Permit •
CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2001 -00478
VII DEVELOPMENT SERVICES DATE ISSUED: 9/17/01
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 11756 SW SUMMER CREST PL PARCEL: 1 S134CD -06800
SUBDIVISION: BURLWOOD NO.3 ZONING: R -4.5
BLOCK: 01 LOT: 028 JURISDICTION: TIG ,
REMARKS: 630 sq. ft. upper level addition. 400 sq. ft. new garage. ALSO INCLUDES 444 sq-ft-ROOM BUILT .
WITH OUT PERMIT OR INSPECTIONS BUILT PRIOR TO THEIR - OWNERSHIP.
BUILDING
REISSUE: STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: FIRST: 444 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 630 sf GARAGE: 400 sf FRONT: PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: FINBSMENT: of RIGHT:
VALUE: $ 106,824.40
OCCUPANCY GRP: R3 BDRM: 3 BATH: 2 TOTAL: 1,074.00 sf REAR: 15
PLUMBING
SINKS: WATER CLOSETS: 2 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 3 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: 1 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: CLOTHES DRYER:
GAS FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: 6 WOODSTOVES: • GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 1 0 • 200 amp: 0 • 200 amp: W /SVC OR FDR: 1 PUMP/IRRIGATION: PER INSPECTION:
EA ADM_ 500SF: 2 201 - 400 amp: 201 - 400 amp: 1st W/O SVC /FDR: SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 • 600 amp: 401 • 600 amp: EA ADDL BR CIR: SIGNAL/PANEL: IN PLANT:
MANU HM/SVC /FDR: 601 - 1000 amp: 601 +amps- 1000v: MINOR LABEL:
1000+ ampNolt :
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 8 STEREO: VACUUM SYSTEM: AUDIO 8 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 0 SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 1,860.12
LHOTKA
, CRAIG A OWNER This permit is subject to the regulations contained in the
LHOT A, CRAIG
ARCREST PL Tigard Municipal Code, State of OR. Specialty Codes and
11756 SW S MME all other applicable laws. All work will be done in
accordance with approved plans. This permit will expire if
work is not started within 180 days of issuance, or if the
work is suspended for more than 180 days. ATTENTION:
Phone: Phone: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set
Reg U: 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
Footing Insp PLM /Underfloor Framing Insp Rain drain Insp
Foundation Insp Mechanical Insp Shear Wall Insp Electrical Final
Post/Beam Structural Plumb Top Out Exterior Sheathing Insf Mechanical Final
Post/Beam Mechanical Electrical Service Low Voltage Plumb Final
Underfloor i sulation Electrical Rough In Insulation Insp Final inspection
rs
• Issu d By : ∎ . • , � d �d �' ' �� ' Permittee Signature : Lam- 1 •' 0•__._!,
Call (503 ;39-4175 by 7:00 p.m. for an inspection needed the next business day
� c�51-9 --.5 o / g'/ / • ._,:,
Building Per lication ....
"" °1,:: City of Tigard t /
D ate received: 4 O / Per mit no.:M5- 1 _„w,,f7e
1,L =- Project/appl. no.: Expire date:
City ofTigard Address: 13125 SW Hall Blvd, Tigard, OR 97223
Phone: (503) 639 -4171 Date issued: By:•0 I Receipt no.:
Fax: (503) 598 - 1960 Case file no.: Payment type: _:-- - f
Land use approval: 1&2 family: Simple Complex:
TYPE OF PERMIT'
❑ 1 & 2 family dwelling or accessory O Commercial/industrial ❑ Multi - family ❑ New construction 0 Demolition
Pi Addition/alteration /replacement 0 Tenant improvement 0 Fire sprinkler /alarm 0 Other:
JOB SITE INFOIU 1ATION
—Job address: t � i �' - � - a , Bldg. no.: Suite no.:
Lot: Block: ubdivision: Tax map /tax lot/account no.:
Project name: X,.t . 5'
• �
Description and location of work on premises/special conditions: _4. ta• a •, ma ,
\ rrii 1, W: cr Iii1 a :. k o rs ( nom . '' u). SX11.515 - EE - - Ious dW e r .
OWNER FOR SPECIAL INFORMATION, USE CHECKLIST
�c Name: -A • (Floodplain, septic capacity, solar, etc.)
Mailing address: e ) - , Aylka fr a W
I & 2 family dwelling: p
Cit -[' d t ate:Oe (ZIP. ) J 3 Valuation of work • / o Z ( $ SO x
Phone:50N4STO -44x91 (Fax y?1$31E- mail••. ._ - ,, No. of bedrooms/baths 3 _&__ .)
Owner's representative: C ( phpnf E • • - • Total number of floors Zi
Phone: Spa 205 - Q ax: E -mail: New dwelling area (sq. ft.) /07g
Garage/carport area (sq. ft.) 41 a O
Name. pt,Z k4 Covered porch area (sq. ft.) j
Mailing addres ("Me er SLt //1f &EA / Deck area (sq. ft.) /
City: c -., rx 1 '6 1 St at . s I ZIP. - - y _Other structure area (sq. ft.)
Phone: , 4 Fax: E -mail: Commercial/industrial/multi- family:
... : CONTRACTOR " _ Valuation of work $
Business name: C' Lk) r Existing bldg. area (f ft ft)
New bldg. area (sq. .) )
Address:
City: 'State: 1 ZIP: Number of stories ...
Phone: 'Fax: 1E-mail: Type of construction
CCB no.: Occupancy group(s): Exis g:
Ne :
City /metro lic. no.:
Notice: All contractors and subcontractors are required to be
- ARCHITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
City: State: IZIP: exempt from licensing, the following reason applies:
Contact person: Plan no.:
Phone: Fax: E -mail:
Name: Contact person: Fees due upon application $
Address: Date received:
City: (State: IZIP: Amount received $
Phone: 'Fax: 1E-mail: 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 and ordinances governing this ❑ Visa ❑ MasterCard
work will be complied wi wheth pecifi in or not. Credit card number: / /
$
Expires
76
Authorized signature:
Print name:Cr'0. 0 k Date: i` "a0 Name of cardholder as shown on credit card
Cardholder eigoature Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440-4613 (6/00ICOM)
1
One- and Two - Family Dwelling " ._
_i Building Permit Application Checklist Reference no.:
Associated permits:
City of Tigard City Tigard t3' g ❑ Electrical ❑ Plumbing ❑ Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 ❑ Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW i['es No N/A
I Land use actions completed. See jurisdiction criteria for concurrent reviews.
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc.
3 Verification of approved plat/lot.
4 Fire district approval required. _
5 Septic system permit or authorization for remodel. Existing system capacity
6 Sewer permit.
7 Water district approval.
8 Soils report. Must carry original applicable stamp and signature on file or with application.
9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of
/~ .catch -basin protection, etc.
29 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
.1if copyright violations exist. ` .
1 ,5 / Site/plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if
there is mom 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,
erne" pew existing structures on site; and stAteedm►nage.
12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent
size an 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.
— 0 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
0
over 10 feet long and/or any beam/joist carrying a non - uniform load.
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.
,Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or
architect licensed in Oregon and shall be shown to be applicable to the project under review.
JURISDICTIONAL SPECIFICS
Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ".
24 Two (2) sets each are required for Items 16, 19, 20 & 22 above. _
25 Building plans shall not contain red lines or tape -ons.
_ 26 No rolled, reversed or mirrored building plans will be accepted.
27
_ 28
Checklist must be completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 440-4614 (6/00 /COM)
M5TT CJC / -cam 97 •8'
•
,
Plumbin Permit Application
Date received: Permit no.:
-'1 1; City of Tigard
l,L A 1 ` J Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date:
Fax: (503) 598 - 1960 Date issued: By: I Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT '
0 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Food service 0 Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: I ( 1 5 5c,,() Sf (mfl arcrej I / Description I . Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: IBlock: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: —11 r, (;( rr i I ZIP: 47701-`)--3 Each additional bath/kitchen
III Description and location of work on premises: C1dd ■ i- -. Site utilities: _
Catch basin/area drain .
Est. date of completion/inspection: Drywells/leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: n W /L 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:
X Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve •
h.' CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump .
Phone: Fax: E -mail: Expansion tank
• OWNER Fixture/sewer cap
1ll� Floor drains/floor sinks/hub
Name (print): �ptK f Garbage disposal
Mailing address: I (15 SU) �U lest Y10R9f 119( Hose bibb
City: ' %c I Stateett I ZIP: 'r1.2..3 Ice maker
Phone: WI- 5 50 --cU5d Fax:923. 5.11-7/5:31E-mail: 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 wn as per Cha 7. _ _ i Sink(s), basin(s), lays(s)
Owner's signature: Date: 3 01 Sump
Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater _
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $
Notice: This permit app Plan review (at _ %) $
• 0 Visa 0 MasterCard expires if a permit is not obtained
Credit card numtrr: 1 / 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 -4616 (6/00 /COM)
PLUMBING PERMIT FEES: "
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE • TOTAL
Sink ii 16.60 IL 16.60 f Q , 0 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory S $ Q One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 I �e • �� for each utility connection)
Two (2) bath $350.00
Shower Only 1 16.60 ( e 1 r 'o 0 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San/Storm Sewer 46.40 Lavatory .
•
Tub or Tub /Shower
Hose Bibs 16 Combination
Roof Drains 16.60 Shower Only !
Drinking Fountain 16.60 Water Closet
Urinal
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3"
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Other Fixtures
Water Service - each additional 200' 46.40 (Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin , 16.60
Inspection of Existing Plumbing or Specially 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
**PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
** AII New Commercial Buildings require plans with isometric or riser diagram and
plan review.
i:ldstslforms\plm- fees.doc 10/10/00
Electrica Permit Application
Date received: Permit no.:
_.14 ..l i ! City of Tigard Project/appl. no.: Expire date:
•
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 Date issued: By: I Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval:
•
TYPE OF PERf91T
❑ 1 & 2 family dwelling or accessory 0 Commercial/industrial Cl Multi- family 0 Tenant improvement
❑ New construction 71 Addition/alteration /replacement 0 Other: 0 Partial
JOB SITE INFORMATION
Job address: 1 1 4 , A i , _ - + ( Bldg. no.: Suite no.: Tax map /tax lot/account no.:
Lot: Block: Subdivision:
Project name: I Description and location of work on premises: 044 { Oil
Estimated date of completion/inspection:
CONTRACTOR APPLICATION FEE SCIIEDU.E
Job no: QGU/Jg Fee Max
Business name: Description Qty. (ea.) Total no. insp
New residential - single or multi - family per
Address:
City:
dwelling unit Includesattat�redgarage.
I State: I ZIP:
Service Winded:
Phone: Fax: I E -mail:
1000 sq. ft or less 4
Each additional 500 sq. ft. or portion thereof
CCB no.: I Elec. bus. llC. no: Limited energy, residential 2
City /metro lie. no.: Limited energy, non- residential 2
Each manufactured home or modular dwelling
Signature of supervising electrician (required) Date Service and/or feeder 2
Sup. e name (print): License no: Services or feeders—installation,
\ alteration or relocation:
PROPERTY OWNER 200 amps or less 2
eJ (e 201 amps to 400 amps 2
,.. .,..4 Name (print): U�TFt
401 amps to 600 amps 2
Mailing address :M$ g{,) 5(n(Qr / 601 amps to 1000 amps 2
City: 'Mc 'M I State I Q7 ) Over 1000 amps or volts 2
PhoneG( 1 590-47A II Fax: .Ezof ..1(E-mail: Reconnect only 1
Owner installation: The installation is being made on property I on Temporary services or feeders -
which is not intended for sale, lease, rent, or exchange according to ins tallaton,alteration •
ORS 447, 455, 479, 67p, 701. 200 amps or less 2
201 amps to 400 amps 2
Owner's signature: , l Date 01 401 to 600 amps 2
ENGINEER Branch circuits - new, alteration,
or extension per panel:
Name: A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 2
City: I State: • I ZIP: B. Fee for branch circuits without purchase
of service or feeder fee, first branch circuit: 2
Phone: Fax: E -mail: Each additional branch circuit:
PLAN REVIEW (Please check all that apply) Misc. (Service or feeder not included):
❑ Service over 225 amps- commercial ❑ Health -care facility Each pump or irrigation circle 2
O 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
O Building over three stories ❑ Feeders, 400 amps or more *Description:
O Occupant load over 99 persons ❑ Manufactured structures or RV park Each additional inspection over the allowable in any of the above:
O Egress/lightingplan 0 Other. Per inspection
Submit sets of plans with any of the above. Investigation fee
The above are not applicable to temporary construction service. Other
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Permit fee $
❑ Visa ❑ MasterCard expires if a permit is not obtained Plan review (at _ %) $
' Credit card number / / within 180 days after it has been State surcharge (8 %) .... $
Expires accepted as complete. TOTAL $
Name of cardholder as shown on credit card
$
Cardholder signature Amount 440 -4615 (6/00/COM)
Electrical Permit Fees: Limited Energy Fees: •
Complete Fee Schedule Below: TYPE OF WORK INVOLVED - RESIDENTIAL ONLY
Restricted Energy Fee $75.00
Number of Inspections per permit allowed (FOR ALL SYSTEMS)
Service included: Items Cost Total y Check Type of Work Involved:
Residential - per unit
1000 sq. ft. or less I $145.15 I\ , l._5 4 0 Audio and Stereo Systems
Each additional 500 sq. ft. or �� mm
portion thereof $33.40 I41(P `Y 0 1 0 Burglar Alarm
Limited Energy $75.00
Each Manufd Home or Modular Garage Door Opener
Dwelling Service or Feeder $90.90 2 III
Services or Feeders ❑ Heating, Ventilation and Air Conditioning System*
Installation, alteration, or relocation
200 amps or less $80.30 2 Vacuum Systems
201 amps to 400 amps $106.85 2
401 amps to 600 amps $160.60 2
601 amps to 1000 amps $240.60 2 n Other
Over 1000 amps or volts $454.65 2 •
Reconnect only $66.85 2
Temporary Services or Feeders TYPE OF WORK INVOLVED - COMMERCIAL ONLY
Installation, alteration, or relocation Fee for each system $75.00
200 amps or less $66.85 2 (SEE OAR 918 - 260 -260)
201 amps to 400 amps $100.30 2
401 amps to 600 amps $133.75 2 Check Type of Work Involved:
Over 600 amps to 1000 volts,
see "b" above. ri Audio and Stereo Systems
Branch Circuits Controls
New, alteration or extension per panel
a) The fee for branch circuits •
with purchase of service or D Clock Systems
feeder fee.
Each branch circuit $6.65 2 n Data Telecommunication Installation
b) The fee for branch circuits
without purchase of service n Fire Alarm Installation
or feeder fee.
First branch circuit $46.85
Each additional branch circuit $6.65
Miscellaneous 0 Instrumentation
(Service or feeder not included)
Each pump or irrigation circle $53.40 and Paging Systems
• Each sign or outline lighting $53.40
Signal circuit(s) or a limited energy
panel, alteration or extension $75.00 E Landscape Irrigation Control
•
Minor Labels (10) $125.00 ❑
Medical
Each additional inspection over
the allowable in any of the above Nurse Calls
Per inspection $62.50 Li
Per hour $62.50 _ ❑
In Plant $73.75 Outdoor Landscape Lighting
Fees: n Protective Signaling
Enter total of above fees $ _ n Other
8% State Surcharge $ Number of Systems
25% Plan Review Fee
* No licenses are required. Licenses are required for all other installations
See "Plan Review" section on $
front of application.
Fees:
Total Balance Due $
Enter total of above fees $
❑ Trust Account # 8% State Surcharge $
Total Balance Due $
•
i:\dsts\forms \elc- fees.doc 10/09/00
Mechanical Permit Application
Date r eceived: Permit no.:
A. 4r,iY%1 =fi • City of Tigard
Project/appl. no.: Expire date:
•
_, I,L :
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 Dateissued: By: I Receiptno.:
Phone: (503) 639 -4171
Fax: (503) 598 - 1960 . Case file no.: Payment type:
Land use approval: Building permit no.:
J
TYPE OF PERMIT
•
0 I & 2 family dwelling or accessory 0 Commercial/industrial O Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Other:
' JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
Job address: I 3 5 S /fl // c) PS / 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.: profit. Value $ .
Lot: (Block: I Subdivision: *See checklist for important application information and
Project name: jurisdiction's fee schedule for residential permit fee.
City /county:'-'17 90 rc ( I ZIP: c7 a-13 I & 2 FAMILY DWELLING PERMIT FEE SCHEDULE
Description and location of work on premises: 4an l h OY1 AND COMMERICAL /INDUSTRIALVEQUIPMENTSCIIEDULE
Fee(ea.) Total
Est. date of completion/inspection: Description Qty. Res. only Res. only
Tenant improvement or change of use: HVAC:
•
Is existing space heated or conditioned? 0 Yes 0 No Air handling unit CFM
space insulated? 0 Yes ❑ No Air conditioning (site plan required)
Is existing P Alteration of existing HV AC system
' MECHANICAL CONTRACTOR . Boiler /compressors
Business name: (^)(,v, ER__ State boiler permit no.:
HP Tons BTU/H
Address: Fire/smoke dampers/duct smoke detectors
City: I State: ( ZIP: Heat pump (site plan required)
Phone: ( Fax: I E -mail: Install/replace furnace/burner BTU /H
Including ductwork/vent liner 0 Yes 0 No
CCB no.: —
. Install/replace/relocateheaters- 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: Chillers HP
Address: Com HP
Environmental exhaust and ventilation:
City: I State: I ZIP: Appliance vent
Phone: Fax: E -mail: Dryer exhaust
OWNER Hoods, Type U 11/res. kitchen/hazmat
hood fire suppression system
Name: Exhaust fan with single duct (bath fans)
Mailing address: Exhaust system apart from heating or AC
City: State: ZIP: Fuel piping and distribution (up to 4 outlets)
Type: LPG NG Oil
Phone: Fax: E - mail: Fuel pi ing each additional over 4 outlets
rocess pip ng (schematic required)
Name: Number of outlets
Other listed appliance or equipment:
Address: Decorative fireplace
City: ( State: ( ZIP: Insert - type
Phone: I Fax: I E - mail: Woodstove/pellet stove
A Applicant's signature: Da te Other:
PP g �>��� I " �' D Other: r
_ Name (print): braj n 4 - k C .
'Not all jurisdictions accept credit cards, please call jurisdiction for more information. Permit fee $
Cl 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 (6I00/COM)
MECHANICAL PERMIT FEES
•
COMMERCIAL FEE SCHEDULE: 1 & 2 FAMILY DWELLING FEE SCHEDULE:
TOTAL VALUATION: FEE: Description: Price - Total
$1.00 to $5,000.00 Minimum fee $72.50 Table 1A Mechanical Code QtY (Ea) Amt
$5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and 1) Furnace to 100,000 BTU
$1.52 for each additional $100.00 or including ducts & vents 14.00
fraction thereof, to and including 2), Furnace 100,000 BTU+
$10,000.00. including ducts & vents 17.40
$10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and 3) Floor Furnace
$1.54 for each additional $100.00 or including vent 14.00
fraction thereof, to and including 4) Suspended heater, wall heater
$25,000.00. or floor mounted heater 14.00
$25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and 5) _ Vent not included in appliance permit •
$1.45 for each additional $100.00 or 6.80
fraction thereof, to and including 6) Repair units •
$50,000.00. 12.15
$50,001.00 and up $742.00 for the first $50,000.00 and Check all that apply: . Boiler Heat Air
$1.20 for each additional $100.00 or For items 7 -11, see or Pump Cond .
fraction thereof. footnotes below. Comp* **
7) <3HP;absorb unit
to
ASSUMED VALUATIONS PER APPLIANCE: 15 BTU 14.00
. 8) 8) 3-15 HP; absorb
Value Total unit 100k to 500k BTU 25.60
Description: Qty (Ea) Amount , 9) 15-30 HP; absorb
Furnace to 100,000 BTU, including 955 unit .5-1 mil BTU 35.00
ducts & vents - 10) 30 -50 HP; absorb
Furnace > 100,000 BTU including 1,170 unit 1 -1.75 mil BTU 52.20
ducts & vents 11) >50HP: absorb
Floor furnace including vent 955 unit >1.75 mil BTU 87.20
Suspended heater, wall heater or 955 12) Air handling unit to 10,000 CFM
floor mounted heater - 10.00
Vent not included in applicants 445 13) Air handling unit 10,000 CFM+
permit 17.20
Repair units 805 14) Non - portable evaporate cooler
< 3 hp; absorb. unit, 955 10.00
to 100k BTU .
- 15) Vent fan connected to a single duct
3 -15 hp; absorb. unit, 1,700 6.80
101k to.500k BTU - 16) Ventilation system not included in
15-30 hp; absorb. unit, 501k to 1 2,310 appliance permit 10.00
mil. BTU 17) Hood served by mechanical exhaust
30 -50 hp; absorb. unit, 3,400 10.00 . - 1 -1.75 mil. BTU _
>50 hp; absorb. unit, 5,725 18) Domestic incinerators 17.40
>1.75 mil. BTU 19) Commercial or industrial type incinerator
Air handling unit to 10,000 cfm 656 - 69.95 ...
Air handling unit >10,000 cfm 1,170 - 20) Other units, including wood stoves
Non - portable evaporate cooler 656 10.00
Vent fan connected to a single duct 446 - 21) Gas piping one to four outlets
Vent system not included in 656 5.40
appliance permit - 22) More than 4 -per outlet (each)
Hood served by mechanical exhaust 656 - 1.00
Domestic incinerator 1 Minimum Permit Fee $72.50 SUBTOTAL: $.- ,
Commercial or industrial incinerator 4,590 - .
Other unit, including wood stoves, 656 8% State Surcharge . ' $
inserts, etc.
Gas piping 1-4 outlets 360 25% Plan Review Fee (of subtotal) • -. $
Each additional outlet 63 Required for ALL commercial permits only
TOTAL COMMERCIAL $ TOTAL RESIDENTIAL PERMIT FEE: - . $
VALUATION: ,
Other Inspections and Fees:
1. Inspections outside of normal business hours (minimum charge -two hours)
$72.50 per hour.
2. Inspections for which no fee is specifically indicated (minimum charge -half hour)
$72.50 per hour
3. Additional plan review required by changes, additions or revisions to plans (minimum
charge-one-half hour) $72.50 per hour
* State Contractor Boller Certification required for units >200k BTU.
* 'Residential NC requires site plan showing placement of l:hlt.
i:\dsts\forms\mech- fees.doc 10/11/00
Permit #:x,00- OOg7
1 j • F 75 1/1
o �' Address: �� S
Issued by: Date:
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:
K L. I own, reside in, or will reside in the completed structure.
I 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
I I before or upon completion.
n 3A. My general contractor is
I I (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
j El 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 above information is correct and that I have read and do understand the Information
Notice to Property Owners about Co truction Responsibilities on the reverse side of this form.
(Signature of p it applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
Information Notice to Properil Owners
Aboi:1 Construction Respon_sibilities
Note: This fillr,rio Propeit:, les
!;_v /jut IC! t% ,r; 7r) 7 5
L,oi.1:;Ie actin.L. c yca ow at:! in Yoi7st, C" '1 • LO '
you car, ore nao FoLlerns by 1 awarc, of r)f
EMPLOYEE RESPONSIBILI1 IES:
if you bira porsons .1.n: registered with t Consfr Coacaclor. ;: I J:ii•
eiscu ion or or it van v. ill, in 1 ;_
you hire will be employees. As the employer. you nest comply w:th
Orugon's r,ithholcling tax l ow: As
an employer, you . Iron] 11,
12: paid. You v, il he liable for the Lx payments t' en if you don't acmall:, t
information, call the Oregon Dept. of Revenue at 945
Unemplopperit insurance tax.. As an employer, 1 :rsur3iic p1:1 pe cc
,:,, o f a il ernpio cCs Fur mare infoimation. call the Ore Ernplo, merit Llivi:4ion at. the D of I lupiaa
at 378-3524.
orkers' compensation insurance: As an cmployci. to the n
Work Compensation I
obtain workers' compensatiI insz,rr nec !la your empi cc Fy(Tt thil a obtain nia')
he subject to penalties andx‘ Me liable lor all I
c.a,m casts t! nec oi voar ;s injorcd c.lithe Job For
call the Workers Compensation Division at the Department of Consumer and Business Set it c)4
U.S. Internal Revenue Service: As an employer, you mw-t iacometx from teriirlo:'eeS' Wa,r:f.:S. You il
liable for the tax payment even if you didn't actually withheld rhc La. For .core mdi
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 an failure to meet code tec
that may be brought to your attention through inspections.
Liability and property damage insurance: Contact your insurance agent to see if cc hit', c adequate insurance coverage for
accidenti and omissions such as falling tools, paint overspray. water damage from pipe punctures, fire, or work that must he
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
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