Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENV 0 1 ,
lig
�,' Request Permit Action _ .
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigar or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor jg City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
i CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: rPS aD / 2,- O 5� /
Site Address or Parcel #: 115406 o Pte, Fr c_ /I-W'
Project Name: r2e7, /E y bt-
Subdivision Name: (� Lot #:
EXPLANATION: - D t,t.10 i_t 0_4 ff i ..2 -t 1 T — LoorLli PEA. ( i.7) a-
Signature: ft' Date: S/4 // 3
Print Name: ` - -1
Refund Pohcy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits pnor to any inspection requests.
2. Refunds will be returned to the onginal Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date V ®EM, Rte to Bld. Admin: Date Aa= B, �j ,
Refund Processed: Date w 4 By VA Invoice Processed: Date By
Permit Canceled: Date B .,ar� arcel Ta: Added: Date B
-
Receipt # Date Metho• Amount $
I: \ Building \ Forms \RegPermitAction.doc Rev 05/25/2012
CITY OF TIGARD. FIRE PROTECTION SYSTEM PERMIT
3 .' COMMUNITY DEVELOPMENT Permit 4: FPS2012 -00094
Date Issued: 06/27/2012
T lGARD 13125 SW Hall Blvd., Tigard OR.97223 503.718.2439 Parcel: 1S136D600201
Jurisdiction: Tigard
Site address: 11565 SW PACIFIC HWY
Project: Fred Meyer Subdivision: 2000 -025 PARTITION PLAT Lot: 2
Project Description: Fire suppression for (4) Type I hoods
Contractor: SD DEACON CORP OF OREGON Owner: FRED MEYER INC
901 NE GLISAN ST SUITE 100 3800 SE 22ND AVE
PORTLAND, OR 97232 PORTLAND, OR 97202
PHONE: 503 - 297 -8791 PHONE: 503 - 232 -8844
FAX: 503 - 297 -8997
FEES'
Description Date Amount
Specifics: Permit Fee - COM 06/20/2012 $285.12
12% State Surcharge - Building 06/20/2012 $34.21
Type of Use: COM Plan Review - Fire Life Safety - COM 06/20/2012 $114.05
Class of Work: ALT Type of Const: IIB Info Process /Archiving - Lg $2.00 (over 06/27/2012 $24.00
Occupancy Grp: M Height: ft 11x17)
Stories: 1
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard: .
•
Density: 0 Design Area 0 •
K Factor: 0
Commercial Fire Alarm System:
Fire Alarm Required: Alarm Type:
Pull Station Required: Smoke Detectors Req:
Battery Calcs Provided: Cut Sheets Required:
Total $457.38
Valuations: Required Items and Reports (Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $0.00
•
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 nter. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or ect questions to O C by ' g 503.232.1987 or 1.800.332.2344.
I ued By: 1� Permittee Signature: '
•
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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
Fire Protection System p FOR OFFICE USE ONLY
City of Tigard Rk am " Date/By: fl� 1� A Permit No.: M�4/1 ly
Ill =
°
13125 SW Hall Blvd., Tigard, OR 97223-I U N 2 U 2012 P lan Review ► � i +
Phone: 503.718.2439 Fax: 503.598.19 0 Date/By: : Other Permit:
TI G A R D Inspection Line: 503.639 CITY OF TIG��iD Date Ready/By: ,, Juris: ® See Page 2 for
Internet: www.tigard - or.gov 1 No' d/Method: _ Supplemental Information
BUILDING DIVISION • li e.....,
TYPE OF WORK ' REQUIRED DATA: 1- AND 2- FAMILY DWELLING f* f
Permit fees* are based on the value of the work performed. "
❑New construction ❑Demolition I 1 r
Indicate the value (rounded to the nearest dollar) of all 1 I
® Addition/alteration/replacement El Other: equipment, materials, labor, overhead, and the profit for the h
CATEGORY OF CONSTRUCTION
work indicated on this application.
V
I
aluation: $
❑ 1- and 2- family dwelling ® Commercial/industrial
❑ Accessory building ❑ Multi- family Number of bedrooms: i
Cl T.
Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION To number of floors:
Job site address: 11565 SW Pacific Hwy New dwelling area: square feet l p,
City/State /ZIP: Tigard, OR 97223 Garage /carport area: square feet 01
IN
Suite/bldg. /apt. no.: Project name: Fred Meyer #375 Covered porch area: square feet i '
Cross street/directions to job site: Intersection of 72°d and Hwy 99 Deck area: square feet ,.
Other structure area: square feet i+
REQUIRED DATA: COMMERCIAL -USE CHECKLIST 1 t
Subdivision: I 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.
Fire suppresion system within commerical kitchen hoods Valuation: $19,579
Existing building area: square feet
New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City/State /ZIP: Existing:
g
Phone: ( ) Fax: ( ) New:
❑ APPLICANT ® CONTACT PERSON NOTICE
Business name: 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: ( ) Fax:: ( )
E -mail:
CONTRACTOR BUILDING PERMIT FEES*
(Please refer to fee schedule)
Business name: S.D. Deacon Corp. of Oregon
Permit fee:
Address: 901 NE Glisan St, Suite 100
City/State /ZIP: Portland, OR 97232 State surcharge (12% of permit fee):
FLS plan review (40% of permit fee):
Phone: (503) 297 -8791 I Fax: (503) 297 -8997 (Due upon application.)
CCB lic.: ( ? j y394 Total permit fees:
Authorized signature: ( / Amount received: A/ i
".::�� This permit application expires if a permit is not obtained
Print name: Ovs GI L6 Date: G /zcv( '2_ within 180 days after it has been accepted as complete.
* Fee methodology set by Tri -County Building Industry
Service Board.
t:\BuildingWermits \FPS- PermitApp.doc Rev 01/05/2012 440 4613T(11/02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2 - Supplemental Information
Describe work to be done:
1.) ❑ New 2.) Modification to sprinkler heads only:
❑ Addition ❑ 1 -10 heads: No plan review required.
❑ Alteration ❑ 11+ heads: Plan review required.
❑ Repair
Number of sprinkler heads:
Additional description of work:
Type of System (Complete A, B, C or D as applicable): •
A.) Commercial Sprinkler
❑ Wet ❑ Dry
Additional Standpipes
Information: Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) e I - Hood Fire Suppression System
Ho Project Valuation: $
1
C.) Fire Alarm
Submittal shall Battery Calculations ❑ Yes
include: Individual Component ❑ Yes
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $
FLS Plan Review (40% of permit fee): $
TOTAL: $
Plan review requires a completed application and three (3) sets of plans at submittal.
Plan review fees are required at submittal.
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