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Permit CITY OF TIGARD MASTER PERMIT 1111 s COMMUNITY DEVELOPMENT lir, Permit#: MST2012 00221 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 ®� Date Issued: 09/18/2012 Parcel: 2S102BB00818 Jurisdiction: Tigard Site address: 10225 SW BROOKSIDE PL Subdivision: BROOKSIDE PARK Lot: 3 Project: Nguyen Project Description: 755 square foot addition. 1/22./13_reprinted to add to scope of work: move electrical panel and move gas piping to new meter location. BUILDING Floor Areas Required Setbacks Reauired Stories: 1 Bedrooms: 1 First 755 sf Basement 0 sf Left: 5 Parking Spaces. 0 Height: 14 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 20 Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Yes Total: 755 sf Value: $78,459.60 Rear: 15 PLUMBING Sinks: 1 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 1 Dishwashers: 1 Floor Drains: 0 Sewer Lines 0 SF Rain Storm Sewer 0 Drains 0 Tubs/Showers: 1 Garbage Disp: 1 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 1 Hose Bib: 0 Backwater Value: 1 Drywell-Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 1 Fum<100K: 0 Vents 0 Woodstoves 0 Gas Outlets: 2 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temo Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 1 0-200 amp. 0 WI Svc or Fdr: 0 Ea add'I 500 sf: 0 201-400 amp: 0 201-400 amp 0 W/O Svc/Fdr: 4 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+ampNolt 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-3 755 Owner: Contractor: NGUYEN,CHIEN VAN OWNER Required Items and Reports(Conditions) NGUYEN-VO,TO 1 Ersn Cntrl 503-639-4175 10225 SW BROOKSIDE PL TIGARD,OR 97223 PHONE: 503-539-7528 PHONE: FAX: Total Fees: $3,150.65 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 i -.+•r•ance . 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. ENTION: Oregon aw -•uires you to follow the rules adopted by the Oregon Utility No - Center. Those rules are set forth in OAR 952 11-0010 . rough OAR 952-,r -80.0. ou may obtain a ••y of the rules or direct questions to•- • • (?11uu-,03.232.1987 or 1.800.332.2344. Is ued By: ■ -�;,�` Permittee S •nature: _�� !1r Call 503.639.4175 by 7:00 a.m.for the next availableinspecti• date. J This permit card shall be kept in a conspicuous place on the job site ompletlon of the project. Approved plans are required on the job site at the time of each inspection. Electrical Permit Applica1RECEIVED FOR OFFICE 'USE ONLY City of Tigard 2 2 2013 Received Date/By: / s9"/3 ( Permit No.: /�� -��/ 1114 13125 SW Hall Blvd.,Tigard,OR 9721/11N Plan Review Phone: 503.718.2439 Fax: 503.598.1960 ❑r� Date/By: Other Permit: I I . `I,l) Inspection Line: 503.639.4175 CITY Ot[TIGARD Date Ready/13y: tuns: ® See Page 2 for Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: - Supplemental Information TYPE OF WORK PLAN REVIEW ❑New construction ❑Addition/alteration/replacement Please check all that apply(submit 2 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 ❑ 1-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 ❑Emergency system. larger separately derived system. JOB SITE INFORMATION AND LOCATION ❑Addition of new motor load of ❑"A","E","I-2","I-3", Job no.: Job site address: /(:52--,2-5 -to I C) t ' /7:28, 100HP or more. occupancy. ❑Six or more residential units. ❑Recreational vehicle parks. City/State/ZIP: ❑Health-care facilities. ❑Supply voltage for more than ❑Hazardous locations. 600 volts nominal. Suite/bldg./apt.no.: Project name: ❑Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total I • New residential single-or multi-family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq.ft.or less 168.54 4 Ea.add'l 500 sq.ft.or portion 33.92 1 Tax map/parcel no.: Limited energy,residential D ON OF WORK (with above sq.ft.) 75.00 2 M O t 1V �0 Limited energy,multi-family sq. 75.00 2 J �L.• residential(with above sq.ft.) Services or feeders installation,alteration,and/or relocation 200 amps or less i 100.70 /pd.7d 2 ❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: 644 I N 1\,( 144 Al 601 amps to 1,000 amps 301.04 2 Address: ( 0 )r S 1N Nik 0-b-t�i pp p( Over 1,000 amps or volts 552.26 2 1 V t {/ Temporary services or feeders installation,alteration,and/or City/State/ZIP: Ti' 61412.42 MK_� 9 ?-Z)i� relocation Phone:( ) 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,le , nt,or exchange,according to ORS 447,449,670,and 701. Branch circuits-new,alteration,or extension,per panel Owner signature: Date: r_"2...1„..-—I A.Fee for branch circuits with ❑ APPLICANT I El CONTACT PERSON above service or feeder fee, 7.42 2 each branch circuit Business name: B.Fee for branch circuits without service or feeder fee,first 56.18 2 Contact name: branch circuit Each add'I branch circuit 7.42 _ 2 Address: Miscellaneous(service or feeder not included) _ City/State/ZIP: Each manufactured or modular 67.84 2 ty dwelling,service and/or feeder Phone:( ) Fax: :( ) Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 E-mail: Sign or outline lighting 67.84 2 CONTRACTOR Signal circuit(s)or limited-energy Business name: panel,alteration,or extension. Page 2 2 Each additional inspection over allowable in any of the above Address: Additional inspection(1 hr min) 66.25/hr City/State/ZIP: Investigation(1 hr min) 66.25/hr Industrial plant(1 hr min) 78.18/hr Phone:( ) Fax:( ) inspections for which no fee is 90.00/hr specifically listed(/3 hr min) I CCB Lic.: Electrical Lic.: Suprv.Lic.: ELECTRICAL PERMIT FEES Subtotal: Suprv.Electrician signature,required: Plan review(25%of permit fee): Print name: Date: State surcharge(12%of permit fee): !I l TOTAL PERMIT FEE: `Ff Authorized signature: C 'I This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: i / Date: p_1,1 12 • Number of inspections allowed per permit. I:\Building�Permita\ELC-PermitApp.doc 07/01/10 440-4615T(11/05/COOMM/WEB Electrical Permit Application - City of Tigard Page 2- Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: . Fee for all residential systems combined .. $75.00 • Check Type of Work Involved: ❑ Audio and Stereo Systems* ❑ Burglar Alarm • ❑ Garage Door Opener* ` ❑ Heating,Ventilation and Air Conditioning System* ❑ Vacuum Systems* ❑ Other: COMMERCIAL WORK ONLY: • Fee for each commercial $75.00 system (SEE.OAR 918-309-0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ElData Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls El Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I\Building\Pennrts\ELC-PermitApp doc 07/01/10 Mechanical Permit Applicl civED FOR OFFICE USE ONLY City of Tigard Date/By:Received ��_ 1� Permit No.: �/� /�� • 13125 SW Hall Blvd.,Tigard,OR 97223 2 2 Plan Review ffff// Eril Phone: 503.718.2439 Fax: 503.598.19�(\N {� Li 2013 Date/By: Other Permit: T(GA R D Inspection Line: 503.639.4175 Date Ready/By: Jurir. ® See Page 2 for Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information n I t TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST Mechanical permit fees*are based on the value of the work ❑New construction ❑Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all ❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,mid profit. Value:$ CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT/SYSTEMS FEES* ❑ 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special 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: 4 0 ?j5- , w ‘),opl(ci/f e L (requires site plan showing placement) 46.75 City/State/ZIP: /�.� !�� Furnace 100,000 BTU(ducts/vents) 46.75 �1 &7 41 7/7/ Furnace 100,000+BTU(ducts/vents) 54.91 Suite/bldg./apt.no.: Project name: Heat pump (requires site plan showing placement) 61.06 Cross street/directions to job site: Duct work 23.32 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 C " /11,2e C tt�,(. f" }'Y1 Y .i.� Gas fireplace/insert vent water 33.39 Flue vent for water heater or gas e _ j fireplace 23.32 ! �p� �M I� w b"" Log lighter(gas) 23.32 (fr)sr, `�1 }/ / Wood/pellet stove 33.39 -rt) Ex/ 5 T/ N a P e�Nt( r(5j' v`^S 4f) Wood fireplace/insert 23.32 ❑ PROPERTY OWNER I ❑ TENANT Chimney/liner/flue/vent 23.32 Other: 23.32 Name: . Ni „ t �(/( '1" Environmental exhaust and ventilation: _ _ Address: I (I Z Z'� c !� 7'"_ "1` 012e- equ Range hood/other kitchen �/ P� equipment 33.39 • City/State/ZIP: -ilk / n �1 3 Clothes dryer exhaust 33.39 C77° I"r Single-duct exhaust(bathrooms, Phone:( V)-)) 5" 22 q — 7 5--2.--g Fax:( ) toilet compartments,utility rooms) . 23.32 _ __ ❑ APPLICANT ❑ CONTACT PERSON Attic/crawlspace fans 23.32 Business name: Other: 23.32 Fuel piping: Contact name: S14.15 for first four;54.03 for each additional Address: Furnace,etc. / Gas heat pump City/State/ZIP: WalUsuspended/unit heater Phone:( ) Fax: :( ) Water heater / E-mail: Fireplace Range . CONTRACTOR Barbecue , Business name: W `v l.-- Clothes dryer(gas) Other: Address: MECHANICAL PERMIT FEES* City/State/ZIP: Subtotal Phone:( ) Fax:( ) Minimum permit fee($90.00) Plan review(25%of permit fee) _ CCB lie.: State surcharge(12%of permit fee) TOTAL PERMIT FEE Authorized signa I re: (A 4I r e I V Y�;/\/ This permit application expires if a permit is not obtained within 180 (n/`� +mot— days after it has been accepted as complete. Print name: I Date: 4 _7/'.. — i )7 * Fee methodology set by Tri-County Building Industry Service Board 1:\Building\PermitsMEC-PermitApp.doc 03/07/! 440.4617T(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. fi I:\Building\Permits\MEC-PermitApp.doc 03/07/12 2 CITY OF TIGARD MASTER PERMIT s • • COMMUNITY DEVELOPMENT Permit# MST2012 00221 Date Issued 09/18/2012 TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503 718 2439 Parcel 2S102BB00818 Jurisdiction Tigard Site address 10225 SW BROOKSIDE PL Subdivision BROOKSIDE PARK Lot 3 Project Nguyen Project Description 755 square foot addition BUILDING Floor Areas Required Setbacks Required Stories 1 Bedrooms 1 First 755 sf Basement 0 sf Left 5 Parking Spaces 0 Height 14 Bathrooms 1 Second 0 sf Garage 0 sf Front 20 Smoke Dwelling Units 0 Third 0 sf Right 5 Detectors Yes Total 755 sf Value $78 459 60 Rear 15 PLUMBING Sinks 1 Water Closets 1 Washing Mach 0 Laundry Trays 0 Rain Drain 0 Urinals 0 Lavatories 1 Dishwashers 1 Floor Drains 0 Sewer Lines 0 SF Rain Storm Sewer 0 Tubs /Showers 1 Garbage Disp 1 Water Heaters 0 Water Lines 0 Drains 0 Catch Basins 0 Bckflw Prevntr 0 Footing Drain 0 Ice Maker 1 Hose Bib 0 Backwater Value 1 Drywell- Trench Drain 0 Other Fixtures 0 Other Fixture Units MECHANICAL Fuel Types Air Conditioning N Vent Fans 1 Clothes Dryers 0 Heat Pump N Hoods 0 Other Units 1 Furn <100K 0 Vents 0 Woodstoves 0 Gas Outlets 0 Furn > =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 add'I 500 sf 0 201 -400 amp 0 201 -400 amp 0 W/O Svc/Fdr 4 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 8 Stereo N HVAC N Secunty Alarm N Vaccuum System N Garage Opener N All Other N Other Descnption Ecompasrng N BUILDING INFO Class of Work Type of Use Type of Constr Occupancy Group Square Feet ADD SF VB R -3 755 Owner Contractor NGUYEN, CHIEN VAN OWNER Required Items and Reports (Conditions) NGUYEN - VO, TO 1 Ersn Cntrl 503 - 639 -4175 10225 SW BROOKSIDE PL TIGARD, OR 97223 PHONE 503 -539 -7528 PHONE FAX Total Fees $3,087 79 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 ENTION Ore!• • law - .wires you to follow the rules adopted by the Oregon Utility Notification Center Those rules are set fort in OAR 9 - 001 -0010 through OAR 95 • s -00 '0 ' .0 may obtain aaccop�y of the rules or direct questions to OUNC by calling 50 2 1987 or 1 800 332 234 I sued By \ t..— / /. CX/'" ` I Permittee Signature .N AA Call 503 639 4175 by 7 00 a m for the next available Inspection da e This permit card shall be kept In a conspicuous place on the Job site until completion of the project Approved plans are required on the job site at the time of each inspection Iuilding Permit Application Residential FOR OFFICE USE ONLY RECEIVE City of Tigard I Received Date/B � _In T ] �� 0 O� Perini No 13125 SW Hall Blvd , Tigard, OR 97223 Plan Review r� II . Phone 503 718 2439 Fax 503 598 1960 � '' J 2 2 / u :2 Date/B WET Other Permit I' I A It D ins Line 503 639 4175 Date Ready/By ( !o mn9 El See Page 2 for Internet www tigard - gov CL ° 4FTIGARD . i N. ied/Mj oil O � � Supplemental Information BUI it►._ _ ii . ts 4 1 0 ' e r ',- TYPE OF WORK REQUiR A DA ' • : I- 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 ( gAddition/alteration/replacement ❑ Other equipment, materials, labor, overhead, and the profi . for e CATEGORY OF CONSTRUCTION work indicated on this application „idle � ` Ig 1- and 2 -family dwelling ❑ Commercial/Industrial �. .i rI lndustrial ) ❑ Accessory building ❑ Multi - family Number of bedrooms f ❑ Master builder ❑ Other Number of bathrooms JOB SITE INFORMATION AND LOCATION Total number of floors Job site address 1 6 2 -- C vJ 12j /-d((> 4 p New dwelling area 75 square feet City /State /ZIP `T 1 4 (5-R q 7 2- Garage /carport area square feet Suite/bldg /apt no 1 Project name q Covered porch area square feet Cross street/diredions to job site S h/ 0 — tr ic e i - J A Deck area square feet Other structure area square feet 14— 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 Valuation S PFD (To !■ Existing building area square feet New building area square feet ❑ PROPERTY OWNER ❑ TENANT Number of stones Name 4'i FN Ai' F/V Type of construction Address S a /14i11L (11615.0— Occupancy groups City /State /ZIP Existing Phone ( ) Fax ( ) New ❑ APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES* (Please refer to fee schedule) Business name Structural plan review fee (or deposit) Contact name FLS plan review fee (if applicable) Address City/State/ZIP Total fees due upon application �,�[ Phone ( ) Fax ( ) Amount received i/5 ' 4 E -mail PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* Commercial and residential prescnptive installation of CONTRACTOR roof -top mo nted PhotoVoltaic Solar Panel System Business name Submit two ( - sets of roof plan with connection det. ils and fire dep. • i t access, along with the 2011 $ on Address Solar Installation .: rally Code c I - City /State /ZIP Permit Fee (inclu I, •,. . review $180 00 ...ministr.. - fees) Phone (G9 2 C • ? 4_ - q ys Fax ( ) S a e surcharge (12% of permit - • $21 60 CCB lic Total fee due upon application $201 60 Authonzed signature / , This permit application expires if a permit is not obtained Print name within 180 days after it has been accepted as complete. Date * Fee methodology set by Tn -County Building industry c-{�l �) J /� �.6.44 ! Dt - �2 — Service Board. 1 kBuilding\Permits\BUP- RESPermitApp doc 02/ 24/2011 440- 4613T(11/02 /COM/WEB) , Building Permit Application Checklist One- and Two - Family Dwelling FOR OFFICE USE ONLY City of Tigard 4 Z Received Permit No u 13125 SW Hall Blvd , Tigard,OR 97223 AsteBy G 1 Phone 503 718 2439 Fax 503 598 1960 0 Associated permits 24- Hour Inspection Line 503 639 4175 ❑ Electncal 0 Plumbing 0 Mechanical I" I c. A It D Internet www tigard -or gov 115-. —. ?i 9 1 ❑ Other THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW 1 e No N/.- 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 CI CI CI 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 I I 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 sand 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 12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ El location 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ CI 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- CI ❑ 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 Ore:on and shall be shown to be as •licable to the . ro ect under review JURISDICTIONAL SPECIFICS 23 Three (3) 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 and 22 above ❑ ❑ ❑ 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 pnor to September 9, 1995 I \Building \Permits \BUP- RESPermitApp doc 02/24/2011 440- 4613T(I I /02 /COM/WEB) Plumliin2 Permit Application RECEIVED r Received 1/� 14 City of Tigard 7 DateB v / ,p. Permit No ` �, -�Q / a 13125 SW Hall Blvd , Tigard, OR 97223A 1 1' 2 2 ( Plan Review Phone 503 718 2439 Fax 503 598 1460 Date/By Other Permit No T I G A R D Inspection Line 503 639 4175 (` OFTIGARD Date Ready/By lures RI See Page 2 for Internet www tigard -or CITY Notified/Method Supplemental Information TYPE E OF WI�i FEE* SCHEDULE ❑ New construction ❑ Demolition For specsl information use checklist Description I Qty I Ea I Total Addition /alteration/replacement ❑ Other New I - 2 - family dwellings (includes 100 ft for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 312 70 � 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437 78 [► SFR (3) bath 500 32 ❑ Accessory building ❑ 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 ' O - ); C w 17 f O < , ` (� ,P F � Catch basin or area drain 18 76 City /State /ZIP ✓✓ Drywell, leach line, or trench drain 18 76 6_,AID r �� q 7 2-2- Footing drain (no linear ft ) Page 2 Suite/bldg /apt no Protect name Manufactured home utilities 50 03 Cross street/directions to job site S W n ._,iII 4 c. a4 qua Manholes 18 76 Rain drain connector 18 76 Sanitary sewer (no linear ft ) Page 2 Stone sewer (no linear ft ) Page 2 Water service (no linear ft ) Page 2 Subdivision 1 Lot no Fixture or item: Tax map /parcel no Backflow preventer 31 27 DESCRIPTION OF WORK Backwater valve I 12 51 Clothes washer 25 02 PM D C Dishwasher ( 25 02 Drinking fountain 25 02 Ejectors /sump 25 02 ❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12 51 Name / v G 4 . A j Fixture /sewer cap 25 02 I 1 Floor drain/floor sink/hub 25 02 Address c• MI cc irm 1 - 2 -- Garbage disposal ' 25 02 City /State /ZIP Hose bib 25 02 Phone ( ) Fax ( ) Ice maker r 12 51 ❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25 02 Business name Medical gas (value $ ) Page 2 Contact Primer 12 51 ontact name Roof drain (commercial) 12 51 Address Sink/basin/lavatory 25 02 City /State /ZIP Solar units (potable water) 62 54 Phone ( ) Fax ( ) Tub /shower /shower pan / 12 51 E -mail 1 Urinal 25 02 CONTRACTOR Water closet 1 25 02 Water heater 37 52 Business name ) p� Water piping/DWV 56 29 Address c.e e l( Other 25 02 City /State /ZIP Subtotal Phone (rr0 2.) L 4 q _ 7s" 2' Fax ( ) Minimum permit fee $72 50 CCB Lic Plumbing Lic no Plan review (25% of permit fee) — State surcharge (12% of permit fee) Authorized signature �TOTAL PERMIT FEE / Date [� This permit application expires if a permit is not obtained within 180 days Pent name < Ai N It - �1^ 20/2_ after it has been accepted as complete *Fee methodology set by Tri -County Building Industry Service Board \Buddmg\Permits\PLMU- PermitApp doc 10/01/09 440- 4616T(I0 /02/COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: Footing drain - I c 100' 50 03 0 to 2,000 $121 90 Footing drain - each additional 100' 37 52 2,001 to 3,600 $169 69 3,601 to 7,200 $233 20 Sewer - 1st 100' 62 54 7,201 and greater $327 54 Sewer - each additional 100' 37 52 Water Service - 1st 100' 62 54 Medical Gas Systems: Water Service - each additional 100' 37 52 Storm & Rain Drain - 1st 100' 62 54 Valuation: Permit Fee: $1 00 to $5,000 00 Minimum fee $72 50 Storm & Rain Drain - each additional 100' 37 52 $5,001 00 to $10,000 00 $72 50 for the first $5,000 00 and $1 52 for Q ty. Fee (ea) Total each additional $100 00 or fraction thereof, to Other Inspections or Fees and including $10,000 00 Inspection of existing plumbing or for $10,001 00 to $25,000 00 $148 50 for the first $10,000 00 and $1 54 for which no fee is specifically indicated 90 00/hr each additional $100 00 or fraction thereof, to (minimum charge — 1/2 hour) and including $25,000 00 Inspections outside of normal business 90 00/hr $25,001 00 to $50,000 00 $379 50 for the first $25,000 00 and $1 45 for hours (minimum charge — 2 hours) each additional $100 00 or fraction thereof, to Reinspection Fees 90 00/hr and including $50,000 00 Additional plan review for revisions 90 00/hr $50,001 00 and up $742 00 for the first $50,000 00 and $1 20 for (minimum charge — 1/2 hour) each additional $100 00 or fraction thereof Subtotal: Commercial Fixture Work: Are you capping, adding or replacing fixtures? If "yes ", Plan Review for Plumbing Installations please indicate work performed by fixture. Failure to Plan review is required for any of the following accurately report fixtures could result in increased sewer fees * . Please check all that apply Quantity by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and Fixture Type: Replace greater, except systems designed and stamped by licensed Previous Capped Added Existing engineer Baptistry/Font Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure -Tub/Shower -Jacuzzi/Whirlpool as defined in OAR918- 780 -0040 Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities Dave tall ❑ Any multipurpose fire sprinkler system Cuspidor/Water Aspirator ❑ Any complex structure as defined in OAR918 -780 -0040 Dishwasher - Commercial Domestic Submit 2 sets of plans with any of the above. Drinking Fountain Eye Wash Isometric or Riser Diagram Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings 3 that meet the qualifications above Car Wash Drain Garbage - Domestic Disposal - Commercial Industrial Comments regarding fixture work: Ice Mach /Refrig Drains Oil Separator (Gas Station) Rec Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley - Commercial *Note: If the fixture work under this permit results in an - Service increase of sewer EDUs, a sewer permit will be issued and Swimming Pool Filter fees assessed for the sewer increase must be paid before the Washer - Clothes Water Extractor plumbing permit can be issued. Water Closet - Toilet Urinal Other Fixtures I \Building\Permits\PLM- PermitApp doc 2 Mtechadical Permit Application Received City of Tigard ENE Date/By g .9 a /4 Permit No 1.51reva !hi ° 13125 SW Hall Blvd , Tigard, OR 97223 Phone 503 718 2439 Fax 503 598 1960 AUG 2 2 '; "', i Date/By Plan Review Other Permit TI G A R U Inspection Line 503 639 4175 Date Ready/By Jung la See Page 2 for Internet www tigard-or gov CITY 'rIG_ ARD Notified/Method Supplemental Information TYPE OF WOR � C� I1LlDiIAiGDlIINJJISI0N COMMERCIAL FEE" SCHEDULE — USE CHECKLIST Mechanical permit fees' are based on the value of the work ❑ New construction ❑ Addition/alteration/replacement performed Indicate the value (rounded to the nearest dollar) of all (Demolition ❑ Other mechanical materials, equipment, labor, overhead, and profit Value $ CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES* [g I- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist. ❑ Multi - family ❑ Master builder ❑ Other Description I Qty I Ea Total JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning Job site address j O 1j24— D, l�„( a'C c _ + tL P (requires site plan showing placement) 46 75 City/State /ZIP -'- h Furnace 100,000 BTU (ducts/vents) 46 75 (sf % . '7 -Y y / q 3 Furnace 100,000+ BTU (ducts /vents) 54 91 Suite/bldg /apt no � 1 Project name Heat pump pp n (requires site plan showing placement) 61 06 Cross street/directions to job site , ln/ r17 S t 4 /k-vx_ Duct work / 23 32 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 Pr ---r � Gas fireplace/insert 33 39 P I� ! J ;-� ,([ 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 ❑ PROPERTY OWNER ❑ TENANT Chimney/liner/flue/vent 23 32 Other 23 32 Name ' Environmental exhaust and ventilation: Address Range hood/other kitchen ff ol/Yi� �— equipment 1 33 39 City/State /ZIP Clothes dryer exhaust 33 39 Single -duct exhaust (bathrooms, Phone ( ) Fax ( ) toilet compartments, utility rooms) 23 32 ❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23 32 Business name Other 23 32 Fuel piping: Contact name $14.15 for first four; $4 03 for each additional Address Furnace, etc Gas heat pump City /State /ZIP Wall /suspended/unit heater Phone ( ) Fax ( ) Water heater Fireplace E -mail Range CONTRACTOR Barbecue Business name \ Clothes dryer (gas) D / / , 1 t Other Address (/lf N MECHANICAL PERMIT FEES` City/State /ZIP Subtotal Phone ( — a';) 15 7 ) C , c 2 , K Fax ( ) Minimum (25% of r mit 00) 1 -1,9 7 Plan review (25% of permit fee) CCB Inc State surcharge (12% of permit fee) TOTAL PERMIT FEE Authorized signature r j This permit application expires if a permit is not obtained within 180 I ( 1 / days after it has been accepted as complete. Print name e..44 RA/ /11 - Date e_2_,_ Fee methodology set by Tn -County Building Industry Service Board Permits \ M I \ Budding \EC- Penni.App doc 03/D7/12 y 440-46I7T (I I /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 \Budding\Pertmts\MEC- PertmtApp doc 03/07/12 2 Electrical Permit ApplicationRECENED FOR OFFICE USE ONE Received , 149... / ` �abi�—�� City of Tigard q �! r, 2 2 ', Date/By Permit No 13125 SW Hall Blvd , Tigard, OR 97223 Plan Review Phone 503 718 2439 Fax 503 598 } � �p� Date/By Other Permit I' I G r\ R D Inspection Line 503 639 4175 �+ �TIGCilIIJ Date Ready/By ions 67 See Page 2 for Internet www tigard -or gov BUILDING DIVISION Notified/Method - Supplemental Information TYPE OF WORK PLAN REVIEW Please check all that apply (submit 2 sets of plans whtems checked below) ❑ lew construction ❑ Addition/alteration/replacement ❑ Service or feeder 400 amps or more ❑ Building over three stories ,rU 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 [gl- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations buildings ❑ Multi- family El Master builder El Other ❑ Fire pump ❑ Installation of 75 KVA or JOB SITE INFORMATION AND LOCATION ❑ Emergency system larger separately denved system ❑ Addition of new motor load of ❑ "A ", "E ", "l -2 ", "I -3 ", Job no Job site address 2 S S l Six or or more occupancy �n S 1 ❑ Six or more residential units ❑ Recreational vehicle parks City/State /ZIP ❑ Health -care facilities ❑ Supply voltage for more than T (\ - /111�7 ( C � 7 Z Z 7 0 Hazardous locations 600 volts nominal Suite/bldg /apt no Project name ❑ Service or feeder 600 amps or more FEE SCHEDULE Cross street/directions to job site �� R 1� �. � t �E Description Otv I Fee I Total I • v / IiO O� \ New residential single- or multi - family dwelling unit. Includes attached garage. Subdivision Lot no 1,000 sq ft or less 168 54 4 Tax map /parcel no Ea add'I 500 sq ft or portion 33 92 1 Limited energy, residential 75 00 2 DESCRIPTION OF WORK (with above sq ft ) Limited energy, multi -family 75 00 2 /9-1D"D ! [ ON \ residential (with above sq ft ) Services or feeders installation, alteration, and/or relocation 200 amps or less 100 70 2 ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133 56 2 / Name / . y , o r , , 401 amps to 600 amps 200 34 2 ` "►vww"" "" 601 amps to 1,000 amps 301 04 2 Address �� _ �� Over 1,000 amps or volts 552 26 2 Temporary services or feeders installation, alteration, and/or City/State /ZIP relocation Phone ( ) 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, leas - , e nt, or exchange, according to ORS 447, 449, 670, and 701 Branch circuits — new, alteration, or extension, per panel Owner signature ,t A '_L41`!'A‘ Date —'Z(. V I 2.--- A Fee for branch circuits with r I above service or feeder fee, ❑ APPLICANT ❑ CONTACT PERSON each branch circuit 7 42 2 Business name B Fee for branch circuits without service or feeder fee, first 56 18 2 Contact name branch circuit Each add'I branch circuit 7 42 2 Address Miscellaneous (service or feeder not included) City/State/ZIP Each manufactured or modular 67 84 2 ty dwelling, service and/or feeder Phone ( ) Fax ( ) Reconnect only 67 84 2 Pump or imgation circle 67 84 2 E Sign or outline lighting 67 84 2 CONTRACTOR Signal circuit(s) or limited- energy Business name panel, alteration, or extension Page 2 2 Each additional inspection over allowable in any of the above Address ne) W Additional inspection (1 hr mm) 66 25/ hr A - ) City /State /ZIP Investigation (I hr min) 66 25/ hr Industrial plant (1 hr mm) 78 18/ hr Phone ( ) Fax ( ) Inspections for which no fee is 90 00/ hr specifically listed (%: hr min) CCB Lic Electrical Lic Supry Lic ELECTRICAL PERMIT FEES Supry Electrician signature, required o Subtotal Plan review (25% of permit fee) Print name State surcharge (12% fee) / f TOTAL PERMIT FEE Authorized signature , Z This permit application expires if a permit is not obtained within 180 Print name ,,� r Date 'y days after it has been accepted as complete • Z.44.1 N I V �j -f Y p N d ' �i(� 12_ Number of inspections allowed per permit 1 \Bwlding\Penmts\ELC- PermiiApp doe 07/01/10 440- 4615T(11/05/COM/WEB Electrical Permit Application - City of Tigard r Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: , RESIDENTIAL WORK ONLY: Fee for all residential systems combined ... $75.00 Check Type of Work Involved: El Audio and Stereo Systems* ❑ Burglar Alarm ❑ Garage Door Opener* ❑ Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* ❑ Other COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: El Audio and Stereo Systems ❑ Boiler Controls El Clock Systems El Data Telecommunication Installation El Fire Alarm Installation El HVAC El Instrumentation El Intercom and Paging Systems ❑ Landscape Irrigation Control* El Medical El Nurse Calls El Outdoor Landscape Lighting* El Protective Signaling El Other Total number of commercial systems _ *No licenses are required. Licenses are required for all other installations 1 \Bmlding\Pertmts\ELC- PernntApp doc 07/01/10 I Building Division Development Code Provision Review T I G A R D Residential Projects Building Permit No: 1 ` 90 i 2- 06 21.P1 �� " CWS Service Provider Letter Received Yes ❑ No ❑ N/A ❑ 4PPL, (�-r )i i4 9-S 4ppL/gt, /D atoS Routed Plans Original Plan Submittal Date 22 / r 1„ Revision Submittal Date ❑ Site Plan Only 2 ^d 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) hsted above each section Staff: please check items along left only if approved. Planning Review (contact -.,, , at 503 - 718 -i3 gyp or 46____@ugard-or gov) La • . Use Case No Name is Zoning /L - II, 5 Er Setbacks Front - 2•17 Rear /S Side , Street Side / ,/, Garay c D Maximum Building Height 30 Actual Building Height ' / q C / Visual Clearance l asements LY Sensitive Lands Type Notes Original Plan Approved / Not Approved ❑ Date 4 //4/ 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) ,0''Actual Slope 3 Notes Original Plan Approved Not Approved ❑ Date E H' Z Revision 1 Approved ❑ Not Approved ❑ Date Revision 2 Approved ❑ Not Approved ❑ Date (Review Continues on Page 2) Page 1 of 2 City Arborist Review (contact Todd Prager at 503- 718 -2700 or todd @tigard -or gov) ❑ Street Trees ❑ Protected Trees Notes t �4 y Original Plan Approved V Not Approved ❑ Date g f Revision 1 Approved ❑ Not Approved ❑ Date Revision 2 Approved ❑ Not Approved ❑ Date Permit Coordinator Review (contact Albert Shields at 503 - 718 -2426 or albert @ttgard -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 Apphcant Okay to Issue Permit Yes No Date Routed to Building Page 2 of 2 H 6T dror a -Go aa/ I iij ; I l o��( ; � Clean Water Services File Number il, Clean\ ter �` Services z " 2 « ' O 1 B ,, Sensitive Area Pre - Screening Site Assessment RCEWE 1 Jurisdiction _ a -'2-(9--, u tU12 2 Property Information (example 1S234AB01400) 3 Owner Infor ation ' Tax lot ID(s) Z S 1 D L 13 13 r9 v f l e Name (- • %.2 I. s - . : ! 1 Company _ �n1fC1 ()r �, Address _, U W M. : I' _,/ i X11 Site Address 10 225 SW ? t `j1 C1 4 , p i City, State, Zip', re, C� e gr City, State, Zip 1.--%' J jv t , {� ,. � 27 Phone /Fax ( j 5 - T , e Nearest Cross Street _ 6\4/ P,rr ..1 (coo}? 4-v-( E -Mail _ • • A c �� A • - 4 Development Activity (check all that apply) 5 Applicant Information IC Addition to Single Family Residence (rooms, deck, garage) Name - (11-01 5(41- {/N ❑ Lot Line Adjustment ❑ Minor Land Partition Company � - LL � ❑ Residential Condominium ❑ Commercial Condominium Address k0 4 5 -4 )\•)/ �13D+� Pt ❑ Residential Subdivision ❑ Commercial Subdivision p ❑ Single Lot Commercial Li Multi Lot Commercial City, State, Zip 1 CL21 c(? q Other y` r Phone /Fax Q..563 ' 5 `� E-Mail C.V1011AltA,1 -el/I L K j /Yt l ( -Cck 6. Will the project involve any off -site work? ❑ Yes 14 No ❑ Unknown Location and description of off -site work 7 Add t comments or information that may be needed to understand your project .4 , ((IA . o S g L Cir'4 0 Ylcuct This application does NOT replace Grading and Erosion Control Permits, Connection Permits, Building Permits, Slte Development Permits, DEQ 1200 -C Permit or other permits as issued by the Department of Environmental Quality, Department of State Lands andlor Department of the Army COE All required permits and approvals must be obtained and completed under applicable local, state, and federal law By signing this form, the Owner or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water Services have authority to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site I certify that I am familiar with the information contained in this document, and to the best of my knowledge and belief, this information is true, complete, and accurate Print/Type Nam :^ Oil ii /1 11114 ti Print/Type Title vlNI V Signature 1 = , ,44 _ „ Date - 2_L '2.0 Z, �r 1 f FOR DISTRICT USE ONLY ❑ Sensitive areas potentially exist on site or within 200' of the site THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A SERVICE PROVIDER LETTER If Sensitive Areas exist on the site or within 200 feet on adjacent properties, a Natural Resources Assessment Report may also be required ❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200' of the site This ensitive Area Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3 02 1 All required permits and a pprovals must be obtained and completed under applicable local, Slate, and federal law Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s) found near the site This Sensitive Area Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas if they are subsequently discovered This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3 02 1 All required permits and approvals must be obtained and completed under applicable local, state and federal law ❑ This Service Provider Letter is not valid unless CWS approved site plan(s) are attached ❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92 040(2) NO SITE ASSESSMENT OR SERVICE PROVI LE TTER IS RE U ED Reviewed by C' /a/La - - , /1-4 —f" Date ' ?/ / Z- 2550 SW Hillsboro Highway • Hillsboro, Oregon 97123 • Phone: (503 661.5100 • Fax (503) 681 -4439 • www.cleanwaterservices.org / FOR OFFICE USE ONLY — SITE ADDRESS: This form is recognized by most building departments in the Trt -County area for transmitting information. Please complete this form when submitting information for plan review responses and revisions This form and the information it provides helps the review process and response to your project. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT r Transmittal Letter a e e T1 G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov . TO: 2f} it/ &L Son/ DATE RECEIVED: DEPT: BUILDING DIVISION RECEIVED FROM: --1-i-IE N NGbi PI 1G 27 2012 COMPANY: CITY OFTIGARD PHONE: (cb 2 7) - q - > i q— — 5-2-e BUILDING DNI ON RE: /0d .Z-S- .Si) - "/ s / IN-c' psi ao 4,2 —0 0 .2.--/ (Site Address) (Permit Number) / Al (Project name of subdivision name and lot number) ATTACHED ARE THE FOLLOWING ITEMS: Copies: Description: Copies: Description: Additional set(s) of plans. Revisions: Cross section(s) and details. ✓ Wall bracing and/or lateral analysis Floor /roof framing. Basement and retaining walls. Beam calculations. Engineer's calculations. Other (explain): REMARKS: FOR 9FFIGE USE ONLY Routed to Permit Technics Date: I (a k Z Initials. / Fees Due: 111 Yes a o Fee Description: Amount Due: $ $ $ $ Special Instructions: Reprint Permit (per PE): ❑ Yes ❑ No ['Done Applicant Notified: Date: Initials: 1 \13wldmg\ Forms \TransmittalLetter - Revisions doc 05/25/2012 Property Owner Statement Regarding Construction Responsibilities 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. 64-1--(C- N6 ( (C—N Print Name of Permit Applicant Signss ure of Permit Applicant if I Date Permit # T g019•-Co 9`9'l Address. 10 29.5 D 'D6 oa, Q793-3 Issued y Date / /g /a • This Copy for Permit Offices Location: Record Type: Inspection Type: Comments: Inspection Date: Record ID: Result: City of Tigard 13125 SW Hal Blvd. Tigard, OR 97223 Tel: 503.718.2439 10225 SW BROOKSIDE PL, TIGARD, OR, 97223 Residential - Master Permit 115 Electrical service 04/12/2013 00:00 MST2012-00221 PASS Violation Summary: Inspector Contractor