Permit `. V CITY OF TIGARD BUILDING PERMIT
' '- '- COMMUNITY DEVELOPMENT Permit #: BUP2012 -00232
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/15/2013
Parcel: 1 S 134 BC00300
Jurisdiction: Tigard
Site address: 12240 SW SCHOLLS FERRY RD
Project: Rite Aid Subdivision: WINDSOR PLACE Lot: 32
Project Description: TI for new consultation room, reorganize shelving, upgrade restroom accessories.
Contractor: JAMES JOHN CONSTRUCTION CO Owner: FW OR- GREENWAY TOWN CENTER LLC
1701 SE COLUMBIA RIVER DR PO BOX 790830
VANCOUVER, WA 98661 SAN ANTONIO, TX 78279
PHONE: 503 - 283 -5365 PHONE:
FAX:
Specifics: FEES
Description Date Amount
Type of Use: COM .
Class of Work: ALT Type of Const: IIIB Permit Fee - Additions, Alterations, 01/09/2013 $453.95
Demolition
Occupancy Grp: M Occupancy Load: 12% State Surcharge - Building 01/09/2013 $54.47
Dwelling Units: 0 Plan Review 11/21/2012 $295.07
Stories: 0 Height: 0 ft Plan Review - Fire Life Safety 01/09/2013 $181.58
Bedrooms: 0 Bathrooms: 0 Info Process /Archiving - Lg $2.00 (over 01/09/2013 $18.00
Value: $25,000 11x17)
Floor Areas:
Total Area: 0
• Accessory Struct: 0
Basement: 0
Carport: 0
Covered Porch: 0
Deck: 0
Garage: 0
Mezzanine: 0
Total $1,003.07
Required: Required Items and Reports (Conditions)
Fire Sprinkler: Parapet:
Fire Alarm: Protected Corridors:
Smoke Detectors: Manual Pull Stations:
Accessible Parking: 0
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. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OAR 952- 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: AfAb-c-i 17, JI Permittee Signature: 000ddd CLLXXX i t �y
Call 503.639.4176 by 7:00 a.m. for the next available inspe • • date.
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.
t uilding Permit Application
Commercial RECEIVED � ° � � aar t , . ;ei $7� �; a�:
r "�, , ` p' , s �} '�` -FOR`OFFICE USE ONLY t f �1 4! .:r
W
City of Tigard Received / Permit N o.
y NOV 21 2012 Date /By: / �� /a— 4,� / o /� — �Y�3 _
TIGARD
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.196A Date /13y: � ) (21 4 ,. Other Permit
' Inspection Line: 503.639.4175 I ITY OFTIGARD Date Ready/By: / "� 1uri+. ® See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: / Ic / /'Se 176 Supplemental Information
TYPE OF WORK REQUIRED DATA: I - 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
, Additio alteratio replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ I - and 2 - family dwelling ommercial industrial Valuation: S
El Accessory building 1=1 Multi-family Number of bedrooms:
1:1 Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: /22,40 SYt/ creAilii /� Ili New dwelling area: square feet
City /State /ZIP: / r4 � "7 Garage /carport area: square feet
Suite /bldg. /apt. no.: , r Project name: ie -7 Ig l h overed porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL - USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: ��7� Indicate the value (rounded to the nearest dollar) of all
/� 1 equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Valuation: s
enhs. d v (ol,.ry /tom t�n, fe c; cc.,, ? 5 ewe
building ti
Exisng ung area: s
eheia: i G i.e-- 7-ai /t / i O* Ace /�or cJ / ,7i -b uare feet
q
New building area: SAya,. square feet
❑ PROPERTY OWNER (TENANT Number of stories: /
Name: k/ 1-t-7-- / j 6o to/et Type of construction: in pj
Address: 71, 44 4asLv r 160 % CA PI Occupancy groups: /t1
City/State /ZIP: rG il6thoht.d i4 51024. Existing:
Phone: ( ) Fax: ( ) Y New: M
❑ APPLICANT dONTACT PERSON BUILDING PERMIT FEES*
Business name: ¢- fe KjmV r- ` p7 / G review refer tojeeschedule)
G/L� Structural plan review fee (or deposit):
Contact name: ,j�.yywary �t ,nxJr�
Aft, Q .' �• / FLS plan review fee (if applicable):
PO -
Address: i £- A PI
City/State /ZIP: /p A.. ce , r , / ��j� Total fees due upon application:
,l� 7r--- � ,), Amount received:
Phone: ( 4l ) «I if I Fax: : ( 4 , uv / 23 a
3
�
E -mail:
h3 /31 PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
�� 11i1 .5"17', Commercial and residential prescriptive installation of
CONTRACTOR roof -top mounted PhotoVoltaic Solar Panel System.
Business name: art two (2) sets of roof plan with connection details
I►��� f� =�L : V 1� .� Pgc fire department access, along with the 2010 Oregon
Address: n o t . co u iv ti W O K /
�/ 1 J . So la r Installation Specialty Code checklist.
City/State /ZIP: .0 AN C U V \1 p/ Permit fee (includes plan review $180.00
11 - • and administrative fees):
Phone: ( 510 COl 0 Fax: ( ) State surcharge (12% of permit fee): $21.60
CCB lit.: c3'2_ \ 113 I (1 Total fee due upon application: $201.60
Authorized signature: ( This permit application expires if a permit is not obtained
ice` , ��" within 181) days alter it has been accepted as complete.
Print name: Date: "/ ��,�� * Fee methodology set by Tri- County Building Industn
� � --.-^ Serv ice Board.
r=
1:A13uilding\ Permits\ 13UP -COM PermitApp.doc 02/24/2011 440- 4613T( I /02 /COM /WE13)
1
RECEIVED
NOV 21 2012
1111 Building Division
CITY OF TIGARD
Accessibility: Barrier Removal Improvement PBiiILD1NG DIVISION
TIGARD
REQUIREMENT: OREGON REVISED STATUTE (ORS) 447.241.
(1) Every project for renovation, alteration or modification to affected buildings and related
facilities shall be made to insure that the path of travel to the altered area and the restroom,
telephones and drinking fountains are readily accessible to individuals with disabilities unless
such alterations are disproportionate to the overall alterations in terms of cost and scope.
(2) Alterations made to the path of travel to an altered area may be deemed disproportionate to
the overall alteration when the cost exceeds twenty-five per -cent (25 %).
VALUATION: Total of all renovation, alteration or modification being done,
excluding painting and wallpapering: [1] $ 2-o/ 00 0
MULTIPLIER (25% barrier removal requirement): x .25
TOTAL BUDGET FOR BARRIER REMOVAL: [2] $ 0e
ELEMENTS: In choosing which accessible elements to provide under this section, priority shall be given
to those elements that will provide the greatest access. Elements shall be provided in the
following order:
(a) Parking $
(b) An accessible entrance: $
(c) An accessible route to the altered area: $
(d) At least one accessible restroom for each sex or a single unisex
restroom: $ 6190 °�
(e) Accessible telephones: $
(f) Accessible drinking fountains: and, $
(g) When possible, additional accessible elements such as storage and
alarms: $
TOTAL (shall equal line [2] of Valuation Computation): $ 6,0f, p CD
l:ABuilding \ Permits \BUP -CON1 PermitApp.doc 03/03/2011
Commercial Application Checklist RECEIVED
City of Tigard NOV 21 2012
a ° 13125 SW Hall Blvd., Tigard, OR 9722 CITYOFTIGARD
Phone: 503.718.2439, Fax: 503.598.1960
TIGA RD BUILDING DIVISION
Internet address: www.tigard- or.gov
PROJECT INFORMATION I
Project name: Awe ,0( T n'i f Aphoevi.rdo, cst f Date: 1/ 10 – /2—
Address: /2.2.4o Su/ Saw //t J -s1 Re/ City: 1 *r su State: G4- ZIP: 9722_3
Scope of work: COn sir nem/ Cos h' /fz /Mk R/Si ,1 1 el S4eievai
Reference no.: Map and tax -lot no.: R 9 A 31 7
Contact person name: -}-vi /-z( J iw, vrr/ Company: f 1Z. K /r» ✓r3 4h d. P4 C.
Phone: s/?; ill- air- Fax: "/Zr 2 71- 2 3 P3
Cellular phone: E -mail: hl ✓YET a Gd "* ca S7` K cam'
NOTES AND INSTRUCTIONS
▪ The purpose of this checklist is to help define a complete submittal package for the scope of work. Plan
review will not take place until a complete package is submitted.
▪ This checklist can be used for all commercial construction projects, including new construction, additions,
alterations and tenant improvements.
® For complex projects, applicants should use the "location" space to note the item's location and page
number from the plans or the specification book.
® It is not necessary to duplicate submittal information, even if it is asked for in multiple sections.
® In the checklist, "Required" means that the applicant must provide this information for plan review.
® In the checklist, "P" means —
• if checked by the applicant — the information is provided for the plan review.
• if checked by the plans reviewer — this information is required for the plan review.
® In the checklist, "NA" means that the information does not apply.
® Choose only those sections of the checklist that apply to your scope of work. Section 1.0, "General Project
Data," must be included with each project submitted.
PRE= SUBMITTAL PROCESS
An applicant may request a pre - submittal meeting with representatives of the jurisdiction in which the project
will be built. The meeting may take place during the conceptual, schematic, or in- progress phase, or when the
applicant has completed plans.
ifNDEX 'OF CHECKLIST SECTIONS
1.0 General project data Page 2 7.0 Mechanical data (Types I and II
2.0 Civil data Page 2 kitchen -hood permits) Page 6
3.0 Architectural data Page 3 8.0 Plumbing data Page 7
4.0 Structural data Page 4 9.0 Electrical data Page 8
5.0 Mechanical data (new construction, tenant 10.0 Fire - suppression data Page 9
improvement, gas - piping permits) Page 5 11.0 Fire - detection and fire -alarm data Page 9
6.0 Mechanical data (additional or replacement 12.0 Re -roof installation data Page 10
rooftop- equipment installation permits) Page 6 13.0 Jurisdictional requirements Page 10
This checklist is for building department jurisdictions in Clackamas, Multnomah, and Washington counties.
440 -2734 (8/01 /WEB /COM)
1: \Building \Forms \COM- Checklist.doc 11/19/12
SECTION 1.0 — GENERAL PROJECT DATA
Construction documents Location (sheet number or spec section)
1.1 ® Required No. of sets of plans: New: 1 TI: 2
1.2 ® Required Cover sheet title block App/
1.3 ® Required Cover sheet vicinity map app/
1.4 ® Required Cover sheet plan indexpo0
1.5 P ❑ NA Code summary 4-v0 /
1.6 [ P El NA Deferred submittal summary a_
1.7 Zr P ❑ NA Professional stamp and signature i / SA fs
1.8 ❑ P 121' NA Fire and life- safety plan
1.9 ❑ P NA Landscape plan
1.10 ❑ P ,[mil NA Landscape specifications
Supporting documents Notes
1.20 ❑ P 21 NA Land -use or planning actions
1.21 ❑ P E' NA Required fire -flow calculations
1.22 ❑ P NA Fire - hydrant flow -test report
1.23 ❑ P NA Fire department or fire district building survey report
1.24 El P 0' NA Material safety data sheets (MSDS)
SECTION 2.0 — CIVIL DATA
Construction documents Location (sheet number or spec section)
2.1 ® Required Site plan Avn, /
2.2 ® Required Site utility plan T /
2.3 ® Required Grading plan
2.4 ® Required Erosion - control plan 1:/,
2.5 ❑ P ❑ NA Utility -vault location and details 1
Supporting documents Notes
2.20 ❑ P 4 NA Geotechnical/soil engineer report
2.21 ❑ P nijg NA Storm -water calculations
2.22 ❑ P al NA Site retaining -wall structural calculations
2.23 ❑ P k] NA "Assurance of Compliance" with environmental rules
440 -2734 (8/01 /WEB /COM) Tri- County Commercial Application Checklist 2
For use in building department jurisdictions in Clackamas, Multnomah, and Washington Counties
I: \Building \Forms \COM- Checklist.doc
SECTION 3.0 — ARCHITECTURAL DATA
Construction documents Location (sheet number or spec section)
3.1 ® Required Floor plan(s) Me/
3.2 ® Required Transverse and longitudinal cross sections A
3.3 ® Required OSSC Chapter 11 accessibility requirements moo/
3.4 P ❑ NA Interior elevations An/2 --
3.5 ❑ P f" NA Exterior elevations
3.6 ❑ P la NA Roof plans
3.7 ❑ P 0r NA Exterior wall sections and details
3.8 j- P ❑ NA Reflected ceiling plan(s) 44
3.9 ❑ P p Fire -rated construction details
3.10 ❑ P p NA Energy code compliant construction details and
specifications
3.11 0 NA Door schedule AM/
3.12 1P ,0 NA Glazing schedule
3.13 [2- P ❑ NA Furniture plan ____
Supporting documents Notes
3.20 ❑ P ,0' NA Energy code compliance forms /calculations
3.21 ❑ P ,0" NA Material safety data sheets (MSDS)
3.22 ❑ P [ "NA Hazardous materials inventory statement (HMIS)
3.23 ❑ P ® NA Hazardous materials management plan (HMMP)
3.24 ❑ P p NA Written fire and life - safety evacuation plan for area
of rescue assistance
3.25 ❑ P ❑' NA Active and passive smoke - control information
440 -2734 (8/01 /WEB /COM) Tri- County Commercial Application Checklist 3
For use in building department jurisdictions in Clackamas, Multnomah, and Washington Counties
i:\BuildingTorms\COM-Checklistdoc
SECTION 4.0 — STRUCTURAL DATA
Construction documents Location (sheet number or spec section)
4.1 ® Required Structural cover sheet
4.2 ❑ P E' NA Foundation plan
4.3 ❑ P 0 NA Under -slab mechanical plan
4.4 ❑ P NA Under -slab electrical plan
4.5 ❑ P NA Under -slab plumbing plan
4.6 ❑ P NA Floor framing plan
4.7 ❑ P NA Roof framing plan
4.8 El P NA Structural elevations
4.9 ❑ P NA Structural details and cross sections
4.10 ❑ P NA Standpipe information
4.11 ❑ P NA Special inspector /structural observation matrix
Supporting documents Notes
4.20 ❑ P NA Geotechnical /soil engineer report
4.21 El P NA Site - specific seismic hazard report
4.22 ❑ P NA Design narrative
4.23 ❑ P NA Structural calculations
440 -2734 (8/01 /WEB /COM) Tri- County Commercial Application Checklist 4
For use in building department jurisdictions in Clackamas, Multnomah, and Washington Counties
1:\B u i Id i ng \Forms \COM- Checkl ist.doc
SECTION 5.0 - MECHANICAL DATA (New construction, tenant improvement, gas piping permits)
Construction documents Location (sheet number or spec section)
5.1 ® Required Floor plan p/
5.2 ® Required Equipment schedule
5.3 zip ❑ NA Site plan moo/
5.4 ❑ P NA Under -slab mechanical plan
5.5 ❑ P 1.1 NA Roof plan
5.6 ❑ P 11 NA Fuel gas piping plan
5.7 ❑ P 11 NA HVAC equipment and duct plan(s)
5.8 ❑ P 11 NA Roof access details
5.9 ❑ P 11 NA Duct smoke detector plans
5.10 ❑ P 1 . 1 NA Fire /smoke damper locations
5.11 ❑ P 11 NA Smoke control plan
5.12 ❑ P II NA Outside air (OSA) table
5.13 ❑ P II NA Refrigeration equipment and piping plan
5.14 ❑ P 11 NA Kitchen equipment plan
5.15 ❑ P 11 NA Type I and/or Type II kitchen hood plan
(see Section 7.0 - Mechanical Data)
5.16 ❑ P II NA Fume /vapor hood plan
5.17 ❑ P ■I NA Process piping /product and/or exhaust- conveying
duct plan
5.18 ❑ P II NA Fire -rated construction details
5.19 ❑ P 1 NA Equipment hanger /fastener details
Supporting documents Notes
5.20 ® Required Structural calculations for vertical loads and lateral
loads for equipment weighing over 400 pounds /
5.21 pr P NA Equipment manufacturers' catalog "cut sheets"
or specifications
5.22 ❑ P NA Outside air (OSA) calculations
5.23 ❑ P NA Smoke - control calculations
5.24 ❑ P NA Combustion air calculations
5.25 ❑ P NA Fuel gas piping sizing calculations
5.26 ❑ P NA Make -up air calculations
5.27 ❑ P NA Energy code compliance forms
5.28 ❑ P NA Boiler information
440 -2734 (8/01 /WEB /COM) Tri- County Commercial Application Checklist 5
For use in building department jurisdictions in Clackamas, Multnomah, and Washington Counties
i:\B uilding \Forms \COM- Checklist.doc
CITY OF TIGARD RECEIPT
V
E 5 . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 189744 - 01/09/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
BUP2012 -00232 Permit Fee - Additions, Alterations, 230 - 0000 - 43104 $453.95
Demolition
BUP2012 -00232 12% State Surcharge - Building 100 - 0000 -24001 $54.47
BUP2012 -00232 Plan Review - Fire Life Safety 230- 0000 -43108 $181.58
BUP2012 -00232 Info Process /Archiving - Lg $2.00 (over 230 - 0000 -43135 $18.00
11x17)
Total: $708.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 16807B STREAT 01/09/2013 $708.00
Payor: Howard G Kimura HG Kimura Architect PUC
Total Payments: $708.00
Balance Due: $0.00
CITY OF TIGARD PERMITS
13125 SW HALL BLVD CITY OF TIGARD PERMITS
TIGARD, OR. 97223 CITY OF TIGARD PERMITS 13125 SW HALL BLVD
TERMINAL I.D. 8811348880880313065801 13125 SW HALL BLVD TIGARD, OR. 97223
iIGRRD. OR. 97223 I TERMINAL I.D.; 0817348808800313865801
MERCHANT 0: 8083138658 1 TERMINAL I.D.: 8817340880880313065881
VISA MERCHANT 8: 8803130658
1 13MI 736 8 MERCHANT N: 8883138658
SALE UISR
RECORD N: 2 IHU: 088882
DATE: JAN 89, 13 TIME: 87:58 uOR1IDit#I<t736 8 SALE
DATE: 4
INV: 088803
BATCH: 54 RECORD N: 2 INU: 808882 DATE: JAN 09, 13 TINE: 08 :02
AUS RESPONSE: y AUTH: 871038 DATE: JAN 89, 13 TIME: 87:58 BATCH: 54
CUU2 RESPONSE: P AUTH: 168878
RUTH: 871830 AUS RESPONSE: Y
ADDRESS AND 5 DIGIT ZIP MATCH AUS RESPONSE: V CUU2 RESPONSE: P
CUU2 RESPONSE: P
ADDRESS AND 5 DIGIT ZIP MATCH
TOTAL $1003.07 ADDRESS AND 5 DIGIT ZIP MATCH
TOTAL $708.00
TOTAL — $1003.07
ACCORDING ISSUER AGREEMENT
(MERCHANT AGREEMENT IF CREDIT VOUCHER) CUSTOMER COPY I AGREE TO PAY ABOVE TOTAL AMOUNT
CUSTOMER COPY
(MERCHANT AGREEMENT IF
CUSTOMER COPY
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