Permit CITY OF TIGARD SITE WORK PERMIT
I COMMUNITY DEVELOPMENT Permit#: SIT2014-00017
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/07/2015
Parcel: 1 S133DA07200
Jurisdiction: Tigard
Site address: 11470 SW 130TH AVE
Project: Summer Lake Park Restroom Subdivision: AMART SUMMER LAKE Lot: A
Project Description: Site preparation for new pre-engineered restroom facility,water quality raingarden and erosion control.
Contractor: DA NEAL CONSTRUCTION INC Owner: TIGARD, CITY OF
36296 NE WILSONVILLE RD 13125 SW HALL
NEWBERG, OR 97132 TIGARD, OR 97223
PHONE: 503-625-6802 PHONE: 503-639-4171
FAX:
FEES
Description Date Amount
Specifics: Permit Fee-Site Work 04/01/2015 $443.70
Plan Review 04/01/2015 $288.41
Type of Use: COM 12%State Surcharge-Building 04/01/2015 $53.24
Class of Work: NEW Info Process/Archiving-Sm$0.50(up to 04/01/2015 $5.00
11x17)
Project Valuation: $37,225.00 Erosion Control w/Development-Eng 04/01/2015 $107.60
Site Specifics:
Excavation Volume: 100 cu.yd.
Fill Volume: cu.yd.
Impervious Surface: 667 sq.ft.
Engineered Fill: Soil Report Required:
Paving: Yes Grading: Yes
Landscaping: Yes Site Prep: Yes
Storn Drains: Retaining Wall:
Fire Underground: Accessible Parking:
Fence:
Total $897.95
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, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility No• . ion Cen - . Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or dire• questions to OUNC • ca g 503.232.1987 or 1.800.332.2344.
Issu d By: j i ake.„, Permittee Sign'ture: fr
/
Call 503.639.4175 by 7:00 a.m.for the next available inspe ion 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 REcu FOR OFFICE USE ONLY
City of Tigard Date Received 717//./ Permit No.. , i/4/-‘904/7 di.• 13125 SW Hall Blvd.,Tigard,OR 97223 SEP 8 2014 Plan Review „� \
• Phone: 503.718.2439 Fax: 503.598.1960 Cr T Date/B : m ri Other Permit:
I I GARD Inspection Line: 503.639.4175 Date Ready/By: �l 0 See Page 2 for
Internet: www.tigard-or.gov CITY OFTIGA' I otified/Method: / /7 I7 Supplemental Information•/ r
►1 It, 1 1 / ti - 10 ..011FA
TYPE OF RE-LW.") J TA: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.
Allt. Valuation: $
❑ I-and 2-family dwelling ❑Commercial/industrial
El Accessory building ❑Multi-family Number of bedrooms:
El Master builder ®Other:Park Site Wk Number of bathrooms:
JOB SITE INFORMATION AND LOCATION 1 l(?76- ,.., ) Total number of floors:
Job site address: '. . - -• - • i g I% New dwelling area: square feet
City/State/ZIP:Tigard,OR 97223 Garage/carport area: square feet
Suite/bldg./apt.no.:N/A Project name:Summer Lake Park Restroom Covered porch area: square feet
Cross street/directions to job site:Head westbound on Walnut St from Hwy 99W Deck area: square feet
Head northbound(rt)on 128th Avenue to intersection of Winterlake Dr.Head east Other structure area: square feet
(rt)on Winterlake Dr.take left on Lakeview Terrace.Project at end of roadway. REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision:N/A f Lot no.:N/A Permit fees*are based on the value of the work performed.
Tax map/parcel no.: 1S133DA07200 Indicate the value(rounded to the nearest dollar)of all
equipment,materials,labor,overhead,and the profit for the
MEL DESCRIPTION OF WORK work indicated on this application.
Minimal excavation for restroom facility pad and for water quality rain garden Valuation: $37,225.00
Erosion Control,erection of pre-engineered modular block Romtec Existing building area: square feet
restroom facility New building area: 202 square feet
IM ® PROPERTY OWNER ❑ TENANT Number of stories: 1
Name:City of Tigard Type of construction: VB
Address:13125 SW Hall Blvd Occupancy groups:
City/State/ZIP:Tigard,OR 97223 Existing:
Phone:(503)718-2466 Fax:(503)624-0752 New: U
® 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::(503)624-0752
E-mail:jeffp@tigard-or.gov
MrMOW CONTRACTOR
Business name: D[t N�� L QoSST /0Ci. BUILDING PERMIT FEES*
Address: 36 IGj6 NJE_ rL!�p �r i_z_ Q�, (Please refer w fee schedule)
Structural plan review fee(or deposit):
City/State/ZIP: tiW 1,fQ-1, e� q712)2----
Phone:( ) �7r&le>y Fax:( j) te7S—e96-540 FLS plan review fee(if applicable):
CCB lie.: 4/7(Q 6 3 Total fees due upon application:
Amount received:
(:::: _j_.....—, +
Authorized signatu
This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: 3 Elm Fes_ Date: 9_1,,., l t,..t. * Fee methodology set by Tri-County Building Industry
Service Board.
1:\Building\Permits\SIT-PermitApp.doc 10/01/09 440-4613T(I1/02/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: 100 cu.yds.
Grading Volume:
(Soils report required for>5,000 cu.yds.) cu.yds.
Fill Volume:
(Fill exceeding 12"in depth shall be compacted to
90%of maximum density) cu. yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
❑ Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks,and avin : 667 s . 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 ❑ *Parking(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 5.00 to$500.00 551.09 minimum permit tee
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.
I:\Building\Permits\SIT-PermitApp.doc 05/25/2012 2
Ph City of Tigard
COMMUNITY DEVELOPMENT DEPARTMENT
TI C;A k D Building Permit Review — Commercial - No Land Use
Building Permit #: _5 i 7-02.0/4i—000/7
470 Sw 3 3o- -
Site Address: OA G IS l33D! (YU oo Suite/Bldg#:
Project Name: dU.nlrner t4-ICC PadL
(Name of commercial business occupying the space. If vacant,enter Spec Space.)
Planning Review
Proposal: Con 5.4-rc4..J 1eJ41-0-e: -C a-(2, l' 'I it pv.b(,l` pe_ctc .
Existing Business Activity: h/�
Proposed Business Activity: r/a-I
VS Verify site address/suite#exists and active in permit system.
Zoning: FR
0 Permitted Use: IX Yes ❑ No ❑ Spec Space
XConfirm no land use required.
Notes: ButAcl`.nel 'LS ofpruiC;Mate(5�OD St 4'et •) cypr ,, . I.1 + h.
ore -1A c l 0 b 4•r. ab
A.5 t-e s.d.e r J..1 -dvt e •
Approved by Planning: C a. ,,.i.---1 Date: q -8 -/
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
Building Permit Submittal
Original Submittal Date: J//,
Site Plans: # i/A'
Building Plans: # 3
Building Permit#: ,,2"Enter building permit#above.
Workflow Routing: LPlanning EY1 ermit Coordinator [ ilding
Workflow Sign-off: Sign-off for Planning(include notes from planning review)
Route Application Documents: ❑ Building: original permit application, site plans,building plans,engineer and
beam calculations and trust details,if applicable,etc.
Notes:
By Permit Technician: A _.I diA_, ! - Date: WO
l:\Building\Forms\B IdgPerm itRvw_COM_NoLandUse_07 15 14.docx
Permit Coordinator Review
❑ Conditions Met-Prior to Issuance of Building Permit
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant:
Revision Notice 2: Date Sent to Applicant:
Revision Notice 3: Date Sent to Applicant:
700K to Issue Permit
Approved by Permit Coordinator: Date: f/9//a
I:\Building\Forms\B IdgPermitRvw_COM_NoLandUse_07 15 14.docx