Permit .1 CITY OF TIGARD SITE WORK PERMIT
"! B • COMMUNITY DEVELOPMENT Permit#: SIT2015-00010
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/25/2015
Parcel: 2S11013A12500
Jurisdiction: TIGARD
Site address: 14121 SW 118TH CT
Project: Medallion Meadows,Lot 18 Subdivision: MEDALLION MEADOWS Lot: 18
Project Description: Engineered rock wall
Contractor: PARKER CONCRETE INC Owner: JT ROTH CONSTRUCTION INC
11000 NW MARSHALL DR FOUR D CONSTRUCTION CO
YAMHILL, OR 97148-8331 12600 SW 72ND AVE#200
TIGARD, OR 97223
PHONE: 503-680-9925 PHONE:
FAX:
FEES
Description Date Amount
Specifics: Permit Fee-Site Work 08/25/2015 $102.20
Plan Review 08/25/2015 $66.43
Type of Use: SF 12%State Surcharge-Building 08/25/2015 $12.26
Class of Work: ALT Info Process/Archiving-Sm$0.50(up to 08/25/2015 $3.50
11x17)
Project Valuation: $3,000.00
Site Specifics:
Excavation Volume: 60 cu.yd.
Fill Volume: 60 cu.yd.
Impervious Surface: sq.ft.
Engineered Fill: No Soil Report Required: Yes
Paving: No Grading: Yes
Landscaping: No Site Prep: Yes
Storn Drains: Retaining Wall: Yes
Fire Underground: No Accessible Parking: No
Fence: No
Total $184.39
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, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503. .1987 or . 44.
Issued By: a Signature: lit _.-.2rall 1..g.i......ze„.0.1.,. .._ Call 503.639.4175 by 7:00 a.m.for the next available inspection date. i
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.
'" t ililing Permit Application
Site Work R Fr,r•.7.., `r.. I.OIiOFFR 1.: I tiF: O\I.\
114 ei City of Tigard Date/B : / Permit No.: jt 5
13125 SW Hall Blvd.,Tigard, 97223 —tom/O
g �U G 18 2 015 Plan Revie ��� iV •her Permit: i�>°yT2p/g�aoo fig'
Phone:SW 503.718.2439 Blvd. Fax: 503.598.19 Date/B
I I t i,\It l Inspection Line: 503.639.4175 CI i y q,, ` Date Ready Ty: �� halt: See Page l for
Internet: www.tigard-or.gov tt ''++ ff RR,, i t,� ��p No'led/Method: * �� Supplemental Information
TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING
Igi New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rotnded 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.
to 1-and 2-family dwelling n Valuation: $ g 0Ov
❑Commercial/industrial t
❑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: 1 L 1 5,, \`Q 0. New dwelling area: square feet
City/State/ZIP: '�\ ?t en--3- Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: Ok. 0.-k\'O h Covered porch area square feet
Cross street/directions to job site: (,:,..:0_0_,(151,4_ �b� Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: \Q W,. h tl wA Lot no.:`8 Permit fees*are based on the value of the work performed.
Tax map/parcel no.: Indicate the value(routded to the nearest dollar)of all
equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
E S .0 om$ �3- 1 Valuation: $
Existing building area square feet
New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: S 0. A,-,.-`2 0...S C%--0 ta��A Type of construction:
Address: Occupancy groups:
City/State/ZIP: Existing:
Phone:( ) Fax:( ) New:
❑ APPLICANT ❑ CONTACT PERSON
NOTICE
Business name: 3 \ a C� p All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name:
tAS I under ORS 701 and may be required to be 1censed in the
Address: (.4. 4S-46 5 v4 �l �•O�,�rQ g�,� 4�gD jurisdiction in which work is being performed.If the
City/State/ZIP: ��� � bO'— !' 9°� �3 applicant is exempt from licensing,the following reasons
fp !t/ apply:
Phone:(r a 3) b,j�/— 3/ Fax: :(9,3) -L/'64,3°1
E-mail: D,,, J p J 6...kinl✓,..L . ( d rl•,.
CONTRACTOR
Business name: PU,Nkc_a_✓ (Itiv,__Lir,e,k BUILDING PERMIT FEES*
Address: `` W {\n a NC., f (Please refer to fee schedule)
City/State/ZIP: \��" ay..._ X1.1 i Structural plan review fcc(or deposit): —
Phone:(40,2,) L O — ` / S I Fax:( ) FLS plan review fee(if applicable):
CCB lic.: tibl �ov,i l(rt Total fees due upon application:
10,\ W Amount received:
Authorized signature: This permit application expires if a permit is not obtained
�, within 180 days after it has been accepted as complete.
Print name: sl/7 leis Date: ,g f t 8I!`c-" * Fee methodology set by Tri-County Building Industry
Service Board
I:\Building\Permits\SIT-PermitApp.doc 10/01/09 440-4613T(11/02/COM/WEB)
•
y
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: too 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
I CMU
111 Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks,and paving: a DO 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 ❑ *Parking(including ADA)and Lighting
compliance Plan
❑ Grading Plan and details ❑ *Landscaping Plan
❑ Erosion Control Plan and details ® Soils Report(if required)
Ea Retaining Structures ❑ Fire Line
*Does not apply to One-and Two-family dwellings.
Plan Submittal: Permit Fcc:
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.
1:113uilding\Permits\.SIT-PermitApp.doc 05/25/2012 2
r• •
City of Tigard
IIII COMMUNITY DEVELOPMENT DEPARTMENT
■
T I G A R D Building Permit Review — Residential
Building Permit #: 1 '7--,9.4,i S -coal ()
Site Address: It-1121 SW 1 1g4 a.
Project Name: Medallion Meadows Lot #: 1%
(New dwelling=subdivision name;Addition or Alteration=last name of owner)
Planning Review
Proposal: e-r l neerecl ('o c.k Wcd
0/Verify site address/suite#exists and active in permit syst
Ef River Terrace Neighborhood: ❑ Yes V No
Sit Ian Elements: ,_,/
ree(3)copies of site plan MExisting structures on site
ite plan must be on 8-1/2"x 11"or 11 x 17"paper ' Footprint of new structure(including decks)with finished
❑ rawn to scale(standard architect or engineer scale) oor elevations
��°rth arrow M Utility locations(required for new,may apply for additions)
l address,project or subdivision name and lot number $i ocation of wells/septic systems
L�'. �plicant information(name and phone number) ❑Erosion control(including drainage-way protection,silt fence
;►Lot dimensions and building setback dimensions sign,location of catch basin,etc.)
- itzt area,building coverage area,percentage of coverage and Street names
)pervious area(applicable if R-7,R-12,R-25&R-40) —treet tree size,type and location
Lf Property corner elevations(2 foot contour lines if more than .-e5xisting trees to be retained with drip line,and tree
,foot differential) protection measures
,Lr.,,ll Clean Water Services-Service Provider Lett (lot platted prior to 9/10/1995):
equired: ❑ Yes,applicant was notified Received: ❑ Yes El No
A Public Facilities Improvement(PFI) Permit
/Required: ❑ Yes,applicant was notified No Applied For ❑ Yes ❑ No,stop intake
Land Use Case#: S R-L ,S _
Setbacks: Front 1,0' Rear 1Z Side Ss Street Side -- Garage Zoo
$Landscape Requirement %
'$-Lot Coverage Maximum: cyo
-(J Building Height: Maximum Height Actual Height
$/Visual Clearance
LJ Easements
Er Sensitive Lands: ❑ Yes IN. Type
tt Drban Forestry Plan
-B-conditions "Met"prior to issuance of building permit
Notes:
Approved By Planning: A le .i asrAh Date: g 1 g 1 t
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
1:\Building\Forms\BldgPermitRvw_RES_070915.docx
f - _ -•
Building Permit Submittal
9
Original Submittal Date: /
Site Plans: # �j
Building Plans:
Building Permit#: enter building permit#above.
Workflow Routing: Manning IJ gi...neering t Coordinator LfiBuilding
Workflow Sign-off: 'Sign-off for Planning(include notes from planning review)
Route Application Documents: Engineering. (1) copy of permit application, (1) site plan, (1) building plan and
o al 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 Technicia Date:
Engineering Review
Je Slope at building pad: 4 0 4
❑ 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 'No
Assess Water Quantity Fee in-lieu: ❑ Yes An No
LIDA Facility on lot: ❑ Yes 0'No
❑ NOT Approved by Engineering: Date:
Notes:
Approved by Engineering: ) at, Date: $ /
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:
❑ SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes ❑ N/A
Tigard Trans SDC: ❑ Yes ❑ N/A
Parks SDC: ❑ Yes ❑ N/A
4•K to Issue Permit
Approved by Permit Coordinator: Date:
�/-4) 15-
1:\Bui Iding\Forms\BldgPetmitRvw_RES_070915.docx