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Permit
CITY OF TIGARD MASTER PERMIT PERMIT #: MST2004 -00251 ;11; DEVELOPMENT SERVICES DATE ISSUED: 8/26/2004 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 SITE ADDRESS: 06614 SW PINE ST PARCEL: 1 S136AD -05400 SUBDIVISION: ZONING: R -4.5 BLOCK: LOT: JURISDICTION: TIG REMARKS: Convert garage into bedroom & bath. Mechanical fees included in building permit. BUILDING REISSUE: CUSTOM STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED CLASS OF WORK: ALT HEIGHT: FIRST: 308 sf BASEMENT: sf LEFT: SMOKE DETECTORS: Y TYPE OF USE: SF FLOOR LOAD: 40 SECOND: sf GARAGE: sf FRONT: PARKING SPACES : TYPE OF CONST: 5N DWELLING UNITS: THR sf RIGHT: VALUE: 4,000.00 OCCUPANCY GRP: R3 BDRM: 1 BATH: 1 TOTAL: 308 sf REAR: PLUMBING SINKS: WATER CLOSETS: 1 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS: LAVATORIES: 1 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS: TUB /SHOWERS: 1 GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS: OTHER FIXTURES: MECHANICAL FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: 1 CLOTHES DRYER: FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: ELECTRICAL RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS 1000 SF OR LESS: 0 - 200 amp: 1 0 - 200 amp: W/SVC OR FDR: 00 PUM P/IRRIGATION: PER INSPECTION: EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st IMOSVC/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 +amps- 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: $ 335.11 This permit is subject to the regulations contained in the HILLMAN, JONATHAN Tigard Municipal Code, State of OR. Specialty Codes 6614 SW PINE ST and all other applicable laws. All work will be done in TIGARD, OR 97223 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- 267 -5264 Phone: ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those Reg C: 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 Underfloor insulation Insulation Insp PLM /Underfloor Electrical Final Electrical Service Mechanical Final Electrical Rough In Plumb Final Framing Insp Final inspection , Al .i. I Agri Issued By : , Permittee Signature :. ��..� ..m...MI.. . Call (503) 639 -4175 by 7:00 p.m. for an inspection neede ' he next business day Building Permit Application FOR OFFICE USE ONLY City of Tigard Received e i , Qy / ! Permit No.: '---- /Q / ,U I 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Phone: 503.639.4171 Fax: 503.598.1960 Ai., +h Date/B : Other Permit: Inspection Line: 503.639.4175 . • y . - L. Date Ready/By: See Attached Checklist for Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information -'," . ' a TYPE OF. WORK::••`• . , .. .; : • REQUIRED DATA: I - 2= FAMILY1DWELLING ❑ 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:. ' - ":s • ' work indicated on this application. tgt 1- and 2-family dwelling Valuation: $ n O � -- y g ❑ CommerciaUindustrial t El Accessory building El Multi-family Number of bedrooms. f ❑ Master builder ❑ Other: Number of bathrooms: l `; • T - =`JOB SITE INFORMATION'AND LOCATION S.:• Total number of floors: Job site address: 6 6, 1 Lj sc.....) 7-, ^ C 5't e New dwelling area: 3 ®Q square feet City/State/ZIP: 1 ∎ Qo1� / o-- 9/ ZZ3 Garage/carport area: square feet Suite/bldg. /apt. no.: v Project name: Covered porch area: square feet Cross street/directions to job site: T-1- � P S-�re - � 3 5 (g - Deck area: square feet 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. 3 �► ` Valuation: $ Co n v e 1`� t!�r0. d"�1 e � A. �D 1: To 0." TN �1 Existing building area: square feet New building area: square feet . . ' ..PROPERTY OWNER . • - , - .0 TENANT . ' , . Number of stories: Name: rx 0 .A-V, . , 1 l M a , Type of construction: Address: C:,(0 i t.' ft.,...) 7.; ,2. A-re..e+ Occupancy groups: City/State/ZIP: ` ,,-4 dig.. 9'77-7-'3 Existing: Phone: 6b3) 2 4, _ 5 2.0 i Fax: ( ) New: Z pPLICANT r'❑ CONTACT PERSON' '' • PA , Y NOTICE' Business name: p 0 3 4 e.. All contractors and subcontractors are required to be Contact name: , ` 44; `l N` q n licensed with the Oregon Construction Contractors Board - f+ ti ti under ORS 701 and may be required to be licensed in the Address: 6 4 / 1.1 5 1 „,„..3 i ne. -r-eQ..4 jurisdiction in which work is being performed. If the City/ State/ZIP: , , ��! �� 2:2:" 7 applicant is exempt from licensing, the following reasons Phone: (503) 7G_ 5 2 Li Fax:: ( ) E -mail: • .• CONTRACTOR Business name: Q CO ? e BUILDING PERMIT - FEES* • :• , Address: Please refer to fee schedule. City/ State/ZIP: Fees due upon application Phone: ( ) Fax: ( ) Amount received CCB lie.: Date received: Authorized signature: Thi permit application expires if a permit is not obtained 66 within 180 days after it has been accepted as complete. Print name: ^ 4 I fl M ty ^ Date: pie, _24 ^ e t. * Fee methodology set by Tri-County Building Industry Service Board. i:\Building \Permits \BUP- PermitApp.doc 12/03 440.4613T(11/02/COM/WEB) One- and Two - Family Dwelling Building Permit Application Checklist FOR OFFICE USE ONLY City of Tigard Received Permit Na.: 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: Associated permits: Phone: 503.639.4171 Fax: 503.598.1960 M 24- Hour Inspection Line: 503.639.4175 j; • ❑ Electrical 0 Plumbing 0 Mechanical I Internet: www.ci.tigard.or.us ❑ Other: TH E 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. Name of district: . ❑ ❑ ❑ 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 Ore:on and shall be shown to be applicable to the .ro'ect under review. 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 and 22 above. ❑ ❑ ❑ 25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be 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 and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑ Street Tree List. 29 Site plan to include tree protection measures as required by conditions of approval. ❑ ❑ ❑ 30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ ❑ including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings • on a lot of record approved prior to September 9, 1995. i:\Building\Pemuts \One - Two- FarnilyChecklist.doc 12/03 Electrical Permit Application FOR OFFICE USE ONLY City of Tigard Datvsea Permit No.: ! T _OD 2 ( 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review / , Phone: 503.639.4171 Fax: 503.598.1960 l/theayt ,:'N ;\ Other Permit: Inspection Line: 503.639.4175 . 1 sI 11 Date/R p --4+i ,� Date Ready/By: fari%: ® See Page 2 for Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information . . , TYPE OF WORK . ' - ` , • -, - i'"; 'PLAN' REVIEW,: . • ❑ New construction .ddition/alteration/replacement Please check all that apply: ❑Demolition 0 Other: ❑Service over 225 amps, comm'l ❑Hazardous location ❑Service over 320 amps — rating ❑ Buildng over 10,000 sq. ft., • CATEGORY OF CONSTRUCTION _ % a "- ; '...:y, ` • ,',:..-..%!';'--• : of 1- and 2- family dwellings 4 or more new residential `�1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure ❑ Multi - family ❑Master builder ❑Other: ❑Building over three stories ['Feeders, 400 amps or more ❑Occupant load over 99 persons ['Manufactured structures or JOB SITE INFORMATION AND LOCATION - ❑Egress/lighting plan RV park �/ ? \ , ❑Health -care facility ['Other: Job no.: Job site address: (601 ei 510 tie Submit 2 sets of plans with any of the above. City/ State/ZIP: 1 e , r . c i 0V-- °r'7 °y`ZeS The above are not applicable to temporary construction service. Suite/bldg. /apt. no.: Project name: . FEE* _SCHEDULE:.,;: . D escription I Qty. I Fee. I Total Cross street/directions to job site: j� ' , 56..„ 7 f) 69 _ New residential single - or multi - family dwelling unit. { Includes attached garage. 1,000 sq. ft. or less 145.15 4 Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 1 Tax map /parcel no.: • Limited energy, residential 75.00 2 Limited energy, non - residential 75.00 2 DESCRIPTION OF WORK - ' Each manufactured or modular dwelling, service and /or feeder 90.90 2 C © & v L:'1 6 \)Q t A b 0 ••••■- 3 Services or feeders installation, alteration, and/or relocation 13■Dk 200 amps or less % 80.30 2 .eROPERTY OWNER ❑ TENANT - 201 amps to 400 amps 106.85 2 401 amps to 600 amps 160.60 2 Name: O W e•-• 601 amps to 1,000 amps 240.60 2 Address: Over 1,000 amps or volts 454.65 2 Reconnect only 66.85 2 City/ State/ZIP: Temporary services or feeders installation, alteration, and/or relocation Phone: ( ) Fax: ( ) 200 amps or less 66.85 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 2 Owner signature: Date: Branch circuits — new, alteration, or extension, per panel • ❑ APPLICANT ❑ CONTACT PERSON A. Fee for branch circuits with service or feeder fee, each Li 6.65 2 Business name: �1A3 ANA-- branch circuit B. Fee for branch circuits Contact name: without service or feeder fee, Address: each branch circuit 46.85 2 Each add'l branch circuit 6.65 2 City/ State/ZIP: Miscellaneous (service or feeder not included) Pump or irrigation circle 53.40 2 Phone: ( ) Fax:: ( ) Sign or outline lighting 53.40 2 E -mail: Signal circuit(s) or limited- • CONTRACTOR energy panel, alteration, or extension. Describe: Page 2 2 Business name: 0 tp..3s.@ Address: Each additional inspection over allowable in any of the above Per inspection 62.50 City/State/ZIP: Investigation per hour (1 hr min) 62.50 Phone: ( ) Fax: ( ) Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES* •. CCB Lic.: Electrical Lic.: Suprv. Lic.: Subtotal Suprv. Electrician signature, required: Plan review (25% of permit fee) Print name: Date: State surcharge (8% of permit fee) TOTAL PERMIT FEE Authorized signature: - - This permit application expires if a permit is not obtained within 1g0 77, days after it has been accepted as complete Print name: 3 eL a " 7¶ J,l t IM A 1 Date: os ... G D ti • Fee methodology set by Tri- County Building Industry Service Board 1 •• Number of inspections per permit allowed. is\ Building \Permits\ELC-PermitApp.doc 12103 4404615T(10/02/COM/WEB Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: Fee for all residential systems combined ... $75.00 Check Type of Work Involved: ❑ Audio and Stereo Systems* El Burglar Alarm ❑ Garage Door Opener* • El Heating, Ventilation and Air Conditioning System* El Vacuum Systems* ❑ Other: COMMERCIAL WORK ONLY: . Fee for each commercial system $75.00 (SEE OAR 918- 260 -260) Check Type of Work Involved: El Audio and Stereo Systems El Boiler Controls El Clock Systems El Data Telecommunication Installation El Fire Alarm Installation El HVAC El Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* • ❑ Medical El Nurse Calls El Outdoor Landscape Lighting* ❑ Protective Signaling El Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations i:\ Building \Pertnits\ELC- PennitApp.doc 04/03 Building Fixtures Plumbing Permit Application FOR OFFICE USE ONLY • City of Tigard Received ed Permit No J f - q_ 0 0aG2 / 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Other Permit No.: Phone: 503.639.4171 Fax: 503.598.1960 *AO Date/By: 24 Hour Inspection Line: 503.639.4175 jJ, • Juris: Internet: www.ciligard.or.us Date Ready/By: See Page 2 for 8 Notified/Method: Supplemental Information TYPE OF WORK ' - , FEE * SCHEDi7LE . . ❑ New construction ❑ Demolition For special information use checklist Description I Qty. I Ea. I Total Wddition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION - - SFR (1) bath 249.20 i SZ11- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00 El Accessory building ❑ Multi- family SFR (3) bath 399.00 • Each additional bath/kitchen 45.00 El Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 . , JOB SITE IN_ FORMATION AND LOCATION . " - Site utilities Job site address: C.& , / 5 T 1 ,e 5- ► Catch basin or area drain 16.60 City/State/ZIP: n q , ` g c � cl- 7'y'Z3 Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: �Ca I Project name: Footing drain (no. linear ft.: ) Page 2 Manufactured home utilities 110.00 Cross street/directions to job site: // q Manholes 16.60 L J t� . e 54- 3 6 / {� S4-><"@o'C� Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2 Fixture or item Tax map /parcel no.: Absorption valve 16.60 DESCRIPTION OF WORK - . ` V Backflow preventer Page 2 A..J G-..4-ne ∎ N � {r ® 0 s ..- Backwater valve 16.60 3 v Clothes washer 16.60 Dishwasher 16.60 ' `ROPERTY OWNER . 41 0 . TENANT Drinking fountain 16.60 Ejectors /sump 16.60 Name: ( "-e... r" Expansion tank 16.60 Address: Fixture/sewer cap 16.60 City/ State/ZIP: Floor drain/floor sink/hub 16.60 Phone: (. ) Fax ( ) Garbage disposal 16.60 - ❑ APPLICANT CI CONTACT PERSON Hose bib 16.60 Ice maker 16.60 Business name: r) 4s.) ^ Q 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: ( ) I Fax: : ( ) Sink/basin/lavatory I 16.60 Tub /shower /shower pan % 16.60 E -mail: Urinal 16.60 CONTRACTOR ' . -.'' • Water closet I 16.60 Business name: Dw C r Water heater 16.60 Address: Other: City/ State/ZIP: Subtotal Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 CCB Lic.: / Plumbin ic. no.: f Plan review (25% of permit fee) Authorized signature: - / j, I State surcharge (8% of permit fee) L TOTAL PERMIT FEE Print name: l 4 " ." ? ‘ � i . Ma^ Date: OQ,.� �, f This permit application expires if a permit is not obtained within ' ` VV 180 days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. i:\ Building \Pemtits\PLMF- PennitApp.doc 12/03 440- 4616T(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 . Footage: `" ' , • - 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 Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit Fee:..='' . . $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 Inspection of existing plumbing or each additional $100.00 or fraction thereof, to specially requested inspections - per hour 72.50 and including $50,000.00. Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for 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 New 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 Commercial Isometric or riser diagram is required if fixture quantity 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: i:\ Building \PemtiuWLM- PertnitApp.doc' 3/03 Mechanical Permit Application FOR OFFICE USE ONLY City Of'Tl g and Received Permit s► a� 7 � - � 4 `1 Date/By: /1/t J 1 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Other Permit: Phone: 503.639.4171 Fax: 503.598.1960 Ueir A,,,, ,�, DateBy: Inspection Line: 503.639.4175 � 1 Date Ready/By: Jum: El See Page 2 for Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information . .TYPE OF WORK . , : -•.,_, ... COMMERCIAL Z:EE* SCHEDULE = DSE CHECKLIST ❑ New construction Addition/alteration/replacement Mechanical permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit. . • CATEGORY OF CONSTRUCTION Value: $ . - RESIDENTIAL EQUIPMENT / SYSTEMS FEES* tiX1 and 2 family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist. ❑ Multi family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total JOB SITE INFORMATION AND LOCATION _- • Heating/cooling Job site address: l 0 &/� 54,....) l ' e S. e �� Air conditioning s se plan or heat placement) pump l , (requires si l showing 14.00 City/ State/ZIP: °T`��r_ 91 2_7.:S Furnace 100,000 BTU (ducts/vents) 14.00 Suite/bldg. /apt. no.: l , Project name: Furnace 100,000+ BTU (ducts/vents) 17.90 Gas heat pump 14.00 Cross street/directions to job site: s( „, ?y Int. , � e ) 6,C)4 Duct work 14.00 00 I Hydronic hot water system 14.00 Residential boiler (radiator or hydronic) - 14.00 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 10.00 Subdivision: Lot no.: ,. Flue/vent for any of above 10.00 Other: 10.00 Tax map /parcel no.: _ Other fuel appliances DESCRIPTION OF WORK , - Water heater 10.00 1 .,r a 3 Q ` i Gas fireplace 10.00 Cr, v e ? G- 4-a. P t A.k-o co.". " \)r) Flue vent for water heater or gas fireplace 10.00 Log lighter (gas) 10.00 Wood /pellet stove 10.00 Wood fireplace/insert 10.00 ','�'- OPERTY OWNER • : ❑ TENANT Chimney/liner/flue/vent 10.00 Other: 10.00 Name: 0 t.....1 , e j - . Environmental exhaust and ventilation Address: Range hood/other kitchen equipment 10.00 City/State/ZIP: Clothes dryer exhaust 10.00 Single -duct exhaust (bathrooms, Phone: ( ) Fax: ( ) toilet compartments, utility rooms) t 6.80 ❑ APPLICANT . ❑ CONTACT PERSON Attic /crawlspace fans 10.00 Other: 10.00 Business name: C) eN e �- - Fuel piping Contact name: $5.40 for first four; $1.00 for each additional Address: Furnace, etc. Gas heat pump City/State/ZIP: Wall/suspended/unit heater Phone: ( ) Fax: : ( ) Water heater • Fireplace _ E -mail: Range CONTRACTOR Barbecue Business name: ® Clothes dryer (gas) w n L s - Ot h er: Address: MECHANICAL PERMIT FEES* , ` City/State/ZIP: Subtotal Phone: ( ) Fax: ( ) — Minimum permit fee ($72.50) Plan review (25% of permit fee) CCB lic.: State surcharge (8% of permit fee) TOTAL PERMIT FEE Authorized Signature: - This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: ;e aLlA+,,k_ R* t Mq ^ Date: c ,,s ...'2,6 _ • Fee methodology set by Tri County Building Industry Service Board B i:\ uilding \Permits \ MEC- PemtitApp.doc 12/03 t u 440 -4617T (11 /02/COM/WB B) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial Fee Schedule: Total Valuation:' Permit Fee:: $1.00 to $2,000.00 Minimum fee $72.50 $2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and $1.80 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and $1.35 for each additional $100.00 or fraction thereof, to and including $50,000.00. $50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and $1.25 for each additional $100.00 or fraction thereof, to and including $100,000.00. $100,000.01 and up $1,396.50 for the first $100,000.00 and $1.10 for each additional $100.00 or fraction thereof. Note: All new commercial buildings require 2 sets of plans. i:\ Building \Permits\MEC- PermitApp.doc 12/03 2 Permit #: jvIS1' '1 - (90251 of - - Address: 6 61 5 w r Sr Issued by � Date: Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli- cants who are not registered with the Construction Contractors Board to sign the following statement before a building permit can be issued. This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from registration under ORS 701.010(7), need not submit this statement. This statement will be filed with the permit. Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B: 1. I own, reside in, or will reside in the completed structure. r FM 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale —"' before or upon completion. Ei 3A. My general contractor is (Name) Contractor regis. # I will instruct my general contractor that all subcontractors who work on the structure must be registered with the Construction Contractors Board. OR M ) , / 1 . I will be my own general contractor. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. If I change my mind and hire a general contractor, I will contract with a contractor who is registered with the CCB and will immediately notify the office issuing this building permit of the name of the contractor. I hereby certif that the above information is correct and that I have read and do understand the Information Notice to Pr erty 1 • ab u Co ction Responsibilities on the reverse side of this form. (Signature of permit applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant) Information Notice to Property Owners About Construction Responsibilities Note: This Information Notice to Property Owners about Construction Responsibilities was developed by the Construction Contractors Board in accordance with ORS 701.055(5). If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and areas of concern. EMPLOYER RESPONSIBILITIES: If you hire persons not registered with the Construction Contractors Board to do tabor in constructing or assisting in the construction or improvement of a residential structure, you will, in most instances, be ruled to be an employer and the people you hire will be employees. As the employer, you must comply with the following: Oregon's withholding tax law: As an employer, you must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Oregon Dept. of Revenue at 945 -8091. Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Division at the Department of Human Resources at 378 -3524. Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may be subject to penalties and will be liable for all claim costs if one of your employees is injured on the job. For more information, call the Workers' Compensation Division at the Department of Consumer and Business Services at 945 -7888. U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be liable for the tax payment even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service at 1 -800- 829 -1040. OTHER RESPONSIBILITIES AND AREAS OF CONCERN: Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements that may be brought to your attention through inspections. Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for accident.; and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be re -done. Time to supervise employees: Make sure you have sufficient time to supervise your employees. Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough -in and finish trades, and to notify building officials at the appropriate times so they can perform the required inspections. If you have additional questions, write or call the Construction Contractors Board (PO Box 14140, Salem, OR 97309 -5052, 503/378 - 4621). The Board is located at 700 Summer St. NE Suite 300, in Salem. prop- own.pm4 1 /94 CITY OF TIGARD 13125 S.W. HALL BLVD. TIGARD, OR 97223 IMPORTANT PERMIT NOTICE ELECTRICAL CONNECTIONS LLC PO BOX 875 NEWBERG, OR 97132 Electrical Signature Form Permit #: MST2004 -00251 Date Issued: 8/26/2004 Parcel: 1 S136AD -05400 Site Address: 06614 SW PINE ST Subdivision: Block: Lot: Jurisdiction: TIG Zoning: R -4.5 Remarks: Convert garage into bedroom & bath. Mechanical fees included in building permit. Your company has been indicated as the electrical contractor for the permit indicated above. In order for the electrical permit to be valid, the signature of the supervising electrician is required. Please have the appropriate individual from your company sign below and return this Electrical Signature Form prior to the start of the work to the address above, ATTN: Building Division. No electrical inspections will be authorized until this completed form is received OWNER: ELECTRICAL CONTRACTOR: HILLMAN, JONATHAN ELECTRICAL CONNECTIONS LLC 6614 SW PINE ST PO BOX 875 TIGARD, OR 97223 NEWBERG, OR 97132 Phone #: 503 - 267 -5264 Phone #: 503 - 538 -8033 • Reg #: LIC 149241 SUP 4715S ELE 36 -102S AN INK SIGNATURE IS REQUIRED ON THIS FORM x»/t9 Signature of Supervising Electrician If you have any questions, please call 503.718.2433. CITY OF TIGARD 24 -Hour - BUILDING Inspection Line: (503) 639 -4175 MST go?) LI -00 51 INSPECTION DIVISION • Business Lire:) (503) 639 -4171 BUP Received Date Requested 3=15— AM PM BUP Location (4 (a (L( f -&rLP _. Suite MEC Contact Person Ph ( ) PLM Contractor Ph ( ) SWR BUILDING Tenant/ ELC Footing of G{L7_-7 , 67 5-aG� ELC Foundation ` Ftg Drain Access: E -1- 3 ON— - rJ-1^ ELR Crawl Drain Slab Inspe tion Notes: SIT 9/ d Post & Beam p/c� Shear Anchors Ext Sheath/Shear /- .06) Int Sheath/Shear Framing Insulation Drywall Nailing �+��CA ` Firewall 1A '1 ) ) + r _ p i P tI D Fire Sprinkler 1 Fire Alarm Susp'd Ceiling Roof Other: „) �� V)) €;'‘) ILL -) 8 3 /L1 . F 6o tn C LOv i\ro P - ART FAIL PL 1 = ING Post & Beam Under Slab Rough -In C C Water Service Sanitary Sewer Rain Drains Catch Basin / Manhole ill Storm Drain Shower Pan Other: mai PART FAIL _ S MECHANICAL Post & Beam Rough -In Gas Line Smoke Dampers • anal _�;;_� PART FAIL E T Service Rough -In UG/Slab Low Voltage Fir; rm 0 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd. :1;i:1? PART FAIL SITE 0 Please call for reinspection RE: ❑ Unable to inspect — no access Fire Supply Line / / /- ADA Approach/Sidewalk Date oZ ' `c �C� Inspector '/ .�L1v / - Ext Other: Final DO NOT REMOVE this inspection record from t job site. PASS PART FAIL