Permit CITY OF TIGARD SITE WORK PERMIT
a:, '- COMMUNITY DEVELOPMENT Permit#: SIT2013-00017
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/13/2013
Parcel: 2S109ACO2100
Jurisdiction: Tigard
Site address: 14850 SW 132ND TER
Project: Alberta Rider Elementary School Subdivision: WOODSIDE Lot: PTS 8-9
Project Description: Playground improvements: adding drainage rock below playground area,replacement of wood chips and
installation of concrete ADA playground access ramp.
Contractor: LAUZON CONTRACTING LLC Owner: TIGARD-TUALATIN SCHOOL DIST 23J
13577 SE WILLINGHAM CT ATTN: BUSINESS MANAGER
CLACKAMAS, OR 97015 6960 SW SANDBURG ST
TIGARD,OR 97223
PHONE: 503-482-5445 PHONE: 503-431-4017
FAX: 503-482-5446
FEES
Description Date . Amount
Specifics: Permit Fee-Site Work 08/13/2013 $371.16
Plan Review 08/13/2013 $241.25
•
Type of Use: COM 12%State Surcharge-Building 08/13/2013 $44.54
Class of Work: ALT Info Process/Archiving-Lg$2.00(over 08/13/2013 $4.00
11x17)
Project Valuation: $29,000.00 Erosion Control w/Development-Ping 08/13/2013 $100.00
Misc Administration Fee 08/13/2013 $5.00
Site Specifics:
Excavation Volume: 243 cu.yd.
Fill Volume: 243 cu.yd.
Impervious Surface: 48 sq.ft.
Engineered Fill: No Soil Report Required: No
Paving: Yes Grading: Yes
Landscaping: Yes Site Prep: Yes •
Storn Drains: No Retaining Wall: No
Fire Underground: No Accessible Parking: No
Fence: No
Total $765.95
Required Items and Reports(Conditions)
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, • ' • suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility •tification Center. Those rules are set forth in OAR 952-001-0010 through O' : • -0a -1090. You may obtain a copy of the rules
or dir:ct questions to OUNC • -Ilin• 50 32.1987 or 1.800.332.2344.
Iss 'd By: _ / i# / I Permittee d,) •i!7/ , if
i... L o
Call 503.639.4175 by 7:00 a.m.for the next available in-•'ction 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
Site Work RECEIVED FOR OFFICE USE ONLY
City of Tigar Received I / 3 ?rrao/3.00017
v 972/13)L U 1 2013 7 l i Permit No.:
13125 SW Hall Blvd.,Tigard,OR Plan Review
7 ' Phone: 503.718.2439 Fax: 503.598.19(Q.���^ADn Date/By:_ 7IIn II 3 Other Permit:
TIGARD Inspection Line: 503.639.4175 �� 1111�Y VV CARD Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method:,/z2 �3 -77 Supplemental Information
vv l:l J�/L.6OA/
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 ®Commercial/industrial Valuation: $
❑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: 14850 SW 132nd Ter New dwelling area: square feet
City/State/ZIP:Tigard,Oregon 97224 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name:Alberta Rider Playground Covered porch area: square feet
, Cross street/directions to job site:SW Bull Mountain Rd Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: I Lot no.:2100 Permit fees*are based on the value of the work performed.
. Tax map/parcel no.:02SOI WO9AC 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.
Playground improvements including:Addition of drainage rock below playground Valuation: $29,000
area,replacement of existing wood chips,and installation of a concrete ADA Existing building area: square feet
iplayground access ramp. New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name:Titgard Tualatin School District Type of construction:
Address:6960 SW Sandburg St Occupancy groups:
City/State/ZIP:Tigard,Oregon 97223 Existing:
Phone:(503)431-4017 Fax:( ) New:
O
❑ APPLICANT ® CONTACT PERSON NOTICE
Business name:Cardno All contractors and subcontractors are required to be
Contact name:Matt Lewis f012-1=.414 503 - y/9- ZS 0 0 licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address:5415 SW Westgate Dr.Suite 100
City/State/ZIP: Portland,Oregon 97221
jurisdiction in which work is being performed.If the
applicant is exempt from licensing,the following reasons
apply:
C Phone:(503)419-2500 Fax: :(503)419-2600
E-mail: matt.lewis @cardno.com
ciCONTRACTOR
M Business name:VW LA-t_.,o,,J CrQd}C-r LLC_. BUILDING PERMIT FEES*
(Please refer to fee schedule)
Address: j 35-7 7 LLD I L1-1 aol4-79-6A1 Cr
City/State/ZIP: ?70l S� Structural plan review fee(or deposit):
�n �/r@.Lr��/y 5 U 2 FLS plan review fee(if applicable):
N Phone:( 9D3) 4'S 7--544S Fax:(i 01.l WI A -5 4q(P
Total fees due upon application:
CCB lic.: /tj, 312, iol�,y/�y 4�� Amount received:
Authorized signature: ��/
[y This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: A./ Date: L Z P
��I/r wC 1 Z /y.3 Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\SIT-PermitApp.doc I0/01/09 440-4613T(11/02/COM/WEB)
City of Tigard: Site Work Permit Checklist
Page 2-Supplemental Information
Commercial,Multi-Family and One- and Two-Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way,or wetland, the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below, unless otherwise noted.
Excavation Volume: 243 cu. yds.
Grading Volume:
(Soils report required for>5,000 cu. yds.) 486 cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) 243 cu. yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
❑ Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks, and paving: 48 sq. ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See"Site Work Permit Application-Plan Submittal Requirements"attached.
The following must accompany this application:
® Site Plan with Vicinity Map showing ADA ❑ *Parlcing(including ADA)and Lighting
compliance Plan
® Grading Plan and details ❑ *Landscaping Plan
® Erosion Control Plan and details ❑ Soils Report(if required)
❑ Retaining Structures ❑ Fire Line
*Does not apply to One-and Two-family dwellings.
Plan Submittal: Permit Fee:
TYPE OF SUBMITTAL #of Plans Valuation: Permit Fee:
(New,Additions or Required at $.00 to$500.00 $51.09 minimum permit fee
Alterations) Submittal $500.01 to$2,000.00 $51.09 for the first$500.00 and
$2.69 for each additional$100 or fraction
Commercial 3 thereof,to and including$2,000.00.
$2,000.01 to$25,000.00 $91.44 for the first$2,000.00 and
Multi-Family R-1 Occupancy 3 $10.76 for each additional$1,000 or
fraction thereof,to and including
$25,000.00.
One-&Two-Family Dwelling 2 $25,000.01 to$50,000.00 $338.92 for the first$25,000.00 and
$8.06 for each additional$1,000.00 or
fraction thereof,to and including
$50,000.00.
$50,001.00 to$100,000.00 $540.42 for the first$50,000.00 and
$5.38 for each additional$1,000.00 or
fraction thereof,to and including
$100,000.00.
$100.000.01 and over $809.42 for the first$100,000.00 and
$4.49 for each additional$1,000.00 or
fraction thereof.
1:\Building\Permits\SIT-PermitApp.doc 05/25/2012 2
SE l'
RECEIVED
DELIVERY SERVICE.INC. JUL 01 2013
1� CITY OFTIGARD
TRANSMITTAL • ` BUILDING DIVISION G� Carinv
Shaping the Future
To: City of Tigard -Building Date: July 01, 2013
Alberta Rider
13125 SW Hall Blvd. Project: Playground 5415 SW Westgate Drive
Suite 100
Tigard, Oregon 97223 Project#: 21303370 Portland,Oregon 97221
USA
Case/File#:
Phone (503)419.2500
Fax#: Total Pages: 9 Fax (503)419-2600
From: Jordan Bernhardt
www.cardno.com
Transmitting Via: Purpose:
® Messenger-3 Hour ® For your approval
❑ Other: ❑ Other:
Quantity Description
1 Site Work Building Permit Application
1 Site Utilities Building Plumbing Permit Application
1 CWS Service Provider Letter
2 Civil/Erosion Control Plans
Comments:
Please let me know if there are any questions, or if you need anything else.
Jordan (503-419-2500)
Signature:
C:
Australia • Belgium • Indonesia • Kenya • New Zealand • Papua New Guinea
United Arab Emirates • United Kingdom • United States • Operations in 60 Countries
t T-2...613-
/7
RECEIVED
JUL 01 2013
CITY OFTIGARD
DING DIVISION
2 �I J p/ Clean Water Services File Number
�LH\) \\\D CleaiiWater Services N3° C)011 2���� 2013 - sitive Area Pre-Screening Site Assessment
4. Jurisdiction:T!9ard
By_r
. operty Information(example 1S234AB01400) 3. Owner Information
Tax lot ID(s):02S01 W09AC 2100 Name:Philip Wentz
Company:Tigard Tualatin School District
Address:6960 SW Sandburg St
Site Address:14850 SW 132 Ter City,State,Zip:Tigard,OR 97223
Cfty,State,Zip:Tigard,OR 97224 Phone/Fax:503-431-4017
Nearest Cross Street:Bull Mountain Rd E-Mail:Pwentz @ttsd.k12.or.us
4. Development Activity(check all that apply) 6. Applicant Information•
❑ Addition to Single Family Residence(rooms,deck,garage) .Name:Matt Lewis
Q Lot Line Adjustment (3 Minor Land Partition Company:Corrine
❑ Residential Condominium ❑ Commercial Condominium Address:5415 SW Westgate Dr,Suite 1.00
1:1 Residential Subdivision ID Commercial Subdivision Portland,OR 97221
City,State,Zip:
❑ Single Lot Commercial 13 Multi Lot Commercial 503 419-2500
Other Replace playground wood-chips and add concrete Phone/Fax:
ramp at Alberta Rider Elementary school. E-Mail:mattJewis @cardno,com
6. Will the project involve any off-site work? Ll Yes Fl No ❑Unknown
Location and description of off-site work
7. Additional comments or Information that may be needed to understand your project
This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits,DEQ
1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands andlor Department of the Army
COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law.
By signing 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. I certify
that I am familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name Malt Lewis printrrype Title Senior Project Manager
Signature Date 06/25/2013
•
FOR DISTRIC USE iLY
❑ Sensitive areas potentially exist on site or within 200'of the site.THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
may also be required.
❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This
• Sensitive Ares Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quaky sensitive areas if they are subsequently
discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1.All required permits and
approvals must be obtained and completed under applicable local,State,and federal law.
Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially
sensitive area(s)found near the site.This SensitiveArea Pre-Screentrg Site Assessment does NOT eliminate the need to evaluate and protect adrulionai water
quality sensitive areas/they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order
07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law.
❑This Service Provider Letter is not valid unless CWS approved site plan(s)are attached.
❑The proposed activity does not meet the definition of development or the lot was platted after 9/9195 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE PROVii LETTER IS REQUI ED. �
Reviewed by 1/111A4 .�/ rK Date b7/c i /13
2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 •• Phone:(503)681-5100 ••Fax:,(503)681-4439 • wWI.cleanwaterservices.org
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
14850 SW 132ND TER, TIGARD, OR, 97224
Commercial - Site Work
499 Final inspection
PASS - No C of O
SIT2013-00017
George Heimos
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
14850 SW 132ND TER, TIGARD, OR, 97224
Commercial - Site Work
499 Final inspection
PASS - No C of O
SIT2013-00017
George Heimos
Violation Summary:
Inspector Contractor