Permit III p CITY OF TIGARD MASTER PERMIT
s COMMUNITY DEVELOPMENT Permit #: MST2012 -00279
T I G A R. D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/24/2012
Parcel: 2S103BC00300
Jurisdiction: Tigard
Site address: 12180 SW WALNUT ST
Subdivision: 2004 -026 PARTITION PLAT Lot: 2
Project: Carroll
Project Description: 342 sq ft expansion of existing master bedroom and relocating master bathroom; relocating
existing deck (no additional sq ft) and covering with trellis.
BUILDING
Floor Areas Required Setbacks Required
Stones: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors:
Total: 0 sf Value: $35,000.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays 0 Rain Drain: 0 Urinals: 0
Lavatories: 3 Dishwashers: 0 Floor Drains: 0 Sewer Lines 0 SF Rain Storm Sewer: 0
Tubs /Showers: 2 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Drywetl- 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: 0
Fum <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 3
Fum > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temo SrvclFeeders Branch Circuits
1000 sf or less: 0 0-200 amp: 1 0 -200 amp: 0 W/ Svc or Fdr: 2
Ea add! 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 0
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 & 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 0
Owner: Contractor:
CARROLL, BRIT E OWNER Required Items and Reports (Conditions)
12180 SW WALNUT ST
TIGARD, OR 97223
PHONE: 503 - 888 -0869 PHONE.
FAX
Total Fees: $1,470.04
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 = • •• nee 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: • —on la requires you to follow the rules adopted by the Oregon Utility Notification Ce • - e rules are set forth in OAR
9 - 001 -0010 through OAR • 5 •0 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.: • .332.2344.
Is- ed By: / •-• - /� / -L - h ./A Perm ittee Signature:
Call 503.639.4175 by 7:00 a.m. for the next available inspection dat>
This permit card shall be kept in a conspicuous place on the job site until co ion of -project
Approved plans are required on the job site at the time of Inspection.
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 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing per mits.
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 a II 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 w ill
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.
C I )‘ )--- &fru \ I
Print Name of Per it Applicant
/2/2 2--
Signature of Perm Applicant Date
Permit #: He too --00 ?7 7
Address: (olf g d L O4LIJLA j S ~�'`��
Issued b(. r " - ) Date: /0042-- El. •
This Copy for Permit Offices
•
Build Permit Application RECEIVED
Residential �! Q FOR OFFICE l SE ON I.1
• NOV V 0 8 2012 Received
Cit of Ti Date/By: (/ Permit No/1/57;20.4z, /� �JDa79
. • 13125 SW Hall Blvd., Tigard, OR 97223 p Ri w - r
Phone: 503.718.2439 Fax: 503.598.1960 CITY DFTIGARD e/B : a'a j� ' ( Z Other Permit
TIGARD Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready/By: luri 6 ® See Page 2 for
Internet: www.tigard or.gov Notified/Method: i Q 12_54 / / Supplemental Information
'� ie 1
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
El New construction ❑ Demolition Permit fees' are based on the value of the work performed.
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.
0 1- and 2- family dwelling ❑ Commercial/industrial Valuation: $35000 IS "NG my.
ow o Accessory building 0 Multi-family Number of bedrooms: 0 a, 6X/ / on/ ��
❑ Master builder ❑ Other: Number of bathrooms: 0 Nod► ev" ri -C/ 0 N
JOB SITE INFORMATION AND LOCATION Total number of floors: 1
Job site address: 12180 SW Walnut St. New dwelling area: 342 square feet
City/State/ZIP: Tigard, OR 97223 Garage/carport area: 0 square feet
Suite/bldg. /apt. no.: Project name: Master Suite addition Covered porch area: 0 square feet
Cross street/directions to job site: 121" and Walnut Deck area: /eri e4 -77n/6— square feet
Other structure area: l O / square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: 1 Lot no.: R4730 Permit fees* are based on the value of the work performed.
Tax map /parcel no.: 2S103BC00300 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.
Adding an 18' x 19' wide long rectangular addition to master Bedroom Valuation: $
Reloacating the existing bathroom and closets into new section Existing building area: square feet
maintaining the exisiting roof pitch . � 6 - LOC 4 eX/S 'fG ,eeLrt.. New building area: square feet
® PROPERTY OWNER & CA"VEL ' ❑ TENANT Number of stories:
Name: Brit Carroll Type of construction:
Address: 12180 SW Walnut St. Occupancy groups:
City /State /ZIP: Tigard, OR 97223 Existing:
Phone: (503)888 -0869 Fax: ( ) New:
® APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
Business name: (Please refer to fee schedule)
Structural plan review fee (or deposit): k 6, , 70
Contact name: Brit Carroll
FLS plan review fee (if applicable):
Address: 12180 SW Walnut St.
City/State/ZIP: Tigard, OR 97223 Total fees due upon application:
Phone: (503) 888 -0869 Fax:: ( ) Amount received: 36 6, 70
E -mail: brit_carroll @hotmail.com PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
CONTRACTOR Commercial and residential prescriptive installation of
roof -top mounted Photo Voltaic Solar Panel System.
Business name: Owner Submit two (2) sets of roof plan with connection details
and fire department access, along with the 2010 Oregon
Address: Solar Installation Specialty Code checklist.
City/State /ZIP: Permit Fee (includes plan review $180.00
and administrative fees):
Phone: ( ) Fax: ( ) u
State surcharge (12% of permit fee): $21.60
CCB lic.: _ Total fee due upon application: $201.60
Authorized signature: V 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
Print name: ) t Gr p f j Date: f - —� Service Board.
I:\Building\Pennits\BUP- RESPermitApp.doc 02/ 24/2011 440- 4613T(11 /02 /COM/WEB)
plumbing Permit Application
Building Fixtures RECEIVED FOR OFFICE USE ONLY
City of Tigard R eceived Permit N 7 C
Date/B �cl'� x
I
`I 13125 SW Hall Blvd., Tigard, OR 97223 N l V 08 2012 ' Plan Review e� /
s Ph one: 503.718.2439 Fax: 503.598.1960 D a t eBy: Other Permit No
Inspection Line: 503.639.4175 C OFTIGARD Da te Rea /B lu res 65 See Page 2 for
TIGARD Ready /By: g
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WO FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility comection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
g 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:
1 J� Catch basin or area drain 18.76
Job site address: I LI%Q SW k► „ S�.
Drywell, leach line, or trench drain 18.76
City/State /ZIP: T 5 O . Ct722.3
i Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Co/rra I ■ Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: _) Page 2
Water service (no. linear ft.: Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
m(Iinh : 1 it iltV" , 1 S*Ak r 1 S4M'e 1 ( Dishwasher 25.02
Add:rS .. 1. s►t�1( l 1 h t I- 110) wf4 er hefty7C( Drinking fountain 25.02
Ejectors/sump 25.02
Er PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Srt4" CAY'N‘ 1
Fixture /sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: Garbage disposal 25.02
City /State /ZIP: Hose bib 25.02
Phone: (503 ) 891 - o 0 p b ot Fax: ( ) Ice maker 12.51
V APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: gr► 4- C veld Roof `
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 3 25.02
City/State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 2. 12.51
E -mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater I 37.52
Business name: Water piping/DWV 56.29
Address: Other: I 25.02
City /State /ZIP: Subtotal
Phone: ( ) 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: w- ---- TOTAL PERMIT FEE
Print name: g r , fi- f Y4 ` J Date: I - I Z 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 Building Industry Service Board.
1 :1 Building \Peemits\PLMU- PermitApp.doe 10 /01/09 440- 4616T(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 - 1 100' 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
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 62.54
$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
Other ec
Ins tions or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
Inspections 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 ",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * . Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply. .
Work Performed: Capped Added Relocate
❑ Any new commercial building with water service 2" and
Baptistry/Font greater, except systems designed and stamped by licensed
Bath: - Tub /Shower 1 engineer.
- Jacuzzi/Whirlpool l
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918- 780 - 0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918 -780 -0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: - 2"
3" Isometric or Riser Diagram
❑ Isometric or riser diagram is required for new buildings
- Car Wash Drain
Garbage Domestic non - food that meet the qualifications above.
Disposal: - Domestic food related
- Commercial food related
- Industrial food related
Ice Mach./Refrig. Drains Comments regarding fixture work:
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav /Bar non -food related 1 Z
- Bradley
- Com/Serv/Util food related
- Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs, a sewer permit will be issued and
Washer - Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet - Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF- PermitApp.doc 08/04/2011 2
Mechanical Permit Application
RECEIVED t ()R I I I 1 1 ( 1 I l () l l
B
City of Tigard Date /By
1114 • v Pmmt N9445-7--„Rom / /AC
13125 SW Hall Blvd., Tigard,OR 97223 I 0 8 2012 y
Phone: 503.718.2439 Fax: 503.598.1960 CI 1+ `1 P lan Rev
p Date/By: Other Permit:
I 1 c , , 1; I Inspection Line: 503.639.4175 C OF TIGARD Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard -or.gov n1 Notified/Method: Supplemental Information
BUILDING Dl V
ISIO
TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Mechanical permit fees* are based on the value of the work
❑ New construction 5t 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*
® 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: I 2J %b SW W 1 1 (1 - S} _ (requires site plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46.75
City /State /ZIP: TI f�p1(d Q, q 1 Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg. /apt. no.: (/ (Project name: C \ \ 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
A4 0 4loci - }o v tMitr CAd4Inl Gas fireplace/insert 33.39
1 J "r�►t11�� GC,! VJir�'ttT r Flue vent for water heater or gas
-r r o.Altill'Y -Floors quS -fir- �r;rep t gQ� fireplace 23.32
V Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
Ca PROPERTY OWNER I ❑ TENANT Chimney /liner /flue /vent 23.32
Other: 23.32
Name: gr.,. afro ■ ( Environmental exhaust and ventilation:
Address: Range hood/other kitchen
equipment 33.39
City /State /ZIP: Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: ( 503 ) ab$ _0869 Fax: ( ) toilet compartments, utility rooms) I 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 i f
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: l Clothes dryer (gas)
/�� / N Address: ` 12. Other: MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal
Minimum permit fee ($90.00)
Phone: ( ) Fax: ( ) Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee)
TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
Authorized signature: days after it has been accepted as complete.
Print name: / r Date: // — S -12..
• Fee methodology set by Tri- County Building Industry Service Board
I:\ Building \Permits\MEC- PermitApp.doe 09/09 /10 440- 4617T(1I /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.
•
I:\Building\Permits\NEC- PermitApp.doc 09/09/10 2
Electrical Permit Application RECEIVED FOR OFFICE t SE °°NI.A
�
City of Tigard Date/By: Received Permit No�GJ/�� _ D,a 77 • 13125 SW Hall Blvd., Tigard,OR 97223 �, (1 V Q 8 20 2 Plan Review 'd
III Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:
I i t. RI) Inspection Line: 503.639.4175 Dat ReadyBy: Juris: ® See Page 2 for
Internet: www.tigard- or.gov CIT OFTIGARD otified/ Supplemental Information
TYPE OF Watts. NG DNISIO ' PLAN REVIEW
❑ New construction fir 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
cd 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
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "l -2 ", 'l -3 ",
Job no.: Job site address: � ` 100HP or more. occupancy.
Z� r p u,4 w (�1h 1a } ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: T i Qcrd� Olt g72-Z ❑ Health-care facilities. ❑ Supply voltage for more than
V r ] ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: C, `I ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: 12,E 0- 4, vJcavWws-- Description I Qty. I Fee- I Total I *
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 12.1..r730 1,000 sq. ft. or less 168.54 4
Tax map /parcel no.: 2 Q3 L3C.00 Ea. add'I 500 sq. ft. or portion 33.92 1
J 3oO Limited energy, residential
75.00 2
DESCRH'TION OF WORK (with above sq. ft.)
Limited energy, multi- family 7500 2
residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less J 100.70 2
It PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
Name: g r k (Arno I ` 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: ' Z) 8 6 SW W c.I nv? Si-. Over 1,000 amps or volts 552.26 2
City/State /ZIP: ' Temporary services or feeders installation, alteration, and /or
1 r jy0rk I 0� Q7 ZZ3 relocation
Phone: (503) $ga -0a6q Fax: ( ) 200 amps or less _ 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This i . • ' • is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or - age, . : • ng to ORS 447, 449, 670, and 701.
✓� Branch circuits – new, alteration, or extension, per panel
Owner signature: / `�-^�— Date: Oh? A. Fee for branch circuits with
❑ • .. CANT I ❑ CONTACT PERSON above service or feedeiT° £ 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'l branch circuit 7.42 7
Address: Miscellaneous (service or feeder not included) _
City/State /ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation 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
/ Ea ch 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 (V2 hr min)
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):
TOTAL PERMIT FEE:
Authorized signature: ! This permit application expires if a permit is not obtained within 180
Date: /p/ days after it has been accepted as complete.
Print name:
r t�v Lift 2- • Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 07/01 /10 440-4615T( 1 1/05/COM/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 $75.00
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
•
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I:\ Building \Pennits\ELC- PennitApp.doc 07/01/10
11 1 1 4 • • Building Division
Development Code Provision Review
T i n D Residential Projects
Building Permit No.: MST Zp/ a — D o A79
Site Address: / /1 SA} 10 0 9"4/1k 7' S
Project Name & Lot No.: C#9 c_.s—
CWS Service Provider Letter
Required: Yes' No ❑
Received: Yes ❑ No ?' 7' 4€ �Scc 43"-i t 77 7 e 6 S
/Liu ST' /2_, --, VE' .." i iE.. T?J ,04--_,L,,7.— /SSLc,rvC ,
Routed Plans:
Original Plan Submittal Date: / / /P,
1st Revision Submittal Date: ❑ Site Plan Only
2" Revision Submittal Date: ❑ Site Plan Only
To the Applicant:
Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies to the
Building Division. Only checked ( items are approved. Items not approved and those listed in the notes must be
revised prior to re- submittal. For questions please contact the appropriate staff person(s) listed above each section.
Staff: please check items along l only if approved.
Planning Review (contact at 503 -718- vi 3'1 or @tigard- or.gov)
Land Use Case No. N/#
Zoning 13 '1 • r
❑ Setbacks:
Front 20 Rear I Side S Street Side /'' #i` Garage a
❑ Maximum Building Height: 3 V Actual Building Height
❑ Visual Clearance
❑ Easements
❑ Sensitive Lands Type: N fr
❑ Street Trees
❑ Protected Trees
Notes: .
Nd v' '$ - s `/ ;616 45 &W)T1 G 414
1 4
Original Plan: Approved.0 Not Approved ❑ Date: 1 1 — I 1 — ( 2—
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
(Review Continues on Page 2)
Page 1 of 2
Engineering Review (contact Mike White at 503- 718 -2464 or MikeW @tigard- or.gov)
$' Actual Slope: s
Notes:
Original Plan: Approved -0 Not Approved ❑ Date: // At /
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
Permit Coordinator Review (contact Albert Shields at 503- 718 -2426 or albert @ tigard - 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 Applicant
Okay to Issue Permit: Yes
i pV
No ❑
Date Routed to Building: _.,0
Page 2 of 2