Permit i,
Y'
CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2003 -00508
���I, DEVELOPMENT SERVICES DATE ISSUED: 10/30/03
�' ---' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 13006 SW ROCKINGHAM DR PARCEL: 2S104DB -03300
SUBDIVISION: AMESBURY HEIGHTS ZONING: R -4.5
BLOCK: LOT: 033 JURISDICTION: TIG
REMARKS: Convert crawlspace into habitable space.
BUILDING
REISSUE: CUSTOM STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ALT HEIGHT: FIRST: sf BASEMENT: 810 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: 1 THIRD: sf RIGHT:
VALUE: q0 000 00
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 0 sf REAR:
PLUMBING
SINKS: WATER CLOSETS: 1 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 1 DISHWASHERS: FLOOR DRAINS: 1 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: 2 WOODSTOVES: GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 - 200 amp: 0 - 200 amp: W /SVC OR FDR: PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/O SVC/FDR: 00 SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EAADDL BR CIR: 1.00 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: LANDSCAPEIIRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL 8 SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 899.11
This permit is subject to the regulations contained in the
SMITH, RYAN OWNER Tigard Municipal Code, State of OR. Specialty Codes and
13006 SW ROCKINGHAM 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. ATTENTION:
Oregon law requires you to follow rules adopted by the
Phone: 203 590 - 9097 Phone: Oregon Utility Notification Center. Those rules are set
forth in OAR 952- 001 -0010 through 952 - 001 -0080. You
Reg p: may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Footing lnsp Electrical Rough In Plumb Final
Foundation lnsp Framing lnsp Final inspection
Slab lnsp Insulation lnsp
Mechanical lnsp Electrical Final
Plumb Top Out Mechanical Final
/ ,� //),
Issued By l /t . ✓L , �f Permittee Signature : �' /�;lor e.
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the n busi e ss day
l to 1 /0- x. 7 - °3 .
•
4 7 . Building Permit a� OFFICE USE ONLY
� City of Tigard OCT ` 003 Date received: I Permit no.: S e . p . r
�
Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tig Ql� 972 ARD
Phone: (503) 639 - 4171 Y OF T� Date issued: By:c6 Receipt no.: d
Fax: (503) 598 - 1960 BUILDING DIVISION
Case file no.: Payment type:
Land use approval: — 776i 1 &2 family: Simple Complex: Q`
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial /industrial ❑ Multi- family ❑ New construction ❑ Demolition
XAddition/alteration /replacement ❑ Tenant improvement ❑ Fire sprinkler /alarm ❑ Other:
. f
JOB SITE INFORMATION
Job address: 1300 6, $ L ., pi, uc. f416 H4 1712_1 vE Bldg. no.: Suite no.:
Lot: 3' j I Block: I Subdivision: API E 13 ..lay /7-1 Ge/rs I Tax map /tax lot/account no.: 1ZZ 0 b g 133
Project name: 5;0 ir7 jz- S/ 1>EiNt;� ,2-;e/"
\� Description and location of work on premises /special conditions: Gvn/V --r 413,/?-""'V. BOO Sc ?-1" OF Tj,� -S eam y ._
A)
OWNER FOR SPECIAL INFORMATION, USE CHECKLIST c
Name: Fyn jc • s 1 TL/ (Floodplain, septic capacity, solar, etc.) O''
r Mailing address: i 3 0 U6 S t.--> 7 (_ - I N 514, 1 i4.1 PR_ 1 & 2 family dwelling:
ity: T � ,q �i J State: pit_ I ZIP: `i - 7z 2-7 Valuation of work $ 4O, 000
v) Phone: 59 0 - 9 d9 7 I Fax: it 0- i E -mail: N. No. of bedrooms/baths I
Owner's representative: d../o, Total number of floors I
Phone: Fax: E -mail: New dwelling area (sq. ft.) I I)
APPLICANT Garage /carport area (sq. ft.) /ti /C(
Name: / 'y#..., Ge • _S Covered porch area (sq. ft.)
Mailing address: /3 006 SW P- vccc .•e, iv 1-3_, p,2-, Deck area (sq. ft.)
City: Ty 6.4-1e..6;, I State: dE I ZIP: 9'72-2-7 Other structure area (sq. ft.)
Phone: 5' - 047 Fax: SA I E -mail: w /ot Commercial /industrial /multi- family: �
CONTRACTOR Valuation of work $
Existing bldg. area (sq. ft.)
Business name: gyrf'rr K• S rw ltL Qid ,,1__fZ New bldg. area (sq. ft.)
Address: i 3 dJ(2 c, (,) 12.-t7GlC I vt5 N ✓7i A21Vc Number of stories
City: 77 1 I State: oil I ZIP: `)12 7.---7
Type of construction
Phone: Ste/ 0- 4 0 9 7 I Fax: "4... I E -mail: e.--/ex
CCB no.: •. 1/4.- Occupancy group(s): Existing:
New:
City /metro lie, no.: 4- Notice: All contractors and subcontractors are required to be
ARCHITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: 50/-1,.1 Fi /./,‘-e..(41.. 4 - 2Ly,rEG7 provisions of ORS 701 and may be required to be licensed in the
Address: 3zZ3 S ht kiri-1 ?o PA'g-taw Ay jurisdiction where work is being performed. If the applicant is
City: T%oR- L rJ p State:OR I ZIP: 9'71-0 l exempt from licensing, the following reason applies:
E /0141 eiv N e / S 7)A,( , 6riv esf_4-C_
Contact person: �.1./.J n t i K t El¢ Plan no.: p /a C-0 xofq.u . (-2 ,./i t-✓1 door .
Phone: 2y8- D617 Fax: 22 E -mail: Ito.
. ENGINEER OFFICE USE ONLY
Name:4%0414 -7CD CONIW i OrrS Contact person: )/46 -A aFH Fees due upon application $
Address: 5;19 5 (nt kicsr pia, 5t.. 1 r 7- y r Date received:
City: pv,>' j L State: O1 ZIP: g 22.. 1 Amount received $
Phone: ?6 cl 0 N6 0 I Fax: E-mail: 3 .Ey_ bc/s1 K /a Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached checklist. All provisions of laws . ■ ordinances governing this ❑ Visa ❑ MasterCard
work will be complied wit r • eth:- :. fi • d herein or not. Credit card number: I /
Expires
Authorized signature: . ' ,'`ir a ate: / 4 /6/0 Name of cardholder as shown on credit card
Print name: gy,ir L• 'M► IrA-/ $
Cardholder signature Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440 -4613 (6/00/COM)
• ate •
•
Electrical Pe mit Application OFFICE USE ONLY
received: Permit no.:lfYls'Ja.� 5 ®Q / ►
t "'
Iii City of Tigard ° � � Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW Hall BlVOCITgard,,OR 97223 Date issued: By: Receipt no.:
Phone: (503) 639 -4171 2003
Fax: (503) 598 - 1960 CIT Case file no.: Payment type:
Land use approval: 8tELDIN D
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory 0 Commercial /industrial 0 Multi- family 0 Tenant improvement
0 New construction ;Addition /alteration /replacement ❑ Other: ❑ Partial
JOB SITE INFORMATION
Job address: 13 006, s .1 1 - - /h 6 W4.1 7,g, Bldg. no.: Suite no.: Tax map /tax lot/account no.: RZO(,, )33
Lot: 33 I Block: 'Subdivision: 4MFSi v/ y lief 6 a rr
Project name: ACM D/) E L I Description and location of work on premises: >S St-/ 1"/ 0 rq pr $04- Sewleti -f'
Estimated date of completion /inspection: Jq,..t ./' A r i z L. 2-00 (.-
CONTRACTOR APPLICATION ' FEE SCHEDULE
Job no: Fee Max
Business name: Description Qty. (ea.) Total no. ins p
Address: New residential - single or multi-family per
dwelling unit. Includes attached garage.
' City: I State: I ZIP: Serviceincluded:
Phone: I Fax: I E -mail: 1000 sq. ft. or less 4
CCB no.: I Elec. bus. 11 C. no: Each additional 500 sq. ft. or portion thereof
Limited energy, residential 2
City /metro lic. no.: Limited energy, non - residential 2
Each manufactured home or modular dwelling
Signature of supervising electrician (required) Date Service and/or feeder 2
Sup. elect. name (print): License no: Services or feeders — installation,
alteration or relocation:
PROPERTY OWNER 200 amps or less 2
Name (print): gyro-1 / e-, s' / 1 o (ie..)&112._ 201 amps to 400 amps 2
Mailing address: l3 0 0 6 544 t`— 0 441.4 N 5 4' - ry, D 401 amps to 600 amps 2
601 amps to 1000 amps 2
City: -rl (-4P-43 I State: 02 I ZIP: 9'7 Z2 3, Over 1000 amps or volts 2
Phone: 51 0 • 9 05 7 I Fax: It (e. I E -mail: a. /A Reconnect only I
Owner installation: The installation is being made on property I own Temporary services or feeders -
which is not intended for sale, lease, re or exchange according to installation, alteration,orrelocation:
ORS 447, 455, 479, , 1, 1 • 200 amps or less 2
� � /( , 4 3 201 amps to 400 amps 2
Owner's signature: , s..41/ Date: 401 to 600 amps 2
ENGINEER Branch circuits - new, alteration,
_ or extension per panel:
Name: ,4SS 0G f 4"/- CO^I,SVI 7' (' 7 S , //V L • A. Fee for branch circuits with purchase of I,
Address: 5 - 3 / 5' 5 G-J W ES r- ,* r6 Pe) STE z c f'S" service or feeder fee, each branch circuit 2
City: PORT - [. 0 N(s I State:ldr I ZIP: el 1 Z 7-- f B. Fee for branch circuits without purchase
I
Phone: sq. 0 Fax: y. 0 E - mail: K (q of service or feeder fee, first branch circuit: 2
Each additional branch circuit:
PLAN REVIEW (Please check all that apply) Misc. (Serviceorfeedernot included):
❑ Service over 225 amps- commercial 0 Health -care facility Each pump or irrigation circle 2
Service over 320 amps- rating of 1 &2 0 Hazardous location Each sign or outline lighting 2
family dwellings 0 Building over 10,000 square feet four or Signal circuit(s) or a limited energy panel,
❑ System over 600 volts nominal more residential units in one structure alteration, or extension* 2
❑ Building over three stories 0 Feeders, 400 amps or more *Description:
❑ Occupant load over 99 persons 0 Manufactured structures or RV park Each additional inspection over the allowable in any of the above:
0 Egress/lighting plan ❑ Other: Per inspection
Submit sets of plans with any of the above. Investigation fee
The above are not applicable to temporary construction service. Other
t credit cards, please call jurisdiction for more information.
Permit fee $
Not all jurisdictions accept p N otice: This permit application
❑ Visa 0 MasterCard expires if a permit is not obtained Plan review (at _ %) $
Credit card number: I / within 180 days after it has been State surcharge (8 %) $
Expires TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4615 (6 /00 /COM)
Plumbing Permit Application OFFICE USE ONLY
� � Date received: Permit no.: /VY�ra fj 3 L
t � ,� City of Tigar v E®
i ,�. •�� Sewer permit no.: Building permit no.:
Address: 13125 SW Hall B v Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 uC 1 7 2003 Project/appl. no.: Expire date:
Fax: 59 -19 60 Date issued: By: Receipt no.:
CITY OF TIGARD Case file no.: Payment type:
L (50 us a pproval: BU,EDING DIVISION
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial /industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction A Addition/alteration /replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: (3 0 O(, St,d 1 ac- 41r/4 rs <v4. t Dz Description Qty. Fee(ea.) Total
Bldg. no.: I Suite no.: New 1- and 2- family dwellings only:
Tax map /tax lot/account no.: Z U (� 13 (includes 100 ft. for each utility connection)
SFR (1) bath
Lot: 3 3 (Block: I Subdivision: pl- McSQvRy/ P'&j014''1 SFR (2) bath
Project name: SM ! r t . . / 7Z I it rJ LE — M ? PC SFR (3) bath
City /county: r/ & - a U / 1c ZIP: 9 7 7 -Z,3 Each additional bath/kitchen
Description and location of work on premises: 6.on(VE d Site utilities:
S C7 Fr u f iSA o." Erg rc /iy}'f3 / -e- SP/1 G E Catch basin /area drain
Est. date of completion/ inspection: A/OL l:5M Veit. ?rvJ q. Drywells /leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: ru 736 7? j 6 Manholes
Address: Rain drain connector
City: I State: I ZIP: Sanitary sewer (no. lin. ft.)
Phone: I Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: I Plumb. bus. reg. no: Water service (no. lin. ft.)
City /metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve
CONTACT PERSON Basins /lavatory
Name: 7 .. T?G—Tt - t1 / Ai FD Clothes washer
Address: Dishwasher
Drinking fountain(s)
City: I State: I ZIP:
Ejectors /sump
Phone: Fax: E -mail: Expansion tank
OWNER Fixture /sewer cap
Name (print): 12vl ,J IL. St. rTL.( oor drain oor sinks /hub /
Mailing address: 13 opt, S w 7.. v GI t ( A4,1 biz, rZ ose bibb disposal
Hose bi
• City: T( 6-A-12 A I State: 0E_ I ZIP: q7 Z27 Ice maker
Phone: 54 o - ri '4 7 I Fax: t - f & I E -mail: I- l - Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(), lays(sD
Owner's signature: Date: Sump
ENGINEER Tubs ow shower pan
Name: .4 5Soc / *T&'D C fSc./ Li?.rri.t Ware
' /��' Water closet
Address: 5315 St"' (r-! t; c t b/Z / 4-X NC Water heater
City: 'pas d- t,,,,a n.0 State: oA. ZIP: 9 72-z-7 Other:
Phone: 3k Off 0 Fax: 3 & c/` 05 S'I E -mail: tA. - /q. Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $
❑ Visa ❑ MasterCard Notice: This permit application Plan review (at _ %) $
expires if a permit is not obtained
Credit card number: / / State surcharge (8 %) .... $
Expires within 180 days after it has been
accepted as complete.
TOTAL $
com
Name of cardholder as shown on credit card P P
$
Cardholder signature Amount 440 -4616 (6 /00 /COM)
I.
•
Mechanical Permit Application OFFICE USE ONLY
Date received: Permit no.: , Y f a3 "OU -�1'/O
'�i City of Ti P r 1
J
Address: 1 • 97 Project/appl. no.: Expire date:
City of Tigard Add 13125 SW Hall QVI . ,e - 6 22 Phone: (503) 639 -4 Date issued: By: Receipt no.:
Fax: (503) 598 -196 " 1 / 2 003 Case file no.: Payment type:
Land use apprelidlY _ Building permit no.:
OF '
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial /industrial ❑ Multi - family 0 Tenant improvement
❑ New construction . ' Addition/alteration/replacement ❑ Other:
JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
Job address: I 06 s t,.► Te - o-wt rt [r </.4• -f PE i y E Indicate equipment quantities in boxes below. Indicate the dollar
Bldg. no.: I Suite no.: value of all mechanical materials, equipment, labor, overhead,
Tax map /tax lot/account no.: 1Z 2 D 6 S. 133 profit. Value $ .
Lot: 33 (Block: (Subdivision: /IMES g,,tay it/Ef6-NTS *See checklist for important application information and
Project name: S/4 f 17-( S / D6./CE BEMc.DEt_ jurisdiction's fee schedule for residential permit fee.
City /county: 7"/(J 2.p /! 1 ( ZIP: Qi - 7Z Z-3 I & 2 FAMILY DWELLING PERMIt FEE SCHEDULE
Description and location of work on premises: Corsi VE27 15■$es+e AND COMMERICAL/INDUSTRIAL EQUIPMENT SCHEDULE
1 a L/04 - r t?.-l 5,44 F ' TEND DUCT tJ0 ( Fee (ea.) Total
Est. date of completion/inspection: go J I17,Eh Zuu 3 Description Qty. Res. only Res. only
Tenant improvement or change of use: HVAC:
Air handling unit CFM
Is existing space heated or conditioned? 0 Yes XNo Air conditioning (site plan required)
Is existing space insulated? ❑ Yes 'No
Alteration of existing HVAC system
MECHANICAL CONTRACTOR Boiler /compressors
State boiler permit no.:
Business name: ro TS D FTEEm itiFL HP Tons BTU/H
Address: Fire/smoke dampers/duct smoke detectors
City: I State: I ZIP: Heat pump (site plan required)
Phone: I Fax: I E -mail: Install /replace furnace/burner BTU/H
Including ductwork/vent liner 0 Yes O No
CCB no.: Install/replace /relocate heaters - suspended,
City /metro lic. no.: wall, or floor mounted
Name (please print): Vent for appliance other than furnace
CONTACT PERSON Refrigeration:
Absorption units BTU/H
Name: Tv C Dir re 'i 0-in) Chillers HP
Address: Compressors HP
City: I State: I ZIP: Environmental exhaust and ventilation:
Appliance vent
Phone: Fax: E -mail: Dryer exhaust
OWNER Hoods, Type I/ IUres. kitchen/hazmat .
hood fire suppression system
Name: '' 'j/p9 J /C, SM i Tom/ Exhaust fan with single duct (bath fans)
Mailing address: / 3 0 p & f u hOGiG r m (ri// -M D,Z, Exhaust system apart from heating or AC
Fuel piping and distribution (up to 4 outlets)
'J
City: 76 /q -ft/3 I State: Olt I Z IP: 97 2-Z3 Type: LPG NG Oil
Phone: S "i 0 - g 0 ci 7 Fax: k•-/& E -mail: !.-/e... Fuel piping each additional over 4 outlets
ENGINEER Process piping (schematic required)
Name: A O L/ 4-7-9 G�S VI,Tf9r�7 S, 1"/C- ,
Number listed of outlets
Other listed appliance or equipment:
Address: 5 , S bJ I,.' err(r*r're r e, S re a cfr Decorative fireplace
City: OofZTLi4nf4 I State: Oft I ZIP: ''1 12 1 Insert - type
Phone:3Vq— Otf 6 Fax: %( ay I E -mail: /A la Woodstove /pellet stove .
Other:
Applicant's signature: ci Date: /b /f to /o 3 Other:
Name (print): . 2 voilii /G, Kd !th ,
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Permit fee $
0 Visa 0 MasterCard Notice: This permit application Minimum fee $
Credit card number:
/ expires if a permit is not obtained Plan review (at %) $
Expires within 180 days after it has been State surcharge (8 %) .... $
Name of cardholder as shown on credit card accepted as complete. TOTAL $
Cardholder signature Amount 440 -4617 (6 /00 /COM)
Permit #:N' - raOc, 3 -00508
Address: Moo ( S - l`�O l iIC i I.P4NI
Issued by: Date: 10 1
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.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale •
before or upon completion.
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
� 3B. 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 certify that the abov formation is correct and that I have read and do understand the Information .
• Notic roper ; 0 er abo t Construction Responsibilities on the reverse side of this form.
ANC rr�:` ( igna ure of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
•
information N slice to Property Owners
About Construction Res[oi'ons^b~Nt^es
&uto: This InfOrmation Notice to Property Owners about Construction Responsibilities
was developed br the Construction Contractors Board /o accordance with ORS 70/.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 CoosboodouContruorom Board to do labor in constructing or assisting in the
construction or improvement ot' a residential structure, you will, in most instances, be ruled to be an employer and the people
you hire will he employees. As the employer, you must comply with the following:
Oregon's withholding tax law: Asan employer, you must withhold income taxes from employee waes 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 945-809L
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 Department at 378-3524,
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers Compensation Law, arid m ist
ohtuiomorkcrs'uompenuuboninvuronnef6ryouremp|oyces. If you fail to obtain workers' com pensafion insurance, you may
be subjectto penalties and will be I iab le for all claim costs i Ione ofyour employees is injured on the job. For more information,
call the Workers' Compensation Division ut the Department o[ Consumer and BusincssScrviucout945-7888�
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: /\s the perm it holder forth ix project, !nuun:rcopuonih|cK»rresoivioganytai(urctorncdcvdcrcqu\n:meo\o
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
accidents and omissions such as falling tools, paint overspray, wat rdxmugofrompip:punoturco,fivc`orworkthucrnuothc
re-done.
l'inie to supervise employees: Make sure you have sufficientlithe to supervise your employees.
Expertise: Make sure you have the expertise to act asyour 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 inspections.
Jfyou have additional questions, write or call the Construction Contractors Board (P0 Box 14140, Sx|»n� OR 97309-5052,
503/378'46 !). the Board located at 700 Summer St. NE Suite 300, in Salem. -
prop-onnpm4
1/94
•
CITY OF TIGARD — 24 -Hour
BUILDING Inspection Line; (503) 639 -4175 MST � do
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Requested l ` l AM PM BUP
Location r! 3 v O - r .i.L_`G...;,&-de . Suite MEC
Contact Person 1..tZ,4 Ph ( ) Yap 96.9' 7 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation Access: ELC
Ftg Drain CR, � ELR
Crawl Drain
Slab Post & Beam Inspection Notes: C 6N J �C�v � c, L p, G1 SIT
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING: ` °; a -:;..
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain •
Shower Pan
Other: •
Final
PASS PART FAIL
NIGL.
Post & Beam
Rough -In
Gas Line
Smoke Dampers
<ina1
P PART FAIL
R1
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
CqA 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 `--� 0
— 6-- Inspector 4,1,0/41-gy Approach/Sidewalk Da$e � Ext
Other:
Final DO NOT REMOVE this inspection record from the Jo site.
PASS PART FAIL
•
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST 610S68
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Requested `9/ — AM PM BUP
Location / ;00 (p R,,e9 -4/1?- kav'7L) Suite. MEC
Contact Person 1 (� Ph ( ) 7 6/60-9 7 -7 PLM
Contractor Ph ( SWR
BUILDING Tenant/Owner ELC
Footing ELC
Foundation
Ft Drain Access: 6.6 C awl Drain ELR
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation P0` C o V) \ t
\S*
Drywall Nailing ' `p�In00 ,,4
Firewall �� ) � 1c � r7 e , f 1Wi - U To 4(Yt )49:,
Fire Sprinkler
Fire Alarm \-� < -Tq'Pl`c
Susp'd Ceiling
Roof
Other:
PASS PART A L
PLUMBINGµ
Post & Beam
Under Slab _
Water Service F - 6 b —) -11(1-4")
Sanitary Sewer
Rain Drains
Catch Basin / Manhole n C
Storm Drain
Shower Pan v`
)44
Other:
PASS PART
MEC '`
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: 0 Unable to inspect - no access
Fire Supply Line
ADA
Approach/Sidewalk Date 0 Inspector '& 5 `(7f..' Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL