Permit y y CITY OF TIGARD MASTER PERMIT
3 ' COMMUNITY DEVELOPMENT Permit#: MST2015 00121
T IGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/22/2015
Parcel: 1 S135CD00205
Jurisdiction: Tigard
Site address: 9555 SW LEWIS LN
Subdivision: BOETCHERS ADDITION TO GREENBURG I Lot: 5
Project: Jones
Project Description: Addition of master suite&some interior remodel.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 1 First: 336 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 20 Smoke
Dwelling Units: 1 Third: 0 sf Right: 5
Detectors: Yes
Total: 336 sf Value: $37,850.00 Rear: 15
PLUMBING
Sinks: 0 Water Closets: 1 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
Drains: 0
Tubs/Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Other Fixtures: 0
Drywell-Trench Drain: 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 SrvclFeeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add/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+amp/volt: 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:
ADD SF VB R-3 336
Owner: Contractor:
JONES,JOSHUA DANIEL&MOLLY BET BUILT IN OREGON Required Items and Reports(Conditions)
9555 SW LEWIS LN 530 6TH STREET
PORTLAND,OR 97223 LAKE OSWEGO,OR 97034
PHONE: 971-217-4384 PHONE: 503-928-1352
FAX:
Total Fees: $1,746.92
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 - - •- h 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. • NTION: Oregon :w r,quires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-00 -0010 through OAR 952-" -0*:0. You may obtain a copy of the rules or direct questions to OUNC by calling 50• •:7 or 1.8
Issue• : Permittee Signature: jailLf�
Call 503.639.4175 by 7:00 a.m.for the nest available inspection dat .
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
Residential RECEIVED FOR OFFICE USE ONLY
Received
City of Tigard Permit No.:
. . 13125 SW Hall Blvd.,Tigard,OR 97220 i q Plaan Revie 7 / S .� 5r��s�f'�/
Phone: 503.718.2439 Fax: 503.598. 001- 2015 Date/B : 1111WA1� 1 Other Permit:
T-I�i R l� Inspection Line: 503.639.4175 Date Ready/By. . / J°ris: ® See Page 2 for
Internet: www.tigard-or.gov CITY OF TIGARD . ified/Me od: P,l�I Supplemental Information
BUILDING DIVISIO', IOW A!aff. 4
TYPE OF WORK
q; QUIRED DATA:1-AND 2-FAMILY DWELLING
❑New construction ❑Demolition it 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.
la I-and 2-family dwelling ❑Commercial/industrial Valuation: $ 3`7 g5 Q
1
❑Accessory building ❑Multi-family
Number of bedrooms:
❑Master builder ❑Other: Number of bathrooms: 4
JOB SITE INFORMATION AND LOCATION Total number of floors: 1
Job site address: Q5-SS 563 Lek,....),S Ly. New dwelling area: 3-362 square feet
City/State/ZIP: T CxY� 09_ 9-7223 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name3o , ,m.w,y.- torLtrc:oun jct. Covered porch area square feet
Cross street/directions to job site:r'r.0 b" • Cl s- 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.
Ac&*e S•.'}G wAc l-k-riv Valuation: $
Existing building area square feet
New building area: square feet
tom* PROPERTY OWNER ❑ TENANT Number of stories:
Name: 'SQL "3-0,4e5 Type of construction:
Address: q5--5-s- 51,0 L4„J-,5 L . Occupancy groups:
City/State/ZIP: —ri82.4 (:)Z cr.)2Z3 Existing:
Phone:(q--,( )2 t 7 - i-(38y Fax:( ) New:
❑ APPLICANT yk CONTACT PERSON BUILDING PERMIT FEES*
Business name: 0( .j £ (Please refer to fee schedule)
Structural plan review fee(or deposit):
Contact name:
FLS plan review fee(if applicable):
Address:
Total fees due upon application:
City/State/ZIP:
Phone:( ) Fax: :( )
Amount received: /Y g g.1
E-mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
CONTRACTOR Commercial and residential prescriptive installation of
roof-top mounted PhotoVoltaic Solar Panel System.
Business name: g - - N •r. c LL(_, Submit two(2) of roof plan with connection a-tails
and fire department a :-ss,along w' . . I 0 Oregon
Address: 5-30 GA, C+. Solar Installation Specia . ..e checklist.
City/State/ZIP: �akC Permit Fee '• des pl. eview
(�SvJe Ct O2 x(-10311 . d administrative -s): $180.00
Phone:(5-03) JJ Fax:( )
(Mg ' ICJ S�- State surcharge(12%of permit fee). $21.60
CCB lic.: I9 2 39 mot'— %/j (40 Total fee due upon application: "s $201.60
Authorized signature- a / 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 In sty
Print name: J DS ot� Date:(Q-15-_15-- Servic qd -i/'�/
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB) 7 / ' / 0-1- _
• _ i i
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USE ONLY
14 City of Tigard Received
13125 SW Hail Blvd.,Tigard,OR 97223 Associated
I Phone: 503.718.2439 Fax: 503.598.1960 Associated permits
I Ii. \I:I)
24-Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
Internet: www.tigard-or.gov ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN RIA II'.W 1 e No N/.
I 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.on and shall be shown to be ap p licable to the Iro'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 Buildingplans shall not contain red lines or tape-ons. "Mirrored"buildingplans 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 ❑ ❑ ❑
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(1 l/02/COM/WEB)
Electrical Permit Application FOR OFFICE USE ONLY
CityCity of Tigard p ar Date/By: m� To1O/ 00/a
g b ` Receive: Permit 0:
13125 S W Hall Blvd.,Tigard, R Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Da t : Related Permit#:
Inspection Line: 503.639.4175 JUL 2 2 2015 Ready Date/By: Judy SI Sec Page 2 for
Internet: www.tigard-or.gov Notified/Method Supplemental Information
TYPE tali A 14.1:. i 11."AHU PLAN REVIEW
❑New construction ❑Addittb IteEAor;ifepUdatljeilt0 Pv Please check all that apply(submit 2 sets of plans w/items checked):
❑Demolition ❑Other: ❑Service or feeder 400 amps or more ❑Building over three stones.
where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exce as 10,000 amps at 150 volts or ❑Floating buildings.
❑ I-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
❑Multi-family ❑Master builder amps for all other installations. buildings.
❑Other: ❑Fire pump. ❑Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived
❑Addition of new motor load of system.
Job#: Job site address:9555 Lewis Lane 100HPor more.
❑"A","E "l-2","1-3
City/State/ZIP:Tigard,OR 97223 ❑Six or more residential units. occupancy.
❑Hcalth-care facilities. ❑Recreational vehicle parks.
Sui teibldg./apt.#: Project name: ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site:
FEE SCI3EI)ULF,
Description I Qty. I Each I Total I •
New residential single-or multi-family dwelling unit.
Subdivision: Lot;/: Includes attached garage.
Tax map/parcel#:
1,000 sq.ft.or less 168.54 4
Ea.add'I 500 sq.it or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
Master Permit N.2015-00121.Master bedroom addition
(with above sq.ft.) 75.00 2
. Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
® PROPERTY OWNER ❑ TENANT Renewable Energy 0 See Page 2
. Services or feeders installationzalteration,and/or relocation
Name:Josh Jones 200 amps or less 100.70 2
Address:9555 Lewis Lane 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Tigard,OR 97223 601 amps to 1,000 amps 301.04 2
Phone:(503)718-2439 Fax:( ) Over 1,000 amps or volts 552.26 2
Email: Temporary services or feeders installation,alteration,and/or
relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
❑ APPLICANT ❑ CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
7.42 2
each branch circuit
Contact name: B.Fee for branch circuits without
service or feeder fee,fast 1
Address: branch circuit 56.18 36.18 2
City/State/ZIP: Each add'l branch circuit 3 7.42 22.26 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax: :( ) Each manufactured or modular
dwelling, and/or feeder 67.84 2
Email: g,
Reconnect only 67.84 2
1 CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Bentley Electric,Inc. Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy
Address:41330 SW Edna Lane panel,alteration,or extension. ❑ Page 2 2
City/State/ZIP: Gaston,OR 97119 Each additional inspection over allowable In any of the above
Additional inspection(1 hr min) 66.25i hr
Phone:(503)789-4229 Fax:(503)985-9595 Investigation(I hr min) 90.00/hr
Email:jay(u@bentleyelectricinc.com Industrialplant(1hrmin) 78.18/hr
Inspections for which no fee is
90.00/hr
CCB Lie.: 44467 Elret '.al Lic.: 2020C S)rp{v.Lie.: 5201S specifically listed(li hr min)
L y ELECTRICAL PERMIT FEES
Suprv.Electrician signature,requil . Subtotal: 78.44 \
Print name: Derek F.Cropp Date: ❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fec): 9.41
Authorized signature: TOTAL PERMIT FEE: 87.85
This permit application expires if a permit Is not obtained within 180
Print name: Date: days after it has been accepted as complete
• Number of inspections allowed per permit.
I:tewlar 1ieraats\ELC_PernitApp_ELR_ERE.doc Rev 06/17/2015 440.4615T(I I/05/COM/WEB
Mechanical Permit Application FOR OFFICE I'SE ONLY
Received j�
'City of Tigard E i VE D Date/By: ' 7e ` j Permit No.:• ( S��C J S_QU �]
• 13125 SW Hall Blvd.,Tigard,OR 2 f CT
Plan Review Other Permit:
Phone: 503.718.2439 Fax 503.598 960 Date/By:
I I G A R I) Inspection Line: 503.639.4175 1 2015 015 Date Ready/By: Juris. ® See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
CITY OF TIGARD
EREIMIlliliiiii1011111M1111... 11111.1111.11111111111.1111.1.
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:$
Cal-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist
❑Multi-family ❑Master builder ❑Other: Description I Qty. I Ea. I Total
Heating/cooling:
Job site address: / _ Air conditioning 46.75
5 5 5 5L) Leta;5 L,vv Furnace 100,000 BTU(ducts/vents) 46.75
City/State/ZIP: -ft m r� C) 97223 Furnace 100,000+BTU(ducts/vents) 54.91
J Heat pump 61.06
Suite/bldg./apt.no.: ( Project name:s0 � QS,I4, . 19 av'0v4t^ Ductwork ` 23.32
Cross street/directions to job site: 95'± a- L -,S Lk, 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
Flue/vent for any of above 23.32
Subdivision: I Lot no.: Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert 33.39
i , Flue vent for water heater or gas
M0.4k� 5:ti..-Ee OIOIQi4-:Ov∎ fireplace 23.32
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
Other: 23.32
Environmental exhaust and ventilation:
Name: S? ,L 3—OWe6 Range hood/other kitchen
Q equipment 33.39
Address: 1 5-5-5- 6 c L 'S L,,, Clothes dryer exhaust 33.39
City/State/ZIP: T.;v C 2 ci 7223 Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) ' 23.32
Phone:(cif,) 21.1 - 4{353y{ Fax:( ) Attic/crawlspace fans 23.32
Other: _ 23.32
Business name: Fuel piping:
$14.15 for first four;$4.03 for each additional
Contact name: Furnace,etc.
Address:
Gas heat pump
Wall/suspended/unit heater
City/State/ZIP: Water heater
Phone:( ) I Fax::( ) Fireplace
Range
E-mail: Barbecue
Clothes dryer(gas)
` AA'
Other: 4;F
Business name: Z�fk 1f v.( ✓`
Address: P., Pao x . t!D Subtotal
City/State/ZIP: C.t t d� t� 70 13 Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:('9)3) a(p fr_jay Fax:( ) State surcharge(12%of permit fee)
CCB lic.: /i/OQ g TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
/ days after it has been accepted as complete.
Authorized signs . = • Fee methodology set by Tri-County Building Industry Service Board
Print name: 705L v 5 Date:1-t-is"
I:IBuildingtPennitaVMEC_Pern itApp 040113.doc 440-4617r(I1/02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information •
Commercial & Multi-Famil Fee Schedule:
$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_PermitApp_040113.doc 2
Plumbing Permit Application
Building Fixtures RECEIVED FOR OFFICE USE ONLY
• Received j
ill
City of Tigard Date By 7 /f j S (yam ,y.i Permit No.}r.,)T 11 z7 -c)c),
• 13125 SW Hall Blvd.,Tigard,OR 97223j UL 1 2015 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit No.:
Inspection Line: 503.639.4175 C QTY OF TIGARD Date Read B Juris. 0 See Page 2 for
F IGARD Internet: www.tigard-or.gov BI III n IN Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist
Description I Qty. I Ea. I Total
1KAddition/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
Accessory building SFR(3)bath 500.32
El ry g ❑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: gS5S S(.) Z-e4 `S .1,-An. Catch basin or area drain 18.76
City/State/ZIP: R 012. �72�� Drywell,leach line,or trench drain 18.76
13ar Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: 5ov t.S tv.a esrkOcArobo.. 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: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
AAII
Clothes washer 25.02
AotS+GC ,g Ls- *C r ik C.. - Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
la PROPERTY OWNER J ❑ TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name:
3-
G3Vn S0,,•r5 Floor drain/floor sink/hub 25.02
Address: 14555 SC.J Lbw■g L•".
Garbage disposal 25.02
City/State/ZIP:.17130A 02 ''t72 ..3 Hose bib 25.02
Phone:(CI-j() 2 r,7- 1-13,N Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: ��,f1.r„ Pith C r�
Medical gas(value:$ ) Page 2
1" J Primer 12.51
Contact name: i
I it S 01 110.1c1413 Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 2, 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:(105) 14 2 - 17 9 7.. Fax::( ) Tub/shower/shower pan l I 12.51
E-mail: Urinal 25.02
Water closet ` 25.02
• CONTRACTOR -
' � Water heater 37.52
-
Business name: M f IJ Y 2.b 1 L,4.LH/gi i... E 2..14.- Water piping/DWV 56.29
Address: q7 ( U ii,10 Lc..-16etab j aT-- PM 16 tat 36/ Other: 1 25.02
City/State/ZIP: friT_-r) O(L 979-03 Subtotal
Minimum permit fee: $72.50
Phone:(S03) Vol- 6, !Q 9.. Fax:( )
Plan review (25%of permit fee)
CCB Lic.: Plumbing Lic.no.:
State surcharge(12%of permit fee)
Authorized signs
�c.....r TOTAL PERMIT FEE
Print name: p 5 L �O{.�G$ Date:-7_(_i 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:\Building\Permita\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
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
Storm&Rain Drain 1st 100' 62.54 Valuation: Permit Fee:
$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
Cr ]1}eCt10I13 each additional$100.00 or fraction thereof,to
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*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
❑ Any new commercial building with water service 2"and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2"
Isometric or Riser Diagram
❑ Isometric or riser diagram is required for nee\ buildings
-Car Wash Drain that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -LavBar non-food related
-Bradley
-
-Com/Serv/Util food related
-
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filer increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
WaterCloset-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
City of Tigard
IIIIIIII
COMMUNITY DEVELOPMENT DEPARTMENT
Building Permit Review — Residential
I It , \ I: II
Building Permit #: H �a.0/ 5- -oG /a/
Site Address: °15SS SW Lew i s Ln
Project Name: Jones Lot #:
(New dwelling=subdivision name;Addition or Alteration=last name of owner)
Planning Review
Proposal: 336 scat. -c-f, c cA ii'i ovl
Verify site address/suite# exists and active in permit syste .
CittRiver Terrace Plan District: ❑ Yes ENo
SieP1an Elements: /
1hree(3)copies of site plan M Misting structures on site
Site plan must bs on 8-1/2"x 11"or 11 x 17"paper ®/Footprint of new structure(including decks)with finished
V.I rawn to scale(standard architect or engineer scale) floor elevations
'='` orth arrow ••• Utility locations(required for new,may apply for additions)
"-A.' e address,project or subdivision name and lot number 4$Eocation of wells/septic systems
I.`/lpplicant information(name and phone number) 4Eitrfosion control(including drainage-way protection,silt fence
IN4Lot dimensions and building setback dimensions • sign,location of catch basin,etc.)
$dot area,building coverage area,percentage of coverage and ■T,Street names
/impervious area(applicable if R-7,R-12,R-25&R-40) 'Street tree size,type and location
MProperty corner elevations(2 foot contour lines if more than Existing trees to be retained with drip line,and tree
4 foot differential) protection measures
I10 Clean Water Services—Service Provider Letter(lot platted prior to 9/10/1995):
•equired: E 1 Yes,applicant was notified ❑ No Received: Yes ❑ No
U Pubhc Facilities Improvement(PFI) Permit:
Required: ❑ Yes,applicant was notified Evil No Applied For: ❑ Yes ❑ No,stop intake
$ and Use Case#:
Zoning: R- y .S
❑ Setbacks: recd,.(0„,-}t A0, Front 20' Rear 1S Side 5' Street Side Garage 20'
-E1--Landscape Requirement: cyo
Lot Coverage Maximum:
I
Building Height: Maximum Height 3a Actual Height 1
$Visual Clearance
C asements
n Sensitive Lands: ❑ Yes ENo Type
$—Urban Forestry Plan
-E—Conditions "Met"prior to issuance of building permit
Notes:
Approved By Planning: 44 nil I i( a c(S!LMT. Date: ? / / / 11 S
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
I:\Building\Forms\BldgPermitRvw_RES 031015.docx
Building Permit Submittal _
Original Submittal Date: ?// (1
Site Plans:
Building Plans:
Building Permit#: EVEnter building permit#above.
Workflow Routing: R'Planning Engineering a Permit Coordinator Er Building
Workflow Sign-off: a--Sign-off for Planning(include notes from planning review)
Route Application Documents: Ei Engineering: (1) copy of permit application, (1) site plan, (1) building plan and
original plan review routing form.
Building: original permit application, site plans,building plans,engineer and
beam calculations and trust details,if applicable,etc.
Notes:
By Permit Technician: 60_120&.....44A-4.--Le. Date: 7/
Engineering Review S
f2t' Slope at building pad:
❑ Conditions "Met"prior to issuance of building permit
❑ Easements (encroachments)per engineering conditions of approval and plat
❑ Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: ❑ Yes .B No
Assess Water Quantity Fee in-lieu: ❑ Yes , /No
LIDA Facility on lot: 1=1 Yes ,CJ No
❑ NOT Approved by Engineering: Date:
Notes:
Approved by Engineering: hi I GG 4, Date: 3
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
Permit Coordinator Review
❑ Conditions "Met"prior to issuance of building permit
❑ Approved,NOT Released: Date:
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:
■ 'OK to Issue Permit
Approved by Permit Coordinator: ��/ Date: ?-/L"--/
I:\Building\Forms\BldgPermitRvw_RES_031015.docx
Clean Water Services File Number
C1eanWater Services 15-0 085
CE
Sensitive Area Pre-Screening Site Assessment OVE(
1. Jurisdiction: Washington County Tigard JUL 1 2015
U'TYOFTIO �D
2. Property Information (example 1S234AB01400) 3. Owner Information iTy a
Tax lot ID(s): 1S135CD00205 Name Josh Jones Llt�/14`;ON
Company:
Address: 9555 SW Lewis Ln
Site Address: 9555 SW Lewis Ln City, State, Zip: Tigard,OR 97223
City, State, Zip: Tigard,OR 97223 Phone/Fax: 971-217-4384
Nearest Cross Street: SW 95th E-Mail: wenracer4 @yahoo.com
4. Development Activity (check all that apply) 5. Applicant Information
l Addition to Single Family Residence(rooms,deck, garage) Name: Josh Jones
❑ Lot Line Adjustment ❑ Minor Land Partition Company:
❑ Residential Condominium ❑ Commercial Condominium
Address: 9555 SW Lewis Ln
❑ Residential Subdivision ❑ Commercial Subdivision
❑ Single Lot Commercial Li Multi Lot Commercial
City, State,Zip: Tigard,OR 97223
Other Phone/Fax: 971-217-4384
E-Mail: wenracer4 @yahoo.com
6. Will the project involve any off-site work? ❑Yes No ❑ Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
This is a 336 square foot master suite addition to the north side of existing structure.
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 information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name Josh Jones Print/Type Title
ONLINE SUBMITTAL Date 6/30/2015
FOR DISTRICT USE ONLY
J 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 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 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.
J 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 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed by Date 6/30/15
2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • Phone.(503)681-5100 • Fax.(503)681-4439 • wvwv.cleanwaterservices.org
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9555 SW LEWIS LN, TIGARD, OR, 97223
Residential - Master Permit
399 Plumbing final
FAIL
MST2015-00121
David Young
Fix leak under right side lav in master bath.
Finish back splash in master and seal to cabinet.
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9555 SW LEWIS LN, TIGARD, OR, 97223
Residential - Master Permit
699 Mechanical final
PASS
MST2015-00121
David Young
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9555 SW LEWIS LN, TIGARD, OR, 97223
Residential - Master Permit
199 Electrical final
PASS
MST2015-00121
David Young
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9555 SW LEWIS LN, TIGARD, OR, 97223
Residential - Master Permit
299 Final inspection
FAIL
MST2015-00121
David Young
Provide approved plumbing final, recall building and plumbing final when ready.
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9555 SW LEWIS LN, TIGARD, OR, 97223
Residential - Master Permit
299 Final inspection
PASS - No C of O
MST2015-00121
David Young
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
9555 SW LEWIS LN, TIGARD, OR, 97223
Residential - Master Permit
399 Plumbing final
PASS
MST2015-00121
David Young
Correction complete.
Violation Summary:
Inspector Contractor