Permit CITY OF TIGARD MASTER PERMIT
1 1 C • COMMUNITY DEVELOPMENT Permit #: MST2013 -00013
T I G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/06/2013
Parcel: 2S102DB06500
Jurisdiction: Tigard
Site address: 9125 SW HILL ST
Subdivision: CHELSEA HILL NO.2 Lot: 42
Project: Ettestad
Project Description: Adding new window in master bath
BUILDING
Floor Areas Required Setbacks Required
Stories: 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: Yes
Total: 0 sf Value: $500.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 2 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
Drywell- Trench Drain: • 0 Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Furn <100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea addl 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 4
Mfd Home /Feeder /Svc: 0 401 -600 amp: 0 401 -600 amp: 0
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +ampNolt: 0
ELECTRICAL - RESTRICTED ENERGY
•
SF Residential
Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other. N Other Description: Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ALT SF VB R -3 0
Owner: Contractor:
ETTESTAD, KEITH A/WILLENE A OWNER Required Items and Reports (Conditions)
9125 SW HILL STREET
TIGARD, OR 97223
PHONE: 503- 332 -5034 PHONE:
FAX:
Total Fees: $367.51
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 d• • : in accordan - ith 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
da . ATTENTION: Orego I- • -quires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
• 2- 001 -0010 through OAR • :. 001 -0• • . ou may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
-sued By: Permittee Signature:
' 111 ,e l' e
Call 603.639.4175 by 7:00 a.m. for the next available Inspection 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.
Building Permit Application
RECEIVED
Residential
RECEIVED OFFICE USE c.)NI.Y
City of Tigard JAN 2 8 2013 Received
`J g Date/By: ( ( c og' ( ,. S ( Permit No.:M ,p. / ? _ (3
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie I
- Phone: 503.718.2439 Fax: 503.598.19(TT B y OFTIGARD Date : "big. L�5 ` (5 Other Permit:
T I G n R D Inspection Line: 503.639 BUILDING DIVISION D ate Ready e I J�r;s: ® See Page 2 for
Internet: www.tigard or.gov Notifi ed/Method: � �o Supplemental Information
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees' are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
® Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
® 1- and 2- family dwelling ❑ CommerciaUindustrial Valuation: $500.00
❑ Accessory building ❑ Multi- family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 9125 SW Hill St. New dwelling area: square feet
City/State/Z1P: Tigard, Or 97223 Garage/carport area: square feet
Suite/bldg. /apt. no.: I Project name: Covered porch area: square feet
Cross street/directions to job site: Omara St. Deck area: 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.
Adding a new window (36 "x 19 ") in the master bath Valuation: $
Existing building area: square feet
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name: Keith & Willene Ettestad Type of construction:
Address: 9125 SW Hill St. Occupancy groups:
City /State /ZIP: Tigard, Oregon 97223 Existing:
Phone: (503)332 -5034 Fax: ( ) New: 3 (- (43
® APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
(Please refer w fee schedule)
Business name:
Structural plan review fee (or deposit):
Contact name: Keith Ettestad
FLS plan review fee (if applicable):
Address: 9125 SW Hill St.
Total fees due upon application:
City /State /ZIP: Tigard, Oregon 97223
Phone: (503) 332 -5034 Fax: : ( ) Amount received:
E -mail: keithwillene @msn.com PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR roof -top mounted PhotoVoltaic 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/Z1P: Permit Fee (includes plan review $180.00
and administrative fees):
Phone: ( ) Fax: ( ) State surcharge (12% of permit fee): $21.60
CCB lic.: Total fee due upon application: $201.60
Authorized signature: / This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Keith A. Ettestad Date: 1/3/2013 * Fee methodology set by Tri County Building Industry
Service Board.
I:\ Building \Permits\BUP- RESPermitApp.doc 02/24/2011 440 -4613T(I 1/02 /COM/WEB)
Plumbin Perm A lica EI
Building Fixtures .
City of Ti and JAN 2 8 Received ) w
g 2 13 Date/By: I I 13 f Permit NoA1 , T do 3 _ 12 0
a 13125 SW Hall Blvd., Tigard, OR 97223
C Of HGARD Plan Review
Phone: 503.718.2439 Fax: 503.59 4 I i i Date/By: Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready/By: Junii:!!-- See Page 2 for
Internet: www.tigard -or.gov Notified/Method: - rl to Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
g l Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
I- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: r Catch basin or area drain 1 8.76
�0S 5 ,k�, Hr// 51'
City/State/ZIP: ...--J, Drywell, leach line, or trench drain 18.76
t �
5 � Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: 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
`' D Clothes washer 25.02
M` r ` °ci'� �"'`�`� . Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: KEf-r'N 4 wl LL I -NE �- r- rESTAitl Fl 25.02
Address: 01 k 2S S W hf 1 I ( 5-1-- Floor drain/Floor sink/hub 25.02
Garbage disposal 25.02
City/State/ZIP: -r ( G A 4 0, OR et Da 912.23 Hose bib 25.02
Phone: ( 5)3) 332 - 5 Fax: ( ) Ice maker 12.51
APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: $ ) I Page 2
Business name: -i)0,• tPk►..� -.r L L�
Primer 12.51
Contact name: 31.„S\-- ( 50M A kNr t--1 Roof drain (commercial) 12.51
Address: `I )9n S. LA-'. 17x Sink/basin/lavatory ? 25.02
City /State/ZIP: A-ak..,o. &i _ g esty - / Solar units (potable water) 62.54
Phone: (�t�) .74s.._ /? 0 Fax: : ( ) ./ 57. 7 Tub /shower /shower pan 12.51
E -mail: ` \ ` Urinal 25.02
CONTRACT�SR Water closet 25.02
Water heater 37.52
Business name: m� 1+ \-) (-LC Water piping/DWV 56.29
Address: Other: 25.02
City/ State/ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50
t Plan review (25 % of permit fee)
CCB Lic.: '&0/ s -- 5 i I (tit Plumbing Lic. no.: ri'7� -4
111 State surcharge (12% of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: - tS� l ,5 -er Date: / _ ii, _ l - 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:\ BuildingWennits \PLMU- PermitApp.doc 10/01/09 440- 4616T(10 /02/COM/WEB)
Mechanical Permit Application RECEIVE a FOR OFFICE USE ONLY
City of Tigard 1, Date/By: / f o / 3 4 Permit No tiSTavr 3 . -000/3 13125 SW Hall Blvd., Tigard,OR 97223 Plan Review
14 C Phone: 503.718.2439 Fax: 503.598.1960 JAN 2 8 201 Date/By: Other Permit:
It G A R u Inspection Line: 5013.639 Date Ready/By: lads: RI See Page 2 for
Internet: www.tigard - or.gov CITY OFTIGARD Notified/Method: 10 Supplemental Information
BUILDING DIVISIO
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
Mechanical permit fees' are based on the value of the work
❑ New construction Addition/alteration/replacement performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit
Value: $
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
0-1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use check list.
❑ Multi- family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: /125 5sa t4 1 I ( �' (requires site plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46.75
City /State/ZIP: T 1 G Ai 91 t 0 >z t3 Furnace 100,000+ BTU ( ducts/vents) 54.91
Suite/bldg. /apt. no.: Project name: Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 23.32
Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
/� PAP Gas fireplace/insert 33.39
1� � PtA & r ex ( �f r 1.( C. OA Roo Yn A Flue vent for water heater or gas
(Al r IV 6 W 'F/A M / fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
A PROPERTY OWNER ID TENANT Chimney/liner/flue/vent 23.32
Other: 23.32
Name: K 6 1/14 eykl I L4.E ti(C L - r Environmental exhaust and ventilation:
Address: t11 ZS S l.7 1,40( 5-1---
Range hood/other kitchen
equipment 33.39
City/State /ZIP: -f (.A 1Z b Vg. 11 Uri Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: (9)'3) 3 3 Z - 503 4- Fax: ( ) toilet compartments, utility rooms) 1 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name: Other: 23.32
Fuel piping:
Contact name: $14.15 for first four; $4.03 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax: : ( ) Water heater
Fireplace
E -mail:
Range
CONTRACTOR Barbecue
/� - l E 2
Business name: N C ,(.. Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP:
Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00)
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee)
TOTAL PERMIT FEE
it permit is not obtained within 180
� This p er mit application e Authorized signature: .`,i , / / days after it has been accepted as complete.
Print name: K1v 1 - 1 - 14 A - - - r- (�g'rVica Date: 1 — ( 8_ (3 • Fee methodology set by Tri- County Building Industry Service Board
1:\ Building \Permits\MEC- PermitApp.doc 03/07/12 4404617T (I 1 /02/COM/WEB)
Mechanical Permit Application - City of Tigard) . ' ?. •
Page 2 - Supplemental Information
;O .;
Commercial & Multi- Family Fee Schedule: •.
Total Valuation: Permit Fee: F : t
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
•
•
$2.54 for each additional $100.00 or
fraction thereof, to and including .
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
•
1:\Building\Permits'MEC- PermitApp.doc 03/07/12 2
Electrical Permit AplicatioiRECENED FOR OFFICE USE ONLY •
Permit No.:
Cis•., of Tigard R /3 t I
`J 17mBy: t / c)-C S/�' fi T l 3 - O 3
° 13125 SW Flail Blvd„ Tigard, OR 97223J A N 2 8 2013 Pl Review
' ■ • Phone: Inspection 503.718.2439 Fax: 503.598.1960 D ate /B y: Other Permit:
!' I . K t� Ition Line: 503.639.4175 CITY OF TIGARD Date Ready/By: turi� I GI See Page 2 for
Internet: www.tigard- or.gov , Notified/Method: r'� Supplemental Information
. I ► I► I _
: s°tr °^ a - 3"'�` Y i'1 rte+ e`i`T 1 � tT :�i', -{ m pt
''Y ;p. an VIM- .aW .- 5413'� -LdF' r3 A - ; 1+- T f's; _ 1; i'y •.P• � 'd:n ".li 7 :443 . -- .. ,.
❑ New construction ® Addition /altetation/replacement Plea•e check all that apply (submit I sets of plans wfitems checked below):
O Service or feeder 400 amps or more ❑ Building over three stories.
❑ Dem011tlOn
❑ Other: where the available fault current ❑ Marinas and boatyards.
'7: 1 , ��,�_F� r 91 �� u5"ti 1 � y e p' 0' `�f = �'*'s -- ^ •^ •i , eels Io.000 amps et 1 SO volts Or ❑ Floating bindings.
°. isY + OtS.>: : !1':- =E �. a .r .•:.l& ss n: s.saiC::rr*m: � l '- � er =.
l- a nd 2 - ftlrtiil dwellin less to ground, or exceeds 14,000 O Commercial-use agricutttual
® y g ❑ Commercial/industrial ❑ Accessory building amps for all other installation. buildings_
❑ Multi - family ❑ Master builder ❑ Other: O Ewe pump. ❑ Installation of 75 KVA or
k s I p . , rs 1 :,t IT T 1 1:4F ,r • - t 3: : y7l7r, - �, ❑ Emer gency system. larger separately derived system.
. _ ... . . , I
S • , I. 9 t , 's t.4.. ' ..v . • .., , -..., 4 � ❑ Addition of new motor load of ❑ "A , E , 1.2» 1.3 »,
�.,; .- r _ .�, -ice. .., .:�.,�.• nn,:. r
Job no.: 209213 I Job site address: 9125 SW Hill St 100HP or more. occupancy
O Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: Tigard OR O Health -care facilities. O Supply voltage for more than
❑ Hazardous locations, 600 volts nominal.
Suite/bldg/apt ' no.: I Project name: Heistead O Service or feeder 600 amps or more.
,v :• -t�_ c , m:1/ r_ ir;.
F ' +=F + 'i :^J 9 Hi :.;.�.._ -- gt,q �_
Cross street/dire ctions to job site: 1- ' � ` " "� � ' °' R
Daerlplt.a Qrr. Fee. Tout •
New residential single- or multi- family dwelling unit.
• Includes attached garage.
Subdivision: I Lot no.: 1.000 sq. ft. or less 168.54 4
Tax ma / atcel no.: Ea. add•1500 sq. R or portion 33.92 1
P P Limited energy, residential
r:-rrt_ - - -_.. -r•• + r-- 75.00 2
, Uzi lr7l�'°;i; t��• -� A '-t-� + �' i - ~'1 o r -: '+^`�, , '�'- a: - with above ft.
?" ';{ 4 � ,C Y'�=L•.�cs'� :_ _, ....' -T_L�-'._.c`_... .. h ,.. R 3 ...... s�t�:e.. ti p... _. k `',_ : - •. t _- . sq' )
energy, multi-fam
Master bath remodel Limited
residenti ith above sq ft.) 75.00 2
Services or feeders installation, alteration, and/or relocation
•
. 200 amps or less 100.70 2
t
a ,. c 1: s '.K�••_...7 - ',: •r am to 400 am
::. .n r` 9 �•fr � '� -`• �.]fi)t'1� ►'�at�t�'�j��'.:�''1'1�.. 201 Ps Ps 133,56 2
..; _. . , la�sa -�'.- eet�:a _ .� -:_-� s =y S>� ��= '� ='•�: ���rctt s:sr��.-'t-• �.
401 amps to 600 amps 200.34 2
Name: 611 4 WI -te i 6 E1 T C $TAO 601 amps to 1,000 amps 301.04 2
Address: 9 I. e 5 5 J 1. I I S r Over 1,000 amps or volts . 552.26 2
Ci ty /State/ZIP: TI G R R D ( � i 7 3 Temporary services or feeders installation, alteration, and/or
, relocation " -
Phone: ( ). S3 V 3 4- 1 Fax: ( ) 200 amps or less 59.36 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 gimps 125.08 2
' intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168'54 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fce for branch circuits with
,� _ ,- ya c r � ar c } fir =` r s above service or feeder fee,
1 y -., -r, - -[�� -I"-. 131 ''?� b r 7 • 1. } 9 r,.-' :e .42 2
- +,.:���; €i.�?i.. r..•�. ,.y;.�.:� . ��' i;' � ,.`'r+ €„-= ,�r��,� >�,.�.. -�,rc: _. -�( '._ � .. _ ._. each branch Circuit 7
Business name:. B. Fee for branch circuits without
service or feeder fee, first I 56 18 56.18 2
Contact name: branch circuit
Each add'I branch circuit 3 7.42 22.26 2
Address: • Miscellaneous (service or feeder not included)
Ci /State/ZIP: Each manufactured or modular 67.84 2
tY dwelling, service and/or feeder
Phone: ( ) I Fax :: ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E-mail: Sign or outline lighting 67.84 2 • _. ,:� _-- _ ' n,4_ u. _.'4": F= -4. . ,_ .,Y._ - ` �•I=- . ..:� . • ,. .,-4 -, r.� v -• ° P. S c ircu i ts) or limited- energy
Business name: Boones Ferry Electric panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the abov
Address: PO Box 628 Additional inspection (1 hr min) 6625/ hr
City/State/ZIP: Wilsonville OR 97070 Investigation (I hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: (503) 682 - 4936 I Fax: (503) 682 - 7946 Inspections for which no fee is 90.00/ hr
s: • iftcal listed K hr min _
CCB Lic.: 88482 I Electrical Li . 3 -223C 1 Suprv. Lic.: 3170S : t § 1 ; `E-• T- ^1,��l it s"= i_ T•3 -71 ;
Subtotal: 78.44
Suprv. Electrician signature, required: ! - Lair& Plan review (25% of permit fee): N/A
Print name: Jan Herro 1 11 Date: 1/23/2013 State surcharge (12% of permit fee): 9.41
TOTAL PERMIT FEE: 87,85
Authorized Slgnatu This permit application expires if a permit b not obtained within 180
Print name I Date • N days after It bas been accepted as complete.
umber of inspection allowed per permit.
1:\ 8uadingWPermicsaEL C.PermitApp.doo 07/01/10 440- 4615T(II/OS/COM/WEB
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
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 Inform ation Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
K6I - 0H A . E- r -resr
Print Name of PemiitApplicant
c — I $ -13
Signature of Permit Applicant Date
Permit #: Z Tp 3 — (X30(.3
Address: 1 96 (-lilt
mac', co ii-L.1 cue_ 5723-1
22.3
Issued by:( Date: 0/13 111::
This Copy for Permit Offices
Location:
Record Type:
Inspection Type:
Comments:
Inspection Date:
Record ID:
Result:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9125 SW HILL ST, TIGARD, OR, 97223
Residential - Master Permit
399 Plumbing final
06/06/2013 00:00
MST2013-00013
PASS
Violation Summary:
Inspector Contractor