Permit CITY OF TIGARD SITE WORK PERMIT
I COMMUNITY DEVELOPMENT
Permit#: SIT2014-00007
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/09/2014
T r''�K.17 g Parcel: 28102AC00204
Jurisdiction:
Site address: SW NO ADDRESS
Project: Main Street Sewer Improvements Subdivision: BURNHAM TRACT Lot: 9
Project Description: Erosion control only for parcels,2S102AC00201,2S102AC00204,2S1012AC01100&25102AC01101. Work area
is located behind 12650, 12564&12562 SW Main Street.
Contractor: JEFF KERSEY CONSTRUCTION INC Owner: TIGARD,CITY OF
PO BOX 896 13125 SW HALL BLVD
CANBY,OR 97013 TIGARD, OR 97223
PHONE: 503-351-4412 PHONE: 503-639-4171
FAX:
FEES
Description Date Amount
Specifics: Erosion Control w/Development-Bldg 04/09/2014 $75.00
Type of Use: COM
Class of Work: OTR
Project Valuation: $2,812.00
Site Specifics:
Excavation Volume: cu.yd.
Fill Volume: cu.yd.
Impervious Surface: sq.ft.
Engineered Fill: Soil Report Required:
Paving: Grading:
Landscaping: Site Prep:
Storn Drains: Retaining Wall:
Fire Underground: Accessible Parking:
Fence:
Total $75.00
Required Items and Reports(Conditions)
1 Ersn Cntrl 503-639-4175
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 •- is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utili. Notification Cen- . Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a c the rules
o direct ques ions to OU g 503.232.1987 or 1.800.332.2344.
Issued By: / /� - , Permittee Signature: - J
CjA
Call 503.639.4175 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 �4.qC
Site Work t;C� FOR OFFICE USE ONLY
City of Tigard 1 Received 5`T��
�O Date/B : -'� Permit No.: 7
al 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
II Phone: 503.718.2439 Fax: 503.598.1960 py� 0 Other Permit:
DateB
T 1 C;A R D Inspection Line: 503.639.4175 i` 'C1G Date Ready/By: See Page 2 for
Internet www.tigard-or.gov �`r�v� �`� S�o Notified/Method: r. Supplemental Information
IL \G l
TYPE OF W I 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:Public Sewer Number of bathrooms:
ItJOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address:Main St R/W,12564 SW Main St,2S102AC00204 /;x3 104 col lob New dwelling area: square feet
City/State/ZIP:Tigard,OR 97223 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name:Main St Sewer Improvement Covered porch area: square feet
Cross street/directions to job site:Main St-South of Main St Bridge to Deck area: square feet
Hwy 99 W Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: 1100 Permit fees*are based on the value of the work performed.
Tax map/parcel no.:and 2S102AC00204 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.
Installation of Public Sewer Improvements through park property,private Valuation: $2,812.00
property adjacent to Main St and within Main St right-of-way Existing building area: square feet
Erosion Control Installation in park,on private property,and in Main St r/w New building area: square feet
® PROPERTY OWNER ❑ TENAN Number of stories:
Name:City of Tigard Type of construction:
Address: 13125 SW Hall Blvd Occupancy groups:
City/State/ZIP:Tigard,OR 97223
Existing:
Phone:(503)718-2466 Fax:( 1 New:
® APPLICANT ❑ CONTACT PERSON NOTICE
Business name:City of Tigard All contractors and subcontractors are required to be
Contact name:Jeff Peck licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 13125 SW Hall Blvd jurisdiction in which work is being performed.If the
City/State/ZIP:Tigard,OR 97223 applicant is exempt from licensing,the following reasons
apply:
Phone:(503)718-2466 Fax::( )
E-mail:jeffp @tigard-or.gov
CONTRACTOR
Business name:Jeff Kersey Construction BUILDING PERMIT FEES* --
Address:PO Box 896 (Please refer to fee schedule)
Structural plan review fee(or deposit):
City/State/ZIP:Canby,OR 97013
Phone:(503)351-4412 Fax:( ) FLS plan review fee(if applicable):
3 4 3 9 (t dip ill 5' Total fees due upon application:
CCB lie.: :CO
Amount received: 7 '
Authorized signat This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name:Jeff Peck Date:4/9/14 * Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\SIT-PennitApp.doc 10/01/09 440 4613T(I1/02/COM/WEB)