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Permit
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT lig 1 II Request Permit Action V i /02 /9A3 If TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov TO: CITY OF TIGARD Building Division Services Supervisor 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov / FROM: ❑ Owner ❑ Applicant ❑ Contractor atity Staff (check one) REFUND OR Name: INVOICE TO (Business or Individual) � ' Mailing Address: ! City/State /Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( EKCANCEL/VOID PERMIT APPLICATION. • REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). r! I '�1 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). II REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: /7)577916/A —6 (3 l - 75 Site Address or Parcel #: /A6 G IS Sti. (. r2W"7 )-c . Project Name: �t ( ti q o(e. / A os- f Ax ;M c ) - c>N Subdivision Name: Al r i ; )evrt ✓ A 11c Clod ,. U r ..) Lot #: 5 EXPLANATION: HCAenIA eer 1h; re (a 6 o 1JOJbtesn , in/ .)rrNa( ,nom 7/v.* G f C�.r)s Nell` 7Y) (c1/O - the, Aid i i l ` - t aN. P/Anl re_d: c .) -t i 4 )016k - For. PL ceP Signature: ;�� _ _— _ ___ Date: Q /cj1 /3 Print Name: R r - / 1 �� Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date kL /3 By ,- 7 _ Rtc to Bldg Admit': Date / if ,C3 B' •'"' " Refund Processed: Date �' By .ClY Invoice Processed: Date e tf / r //3 By Permit Canceled: Date / By Parcel Tag Added: Date By Receipt # Date Method Amount $ I:\ Building \Forms \ReqPermitAction.doc Rev 05/25/2012 �� Ci ty of Tiga • • COMMUNITY DEVELOPMENT Building Division 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov TIGARD INVOICE TO: Nys Association Customer ID: C13 -0004 Attn: Steve Nys Invoice No.: INV2013 -00008 10250 SW 87 Ave. Invoice Date: 12/19/2013 Tigard, OR 97223 Date Due: Upon Receipt Case No. Site Address Subdivision - Lot # or Project Name Amount Due MST2012 -00175 12625 SW Grant Ave. Gavajdea Addition $253.67 Note: Per owner on 12/9/2013 project cancelled. Plan review completed prior to cancellation therefore all plan review fees are due. Invoice Total: $253.67 ® Please see attached fee schedule for description of fees due. (Detach and return this portion with payment.) Case No.: MST2012 -00175 Customer ID: C13 -0004 Site Address: 12625 SW Grant Ave Invoice No.: INV2013 -00008 Project: Gavajdea Addition Invoice Date: 12/19/2013 Date Due: Upon Receipt Invoice Total: $253.67 Amount Paid: $ Office Note: Please forward copy of receipt to Dianna Howse for file. Please mail payment to: City of Tigard, Building Division Attn: Dianna Howse 13125 SW Hall Blvd. Tigard, OR 97223 I: \Building \Accounting \Invoice.doc 01/14/2011 71 CITY OF TIGARD FEE AND PAYMENT HISTORY 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD MST2012 -00175 - 12625 SW GRANT AVE, TIGARD, OR 97223 Revenue Payment Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt # Due Plan Review 230 - 0000 -43106 $856.28 $856.28 $856 28 7/3/12 Check 187422 $0.00 Plan Review 230 - 0000 -43106 $176.67 $176.67 $176.67 DC Provision Review, SF - Ping 100-0000-43112 $67.00 $67.00 $67.00 DC Provision Review, SF - LRP 100-0000-43117 $10.00 $10.00 $10.00 Totals for Fees $1,109.95 $1,109.95 $856.28 $253.67 Receipt # Payment Method Check # Payor: Receipt Date Receipt Amount 187422 Check 2203 Grant Home Care Inc 07/03/2012 $856.28 Total Payments: $856 28 Balance Due: $253 67 Building Permit Application V 0 1 0 / /q //3 Residential RECEIVED FOR OFFICE USE ONLI 1„, City of Tigard Date/13y: r 3 f r III. l Permit No.: / 'I5" . • 13125 SW Hall Blvd., Tigard,OR 97223U i 0 3 ' ^ ` ) Plan ReJiew ( ��� • Phone: 503.718.2439 Fax: 503.598.1 Date/By: Other Permit: 1 I [ \ It 1, Inspection Line: 503.639.4175 D Read y: A� ur o See Page 2 for Internet: www.tigard - or.gov CITYOFTIGARD Not ified/Me[ho d: (J /o �� Supplemental Information BUILDING DIVISION lift , S 1 4a3 IA- /sf4i _ 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 Valuation: ` $ { L� 1- and 2- family dwelling ❑ Commercial /industrial -_ ��L I ` GO ❑ Accessory building ❑ Multi - family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: 3 JOB SITE INFORMATION AND LOCATION Total number of floors: 1 Job site address: 1 G 2S 5 4J G - .0 New dwelling area: / 47-G square feet ‘ , z Job City /State /ZIP: 7 7 Q a lyd r Q '? 22 3 L Garage /carport area: 6, ? square feet ! Suite/bldg. /apt. no.: J Project name: 6 fq po,y+ �d d f+I w) Covered porch area square feet job site: Cross street/directions to O j Deck area: 0 square feet 4 9 9 to ((rr a w Sf - e t 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.: 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. GO r Y�'e' d- fr e G( ro O vo lad t( l' 71� Valuation: $ J Existing building area square feet New building area: square feet *PROPERTY OWNER ❑ TENANT Number of stories: Name: / ✓ (( (cif a cy Co, S-ftx. -± G a va ,/ d a- Type of construction: j Address: (2 & 2 S' 5' W 0 o' A--u€ Occupancy groups: I City/State /ZIP: Ti �) CVr eti ©k 5 223 Existing: I Phone: ( ) Fax: ( ) New: ❑ APPLICANT CONTACT PERSON BUILDING PERMIT FEES* `Business name: YS 5 (] G (,, t�.t (Please refer to fee schedule) Contact name: Sf>P /\((:`1 S Structural plan review fee (or deposit): Address: J /2 o S fi t/ .t Pk ,-fit ;, , FLS plan review fee (if applicable): `) l Total fees due upon application: 4 City /State /ZIP: 7- cur I t, ©1_ 0-1 2 2 3 Phone: (roS) 2 ¢ f 7 2) Fax:: ( ) $ t.L Amount received: , AS E -mail: I1 S . aS S Q G 6 a. CO k , cc/14-4 PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* C ONTRA OR 4 Commercial and residential prescriptive installation of roof- to. .1ounted Photo Voltaic Solar Panel Syste'- Business name: ` e p Submit two ) sets of roof plan with conne • en details and fire dep. -nt access, along with - 2010 Oregon Address: Solar Installation ': •cially Code - - cklist. "`- City /State /ZIP: Permit Fee (inclu. - . .. review $180.00 and admi I' .: a fees): Phone: ( ) Fax: ( ) State surcharge % of permit ` $21.60 CCB lic.: Tot. ee due upon application: $201.60 Authorized signature: This permit application expires if a permit is it obtained within 180 days after it has been accepted as complete. Print name: I \ RELY Q41 Date: O 2 * Fee methodology set by Tri -County Building Industry Service Board I: \ Building \Permits\BUP- RESPermitApp.doc 02/ 24/2011 440- 4613T(11/02/COM/WEB) Building Permit Application Checklist One- and Two - Family Dwelling I • o i . ()I 1 t 1. LSE ONLY City of Tigard Permit No 1114 .: 1 3125 S W Hall Blvd., Tigard, OR 97223 Dated t Phone: 503.718.2439 Fax: 503.598.1960 Assoc'aed'ts TIGARD 24 Hour Inspection Line: 503.639.4175 ❑ Electrical ❑Plumbing ❑Mechanical Internet: www.tigard- or.gov ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW ties No N/A 1 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 Fire district approval required. 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 ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑ basin protection, etc. 10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑ building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -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 scale. 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. 14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑ floor, wall construction, roof construction. More than one cross section may be required to clearly portray construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings 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 four foot at building envelope. 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 and locations; for non- ❑ ❑ ❑ prescriptive path analysis provide specifications and calculations to engineering standards. 17 Floor /roof framing. Provide plans for all floors/roof assemblies, indicating member sizing, spacing, and bearing ❑ ❑ ❑ locations. Show attic ventilation. 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 for all beams 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 ❑ ❑ ❑ architect licensed in Ore ton and shall be shown to be ...livable to the r r&ect under review. JURISDICTIONAL SPECIFICS 23 Three (3) 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 not be 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 ❑ El ❑ Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑ and protection measures must be drawn to scale and must include the project arborist's signature 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. I:\Building\Permits\BUP- RESPermitApp.doc 02/24/2011 440- 4613T(11/02 /COM/WEB) • . • • Plumbing Permit Anal' 0 Building Fixtures � FOR OFFICE USE ONLY City of Tigard JUL 0 3 2012 Received 7lif v Per mit No yr�o�a - orJ1 �5- • 131 SW Hall Blvd., Tigard, OR ay Plan Review III 0 Phone: 503.718.2439 Fa ' f ! V. GARD w' Date/By: Other Permit No .: I I G A R p Inspection Line: 503.639. I ' - I �11 I O DIVISIO1, Date Ready/By. lu is El See Page 2 for Internet: www.tigard -or.g Notified/Method: Supplemental Information TYPE OF WORK FEE* SCHEDULE ❑ New construction ❑ Demolition For special information use checklist Description I Qty. 1 Ea. I Total Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath - 312.70 ❑ 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: Job site address: Catch basin or area drain 18.76 City/State /ZIP: Drywell, leach line, or trench drain 18.76 Footing drain (no. linear ft.: ) Page 2 Suite/bldg. /apt. no.: 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 ( (�� f Clothes washer 25.02 a v a t d / 5#4 v o c r i `r t 3 Dishwasher 25.02 u Drinking fountain 25.02 Ejectors/sump 25.02 PROPERTY OWNER I 0 TENANT Expansion tank 12.51 Name: (� Fixture /sewer cap 25.02 M� ?ALA_ mud cousr�ia�,�.1 �.t,1��� D�- Address: 1 . 2 4 5 SW C Floor drain/floor sink/hub 25.02 Garbage disposal 25.02 City/State /ZIP: 1'4 .b 0 k... q 3 Hose bib ' 25.02 9.....8424-- t Phone: (2 4 Fax: ( Dk3) Fie_ Ice maker 12.51 ❑ APPLICANT g, CONTACT PERSO Interceptor /grease trap 25.02 � * q Medical gas (value: $ ) Page 2 Business name: N S '"�' G � ve I.% S Primer 12.51 Contact name: 1 O �� Roof drain (commercial) 12.51 Address: 1 - Sink/basin/lavatory i '4 25.02 City/State/ZIP: T 14 j 0 6711443 e Solar units (potable water) 62.54 Phone: (5 ) 60_ f4 . Fax: : ( ) 5Cte - 1 4• ip Tub/shower /shower pan 12.51 E- mail: (( Urinal 25.02 Water closet 3 25.02 CONTRACTOR Water heater ( " 37.52 Business name: Water piping/DWV 56.29 Address: Other: 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: TOTAL PERMIT FEE Print name: Date: 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. I: \BuildingTeemits\PLMU - PermitApp doe I0 /01/09 440 4616T(10 /OIJCOM/WEB) A 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 Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to p 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 Quantity by Fixture Type Plan Review for Plumbing Installations Fixture Type for Replace/ Plan review is required for any of the following. Performed: Capped Added Relocate a y ow g Baptistry/Font Please check all that apply. Bath Tub /Shower ❑ Any new commercial building with water service 2" and - Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed Car Wash -Each Stall engineer. -Drive Thru ❑ New exterior plumbing site utilities for any complex structure Cuspidor/Water Aspirator as defined in OAR918- 780 -0040. Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities. - Domestic ❑ Any multipurpose fire sprinkler system. Drinking Fountain ❑ Any complex structure as defined in OAk918- 780 -0040. Eye Wash Floor Drain /sink - 2" Submit 2 sets of plans with any of the above. -3" Isometric or Riser Diagram Car Wash Drain ❑ Isometric or riser diagram is required for new buildings - Domestic -non -food s g q g Disposal - Domestic-food related that meet the qualifications above. - Commercial -food related - Industrial -food related Ice Mach./Refrig. Drains Oil Separator (Gas Station) Comments regarding fixture work: Rec. Vehicle Dump Station Shower -Gang -Stall Sink/Lav - Non -food related - Bradley - Commercial -food related - Service Swimming Pool Filter *Note: If the fixture work under this permit results in an Washer - Clothes Water Extractor increase of sewer EDUs, a sewer permit will be issued and Water Closet Toilet fees assessed for the sewer increase must be paid before the Urinal plumbing permit can be issued. Other Fixtures: I:\Building\Permits\PLMF - PermitApp.doc 02/24/2011 2 1 � Mechanical Permit Applicat 1 3 FOR OFFICE USE ONLY City of Tigard Date /Bya Permit No.: f��lT�0�2 „rye/ Other Permit: - 411/Bire Al 91 M • 13125 SW Hall Blvd., Tigard,OR 972. Plan Review Phone: 503.718.2439 Fax: 503.59E.1 Date/By: T IGA R D Inspection Line: 503.639.4175 Date Ready/By: Juris H See Page 2 for Internet: www.tigard or.gov 0 3 2012 Notified/Method: Supplemental Information JUL TYPE OF W y(*TIGARD COMMERCIAL FEE° SCHEDULE — USE CHECKLIST 1! Vi Mechanical permit fees' are based on the value of the work ❑ New construction Vi Addition/a1tVfMINODWISION 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* /A1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist. ❑ Multi- family ❑ Master builder ❑ Other: Description Qty. I Ea. I Total Heating/cooling: SITE INFORMATION AND LOCATION �� 6 2...5 S f , i 6 ( � Air conditioning Job site address: VV � �1-Z (requires site plan showing placement) 46.75 � (t v D 3 Furnace 100,000 BTU (ducts/vents) ( 46.75 City/State /ZIP: T y d 7 J Furnace 100,000+ BTU (ducts/vents) 54.91 Suite/bldg. /apt. no.: Project name: bra v H //- A ( Iv vyl Heat pump (requires site plan showing placement) 61.06 Cross street/directions to job site: Duct work j 23.32 09 n 6 i . c- f v�v j/--- Hydronic hot water system 23.32 J r 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 t 23.32 a r .) a, 0 -+ B tot* D It , / (4- (rr Gas fireplace/inse _ i 33.39 �{ C� Flue vent for water heater or gas fireplace 23.32 Log lighter (gas) 23.32 Wood/pellet stove 33.39 Wood fireplace /insert 23.32 ❑ PROPERTY OWNER I ❑ TENANT Chimney/liner /flue /vent 23.32 �^ Other: 1 23.32 Name: ► V l t t t? (t ¢ Covt s - ch.Q (' Q t /Q J( . C� ., Environmental exhaust and ventilation: Address: 1 2&25 W 5' c:; + — "� c e Range hood/other kitchen / /- r � 2 equipment 33.39 City /State /ZIP: 7 Cw C.k I ©11Q 3? 2 2 > Clothes dryer exhaust 33.39 33.39 ,((' Single -duct exhaust (bathrooms, Phone: 17 G( 0 f3 425 Fax: ( ) toilet compartments, utility rooms) 6 23.32 ❑ APPLICANT A-CONTACT PERSON Attic /crawlspace fans 23.32 Business name: 5 J ¼ / 5 145s 0 LET j Other: 23.32 Sf .0� S Fuel piping: Contact name: $14.15 for first four; S4.03 for ch additional Address: t D Z S p e,?-1-1, A- . Furnace, etc. r Gas heat pump City/State /ZIP: I-9 0 `-'-' - 0{ (9Q. 5 7 22-3 Wall /suspended/unit heater Phone: ( ) Fax: : ( ) Water heater E -mail: Fireplace Range CONTRACTOR Barbecue Business name: -173 p Clothes dryer (gas) t 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 Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: TA RCt.AR (t- J I Date: 1113,31 oI 2 • Fee methodology set by Tri -County Building Industry Service Board 1:\ Building 1Permits\MEC- PermitApp.doe 03/07/12 440 -4617T 1/02/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\MEC- PerrnitApp.doc 03/07/12 2 Electrical Permit Application FOR OFFICE USE ONLY ` /23 q Received � City of Tigard ® O 2�1 Date/By: : v Permit No.: j�QI� G'e) /75 71 13125 SW Hall Blvd., Tigard,OR «cj� Plan Review Phone: 503.718.2439 Fax: 503.598.1 �D� Date/By: Other Permit: B Inspection Line: 503.639.4175 OF�G[yl�l/ Date Read Juris. El See Page 2 for 1 11.:1 K l) p Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: Supplemental Information TYPE OF WORK PLAN REVIEW ❑ New construction ►a ' ddition/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 1 - and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi - family ❑ Master builder ❑ Other: 0 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 ", "1 -2 ", 'l -3 ", Job no.: Job site address: f '26 2 S S L't/ 6 ro f c.u2 100HP or more. occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. City/State /ZIP: ? (f O t,v d © � '� 2 `� ❑ Health -care facilities. ❑ Supply voltage for more than ` J ❑Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: 6tr f (J- .a...k ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Description I Qtv. I Fee. I Total I • New residential single- or multi - family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4 Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1 Limited energy, residential 7500 2 DESCRIPTION OF WORK (with above sq. ft.) Limited energy, multi- family r p(� 6 0.("011. fi—d c1. ( 0'N'1 residential (with above sq. ft.) _ 75.00 2 (J° / Services or feeders installation, alteration, and/or relocation 200 amps or less 100.70 2 ❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2 Name: An l (Vie (4 ¢ C.'`S 'FcA--w . kr.0 1.Z, (/atS 062-(il- 401 amps to 600 amps 200.34 2 c 601 amps to 1,000 amps 301.04 2 I 'LJ Address: { 5 w 5 A`, Over 1,000 amps or volts 552.26 2 City/State /ZIP: - r r 0,,icf , ©R Temporary services or feeders installation, alteration, and/or ff�� relocation Phone: (9)3) L2l/ - p 4- ZS Fax: ( ) 200 amps or less 59.36 l 201 amps to 400 amps 125.08 2 Owner installation: This installation is being made on property that I own which is not 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. Fee for branch circuits with ❑ APPLICANT I above service or feeder fee CONTACT PERSON 7.42 2 C rl/1 each branch circuit Business name: /V V5 - 55 So . i &`- � S B. Fee for branch circuits without I NV service or feeder fee, first 56.18 2 Contact name: ' /� v+ / branch circuit r J /� , , ,, Each add'I branch circuit 8 7.42 2 Address: 1©2_ S D 5W ?-{-e. / t u—e Miscellaneous (service or feeder not included) City /State /ZIP: 71' (j� 3 Each manufactured or modular 67.84 2 C't/� / OR t/ dwelling, service and/or feeder t Reconnect only 67.84 2 Phone: ( 503) `�- S — 6, / Z \ Fax: ( ) Pump or irrigation circle 67.84 2 E -mail: Sign or outline lighting 67.84 2 CONTRACTOR Signal circuit(s) or limited- energy Business name: panel, alteration, or extension. Page 2 2 Each 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 (%1 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 Print name: I Date: * days after it has been accepted as complete. Number of inspections allowed per permit, 1:\Building\ Permits \ELC- PermitApp.doc 07/01/10 440- 4615T(1 I /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 $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical El Nurse Calls ❑ Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\ Building \Permits\ELC- PermitApp.doc 07/01/10 ia6as$- G. -et,it IN 111 Building Division Development Code Provision Review T I CARD Residential Projects Building Permit No: T € O i Z - 00 1 7s CWS Service Provider Letter Received: Yes No ❑ N/A ❑ Routed Plans: Original Plan Submittal Date: 7/ 3/i a Pt Revision Submittal Date: / ❑ Site Plan Only 2nd 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 left only if approved. Planning Review (contact CG1e.- y ( Ca ; i e s at 503-718-0 or CJter%[ / G @ tigard- or.gov) Land Use Case No. Ni A Name 1 g Zoning R . 5 —4 r z Setbacks: Front ao Rear IS Side S Street Side 15. Garage d 0 F, Maximum Building Height 3 D -c 4- Actual Building Height 15 -4 4- si Visual Clearance FA Easements — See b e l o w J Sensitive Lands Type: N/ A Notes: I5' p s i i c. san44-al C.a..lar. -se., A o 1 0 ace.54er^ hou- b- • dal . p o u t% o+G- 1,4;41.1.n il.e. eas a evl e r1.-F' per Ci Ei- cj e e v . No v+ I I I i's 'p Gr.-.;}}Cc %..1.4Vi,n ii-e_ east ••n -e '14. Si 4- 16,. 51-to O✓'I1 CA vCS . Original Plan: Approved 04 Not Approved ❑ Date: 7 - 5 - 1 a- Revision 1: Approved ❑ Not Approved ❑ Date: Revision 2: Approved ❑ Not Approved ❑ Date: Engineering Review (contact Mike White at 503 - 718 -2464 or MikeW @tigard - or.gov) ,I Actual Slope: Notes: Original Plan: Approved] Not Approved ❑ Date: Z Revision 1: Approved ❑ Not Approved 0 Date: Revision 2: Approved El Not Approved ❑ Date: (Review Continues on Page 2) Page 1 of 2 Ci rborist Review (contact Todd Prager at 503 - 718 -2700 or todd @tigard - or.gov) e et Trees Protected Trees Notes: Original Plan: Approved Not Approved ❑ Date: 0,70/1 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 App • ant Okay to Issue Permit: Yes No ❑ Date Routed to Building. Page 2 of 2 • y r r` if -- if U �� ` S ill' j �%- Clean Water Services File Number JUN 14 2012 ' j CleanWate % Services ( 1Z nr i H `k J Sensitive Area Pre - Screening Site Assessment J , - -- - C1 t c( 1. Jurisd 2. Property Information (examptdIS234AB01400) 3. Owner Information. f y cL Tax lot ID(s): 1 -2.tv [,) '2. � C- Name: O i1�� f LC { Ll f l� G�cV�' �l . 1 0 0 Company: G y CI l�1- H (,rlv Q 4C1�v' L f _ Address: f , 2_ (p 'ZS (A/ ( i' c+,✓l,`f fit Site Address: 1 2 �o ._ c) U i GL ' C 4 4 ) t - ' City, State, Zip: `Trc c.&r4. 0 R 91'"2-2 City, State, Zip: — ii 5 i vo OR. 9 7 2.2 Phone/Fax: 50 7 (n 2- - S Nearest Cross Street: E -Mail: 4.1 velopment Activity (check all that apply) 5. Applicant Information / �� Addition to Single Family Residence (rooms, deck, garage) Name: ) t�-'� ! z 0 ❑ Lot Line Adjustment ❑ Minor Land Partition l cf- ' Company: ( rt "7i G I ❑ Residential C ondominium ❑ Commercial Condominium (i '� J/ Address: / O Z 7v 9 Lti Z) I . fi' ❑ Residential Subdivision ❑ Commercial Subdivision ID Single Lot Commercial L.1 Multi Lot Commercial City, State, Zip: T� C I it �' Cf y � `2 }� Other Phone /Fax: n ti 9 J R , . 0 (- '� C{ a' 0 ,, eoi /) E -Mail: SO 3 21 S ( '7 - 1 - ' f 6. Will the project involve any off -site work? ❑ Yes 1No ❑ Unknown Location and description of off-site work - /� 7. Additional comments or information that may be needed to understand your project l%7 CZ L Cf. c\,-, CZ r" Gx B ed i -n0✓v S aLl ci f f IZm at "":zct 9 Ct. v (1 I 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 and /or 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 Info lion contained in this docu nt, and to the best of my knowledge and belief, this infor alien is true, complete, and accurate. Print/Type t 1 Type Name 1 ['i f l U c � '`" PrInUType Title V I GC PT P `i tC�` r ^ � ' L Signature = r Date �J �'� l 51 l FOR DISTRICT USE ONLY a 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 Area 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 latter 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 Sensitive Area Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality 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, ❑ This Service Provider Letter Is not valid unless CWS approved site plan(s) are attached. ❑ The proposed activity does not meet the definition of develo ent or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE PROVIDER3ETTER IS REQUI • D. - Reviewed by / , ' ./sat S/}/i .. Date 2 0 1- II 2550 SW Hillsboro Highway • Hillsboro, Oregon 97123 • Phone: (503) 681 -5100 • Fax: (503) 681 -4439 • www.cleanwaterservices.org ' • I i k- 3B M +N, R36,R`49 AS MtDicAT'Er� % - � �� R- 3o Mart 3 a As IN Die A�t - - - TL _}-- .� ,-., -. . � �� � - � � i -- • -- 21 CYYP NorEo 230 E� I l� �?"ac TL , Tl- ' 2- 8 Cry ft) GNHESS $° ED -- I"71 . o I 197 c.� \ ' RI FOAM SEE TABLE. Nllol,I(I, 41 , +I '15' ' - E- f � ,. I. 11/ cr :r'`I CO DE I EL . -- N �-. C xl� j G) , S �t • ; 'll , j . 1= ' 1 N ; AEt - - f �d N� / / Pi �1 =Ih .1 �✓ l' ! 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