Permit \
ti
A, MASTER PERMIT
CITY OF TIGARD
PERMIT #: MST2003 -00184
'211 DEVELOPMENT SERVICES DATE ISSUED: 6/20/03
11' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171.
SITE ADDRESS: 12265 SW THORNWOOD DR PARCEL: 2S110BC -TS024
SUBDIVISION: THORNWOOD ZONING: R -
BLOCK: LOT: 024 JURISDICTION: TIG
REMARKS: Construction of new SFdetached residence.
BUILDING
REISSUE: DM198 STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: NEW HEIGHT: 29 FIRST: 1.290 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 1,360 sf GARAGE: 410 sf FRONT: 15 PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: 1 THIRD: sf RIGHT: 5
VALUE: 257
OCCUPANCY GRP: R3 BDRM: 5 BATH: 3 TOTAL: 2,650 sf REAR: 15
PLUMBING
SINKS: 1 WATER CLOSETS: 3 WASHING MACH: 1 LAUNDRY TRAYS: RAIN DRAIN: 100 TRAPS:
•
LAVATORIES: 4 DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: 100 SF RAIN DRAINS: 1 CATCH BASINS:
TUB /SHOWERS: 3 GARBAGE DISP: 1 WATER HEATERS: 1 WATER LINES: 100 BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIUCMP < 3HP: VENT FANS: 3 CLOTHES DRYER: 1
GAS FURN > =100K: 1 UNIT HEATERS: HOODS: 1 OTHER UNITS: 1
•
MAX INP: btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: GAS OUTLETS: 4
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVCIFEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 1 0 - 200 amp: 0 - 200 amp: W/SVC OR FDR: PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 5 201 - 400 amp: 201 • 400 amp: 1st W/O SVC/F DR: SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 • 600 amp: 401 - 600 amp: EAADDL BR CIR: SIGNAUPANEL: IN PLANT:
MANU HM/SVC /FDR: 601 - 1000 amp: 601 +amps 1000v. MINOR LABEL:
1000+ amp /volt :
PLAN REVIEW SECTION
Reconnect only:
>=4 RES UNITS: SVC /FDR > =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL • RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 5,414.34
This permit is subject to the regulations contained in the
DON MORISSETTE HOMES DON MORISSETTE HOMES INC Tigard Municipal Code, State of OR. Specialty Codes and
4230 GALEWOOD ST 4230 GALEWOOD ST, STE 100 all other applicable laws. All work will be done in
STE 100 LAKE OSWEGO, OR 97035 accordance with approved plans. This permit will expire if
LAKE OSWEGO, OR 97035 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: 503 387 - 7538 Phone: Oregon Utility Notification Center. Those rules are set
forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
Reg #: 1.4- 387 may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Erosion Control Insp 84 Post/Beam Structural Mechanical Insp Shear Wall Insp Insulation lnsp Appr /Sdwlk Insp
Grading Inspection Post/Beam Mechanical Plumb Top Out Exterior Sheathing Insl Rain drain Insp Electrical Final
Sewer Inspection Underfloor insulation Electrical Service Low Voltage Roof Nailing Mechanical Final
Footing lnsp Crawl Drain /Backwater Electrical Rough In Gas Line Insp Water Line Insp Plumb Final
Foundation Insp PLM /Underfloor Framing Insp Gas Fireplace Water Service lnsp Building Final
/ -
Issued By : - ' - / Permittee Signature : v ` G / --
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the next business day
7 (,-Ig -O' 5(.uR3c2o3 — 00/ V5
A , Building Permit Application - - l`
Date received :5 a_a3 i Permit no.:lyl,S� yop3_ 00 ,
�' ` .. City of Tigard
1
.. r: - Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW H
Phone: (503) 639 -4171 VED
CE1 Date issued: Bye Receipt no.:
Fax: (503) 598 -1960 Case file no.: Payment type:
APR ` 9 2003 1 &2 famil Sim le Com lex:
Land use approval: y p p
:
'1'\ rl. OF PERM 1T
0 1 & 2 family dwelling or accessory • Commercial/industrial 0 Multi- family , 'New construction 0 Demolition
O Addition/alteration /replacement 0 Tenant improvement 0 Fire sprinkler /alarm 0 Other.
: JOB SITE INFORMATION
Job address: 1 JnAM I I I I I 1=11E111 Bldg. no.: Suite no
Lot: _ Block: Subdivision: I p] i 11 Tax map/tax lot/account no.: (9,51i° 1'l' - SD
Project name: R —
Description and location of work on premises/special conditions:
OWNER FOR SI'ECIAL INFORMATION, USE CHECKLIST
,� p C.4 1 (Floodplain,septic capacity,solar, etc.)
Mailing address: a eMIT /3L�rtlli 1 & 2 family dwelling:
EENRIA i♦ ZIP: 'x), VAS Valuation of work $
Phone:. T a= , a No. of bedrooms/baths 2— 1 (a-
Owners representative: , A VFAMOr i f _ Total number of floors
Phone: Fax: E -mail: New dwelling area (sq. ft.) r
APPLICANT ��rr�� ^ �'�
Garage/carport area (sq. ft.)
�1�!�ilt Covered porch area (sq. ft.)
Mailing address: , L a Deck area (sq. ft.)
City: State: ZIP: Other structure area (sq. ft.)
Phone: Fax: E -mail: Commercial/industrial /multi - family:
CONTRACTOR Valuation of work $
Existing bldg. area (sq. ft.)
IMETEDVIAraWreugriral New bldg. area (sq. ft.)
Address: .4vLr &I.
City: Number of stories
ity: State: ZIP:
Phone: Fax: E -mail: Type of construction •
CCB no.: jiMOWLAIME=11111111111IMIMII Occupancy group(s): Existing:
New:
City/metro lie. no.: Notice: All contractors and subcontractors are required to be
F.. ARCHITECT` /DESIGNER licensed with the Oregon Construction Contractors Board under
1 provisions of ORS 701 and may be required to be licensed in the
Address: _ .L 4, , c- /1 l jurisdiction where work is being performed. If the applicant is
City: State: ZIP:
exempt from licensing, the following reason applies:
Contact person: Plan no.:
Phone: Fax: E -mail:
ENGINEER
Name: Contact person: Fees due upon application $
Address: Date received:
City: State: ZIP: Amount received $
Phone: Fax: E -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. A • rovisions of 1 ws and o dinances governing this 0 Visa 0 MasterCard
work will be compll w1 whether s ified �erern t. Credit card number: / /
Expires
Authorized si s atu • n L , f I �1[e Name of cardholder as shown on credit card $
Print name: l! 7 1 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 (6ro0icOM)
One- and Two- Family Dwelling - ,
Building Permit Application Checklist Reference no.:
City of Tigard CI of Tigard
Associated permits:
g 0 Electrical 0 Plumbing O Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 0 Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960
THE FOLLOWING ITEMS ARE FOR PLAN REVIEW Yes No N /A.
1 Land use actions completed. See jurisdiction criteria for concurrent reviews.
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. •
3 Verification of approved plat/lot.
4 Fire district approval required.
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 0 plan 0 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 t/
if copyright violations exist. J�
11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if
there is more than a 4-ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements and
driveway; footprint of structure (including decks); location of wells/septic systems; utility locations; direction indicator, lot ` ,.
area; building coverage area; percentage of coverage; impervious area; existing structures on site; and surface drainage. n
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. J�
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. J�
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. x
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 Oregon and shall be shown to be applicable to the project under review.
JURISDICTIONAL SPECIFICS
23 Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". x
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■10/COM)
Mechanical Permit Application
A Date w received: Permit no. fr j s j
r , y, ,.•� �� 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: Building permit no.:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi family ❑ Tenant improvement . -
iew construction ❑ Addition/alteration/replacement ❑ Other.
JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
. Job address: Ida-t i-AA) — TeNCYON V rib' [D(, Indicate equipment quantities in boxes below. Indicate the dollar
Bldg. no.: 1 Suite no.: value of all mechanical materials, equipment, labor, overhead,
Tax map /tax lot/account no.: profit Value $ .
Lot: . :21111 Block: Subdivision: 4 J 11 LA_ Lea *See checklist for important application information and
Project name: jurisdiction's fee schedule for residential permit fee.
City/county: 'ZIP: 1 & 2 FAMILY DWELLING PERMIT FEE SCHEDULE
Description and location of work on premises: AND COMMERICALIINDUSTRIAL EQUIPMENTSCHEDULE
. 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? ❑ Yes ❑ No Air handling unit red)
Is existing space insulated? ❑ Yes ❑ No
Air conditioning ti ng planrequired)
g P Alteration of existi HVAC system
MECHANICAL CONTRACTOR Boiler /compressors
State boiler permit no.:
. t !!_f1 I F A _ HP Tons BTU/H
Address: fr�� ��` Fire /smoke dampers/duct smoke detec tors
I IIEE t 1 _ ___ ZIP: lifef ll Heat pump (site plan required)
• Phone: P - -? j ) Fax: E -mail: Install/replacefurace/burner BTU /H
Including ductwork/vent liner ❑ Yes 0 No
CCB no.:
? ) Install/replace /relocate heaters— suspended,
City/metro lic. no.: N/A wall, or floor mounted
Name (please print): j . PA t Vent for appliance other than furnace
Refrigeration:
CONTACT PERSON
Absorption units BTU/H
��/ 3`, a ` d Chillers HP
Address: C.
Co • ressors HP
Environmental exhaust and ventilation:
City: j State: rz IP: Appliance vent
' Phone: Fax: E -mail: Dryer exhaust
OWNER Hoods, Type 1/ II/res. kitchen/hazmat
• hood fire suppression system
IIM t i .�glir Exhaust fan with single duct (bath fans)
Mailing address: W i W IJEIM ] Exhaust system apart from heating or AC
1131/Mrip �� � Fuel piping and distribution (up to 4 outlets)
Type: LPG NG Oil
Phone: gs Fax: E -mail: Fuel piping each additional over 4 outlets
ENGINEER Process piping (schematic required)
Name: Number of outlets
Other listed appliance or equipment:
Address: Decorative fireplace
City: I State: [ZIP: Insert — type
Phone: Fax: . E - mail: Woodstove/pelletstove
PP gFI �ir- a Other:
Applicant's s si natu" �� �� , �: Date: � )�� Other.
Name (print): ,AMIIMIffil
Tr-
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Permit fee $
❑ Visa ❑ MasterCard Notice: This permit application Minimum fee $
Credit card number: / 1 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 (6n0/COMM)
•
Plumbing Permit Application - F F.
Date received: Permit no.: a .A • ill) ,
-_ City of Tigard
Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223 Project /appl.no.: Expire date:
City ojTigard Phone: (503) 639 -4171
Fax: (503) 598 -1960 Date issued: By: Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
Cl 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
.= ew construction 0 Addition/alteration/replacement 0 Food service 0 Other.
JOB SITE INFORMATION • FEE SCHEDULE (for special informat use checklist) -
Job address: . „„,„ ow a f\I,■JI f Description Qty Fee(ea.) Total
New 1- and 2- family dwellings only:
Bldg. no.: Suite no.: (includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot spr Block: Subdivision: - O 0 SFR (2) bath
• Project name: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
_ Description and location of work on premises: Site utilities: .
Catch basin/area drain
Est date of completion inspection: — Drywells/leach line/trench drain
_ . Footing drain (no. lin. ft.)
. PLU'IIIING CONTRACTOR Manufactured home utilities
,—
Business name: IN, 1 L . Manholes
Address: I 0 Rain drain connector
���
�/� ZIP: Sanitary sewer (no. lin. ft.)
� Storm sewer (no. lin. ft.)
Phone: ' Fax: E-mail: — ' -vm Water service (no. lin. ft.)
re
CCB no.: [ • - 7l_- Plumb. bus. reg. no:
V Fixture or item:
City/metro lic. no.: N/A ' Absorption valve
Contractor's representative signature _. Back flow preventer
Print name: • , • fr V V. - - �� Backwater valve
CONTACT PERSON Basins/lavatory
Clothes washer
Name: \ , SP�'�171 E Dishwasher
Address: .aa' , / b c ■ Ni— Drinking fountain(s)
City: State: ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
T.':' -s s.- `-. OWNER Fixture/sewer cap _
_ �.}� Floor drains/floor sin -- Name (print): 1 -air t ` fir. � G ar b age disposal
•
Mailing address: 1 {j��j • ' • • 114, ' 1b . , ' ►��� Hose bibb
City: L _ ) 1311MM�' ,filiy� Ice maker
. Phone:. / , — Are! IM . E -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 own as per ORS Chapter 447. Sink(s), basin(s), lays(s) _
Owner's signature: Date: Sump ,
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: State: I ZIP: Other. _
Phone: I Fax: I E -mail: Total
Minimum fee $
Na all jurisdictions accept credit cards, please rill jurisdiction for more infatuation. Notice: This permit application
0 Visa 0 MasterCard a spires if a permit is not obtained Plan review (at _ %) $
C:edit card number. / 1 within 180 days after it has been State surcharge (8 %) ..•• $
Expires TOTAL $ ----
accepted as complete.
Name of cardholder as shown oa credit card
S
Cardholdu signature Amount 44 (6+03COM)
C
Electrical Permi ' A p ication FOR OFFICE USE ONLY
Received Electrical
JUL 2 5 2003 Date/By: Permit No.: mS% _aC7 -- -� f 8 t/
City of Tigard Planning Approval Sign I
Date/Ely: Permit No.:
CITY OF TIGAR
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 BUILDING DIVIS • Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use
/ /%mr�d1� �� l i Date Case No.:
Internet: www.ci.tigard.or.us erl � Contact Juns.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name/Method: Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that appl
New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
Addition/alteration /replacement ❑ Other: ❑ Service over 320 amps - rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
Pig I & 2- Family dwelling ❑ Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over thrcc stories ❑ Feeders, 400 amps or more
nil Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder LI Other: ❑ Egress/lighting plan ❑ Other:
Submit _ sets of plans with any of the above.
JOB SITE INFORMATION and LOCATION The above are not applicable to temporary construction service.
Job site address: I72 (, 1-N ` IA / i oh 04 FEE* SCHEDULE - '
Suite #: I Bldg /Apt.. #: Number of inspections per permit allowed
Project Name: /'j4i?/55 #44 D esc r iption Qty Fee (ea.) Total 1
New residential - single or multi - family per
Cross street/Directions to job site: dwelling unit. Includes attached garage.
Service included:
1000 sq. ft. or less 145.15 4
-
Each additional 500 sq. ft. or portion thereof 33.40 1
Subdivision: tat) 1,000D I Lot #: ail Limited energy, residential 75.00 2
Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
Services or feeders - installation,
alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTY OWNER I ❑ TENANT 601 amps to 1000 amps 240.60 2
Over 1000 amps or volts 454.65 2
Name: Reconnect only ME 66.85 2
Address: Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: 200 amps or less 66.85 1
201 amps to 400 amps 100.30 2
Phone: Fax: 401 to 600 amps 133.75 2
❑ APPLICANT ❑ CONTACT PERSON Branch circuits - new, alteration, or
Name: D 0 11 / / 0f L ]S 5 .t1 a r 5 �� ,6 b extension per panel: of
Address: � 23 b £ /r ��b D 5 () J I is A Fee for branch feeder r e each ranch circuit ui
service or feeder fee, each branch circuit 6.65 2
City /State /Zip: LAM 0514) rests 97 a3 B. Fee for branch circuits without purchase of
service or feeder fee, first branch circuit 46.85 2
Phone: 53.3- 3F7 -7i'3 %I Fax: 503 • 36 - 7 ^7&1 $ Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 _ 2
Each sign or outline lighting 53.40 2
Job No: IU 1 - Signal circuit(s) or a limited energy panel,
alteration, or extension Page 2 2
Business Name• ),,y\ g u-C . Description:
Address: e n 5q laL(
� Each additional inspection over the allowable in any of the above:
City /State /Zip: ,h t.0 joie. - p/ 70 01 Per inspection per hour (min. 1 hour) 62.50
Phone: 5T3 — 3$1,—S'10 2,3 I Fax: ,563- ZS!' - 23) i Investigation fee:
CCB Lic. #: 132222 Lic. #: _ L/, 3 C_
Other:
Electrical Permit Fees*
Supervising electrician 4 0 Subtotal $
Si • attire re • uired: , ,, �, , I 21 i Plan Review (25% of Permit Fee) $
Print Name: 1.1 pp . Lie. #:/ 1 L,7 5 State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit FormskElcPermitApp.doc 01/03
Electrical Permit Application- City of Tigard
Page 2 - Supplemental Information
•
LIMITED ENERGY PERMIT FEES: •
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
• Audio and Stereo Systems
Burglar Alarm
O Garage Door Opener
• Heating, Ventilation and Air Conditioning System
Vacuum Systems
Other •
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
El Audio and Stereo Systems
ID Boiler Controls
• El Clock Systems
Data Telecommunication Installation
ID Fire Alarm Installation
HVAC
Instrumentation
11 Intercom and Paging Systems
•
Landscape Irrigation Control* •
Medical
Nurse Calls
Outdoor Landscape Lighting
Protective Signaling
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
i:\Dsts\Permit Forms\ElcPennitAppPg 01/03
I
Electrical Permit Application
Date received: Permit no.: / h t _.- Q3 , 0010
It City of Tigard Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 Date issued: By: I Receiptno.:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval:
TYPE OF PERMIT
0 1 & 2 family dwelling or accessory 0 Commercial/industrial O Multi- family O Tenant improvement
►' New construction 0 Addition/alteration /replacement O Other. O Partial
- JOB SITE INFORMATION
Job address: t _ a 5 L (. I' 1 Bldg. no.: Suite no.: Tax map /tax lot/account no.:
Lot: I Block: Subdivision: r
Project name: I Description and location of work on premises:
Estimated date of completion/inspection: .
2.CONTRAC'T'OR APPLICATION FEE SCHEDULE - -
Job no:D Fee Max
Business name: CA ELEC,TCA C. Descripti °n Qty. (ea) Total no. Imp
New residential - single or multi- family per
Address: - 1►9 k • Wi stt`. - dwellittgunit . Includes attached garage.
City: 'IA L'51 State: ! ZIP: -t —2 3 Serviceincluded:
Phone:2 .3 - I Q -2,9c; I Fax: 1E-mail: 1003 sq. ft. or less • 4
�� � Each additional 500 sq. or portion thereof
CCB no.: Elec. bus. lic. no: Lirrtited energy, residential ~ 2
C' Limited energy, non - residential 2
Each manufactured home or modular dwelling
natur of supervising electrician (required) Date Service and/or feeder 2
Sup. elect. name (print): 9 R_ License no: I a7 Serncesor feeders — Installation,
alteration or relocation:
200 amps or less 2
Name (print): , &,,,,- t U j 7 201 amps to 400 amps 2
� 401 amps to 600 amps • 2
Mailing address: �. 1( 601 amps to 1000 amps 2
City: LAO, IState ZIP:q -20 3c, Over 1000 amps or volts 2
Phon - /7 Fax: -`7 j( E -mail: Reconnect only 1
Owner installation: The installation is being made on property I own Temporary services or feeders - .-
which is not intended for sale, lease, rent, or exchange according to installation, alteration, orrelocation: 2
ORS 447, 455, 479, 670, 701.
200 amps or less 2
201 amps to 400 amps
Owner's signature: Date: 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: '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):
O Service over 225 amps-commercial 0 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,
O System over 600 volts nominal more residential units in one structure alteration, or extension* 2
O Building over three stories 0 Feeders. 400 amps or more *Description:
O Occupant load over 99 persons 0 Manufactured structures or RV park Each additional inspection over the allowable in any of the above:
O Egress/lighting plan 0 Other. Per inspection _I I I
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 jurisdictioo for more information. Notice: This permit application
Permit fee $
O Visa 0 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
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Cardholder signature Amount • 440 -4615 (6V0/COM)
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TREE CERTIFICATION
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• I . BIA IC,c W- E , Owner /Agent for (wJ M T c o isse 74,,,5
• (PLEASE RINT) (PERMIT HOLDER)
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• Do hereby certify that the following location . ;
• meets City of Tigard /Washington County ►
• land use and development standards for street tree installation. ;
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• • A DDRESS: / Z-2-(05 Sr„) Tflv2N14000 DA_ j
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• • LOT: Z V. SUBDIVISION: Tff l2/v✓vo/a ■
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• BY: DATE: 9-Z., -o 3 ► ■
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A RECEIVED BY: DATE: ■
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CITY OF TIGARD 24 -E'lur
BUILDING Inction Line: (503) 639 -4175 _ Oa
INSPECTION DIVISION Business Line: (503) 639 -4171
� G BUP
Received Ej Date Reque ted s9 / / " AM PM BUP
Location / 2- 2 Cc. c � N UJ o b Suite MEC
Contact Person A c.., Ph ( ) �/ — G Y r 2--PLM
Contractor JJ Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation Access: ELC
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
__•
• • SS PART FAIL
�CUMB1N e
Post &Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
e
PART FAIL
' ANICAL
Post & Beam
Rough -In
Gas Line
mpers
• SS ,'ART FAIL
«' L
Service
Rough -In
UG /Slab
oge
ire arm
am ❑ Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
• • SS PART FAIL
Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line
ADA /
Approach/Sidewalk Date 9'o 7L 03 Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL