Permit 11 - U CITY OF TIGARD MASTER PERMIT
1 _ COMMUNITY DEVELOPMENT Permit #: MST2012 00179
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/06/2012
Parcel: 2S 111 AA00200
Jurisdiction: Tigard
Site address: 14075 SW HALL BLVD
Subdivision: SUMMERFIELD BROOKSIDE CONDO Lot: 63
Project: Bozich
Project Description: Addition and interior remodel
BUILDING
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 0 First: 349 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 20 Smoke
Dwelling Units: 1 Third: 0 sf Right 5
Detectors: Yes
Total: 349 sf Value: $46,268.00 Rear: 15
PLUMBING
Sinks: 1 Water Closets: 1 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Unnals: 0
Lavatories: 1 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Tubs /Showers: 0 Garbage Disp: 1 Water Heaters: 0 Water Lines: 0 Drains: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 .
Drywell- Trench Drain: 0
Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 2 Clothes Dryers: 1
Heat Pump: N Hoods: 1 Other Units: 1
Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Fum > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits
1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea addl 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 3
Mfd Home /Feeder /Svc: 0 401 -600 amp: 0 401 -600 amp: 0
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +amp /volt: 0
ELECTRICAL - RESTRICTED ENERGY
SF Residential
Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing. N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ADD SF VB R -3 349
Owner: Contractor:
BOZICH, DANIEL L SR & MARSHAL OWNER Required Items and Reports (Conditions)
14075 SW HALL BLVD
TIGARD, OR 97224
PHONE: 503- 639 -0218 PHONE:
FAX:
Total Fees: $2,108.86
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 Notification Center. T• • -' rules are set forth in OAR
952- 001 -0010 through - ARR 952- 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 , 2.2344.
Issued By: v Permittee Signature: �`�y
Call 503.639.4175 by 7:00 a.m. for the next available Inspectio date.
This permit card shall be kept in a conspicuous place on the job site until com • etio.
Approved plans are required on the Job she at the time of each inspec • .
Building Permit Application
Residential RECEIVED LD r( .1.1.-,(1.: I ISE ONLY
IPIII City of Tigard Dat 7 �� �I,
•
Pla Permit No.: l/0% � p,
13125 SW Hall Blvd., Tigard,OR 97223J 12 2012 n iw
0 Phone: 503.718.2439 Fax: 503.598.1960 Dat Rev : e �� /fi Other Permit:
- i G A I' a Inspection Line: 503.639.4175 CTTYOFTIGARD Date Ready : y: Ju See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: e / � 2 - t'" f Supplemental Information
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
j gr Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
I- and 2- family dwelling ❑ Commercial/industrial Valuation: %2. $ 4 y ---•
❑ Accessory building ❑ Multi- family Number of bedrooms: Q
❑ Master builder 0 Other: Number of bathrooms: , S
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: I -D'1 S �5 w 11 5)4. New dwelling area: 3q? square feet
City /State /ZIP: 77-44,4/(2g_ A 7 22f Garage /carport area: ' square feet
Suite/bldg. /apt. no.: P roject name: 1, ZJl3t. gym.° I 4- Covered porch area 31 square feet
Cross street/directions to job site: 5 i 1 A J A 11 FiYel Q Deck area: 2 )7_ square feet
cW M e. DO.,114 s-r_ Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
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.
QQ,V.tO, B1U44 tN C M.C.j .� Q►.�p r 4 .34.1 Sr Valuation: $
.O / Q M /;0 �JL
I i 1 Wh.. ek s � 44-re i K � ' p _ e �� I V , t ' Existing building area square feet
pir 11 -fro ioase t�.c'r4') el . t *
p La P.xi S i7'� ��'A.i r 4-1, �Q,SU.tti[,l'r`'�". �d+J � IntLd New building area: square feet
�-PROPER+Y OWNER I ❑ TENANT pe rt. , Number of stories:
Name: Da te. Mmes . DG z j 1 Type of construction:
Address: ' +p7 s - stj /4-4,1,1 EI 4 . Occupancy groups:
City/State /ZIP: Tq /O�/ 97 2. Existing:
Phone: (5 3)4 31 _ 024 S Fax: ( ) New:
APPLICANT pr CONTACT PERSON BUILDING PERMIT FEES*
(Please refer to fee schedule)
Business name: 7 L ( I. iI V„` Structural plan review fee (or deposit):
Contact name: SA
Address: S93 g 51,,1 Xl✓WI� FLS plan review fee (if applicable):
City /State /ZIP: fm "1 etwAJ / J � 9 7 2-31
Amount received: Total fees due upon application: -
93) 2 -(0o — 3 3. & O ( I Fax: 35a 3 7
Phone: ( ax:: ( )
E -mail: ZGq in tJ vi^.@ 5 ,,,,,„..a. e.. & &_ PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
J Commercial and residential prescriptive installation of
CONTRACTOR roof -top mou PhotoVoltaic Solar Panel System.
Business name: • Submit two (2) - is of roof plan with conne ' : . - rls
and fire departme . • ccess, alon: . ' . i e 2010 Oregon
Address: _ 1. . - / Solar Installation Spec . 4 - 4 a checklist.
City/State/ZIP: ''' uol Permit Fee • 1 . es p eview $180.00
administrative e
Phone: (ca r 1 ' � r Fax: ( ) : - surcharge (12% of permit fee): $21.60
CCB lic.: 4 4,1,
/ Total fee due upon application: $201.. I
Authorized signatur : i / / This permit application expires if a permit is not obtained
__/ -AZ/ _ / S ./- within 180 days after it has been accepted as complete.
Print name: 1 Date: * Fee methodology set by Tri -County Building Industry
- - _ , - ems. / - _. - Service Board.
I:\ Building \Permits\BUP- RESPermitApp.doc 02/24/2011 440 -4613T(11 /02 /COM/WEB)
r
. - r
Building Permit Application Checklist
One - and Two - Family Dwelling Folt t)FFICV usi.: (.) l_Y
n
City. of Tigard . Received Permit No.:
7 Date/By:
13125 SW Hall Blvd., Tigard, OR 97223 Associated permits:
C Phone: 503.718.2439 Fax: 503.598.1960 •
I I G A It p 24 - Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
Internet: www.tigard- or.gov ❑ Other:
THE FOLLOW/INC; ITEMS ARE REQUIRED FOR PLAN REVIEW vcs 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); 1 ; utility locations; direction
indicator; lot -area; ; pereettege-vft verage; it ietrs•arsa; existing structures on site; anti—
.,.F se d
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 Orelon and shall be shown to be a, ilicable to the I ro'ect under review.
JURISDICTIONAL SPECIFICS
,® Three (3) site plans are required for Item 11 above. Site p an. must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
Two (2) sets each are required for Items 16, 19, 20 and 22 alloy- . ❑ ❑ ❑
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 trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
and protection measures must be drawn to scale and must include the project arborist's signature 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: \ BuildingTermits \BUP- RESPetmitApp.doc 02/24/2011 440.4613T(l 1/02 /COM/WEB)
Plumbing Permit Application
1
.
Building Fixtures : FOR OFFICE USE ONLY
R eceived
City of Tigard P ermit No .:
IN
n 131 SW Hall Blvd., Tigard, OR 97223
JUL 1 6 7O12Date/BY: �' / .2. �. STUD /��G/ 7 9
Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Other Permit No.:
Inspection Line: 503.639.4175 CITY OFTIGAAII a Re
T I G A R D Internet: www.[i ard or. ov t � j Ready/By: luris: 121 See Page 2 for
g g RI III.DING DIVISIONfied/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. I Total
gAddition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (l) bath 312.70
51.1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
building SFR (3) bath 500.32
❑ Accessory g ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: I4- 0 7 5 L (, l-J J I g ) v _ f , Catch basin or area drain 18.76
T I �f Drywell, leach line, or trench drain 18.76
City /State /ZIP: l .. / Q / D Q / 1 2-2.1-
Footing drain (no. linear ft.: ) Page 2
Suite/bldg./apt. no.: Project name: 15 0 4 od.eI -y Ad Manufactured home utilities 50.03
Cross street/directions to job site: w 14 (�j A , � Manholes 18.76
7 W i(/) G P b K ai 5 , J. , r' Rain drain connector 18.76
/� ' Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer I 25.02
Dishwasher 1 25.02
Drinking fountain I 25.02
Ejectors /sump 25.02
14 PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: Pa,K 4 f! Mars)ti Z
, golGfit. Fixture /sewer cap 25.02
Address: 14- 5 S� fici I gi
Floor drain floor sink/hub 25.02
Garbage disposal , 25.02
City/State /ZIP: T ►S „, -1 O K./ 7 2 2-f Hose bib 25.02
Phone: (3 3) ( - o 2 I g Fax: ( ) Ice maker 12.51
APPLICANT Z. CONTACT PERSON Interceptor /grease trap 25.02
Business name: � .,`L ; 1 / �I,,,t Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: S
Roof drain (commercial) 12.51
Address: 1 q , p
5! J 3 W r lam.► ve4e Lt., Sink/basin/lavatory fl 25.02
City /State /ZIP: 4 2 0 ,4 - I 1 / o � / 3 7 231 Solar units (potable water) 62.54
Phone: ( S-O3 2 by - 33 3 s Fax: : ( ) Tub /shower /shower pan 12.51
• Z i /[ w '�{ ��(4O
r Urinal 25.02
E -mail: J
ONTRACTOR Water closet + 25.02
Water heater 37.52
Business name: n co 1,,,.., Water piping/DW V 56.29
Address: Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50
Plan review (25% of permit fee)
CCB Lic.: Plumbing I,ic..i o.:
State surcharge (12% of permit fee)
Authorized signature: ) TOTAL PERMIT FEE
Print name: tY w 4, ,,, , .„,... ► ; ` 1 S' Date: This permit application expires if a permit is not obtained within 180 days
' f� after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
1:1Building1Permit pL..'NU- PermitApp.doc 10/01/09 440- 4616T(10 /02/COM/WEB)
•
Mechanical Permit Application FOR OFFICE. USE ONLY
City of Tigard e/BiffilliMil Permit No. 2c / 9, - t/t// 7
Iii C q 13125 SW Hall Blvd., Tigard, OR 9 2, .
Plan Review
Phone: 503.718.2439 Fax: 503.5'E , I C Date/By: Other Permit:
Inspection Line: 503.639.4175 ! '
T I G A R D Date Ready/By: dy y: Janis: ® See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
JUL 12 2012
TYPE OF WORK � COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
SFTIG RD Mechanical permit fees* are based on the value of the work
12 New construction .• 4
• ,. NU 1tl performed. Indicate the value (rounded to the nearest dollar) of all
El Demolition ❑ Other:
I. mechanical materials, equipment, labor, overhead, and profit.
Value: $
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
4 .1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For spedal information use checklist
❑ Multi - family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: 1+ ` , L J R.R-,� I Y )4 (requires site plan showing placement) 46.75
-I .117 99 Furnace 100,000 BTU ( ducts/vents) 46.75
City/State /ZIP: J
1 IS Q„�L1 / oR 2Z ¢ Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg. /apt. no.: tJ Project name: g [7 I + M I L ow Heat pump
l ~^�"' !T (requires site plan showing placement) 61.06
Cross street/dir r ections to job site: W J J �.P.- i1 Q� I d . 4 j Duct work 1 23.32
4 W A 70 a.n,1 d S'(. r✓ Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32.
Other: 23.32
Tax map /parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
Gas fireplace/insert 33.39
Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
1 PROPERTY OWNER I ❑ TENANT Chimney/liner /flue /vent 23.32
Other: 23.32
Name: 21 AAA,/ AA L dt4/ . i 711... Environmental exhaust and ventilation:
Address: I 4 7 s 6 H � o � °! V e Range hood /other kitchen r 33.39
City /State /ZIP: � d o � 1 ?7 2 Z Clothes dryer exhaust 1 33.39
�5 / Single -duct exhaust (bathrooms,
Phone: ( 5 411 _ 024 g Fax: ( ) toilet compartments, utility rooms) 23.32
Dit. APPLICANT [CONTACT PERSON Attic /crawlspace fans 23.32
Other: 23.32
Business name: Z_4,44 (ri IIubm. Fuel piping:
Contact name: 4 melt S14.15 for first four; $4.03 for each additional
Address: S 1 3 g s W M ✓G✓f �. a, Furnace, etc.
f �" Gas heat pump
City /State /ZIP: P p ✓ �'lm_ rd bit. / q 7 2 31 Wall /suspended/unit heater
Phone: (5b 3 2 (p s35- Fax: : ( ) Water heater
E -mail: a r Fireplace
zG �l VIM�� q t+v�rl r •� . GO`v.- Range
() CONTRACTOR Barbecue
Business name: b uJ ,/ER— Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES*
City/State /Z1P: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00)
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee)
TOTAL PERMIT FEE
/� This permit application expires if a permit is not obtained within 180
Authorized signature: _ � r. ) 5 Y days after it has been accepted as complete.
Print name: - . _ (_ Date: 6 * Fee methodology set by Tri- County Building Industry Service Board
I:\ Building \Perntits\MEC- PennitApp.doc 03/07/12 4404617T' (I1/02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi - Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
$2.54 for each additional $100.00 or
•
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
•
•
1:\ Building \Permits\MEC- PermitApp.doc 03/07/12 2
Electrical Permit ApplicatimRECENE D FOR OFFICE USE ONLY
111111 City of Tigard Dateiv ved PermitNo.: 7 Z 7 (7
• 13125 SW Hall Blvd., Tigard, OR 97223j UL 16 2012
Recei
Plan Review y
lIl
Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Other Permit:
r 1 G A li D Ins Line: 503.639.4175 CITY OF TIGARD Date Ready/By: Juris: El See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
BUILDING DIVISION
TYPE OF WORK PLAN REVIEW
❑ New construction Addition /alteration/replacement Please check all that apply (submit 3 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
Pi I- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE Pi 1FORr�IAT[ON AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A "E ", "I -2 ", "I -3 ",
G ' , f I P IOOHP or more. occupancy.
Job no.: Job site address: -o7 s ✓ 1/" 1 4jJ vet ❑ Six or more residential units. P
❑ Recreational vehicle parks.
City/State /ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than
TI Jp�,� OF./ 9 7 Z 2 � - ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: f6, Gk rCot pelt! t Aelel I ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: 4 W I g1,,J „4.4.4 Description I Ott. I Fee. I Total I •
/ �� 1 New residential single - or multi - family dwelling unit.
Mr. '.1
'7 ] 0,d Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'1500 sq. ft. or portion 33.92 1
Tax map /parcel no.:
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
5( PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
p 401 amps to 600 amps 200.34 2
Name: 12, AA j M�S�tti PD 601 amps to 1,000 amps 301.04 2
Address: I ¢61 S S W 14.4.,Il , )v1 , Over 1,000 amps or volts I I 552.26 I 12
Temporary services or feeders installation, alteration, and /or
City/State /ZIP: 7 t a, / e n 2, L4 relocation
Phone: (503) 631 O it g Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange _. ccore' • g to • ' S 447, 449, 670, and 701.
Branch circuits - new, alteration, or extension, per panel
—
Owner signature: (� 1.i. , Date: 0 } -/ 2. - )� A. Fee for branch circuits with
14 APPLICANT g CONTACT PERSON above service or feeder fee 7.4/ 2
each branch circuit
Business name: Z GI f i , B. Fee for branch circuits without
U GA service or feeder fee, first 1 56.18 2
Contact name: 44,1v1/.... 9... circuit
Each add'I branch circuit 2• I 7.42 12
Address: 5-61 3 8 S (,� f �) V ell
6/, G Miscellaneous (service or feeder not included)
City/State /ZiP: p Q/ q 7 3 Each manufactured or modular 67.84 2
12 Iew„ot / b / Z ( dwelling, service and/or feeder
Phone: (5 03 ) 24 0 — 3 3 S S' Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail: ZGa1 qIM A),(,owe
tJ cJ
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: panel, alteration, or extension. Page 2 2
0 ul N G. W'_ Each additional inspection over allowable in any of the above
Address: Additional inspection (I hr min) 66.25/ hr
City/State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (l hr min) 78.18 / hr
( )
Phone: ( ) Fax: Inspections for which no fee is
90.00 / hr
specifically listed (' /: hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
Plan review (25% of permit fee):
Print name: I Date: State surcharge (12% of permit fee):
/ TOTAL PERMIT FEE:
�� �,
Authorized signature: / 1 Th is permit application expires if a permit is not obtained within 180
P PP � lication P P
days after it has been accepted as complete.
^ � _♦ cwt.
Print name: _...__ : c.:, \ L 1o.-) .? {, Date: 0 _ I Q - 1 2 • Number of inspections allowed per permit.
S,,
I:\ Building \Permits\ELC- PermitApp.doc 07/01 /10 440- 4615T(tt /05 /COMIWEB
/�o2 $ cw / leas .
---.7_007....,&.1,-
II
C Building Division
Development Code Provision Review
T i e n rz Residential Projects
Building Permit No: M `aT 9C M2.. —00 1.75
CWS Service Provider Letter Received: Yes ❑ No ❑ N/A ❑
Routed Plans:
Original Plan Submittal Date: 7/t Pit 'Y
1" Revision Submittal Date: ❑ Site Plan Only
2 Revision Submittal Date: ❑ Site Plan Only
To the Applicant:
Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies to the
Building Division. Only checked (✓) items are approved. Items not approved and those listed in the notes must be
revised prior to re- submittal. For questions please contact the appropriate staff person(s) listed above each section.
Staff: please check items along left my if approved. ..��,,//,, //``��
Planning Review (contact at 503-718 WC) or @tigard- or.gov)
Lapd Use Case No. Name
Zoning l_ it, rj
fiv Setbacks:
t( Pront Rear is Side `l Street Side ! t Gara a• e9
aximum Building Height 3 / Actual Building Height
isual Clearance
.asements
El Sensitive Lands Type: /0
Notes:
Original Plan: Approved Not Approved ❑ Date: _./((6 147--
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
Engineering Review (contact Mike White at 503 - 718 -2464 or MikeW @tigard - or.gov) i
Xr Actual Slope: 7 % 1
Notes:
Original Plan: Approved Not Approved ❑ Date:
/1712, ,
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
(Review Continues on Page 2)
1
Page 1 of 2
•
City rist Review (contact Todd Prager at 503 - 718 -2700 or todd @tigard- or.gov)
I treet Trees
Protected Trees .
Notes:
Original Plan: Approved / Not Approved ❑ Date: 7' 1 ?' /a-
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
Permit Coordinator Review (contact Albert Shields at 503 - 718 -2426 or albert @tigard - or.gov)
❑ Conditions of Approval Prior to Issuance of Building Permit
Notes :
Original Plan: Date Sent to Applicant:
Revision 1: Date Sent to Applicant
Revision 2: Date Sent to Applic
Okay to Issue Permit: Ye No ❑
Date Routed to Building:
1
- 'n , •
Page 2 of 2
/
RECEIVED
JUI.. 16 2012
Property Owner Statement
DIY OFTIGARD
Regarding Construction Responsibiliti ADRLDING DIVISION
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
•
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
•
N�e
L zia sue.
Print Name of Permit Applicant
IN _aim
_ __ I . =� 7�/c2 //
're of Permit •pli 0: --1121111111M Date
•
Permit #: 1-4' - t , oo 179
Address: / 075 11414-« 'TNUJ7 �,�;ui%
l a _:,, = ,_.�;:•. , .
Issued by: Date:
This Copy for Permit Offices
•
1
1
1
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P ROPERTY LINE -
— - - — - - -- �— - - — - - — - - — - - — - 173' -0• ---- / --- - - - - / ---- -- ,7s' 5938 SWRiveridgeLn
I / Portland, OR 97239
I 5' SIDE SETBACK / / I � =� 55 0: z i.corn
/ / �� , .
I i i / i I JUL 1 2 2012
r I � � � I I \ l^'j
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1841 / s � I / / 1 / A / m
/ / / \ / / / E ai
I 1 " 'BO. / / /
I / I - -- 176 -- \ ��- - - -- --' / / N H
I
/ I I / \ '�B � / / I
/ ! I
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I - - - - -- / / / I \ - -- I
1 r . / / � \ ■ / � 1 74 N
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/, EXISTING - -- —,� , - -- n
� SHOP , 1 //
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EXISTING DRIVEWAY F /I/ I A\ W
W sheet index
* Site Plan
I (/) N
, I I
sheet number
1801 180 _ J 5' SIDE SETBACK 7- J ( x174'
I+ / / PROPERTY LINE / T
1 m ,ss' =7• CIO
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