Permit i'
• v CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2006 -00250
. ` tt: . COMMUNITY DEVELOPMENT DATE ISSUED: 11/8/2006
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 2S103BB - 07000
SITE ADDRESS: 12185 SW WALNUT ST ZONING: R - 4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: 2 story addition.
BUILDING
REISSUE: CUSTOM STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK. ADD HEIGHT: 19 FIRST: 450 of BASEMENT: of LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 50 SECOND: 450 of GARAGE: of FRONT: 20 PARKING SPACES : 2
TYPE OF CONST: 5N DWELLING UNITS: T NR of RIGHT: 5
VALUE. 0
OCCUPANCY GRP: R3 BDRM 2 BATH: 2 TOTAL: 900 Sf REAR. 15
PLUMBING
SINKS 1 WATER CLOSETS: 2 WASHING MACH LAUNDRY TRAYS 1 RAIN DRAIN TRAPS'
LAVATORIES. 1 DISHWASHERS 1 FLOOR DRAINS SEWER LINES: SF RAIN DRAINS: 1 CATCH BASINS.
TUB /SHOWERS: 1 GARBAGE DISP: 1 WATER HEATERS: WATER LINES: BCKFLW PREVNTR GREASE TRAPS
OTHER FIXTURES
MECHANICAL
FUEL TYPES FURN < 100K: BOIUCMP < SHP: VENT FANS' 1 CLOTHES DRYER 1
FURN > =100K: UNIT HEATERS' HOODS. 1 OTHER UNITS:
MAX INP btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: GAS OUTLETS: 2
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC/FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS. 0 -200 atop: 0 •200 anp• WSVC OR RIP 0 PUMP/IRRIGATION. PER INSPECTION
EA ADD'L 500SF 201 • 400 amp 201 - 410 anp let WC SVCFDR• 1 SIGN /OUT LIN LT: PER HOUR
LIMITED ENERGY 401 • 000 amp. 401 - 600 anp EA ADDL BR CR. 5 SIGNAUPANEL: IN PLANT:
MANU HM /SVC /FDR• 601 - 1000 amp: 60f *atps•1000v MINOR LABEL:
1000* amp/volt :
• PLAN REVIEW SECTON
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 0 SYSTEMS
This permit Is subled to the regulations contained in the Tigard
Owner: Contractor: Municipal Code, State of OR Specialty Codes and all other applicable
RICHARD BOLEN OWNER laws All work will be done in accordance with approved plans This
12185 SW WALNUT ST permit will expire if work is not started within 180 days of issuance, or
TIGARD, OR 97223 if the work is suspended for more than 180 days ATTENTION.
Oregon law requires you to follow rules adopted by the Oregon Utility
Notification Center Those rules are set forth in OAR 952 - 001 -0010
through 952 - 001 -0080 You may obtain copies of these rules or direct
Phone: 503 - 579 - 8171 Contact #: questions to OUNC by calling 503 246 6699 or 1 800 332.2344
Reg #:
TOTAL FEES: $ 1,551.24
REQUIRED ITEMS AND REPORTS
I - / ,
Issued y : ../ C +�� Permittee Signatu`_ ° i %��Il
Call 503.639.4175 by 7:00 a.m. for an inspection that busi ess day.
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.
Building Permit Application FOR OFFICE USE ONLY
Received
City of Tigard Date/B . / 9 elk No k I) WST i4 Da „5 Z)
q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Dat • 1/ - : - U& Other Penna.
T I G n It D Inspection Line: 503.639 4175 Date Ready/By into See Attached Checklist for
i
Internet: www.tigard - or.gov OCT � L 2006 Notified/Method ((r/ Supplemental Information
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ,Demolition r) e vLl.__ Permit fees* are based on the value of the work performed.
f Indicate the value (rounded to the nearest dollar) of all
Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
!� CATEGORY OF CONSTRUCTION work indicated on this application.
il - and 2- family dwelling 0 Commercial/industrial
Valuation..' ,, 31, x 5f$ . 3 I 4 0 . � -
❑ Accessory building ❑ Multi- family Number of bedrooms: Z
❑ Master builder ❑ Other Number of bathrooms: 1
JOB SITE INFORMATION AND LOCATION Total number of floors: 2-
Job site address: 121 g �w ' al N I 54--„ New dwelling area 0 6 0 square feet
City /State /ZIP: Tt ' �� o, Z2:3
e
UA'l c i orb arga: 2,76 square feet
Suite/bldg. /apt. no.: Project name: Covered porch area: square feet
Cross street /directions to job site: Deck area. 2_10 square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL - USE CHECKLIST
Subdivision: I Lot no. • Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Cam` ‘ 1 Sr ' A - . LA (i��7 d-ii424PA S * Valuation: $
d� Pr •r l'- • ✓ � S ,, ) Existing building area: square feet
?- I r . -k ` 1) I N I N - V - e....kA « t ) New building area: square feet
X PROPERTY OWNER I ❑ TENANT Number of stories:
Name: ; cAi /t-ee, sts r3 0 (_ eN Type of construction: Iv /fir
Address: \'Z` T S f N ...5-k--. Occupancy groups:
4.
City /State /ZIP: j , C 0 L . ) 7-2 - Existing:
Phone: (46'xj) l7 6 I 1 I Fax: ( ) ■ / A New
APPLICANT ❑ CONTACT PERSON NOTICE
Business name: 5"-A �� C e / _ M contractors and subcontractors are required to be
Contact name: ✓'? licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed. If the
City /State /ZIP: applicant is exempt from licensing, the following reasons
apply:
Phone: ( ) I Fax.: ( )
E -mail:
CONTRACTOR
Business name: 5 CJ/ tie BUILDING PERMIT FEES*
Address: (Please refer to fee schedule)
City /State /ZIP: Structural plan review fee (or deposit).
Phone: ( ) Fax: ( ) FLS plan review fee (if applicable):
CCB lic.: Total fees due upon application:
Amount received:
Authorized signature. 1 This permit application expires if a permit is not obtained
;am ` /p / ,0 within 180 days after it has been accepted as complete.
Print name: � 4 Q , o LZ Date: 1/ * Fee methodology set by Tri- County Building Industry
Service Board.
1. \Building \Permits \BUP- RES- PmnitApp doe 0321/06 4404613T(I1 /02/COM/WEB)
One- and Two - Family Dwelling
Building Permit Application Checklist 1?01r 01- VICE 1)SE ONI,1 -
City of T' and Received Permit No B •
Ass ey.
n 13125 SW Hall Blvd., Tigard, OR 97223
a , Phone: 503.639.4171 Fax: 503.598 1960 Associated permits
TIGAK
24 Hour Inspection Line. 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
I�
Internet. www.tigard- or.gov ❑ Other
11th FOLLOWIN G ITEMS EMS "ARI RI:QUlIZI I) FOR PLAN
\\ )es ` Ni `�
I Land use actions completed. See jurisdiction criteria for concurrent reviews. • ❑ •
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑' •
-, • 3 Verification of approved plat/lot. ❑ ❑ ❑
4 . Firedistrict a i croval re. uired. 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 0, plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection, ° etb: , .�' • ,'
10 3 Complete.sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ .• ❑ ❑
building codes.` Lateral'design4etail$ and connections must be incorporated into the plans or on a'separate4'ull- size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.,"
11 Site /plot plan"drawn to tale. 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.
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., , 't .
14 Cross section(s) and details. Show all framing- member sizes and spacini sucha.4 floor beams; headers, joists; sub- ' ❑ ❑ • IO' '
floor, wall construction, roof construction. More than one cross'si:ction•'tnay be'required to clearly portray
construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material footings' _ ' "; r
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 foot at building envelope .r i ;-:',
• 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 iind locations; -for non -. ' - S ❑ ❑
prescriptive path analysis provide specifications and calculations fotngineeririg •standards. • • •.. . ,
17 Floor /roof framing. Provide plans for all floors /roof assemblies,,indicating'member sizing, spacing, and bearing_ "❑ Q , ❑
locations. Show attic ventilation. ! ► ' r
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 forallbeams 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 0 ❑ ❑
architect licensed in Ore on and shall be shown to be licable to the project under review.
23 Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑
24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ., ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will ribfbe 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 tree protection measures as required by conditions of approval. ❑ ❑ ❑
30 A Clean Water Services' Sensitive Area Pre- Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings _.
on a lot of record approved prior to September 9, 1995.
r5
I \ Budding \ Permits \BLJP- RES- PermitApp doc 0321/06
Plumbing Permit Application
Building Fixtures
_ .f.
- '' 'I • '` � Received
City of Tigard - Date/By IP y /G ( --- 4 , Permit No. g/% -M6Z)
1 1 0 a 13125 SW Hall Blvd., Tigard, OR 97223 ry Plan Review
Phone: 503.639.4171 Fax: 503.598.1960oCT (- 6006 DateBy Other Permit No
T 1 C A R D Inspection Line: 503.639.4175 _ Date Ready/By. ions ® See Page 2 for
Internet: www.tigard - or.gov Noufed/Method. Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑'Demb lition .. + ' For special information use checklist.
Description I Qty. I Ea. I Total
*iddition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
4.I, and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCAT j N Site utilities
Job site address i, 2_.k9 J `� 141/....9"- 5.. Catch basin or area drain 16.60
City /State /ZIP: '1'1'�',_ � , 02_ �j 2-2-5 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: �U �I Project name: ` Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street /directions to job site: Manholes 16.60 //
Rain drain connector / 16.60 i Cp . (aQ d
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION OF WORK
Back flow preventer Page 2
1464 . t, 1,4-4.b A 't * s .e-w") Backwater valve 16.60
e 9" 1.,0-4J.A.A 1 Q-✓‘ J Clothes washer / 16.60 /4.419
J Dishwasher / 16.60 /4.4o
PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: ICA G64A2- () 7 C7 L Expansion tank 16.60
Address: ` 'Lt c-- LA j 0.4_ N K..* S'4-. Fixture /sewer cap 16.60
City /State/ZIP: /1„..42.. D CA.e . a 1 Z ' Z "5 Floor drain/floor sink/hub 16.60
' ` /A- Garbage disposal 16.60 /4.. 60
Phone: 5 i> 4 � � g , " ` Fax: ( ) !"
PLICANT ❑ CONTACT PERSON Hose bib 16.60 j4. 6o
Ice maker f 16.60 /4".60
Business name: Interceptor /grease trap 16.60
Contact name: c A Medical gas (value: $ ) Page 2
Address: iVJ M 01/- Primer 16.60
City / State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax: : ( ) Sink /basin/lavatory/Laoi I , i 7--- 16.60 33 .20
Tub /shower /shower pan / 16.60 /4 . ('O
E -mail: Urinal 16.60
CONTRACTOR Water closet 2 16.60
Business name: Water heater 16.60
Address: ( �
City /State /ZIP: v�"�/ Subtotal 44 .60
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
Authorized signature: State surcharge (8% of permit fee)
� TOTAL PERMIT FEE
( 2_, Print name: , G (4 1 „ sot. _ �� Date: 4) q/ (/' This permit application expires if a permit is not obtained within
�� ' `��� 180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
1 \Butldmeennits\PLMF- PemnApp doe 04/06/06 41046I6T(10/02/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 - l" 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00
7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit Fee: - _
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or It Qty. Fee (ea) Total additional $100.00 or fraction thereof to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Back flow Prevention Device each additional $100.00 or fraction thereof to
(minimum permit fee $36.25) 27.55 - . • ! . and includink$25,000•00: 1
Rain Drain, single family dwelling 65.25 - ' - $25;001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
Inspection of existing plumbing or _ ' '• - `` each additional;$ 100.00 or fraction thereof to
and including
specially requested inspections - per hour 72.50 the
Subtotal: $50,001.00 and up $742.00 for the fast $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
•
Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees!. • r 0 r gr Any,new commercial building with water service 2" and '
Quantity by (Fixture) Work Performed ' • ' •. eater, except systems designed and stamped'by :libensed, . ` ,+
, Fixture Type: Replace , 2z /engineer. ,, 1 , , ; `, t '
Previous Capped Added Existing• ` 0 ' my 'new exterior'plumbing site utilities.
13aptistry/Font ❑ Medical gas and vacuum systems for health care facilities.
Bath - Tub /Shower ❑ Any multipurpose fire sprinkler system.
- Jacuzzi/Whirlpool ❑ My complex structure as defined in OAR918- 780 -0040.
Car Wash Each Stall A ' ■ T‘ ' ; - t".,„1‘,..;. , I '::,a
- Drive Thru ,, t . Submit 2 sets • of plans with aorof the above.
Cuspidor/Water Aspirator
Dishwasher -Commercial •
:: Domestic Isdmetrlc or Ri - .
Drinking Fountain ❑, Isometric or riser diagram is required for -new buildings
' '' "Eye Wash ` that meet the qualifications above. .
i'Floor Drain /sink - 2"
-3"
-
Car Wash Drain Comments''regarding fixture work:
Garbage - Domestic .
• Disposal - Commercial
-Industrial.
Ice Mach./Refrig. Drains
f:• Y
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
1: ;; Shower -Gang , 'i
-Stall '� `
Sink - Bar/Lavatory *Note: If the fixturewprk under this permit results in an
- Bradley increase of sewer EDUs, a sewer permit will be issued and
°�'+ ti!- •,I,+• ; - Commercial fees assessed for the sewer increase'must be paid before the
- Service plumbing permit can be issued.
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures: ' a % '::- I s i ;r
i \BuiIding\Permits\PLM- PermitApp doc 09/22/06
•
•
Electrical Permit Application v roir(arr ic ►_ us► ()Nix: City of Tigard " -'_'- , ! " , . , D Received . / 0 / 1 7 1 4111E2 Pemnt No. i 6 5
a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.639.4171 Fax: 503.598.1960 Date/B Other Permit:
T I . C. n It D Inspection Line: 503.639.4175 � Date Ready/3y. RI See Page 2 for
Internet: www.tigard- or.gov OCT "� , 9 �oo� Notified/Method. Supplemental Information
TYPE OF %'4ORK,. y , ' ,,� x ;,..d 1 ,L_.,7 PLAN REVIEW
❑ New construction Addition/alteration/replacement(: r n , . Please check all that apply (submit 2 sets of plans wiitems checked below).
t--.. o• r { ; : F F ,. i'■ - ❑ Service or feeder 400 amps or more ❑ Building over three stones
❑ Demolition Other: where the available fault current ❑ Marinas and boatyards
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
and 2-family dwelling less to ground, or exceeds 14,000 ❑ Commeraal -use agricultural
y wellin g ❑ Commercial/industrial ❑ Accessory building amps for all other installations buildings
Multi- family ❑Master builder ❑Other: ❑Fire pump. ❑ installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION
k ❑Emergency system larger separately derived system
❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "1 -3 ",
Job no.: Job site address: ' 21 O `7 S l� • 1/4.0 N 10or1P or more occupancy.
❑ Six or more resident un ❑ Recreational vehide parks
City/State/ZIP: e ` ( o e C1 . 2-Z S ❑ 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 Tots] I •
New residential single- or multi- family dwelling unit.
Includes attached garage. �,,'� �`�
Subdivision: Lot no.: 1,000 sq. ft. or less —" 145.15 4
Ea. add'I 500 sq. ft. or portion -- 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
/� • C (I / „ \ y� n , _ C Limited energy, multi - family 75.00 2
/•�� W�� �Q.J (,L J T kpC/�tµ residential (with above sq. ft.)
C' 1 I�� 1+� J1 J Qom/ ■ e"4 /� CD I 1J t /• a7 /1Z- n Q \ Services or feeders iostallation and/or relocation
NC (I l 200 amps or less 80.30 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 10 e (•I e,p 75 0 401 amps to 600 amps 160.60 2
'2_1 S ` 601 amps to 1,000 amps 240.60 2
Address: � JU l " w V Over 1,000 amps or volts 454.65 2
Temporary services or feeders installation, alteration, and/or
City/State/ZII': -7--2-2.7c relocation
Phone: (q5 ) 4"7 ( 7 j Fax: ( ) 0101- 200 amps or less 66.85 1
Owner installation: This ' ation is being made on property that I own ich is not 201 amps to 400 amps 100.30 2
intended for sale, 1 re r exchange, according to ORS 447, 449, 670, d 7 1. 401 amps to 599 amps 133.75 2
Owner signature Date: ` Branch circuits — new, alteration, or extension, per panel
Fee for branch circuits with
PLICANT I 0 CONTACT PERSON A. above service or feeder fee,
each branch circuit 6.65 2
-
Business name: B. Fee for branch circuits
without service or feeder fee,
Contact name:
41I 46.85 2
first branch circuit
a/ Address: / Each add'1 branch circuit 5 6.65 2
Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Phone: ( ) Fax: : ( ) Reconnect only --- 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting ---. 53.40 2
Business name: Signal circuit(s) or limited -
�A / energy panel, alteration, or
` Address: 6'v f extension. Describe: Page 2 2
City/State/ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( )
Investigation per hour (1 hr nun) ■ 62.50
• CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, requited: Subtotal:
Print name: f I Date: Plan review (25% of permit fee):
State surcharge (8% of permit fee):
Authorized signature: TOTAL PERMIT FEE:
• This permit application expires if a permit is not obtained within 180
Print name: R ‘ G i n o - Lttb...) Date: /oh (" days after it has been accepted as complete.
• Number of inspections allowed per permit
I \Bwldmg\Permns\ELC- PennnApp doe 0523 /06 440- 4615T(11 /05 /COM/WEE
Electrical Permit Application - City of Tigard —
Page 2- Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: • 7 7 71
Fee for all residential systems combined $75.00
Check Type of Work Involved:
I=1 Audio and Stereo Systems*
I=1 Burglar Alarm
El Garage Door Opener*
I •
Heating, Ventilation and Air Conditioning System*
El Vacuum Systems*
Y , Other:
1 'COMMERCIAL WORK ONLY: .7 ,
Fee for each commercial $75.00 , .
system
(SEE OAR 918-200-260) i
..; ,
Check Type of WorlEInvolved: _ V.
.
• •••
El :Audio and Ste'r Systems . .
El Boiler Controls • .7, 7
, .
0 .. Clock Systems .
fl Data Telecommunication Installation
El Fire Alarm Installation
[=1 HVAC
e 1 ,J\
I=1 Instrumentation
Intercom and Paging Systems
El Landscape Irrigation Control*
••
1=1. Medical
I=1 'Nurse Calls
•
El Outdoor Landscape Lighting*
El Protective Signaling
I=1 Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
•4• r•••
I \BuildingTennits\ELC-PcmioAppdoc 03/23/06
1'Iechan Per mit Applica E ms.'! \,, f =,Q 4 • F OR OFFICE r_ l sl ONLY 4.
City of Tigard and Received Perrtut No �S /�GI� Ll 0��
O q
illq `J Date/By �p 9 O�
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Ill Phone: 503.639 4171 Fax: 503 598.19 I 14 9 2006 D Other Permit.
.1:1 G A , R D Inspection Line: 503.639.4175 Date Ready/By lun VI See Page 2 for
- --- Internet: wwwtigard -or.gov ,,' Notified/Method , ( e Supplemental Information
\k✓i i OL' L)L)L i_'
- TYPE' OF WORK • • - - COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
❑ New construction Addition/alteration/replacement Mechanical permit fees* are based on the value of the work
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
' CATEGORY OF CONSTRUCTION ' • Value: $
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
L 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/eooling
Job site address: 12- ` O ' kA) v � , A '- Si Air conditioning or heat pump
(requires site plan showing placement) 14 00
City /State /ZIP: Ti ) 0\(Z a 2-2-3 Furnace 100,000 BTU (ducts/vents) 14.00
Suite/bldg./apt. no.: Project name' Furnace 100,000+ BTU (ducts/vents) 17.90
Gas heat pump 14.00
Cross street /directions to job site: Duct work 14.00
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 10.00
Flue/vent for any of above 10.00
Subdivision: Lot no..
Other: 10.00
Tax map /parcel no.: Other fuel appliances
- DESCRIPTION OF WORK Water heater 10.00
P C /` l" C ‘ ‘ _ k s t,244.5L (_g� S Gas fireplace 10.00
Flue vent for water heater or gas
a 6 ' c 1 `'T t.2 Cj _ C5(4-9i-A"- �_ � fireplace 10.00
) / Log lighter (gas) 10.00
aN� Le- f ( - (V 1 is '--(-- \ Wood/pellet stove 10.00
Wood fireplace/Insert 10.00
A PROPERTy OWNER I ❑TENANT Chimney /liner /flue/vent 10.00 Other: 1000
Name: % ( v .// ) a Environmental exhaust and ventilation
"` � V Range hood/other kitchen /
Address: �2,` S'} equipment r 10.00 la -441
City/State/ZIP: it, cie """) -L2:5 ' Clothes dryer exhaust ( 10.00 I . cre
Single -duct exhaust (bathrooms, /
Phone. (c(") ) '7 ,�-1 -1 I Fax: ( ) /A" toilet compartments, utility rooms) I 6.80 (P • o
X APPLICANT ❑ CONTACT PERSON • Attic/crawlspace fans 10 00
Business name: 't ' ` A C/ / � 10.00
k _ Fuel piping
Contact name: $5.40 for first four; $1.00 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP: Wall/suspended/unit heater
Phone: ( ) Fax:: ( ) Water heater
Fireplace
E -mail: Range / 6 V°
CONTRACTOR / Barbecue
Business name: C ,(� Clothes dryer ( s / /• 00 —`� -/ Other:
Address: ���///"' �� PERMIT 'FEES* '
City /State/ZIP: Subtotal 31 .
Phone: ( ) Fax: ( ) Minimum permit fee ($72.50)
Plan review (25% of permit fee)
CCB lic.: State surcharge (8% of permit fee)
r' TOTAL PERMIT FEE
Authorized signatur • This permit application expires if a permit is not obtained within 180
/ days after it has been accepted as complete.
Print name: `r- a r �� I Date: I y /v /p • Fee methodology set by Tri- County Building Industry Service Board
I \Buildmg\PcmnsUNEC ancicp oe /6/06 l� 461 /WJCOM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial Fee Schedule:
=Total Valuation: - Permit Fee:
$1.00 to $2,000.00 Minimum fee $72.50
$2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30
for each additional $100.00 or fraction
thereof, to and including $5,000.00.
$5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and
$1.80 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and
$1.35 for each additional $100.00 or ),
fraction thereof, to and including " `• • •
$50,000.00. • -. ,
$50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and
$1.25 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $1,396.50 for the first $100,000.00 and
$1.10 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
•
• ,.
r • 1. j
. i •
•
Q ., _ ... 7 ` • n .
•
")
I:\Building\Permits\MEC- PermitApp.doc 12/30/05 2 ,
10!09/2006 15:13 5036243681 TIGARD BUILDING DEPT PAGE 01/02
CWS File Number 06_C,v 3 lo I
CleanWater Services
Owr commitment i Sensitive Area Pre-Screening Site Assessment
Jurisdiction (L.. L ° -T-1 c -) Date
Tax Map 8 Tax Lot a,S'/0.135 7 0 owner >01 0L-4,4-1€ 7 k�" e l`
� ( Applicant v"-�-
Site Address t2,16 mil etk Company
Address t 2 Li ` ) W W e t. v -
Proposed Activity Gjo p d , /A. ' 1 . ,v_ City State Zip T ' e , , e - O O s e e . " . 1 2 _ 2 - 1 3
C k 4 eta, /p: A) 446 ( - e - TIS S -a Phone (�i o"3) 4'74
St 1 Z l
C aw/ ) 4 F-r Fax —
By submitting 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.
MMklel wee only below No line
official use only below alts line Official use only below this 16e
Y N NA Y N NA
,,..., Sensitive Area Composite Map (� r Stonnwater Infrastructure maps
l� I I El # ,A.5 I cu." El LJ l # Y3/7 Locally ❑ ❑ ® Specify adopted studies or maps r ❑ (1 Other
44e0:a /piernp
Based on a review of the above information and the requirements of Clean Water Services
Design and Construction Standards Resolution and Order No. 04-9:
❑ Sensitive areas potentially exist on site or within 200' of the site. THE APPLICANT MUST
PERFORM A SITE CERTIFICATION PRIOR TO ISSUANCE OF A SERVICE PROVIDER. If
Sensitive Areas exist on the site or within 200 feet on adjacent properties, a Natural
Resources Assessment Report may also be required.
r2 Sensitive areas do not appear to exist on site or within 200' of the site. This 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 04 -9, Section 3.02.1. All
required permits and approvals must be obtained and completed under applicable local,
state, and federal law.
❑ The proposed activity does not meet the definition of development. NO SITE ASSESSMENT
OR SERVICE PROVIDER LETTER IS REQUIRED.
Reviewer Comments:
a evie T • e4 ••A l ft oY iA/ pAOfOf
7 -4 e / firers Seital pr' j eer w.// Nor 12 ra. /7 ;...,�asr r4 n•
PJ•:,`b1
@ •dIP T 7 vk, boar T4e Jilt -
Reviewed By: ��� _ Date: /0/6/0 6
Official use only �
Returned to Applicant
Mail )( Fax Counter
2550 SW Hillsboro Highway • Hillsboro. Oregon 97123 Date /0/Affil By
Phone: (503) 681 -5100 • Fax: (503) 681.4438 • wwwclosnwatorservtua.org
Permit #: H Gar j o --()C-1 4 57)
Address 19 ` (g 5 L
Issu _ by: ) �� Date: 0
• 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.
'� 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
� before or upon completion.
ri 3A. My general contractor is
(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
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 a ' ' ve in ormation is correct and that I have read and do understand the Information
Notice to Prope Own : s ab ut Construction Responsibilities on the reverse side of this form.
11 e
(Signature of permit applicantj.. (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
•
Information Notice to Property Owners
bout Construction Responsibilities
' Note: This h formation Notice to Property Owners about.Construclion Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5).
lfyou 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.
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement ofa 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 yourd'on'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 - Department 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 to penalties and will be liable for all claim costs ifone 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. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be
liable for the tax payment even ifyou didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1- 800 - 829 -1040.
•
OTHER RESPONSIBILITIES AND AREAS OF CONiCERN: -
Code compliance: As the perm it 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 ow n 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 (P0 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