Permit CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2001 -00033
, lilli DEVELOPMENT SERVICES DATE ISSUED: 2/2/01
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 11620 SW TIGARD DR PARCEL: 1S134CD -10900
SUBDIVISION: BURLWOOD NO.4 ZONING: R - 4.5
BLOCK: LOT: 036 JURISDICTION: TIG
REMARKS: Covert garage into a bedroom and bathroom (288 sq. ft.)
BUILDING
REISSUE: STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ALT HEIGHT: FIRST: 288 sf BASEMENT: sf LEFT: SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: sf GARAGE: sf FRONT: PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: FINBSMENT: sf RIGHT:
VALUE: $ 12,427 00
OCCUPANCY GRP: R3 BDRM. 1 BATH: 1 TOTAL. 288.00 sf REAR:
PLUMBING
SINKS: WATER CLOSETS: 1 WASHING MACH. LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 1 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS:
TUB /SHOWERS: 1 GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: 1 CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: •
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 • 200 amp: 0 • 200 amp: W /SVC OR FDR: PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 - 400 amp: 201 • 400 amp: 1st W/O SVC /FDR: 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+ 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: 0TH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 519.56
MCGINNIS, JEFFREY S + OWNER • This permit is subject to the regulations contained in the
Tigard Municipal Code, State of OR. Specialty Codes and
SUSAN D all other applicable laws. All work will be done in
•
11620 SW TIGARD AVE accordance with approved plans. This perm it will expire if
TIGARD, OR 97223 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 #: 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
Post/Beam Structural Electrical Service Electrical Final
Post/Beam Mechanical Electrical Rough In Mechanical Final
PLM /Underfloor Framing Insp Plumb Final
Mechanical Insp Low Voltage Final inspection
Plumb Top Out Insulation Insp
Issued B Permittee Signature : ■ /I ll/i/L.
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the next business dad"
12/11/00 NON 10:33 FAX 5
4111 i "" o_lt.-- .
____ _
Building
ity ;received: / Permit no.: .
Ci o and Address: 13125 SW Hall Blvd, Tigard, OR 97223 Projecdappl. no.: Expire date:
rY B Phone: (503) 639 -4171 Date issued: 12MI Receipt no.:
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: 1 &2 family: Simple Complex:
7 OF PFIlMIT
❑ 1 & 2 family dwelling or accessory Cl Commei ciat/industrial ❑ Multi - family 0 New construction Cl Demolition
Addition/alteration/replacement 0 Tenant improvement ❑ Fire sprinkler /alarm Cl Other:
Job address: 11(0 X10 i I-) Bldg. no.: Suite no.:
Lot: 3L Block: 'Su bdivision: � , 1 ' vv OOtl No,q J Tax map/tax lot/account no.:
Project name:
•
Description and location of work on premises/special conditions: cartiOc GO'+Vel'SI trYI ';11 Ord? i - tVi
O11NI It FOR SPECIAL INFORMATION, USE CIIECKLIS I
Name: B M�se N N I e (hluodplain, septic capacity, solar, etc.)
Mailing address: 11 L 11V .. ..46 l irr • 1 & 2 family dwelling: Y2. 8` . 3o
City: State: O' :SIP: �7LZ Valuation of work = 11-7. is &. / /4 ya 7, g, -
Phone: 2i4 Ln 1 Fax: . Ermailjvntillhill 5 k („S.t No. of bedrooms/baths 1<•1
Owner's ntative: ! Total number of floors
Phone: Fax: E -mail: New dwelling area (sq. ft.)
Garage/carport area (sq. ft-)
Name: <iliVYLL 110 tW - Covered porch area (sq. ft.)
Mailing address: Deck area (sq. ft.)
City: State: ZIP: Other structure area (sq. ft.)
Phone: Fax: E -mail: . , , clal/Industriallautlti- faldly:
('O` I It:1(TOR ._, Valuation o • k $
Existing bldg. area ft.)
Business name: 44J144 (fl NI New bldg. area (sq. ft.) ..... "..
Address:
City: f State: I ;gyp; Number of stories
Phone: 1 Fax: � E-mail: I�Pe of txa►struc • _.
�
CCB no.: uPar - group(s): Existing:
City /metro lie. no.: New:
Notice: All contractors and subcontractors are required to be
AR('ll I al /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: O VW 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: 1 :IP: exempt from licensing, the following reason applies:
Contact person: Plan no.:
Phone: Fax: E -mail:
Name: imhA ,r Contact person: Fees due upon application ._ $ /0 '1%
_ Address: Date received:
• IState: 12:IP: Amount received $, /D 5', .2.7
Phone: I Fax: I E -mail: Please refer to fee schedule.
I hereby certify I have read and examined this applic:.tion and the Not an Jurisdictions swept credit cards, place call jadadinion for mote Information .
attached checklist. All provisions of laws and ordinal ces governing this o visa 0 MaatetCard
work will be complied with, whether specified herein or not. Credit card number: /
bl " l i '0 1 i i( i
Authorized signature: v I Date: I Name of car as shows on credit c ud
Print name: 1t,A 61 p . C FI 11 h (� $
Cardholder signature Amount
` `
Notice: This permit application expires If a permit is not ot•taincd within 180 days after it has been accepted as complete. 440-4613 (MO/COM)
se7- 64 fi /0 9,
12/11/00 NON 10:35 FAX 503 598 1960 1 CITY OF TIGARD /v[ c , 02 Cre3/ — O N C 1.6 3 3 . _21006
Plumbing Permit Application
. Datereceived Permit no.:
�.. City of .Tigard
' Address: 13125 SW Hall Blvd, Tigard, OR 97223 Sewerpermitno.: Building permit no.:
al. Cit Phone: (503) 639 - 4171 Project/appl.no.: • Expire date:
` Fax: (503) 598 - 1960
. Date issued: By: ' Receipt no.:
Land use approval: Case the no.: Payment type:
1 YI'1'_ or I'(t12:\Ill'
01 & 2 family dwelling or accessory Cl Commucial/industrial `O Multi- family O Tenant improvement
O. New construction 'Additiva/altetation/replacement Cl Food service Cl Other:
.1O It s i' L INi3O12NIA I - 10N ru. sciu11)1 Isom :poolsl Iui waliim iNv cliccldist)
Job address: It WO - 11A . po Qt . Fee(ea.) Total
Bldg. no.: I Suite no.: New 1- and 2- damply dw n elainga only:
Tax anap/tax lot/account no.: ( ineln8es1091t .floreath utility connection)
SFR (1) bath
Lot: (.9 . 'Block: I !Subdivision: t'I W OUII Nn . , SFR 2) bath
Project name: SFR (3) bath • •
City /county: I ZIP: G1O7r2 Bach additional bath/kitchen
0�
Description and location of work on premises: 0 t: MI et b7'l Sheidliltice:
-iv /1941/ OM - , Catch basin/area
- ,Est date of completion/inspection: us 1 I� d ' - ' Drywells/leach line/trench drain
i'LU:1I1ti! \G CONTRA(' . 1'lll2 Footing drain (no.lin.ft
Business name: ' ti - `• Manholes
Address: • Rain drain connector V
City: I State: 12IP: . Sanitary sewer (no. lin. ft)
Phone: j Fax: ) E-mail: f9 Storm sewer (no. lin. ( '
CCB no.: I Plumb. bus. reg. no: ' Water service (no. hn. ft.)
City/metro lie, no.: Fixture or Items
Contractor's -representative signature: Absorption valve •
Back flow preventer •
Print name: • , D.te• • Backwater valve
'Basins/lavatory.
Nsine:' ClothesVwai'her
Address: ,,-Dishwasher
City: State: , 12iP: �� fountain(s)
Phone: Fax: . . Emsil: -, • B sump
'Est � : � : on'tank _
(INV\`I.:It • to sewer cap .
Name (print): e LA . ` L y h i I Lj - oor drains/floor sinks/hub -
Mailing address. li�Vl� a/i1' t• Wage Il • posal -
Hose bibb
Ci : r il'. P • =A 21 i': q7 • Ice maker •
Phone: • y 3q i Fax: E- mail :. 19414 inns s (Wit? Interceptor/grease trap
Owner installation/residential maintenance only: The actual installation , Prhner(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial) .
employee on the property I own : pet; ORS Chapter 447. Sink(s), basin(s), lays(s) (Iynt I pl) 2 Ili • l6D 33.7 ?
Owner's sign ature:6 _ kill Olt it i it _ Dae:OI ' 0 I Su
1..7\61 Ni: F.12 Tubs/shower/ihower pan 1 IlQ . al0 1 b • 100
Name: Urinal
Water closet
Address: , Water heater
City: ( State: 1 TIP: Other:
Phone: I Fax: I E-mail: Total •
' Not all Jurisdictions accept "edit cards, please call jurisdiction for more Was � Notice: This perm application Minimum fee $
0 visa o MasterCard Plan review (at _ %). $
CAM Dumber expires if a permit Is not obtained
fax L— within 180 days alter it has been State surcharge (8 %) .... $
Name of oardharder as shown on credit card accepted as complete.
TOTAL $
Cardholder
%. elgoatwe - Amami / AAA AX111 MIVIYYIIII
12/11/00 NON 10:34 FAX 503 598 1960 CITY OF TIGARD /mil S T2200 l -Clc-76 3 3 el 004_
Electrical Permit.Application
:.,
J Dater&etved: Permit no.: . _
. of Tigard Pro ect/a l.no.:
- 1 pp Expire date:
City of Tigard Address: 13125'SW Hall Blvd, Tigard OR 97223
Date issued: By: 1 pt ,
Phone: (503) 639-4171 1
Fax: (503) 598 -1960 • Case file no.: Payment type:
Land use approval:
•
• TYPE OF PERM rT
0.1 & 2 family dwelling or accessory O Comrr,ercial/indusirial O Multi- family O Tenant improvement
O New construction ja' Additi an/alteration/replacement O Other. 0 Partial
.100 SITE INFORMATION
Job address: i 0 1�,a1� • Stga Bldg. no.: Suite no.: Tax Iot/account no.:
Lot gm Block: I Subdivision: , . Vv 101 ' • . •
er ect name: Descri' Lion and location o work on premises: , aa (,oweir31C)1 ✓1i'D b I { _
Estimated.date of nom , lesion/ , : , , on: f,17711INIZEVA
CONTRACTOR ;1P1'I.I(:AI'rO.' FEE 5(:1 t,1 '
lob no: - • Eke Max
Business name •i
' Descdptlon Qty. (ea) Total no. [nap
Address: l reddends'- -sinker
"dw ingunit. lnebtdidattaediedgarage.
City: —A State: ZIP: servioeinduded: •
Phone: IVY E-mail: 1000 eti. 11. 'or less • 4
Salt additional S00 sq. it. or portion thereof "
CCB'no.: ALL .,bus. 11c. no: ,
C t /rnetry lie. no.: Limited energy, msidaadal 2
Limited energy, non- residential 2 .
- • . -. ..Bach manufactured home or modular dwelling
_SSutature of supervising . -.. 'an` (required) • , Date Service and/or feeder 2 .
S erv i ce s orfe cders— laetallatlon,
Sup. oleo. came {print): • .. -:. _ . , Li, ease no: _
PRO 1'1: R7 l' OWNER : R alteration or relocation: •
A 200 amps or less 2
Name 'AO: Car './, " I hh .', • - 201 amps to400amps 2
401 amps to 600 amps ' 2
Mailing address:
a ! P R– 601' imps to-1000amps 2
City: , j !a Ili, 0 State / r 21P: •, ZZ „ Over,1000attisorvolta 2
Phone: j • / Fax: &mail A ihniy@LS• , I 'Reconnectonly ' 1
•
Owner installation: The installation is being made on property I own `.Temporary services or feeders -
which'is not intended for sale, lease, rent, orexchang: according to batsll oa,altexatlac,orreloesdoa
ORS 447, 455, 479, 670,'701 - . • � 2
. ,,� ",, n 201 amps to'400 amps 2
Ownefs • • c : tore: 'U f U/ ' Da - : 01- D i 401 to 600 amps 2
ENGINEER Braneh"drealis -new, alteration, •
Name: EM , orexkeslonperpae&,
A Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 2
City: I State: I21P: B. Pee for branch oimoltawithoutpurchase
Phone: Fax: g 1; of service or feeder tbe, I ' 1416 4 IS 2
. Bach additional branch circuit Is • , 5 .A
PLAN iil•:YII• W (Please check all that apple) Mbc. (Service or feeder not , uded):
CI Service over 224 amps - oomr clal Cl Realth Bach pump or irrigation circle 2
O Service over 320 amps - rating of l&2' Cl Hazardous lccatior . Each signor outline Ilghtl 2
famllydwellings 0 Building over 10,0 square fret four or Signal circuits) or a limited energy panel. • "-
0 System over 600 volts nominal tare eesidauial ut ha in one structure alteration, or extension " • 2
Cl Building over three stories O !Feeders. 400 amps or more *Desuiptioa •
Cl Occupant load over 99 persons 0 Manufactured Mutt urev or RV park Each addition inspection over the allowable in any oldie above
0 Egress/ ightingplan 0 Other.• Perinspection I 1 I 1
Submit ___, sets of plans with any of the above. . Investigation Pee • The above are not applicable to te'ariorary constirlctlon service. Other
rNot all Jurtrmedons acwpt cmdh cards. please ca11 jurisdicdoe for more ktfout ao Notice: This permit application Permit fee - • $
C i Visa 0 MasterCard expires if a permit is not obtained Plan review (at — %) $
credit card combo: 1 t'_ within 180 da after it has been State surcharge (8%) .... $
Nome of c alda as ebowu on credit card
rs accepted as cwriplete. TOTAL $
S •
Ammo a . 4404615 (6100/COM)
/ 05 i CJ /- o-cro 33
. Mechanical Permit Application
Date received: Permit no.:
`;j'i . I� i City of Tigard Project/appl. no.: Expire date:
City of Tigard Address 13125 SW Hall Blvd, Tigard, OR 97223 Da is sued: By: l Receipt no.:
Phone: (503) 639 - 4171
Fax: (503) 598 - 1960 Case file no.: Payment type:
Land use approval: Building permit no.:
TYPE OF /CY' & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family ❑ Tenant improvement
❑ New construction o • ddition/alteration /replacement ❑ Other:
JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
Job address: 1 II riO t f 6 /-D • n12._ 16 ' r $ 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: 33 (/ I Block: I Subdivision: *See checklist for important application information and
Project name: jurisdiction's fee schedule for residential permit fee.
City /county: VU Cf11 YIG)1rn I ZIP: O1 I & 2 FAMILY DWELLING PERMIT FEE SCHEDULE
Description and location of work on premises: AND COMMERICAL /INDUSTRIAL EQUIPMENT SCHEDULE
V6K1 (iv"' Fee(ea.) Total
Est. date of complet ion /inspection: ( j Description Qty. Res. only Res. only
Tenant improvement or change of use: HVAC:
Is existing space heated or conditioned ?10 Yes ❑ No Air handling unit CFM
space insulated? Yes ❑ No Al
Alteration o of conditioning existing plan HVAC Is existing system
P � Altration of existing HVAC system
M ECHANICAL CONTRACTOR Boiler /compressors
/v Business name: 5 W State boiler permit no.:
HP Tons BTU /H
Address: Fire/smoke dampers/duct smoke detectors
City: I State: I ZIP: Heat pump (site plan required)
Phone: I Fax: I E - mail: Install/replace furnace/burner BTU /H
Including ductwork/vent liner ❑ Yes ❑ No
CCB no.: Install/replace/relocate heaters - suspended,
City/metro lic. no.: wall, or floor mounted
Name (please print): Vent for appliance other than furnace
CONTACT PERSON Refrigeration:
Absorption units BTU/H
Name: Chillers HP
Address: Compressors HP
Environmental exhaust and ventilation:
City: I State: I ZIP: Appliance vent
Phone: Fax: E -mail: Dryer exhaust
OWNER Hoods, Type U IUres. kitchen/hazmat
hood fire suppression system
Name: Ce ° 4- s V S M L 11 V) I S Exhaust fan with single duct (bath fans)
Mailing address: j 1 s W � I Mr) D12— Exhaust system apart from heating or AC
City: : ?;It Ph a State: OK- ZIP: ol 1 Z 0 Fue p ping and 1 abut on up to 4 outlets)
Type: LPG NG Oil
Phone: G . Fax: E -mail' . .I VIhi @ CC Fuel piping each additional over 4 outlets
Process piping (schematic required)
Name: Number of outlets
Other listed appliance or equipment:
Address: Decorative fireplace
City: I State: I ZIP: Insert - type
Phone: I Fax: ., I E -mail: Woodstove/pellet stove
Applicant's signature: / , Other:
I Date: �� ' ��' � ` Other.
Name (print): 60010 D '1,,i115
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Permit fee $
CI Visa ❑ MasterCard Notice: This permit application Minimum fee $
Credit card number: / / expires if a permit is not obtained Plan review (at %) $
Expires within 180 days after it has been State surcharge (8 %) .... $
Name of cardholder as shown on credit card accepted as complete. TOTAL $
Cardholder signature Amount 440 -4617 (6/00 /COM)
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 'fond
fraction thereof. , footnotes b Comp* * * •
7) <3HP;absorb unit
to 100K BTU 14.00
ASSUMED VALUATIONS PER APPLIANCE: 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 applicance 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 18) Domestic incinerators
>50 hp; absorb. unit, 5,725 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 1,170 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 14 outlets 360 25% Plan Review Fee (of subtotal) $
Each additional outlet 63 Required for ALL commercial permits only ., ' ` J
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 Boiler Certification required for units >200k BTU.
" A/C requires site plan showing placement of unit.
i:\dsts \forms\mech- fees.doc 10/11/00
Permit #: It1 5T.. 7 4)C.( — 6 0033
Address: / /6 010 Sc) 776'4'26
�a �o
. .•' Issued Date:
/859
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
1. I own, reside in, or will reside in the completed structure.
gy4-'71 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
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
1:6■frg 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 Construction Responsibilities on the reverse side of this form.
� � � t � u . . , � . . 1 . • 0 1 0
(SiV e of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
Inf rmAtion.r. 'elite to Property Owners
.About - Construction [ espin.eabillti s
Note: This Information Notice to Property Owners about Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5).
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent many problems by being,aware of the following responsibilities and areas of concern.
CEEWIPL ■VER RESPOIS1 ILBTDES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement of a residential structure, you will, in most instances, be ruled to be an employer and the people
you hire will be employees. As the employer, you must comply with the following:
Oregon's withholding tax law: As an employer, you must withhold income taxes from employee wages at the time employees
are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more
information, call the Oregon Dept. of Revenue at 945 -8091.
Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information, call the Oregon Employment Division at the Department of Human Resources
at 378 -3524.
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must.
obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject tb penalties and will be liable for all claim costs if one of your employees is injured on the job. For more information, ' •
call the Workers' Compensation Division at the Department of Consumer and Business Services at 945 -7888.
U.S. llnternal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be
liable for the tax payment even if you didn't actually withholdthe tax. For more information, call the Internal Revenue Service
at 1- 800 -829 -1040.
(•THE RIESPONSD flJTlES AND Al' EAS OF CONCERN:
Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections. -
Liability, and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
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
1 /94
CITY OF TIGARD BUILDING INSPECTION DIVISION M T- / ,6,e3
l k tr il4-Hour Inspection Line: 639 -4175 Business Line: 639 -4171
eql5 Date Requested '11 - AM PM BLD
Location //6;10 $v � , Suite "� MEC
�
Contact Person Ph 2.1N T3, PLM
Contractor c : 31' — 67, 7cl SWR
BUILDING Tenant/Owner Cede ELC
Retaining Wall ELR
Footing Access:
Foundation FPS
Ftg Drain - SGN
Crawl Drain Inspection Notes:
Slab � SIT
Post & Beam )
Ext Sheath /Shea �l CA •
Int Sheath /Sh��i;� 4
F in ��II//"" ilelAA C(/t GL-r
D Drywa ailing d 7 _ l re /L✓� S ' <<. .
Firewall �elj
Fire Sprinkler I Q
Fire Alarm � 10 , ✓] /u _ 4— J \�^
Susp'd Ceiling , P `� �0 J'��
Roof L uf'Z/--'Q--(__ Svc k......__
• Mis
- As
ART FAIL
PLUMBING
Post & Beam
Under Slab •
Top Out
1
_ Water Service
Sanitary Sewer
Rain Drains
Final
PASS PART FAIL /
MECHANICAL
-
--7
Post & Beam
Rough In /
Gas Line / �
Smoke Dampers /
Final
PASS PART FAIL
ELECTRICAL -
Service . _
Rough In
UG /Slab .
Low Voltage
Fire Alarm
Final •
. PASS PART FAIL -
SITE
" Backfill /Grading -
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: • [ ] Unable to inspect - no access
ADA
Approach /Sidewalk
Date � 1 5
Other Q 1i Inspector t 2 ETD
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.
-
A RD BUILDING INSPECTION DIVISION ,,. t °
MST 990/- G1pDv 3
2 ili r
ection Line: 639 -4175 Business Line: 639 -4171 •
BLIP . . `
Date Requested 0/-6-0/ AM PM BLD
Location J/6„26 -) gip, f '€_b . %is` / Suite . MEC
MEC
Contact Person dr..l. .-,i- /0 Ph 503 - ` 7/- 13 97 PLM
Contractor I 6 c izs. Ph SWR
, BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:
Foundation J FPS
Ftg Drain Co- Nl/a.f°f- li4J c " / °j */-* SGN
Slab
Crawl Drain Inspection Notes: C 4-� Iliki,
SIT
Post & Beam '' 11 d •
Ext Sheath /Shear // li Har f/ 7-a /Tg.
Int Sheath /Shear
Framing
Insulation
Drywall Nailing `
Firewall
Sprinkler ,
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Misc:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Top Out
Water Service
Sanitary Sewer
Rain Drains
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
•
FAIL
ECTRICAL
- ough In
Low Voltage
•
Fire Alarm
- PART FAIL
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: ] Unable to inspect - no access
ADA
Approach /Sidewalk
Other Dat vZ :/ O 7 Ins Ext
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.