method: Supplemental l Information
,,� TYPE OF WORK FEE* SCHEDULE
"[_i sew construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
. CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 915 7 sle) w,v7.9� Catch basin or area drain 16.60
City/State/ZIP: , I Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivisioj • ,,Z30/4".00- S. I Lot no./0•7_ Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
ROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: f4s���A/�� Expansion tank 16.60
Address: ` / j. , g Vs Fixture/sewer cap 16.60
City/State/ZIP: j' < L 7 2..-__.2.9/ Floor drain /floor sink/hub 16.60
Phone: �
( ) �3l oc.5 D 1 Fax: ( ) Garbage disposal 16.60
JJJ
❑ APPLICANT Hose bib 16.60
❑ CONTACT PERSON
' Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 1 6.60
Business name: i��� d3,/��e.../,,te gyp( Water heater 16.60
Address: �d��0,/T4� „1e ' Other:
City/State/ZIP: 2 Subtotal
- - /�� Mini mum permit fee: $72.50
Phone: ( ) 53 1-37 8 Fax: ( ) Residential backflow minimum permit fee: $36.25
Plan review (25% of permit fee)
CCB Lic.: . 45 - 4 :• _. Plumbing Lic. no.Sa ye7 State surcharge (8% of permit fee)
Authorized signature: :31: /
�
_ ^ TOTAL PERMIT FEE
Print name: - - • ' .5 ! Date: AO f6 This permit application expires if a permit is not obtained within
. 7.. ��C
180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
i:\Building\Permits\PLMF- PermitApp.doc 12/03 440 - 4616x(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard •
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1" 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
•
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 _ and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by (Fixture) Work Performed
Fixture Type: Replace
Na , Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
-3 „
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory Quantity Total
- Bradley _ Isometric or riser diagram is required if fixture quantity
- Commercial
Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
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CITY OF TIGARD 24 -Hour . •
BUILDING Inspection Line: (503) 639 -4175 MST X60 (
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date ' -que ed 1 / /g AM PM BUP
OO �
Location s0 / Suite MEC
Contact Person � Ph ( ) 0,R o - 6?-37 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
ELC
Foundation
Ftg Drain Access: ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear a
Framing
Insulation s � � , A'"
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:
( ��ART 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.
PASS PART FAIL
SITE Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line X
ADA `�
Approach/Sidewalk Date U f'J Inspector Ext
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 MST0 -0
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Requested U AM PM BUP
Location C f Suite MEC
Contact Person Ph ( ) (- 1 (- 12- z g06) PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing ELC.
Foundation Access:
Ftg Drain 6d/ 6) 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
497
- 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
41 tiii) PART FAIL Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
SITE Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line /
ADA 1 ,7 ks d
Approach/Sidewalk Date / Inspect° ����a
Other:
Final DO NOT REMOVE this Inspection record from the Job ite.
PASS PART FAIL
CITY OF TIGARD 24 -Hour •
BUILDING Inspection Line: (503) 639 -4175 MST L d o -
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received / Date R quested � AM PM BUP
Location 5 Suite MEC
Contact Person Ph ( ) 7.2o— 6cz 37 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Ftg Drain Access: / ' [_,(
Crawl Drain `� / / x / � � ELR
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear / )
Framing % > i..0 prP rc,/14.s. OA (-
Insulation cA..1 '77 -1 (
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
LASS ?ART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
T FAIL
MECHANIC
Post & Beam
Rough -In
Gas Line
Smoke Dampers
PAW 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 Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line
ADA / Z / 6 ---e
Approach/Sidewalk Date Inspector • Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL