Permit INCITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit#: MST2015 00172
,t,..„4.t. Date Issued: 10/05/2015
TigAR1? 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1 S134CD07900
Jurisdiction: Tigard
Site address: 11810 SW SUMMER CREST DR
Subdivision: BURLWOOD NO.4 Lot: 12
Project: JOHNSON
Project Description: Interior remodel:Added interior walls to NE corner of home, and installed(1)sink, (1)tub, (1)
shower, (1)water closet, (2)branch circuits, and (1)bathroom fan.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 1 Third: 0 sf Right: 0
Detectors: Yes
Total: 0 sf Value: $7,000.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Drains: 0
Tubs/Showers: 2 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 Srvc/Feeders 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: 2
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+a m p/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio 8 Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Ecompasing: Y
Other: N Other Description: P 9
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ALT SF VB R-3 0
Owner: Contractor:
JOHNSON,EVAN L&SARA OWNER Required Items and Reports(Conditions)
11810 SW SUMMER CREST DR EVAN&SARA JOHNSON 1 Subject to on-site review by
TIGARD,OR 97223 11810 SW SUMMER CREST DR inspection staff
TIGARD,OR 97223
PHONE: PHONE:
FAX:
Total Fees: $767.47
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 . - Those ides. 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 c- •503.23 . 987 or 1 I:(.332.2344.
VIIMIll
Issued By: //��.L..—..., ` .e."------ .111 Permittee Signature:
a 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 pr.riy
Approved plans are required on the job site at the time of each in •• tion.
Building Permit Application
Residential FOR OFFICE USE()NI,V
City of Tigard G�`ve Received y/30 J /s- ' Permit No.: i 5- !s` CX)l
° 13125 SW Hall Blvd.,Tigard,OR 9'i% v Plan Review• g Plan Review
' 0.` Phone: 503.718.2439 Fax: 503.59:'•1 '.. 201C3 Date/By: )O,J j I )3 Other Permit:
Ti G A IZ'.D Inspection Line: 503.639.4175 �[Q �7 o Date Ready/By: Juris: 65 See Page 2 for
Internet: www.tigard-or.gov ` 1^A90 we Notified/Method: 101 fig _ Supplemental Information
TYPE OF WO r f) REQUIRED DATA 1-AND 2-FAMILY DWELLING
❑New construction Iemolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
RAddition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
•,. CATEGORY.OF CONSTRUCTION . . `
work indicated on this application.
Valuation: $
43and 2-family dwelling ❑Commercial/industrial -7l Oc.G
❑Accessory building ❑Multi-family Number of bedrooms:
❑Master builder ❑Other: Number of bathrooms:
' JOB SITE.`INFORMATION AND LOCATION ATION Total number of floors:
Job site address: t{ to Jnnvy\W"- .-k a c` New dwelling area: square feet
City/State/ZIP: `\r. na�'R q ` Garage/carport area: square feet
Suite/bldg./apt.no.: 0 Project name: Covered porch area: square feet
o
Cross street/directions to job site: , dt) AS S I N^n Deck area: square feet
g ('(1E "`� of In yY e- 1 Other structure area: square feet
-f-r( A(3d 115 6''r+ REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: l 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.
c-W r CUCLA_ ` Valuation: $
1► y:J \ Existing building area: square feet
New building area: square feet
, PROPERTY OWNER-.", ❑.TENANT Number of stories:
Name: 7Cn(tm, J )^ Type of construction:
Address: ( n La Z n lv ,' )' \ C - — 1c)r' Occupancy groups:
City/State/ZIP: 0. v, _^i OR f, �L�` �6 Existing:
Phone:((SQ,) �0 q Q`'T- Fax:( ) �`
New:
APPLICANT ❑ CONTACT'PERSON BUILDING PERMIT FEES*.' -
�
(Please refer to fee schedule
Business name: — \
-U O0\k-L_. Structural plan review fee(or deposit):
Contact name:
FLS plan review fee(if applicable):
Address:
Total fees due upon application:
City/State/ZIP: 7
Phone:( ) Fax::( ) Amount received:
E-maiL6C ) !!�� i r PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
1 . 1 ` Commercial and residential prescriptive installation of
C e► TRACTOR . - roof-top mounted Photo Voltaic Solar Panel System.
Business name: Y�- - Submit two(2)sets of roof plan with connection details
Afr�'"� � and fire department access,along with the 2010 Oregon
Address: Solar Installation Specialty Code checklist.
City/State/ZIP: Permit Fee(includes plan review
and administrative fees): $180.00
Phone:( ) Fax:( )
State surcharge(12%of permit fee): $21.60
CCB lic.:
Total fee due upon application: $201.60
Authorized si u ature: * 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
Print name: To v Date: q/ ` c /�
C\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-461 3T(I 1/02/CO 1M/WEB)
Electrical Permit Application `� l oR OFFICE USE ONLY • -
City of Tigard ` Received /�
�� Date/B : `/ O . _i.. a1 ,.I
n 13125 SW Hall Blvd.,Tigard,OR' �J Plan Review
a • Phone: 503.718.2439 Fax: 503.7!V. 0 015 Date/B : Related Permit#:
Inspection Line: 503.639.4175 0 Ready Date/By: m`� � HI See Page 2 for
TI G A R f Internet: www.tigard-or.gov ��� let., Notified/Method: J�—+� Supplemental Information
".TYPE OF,W O 1^ v
�� el. >,'^ PLAN:REVIEW :.
❑New construction 'Addition/altet l OTnent Please check all that apply(submit 2 sets of plans w/items checked):
❑Service or feeder 400 amps or more ❑Building over three stories.
❑ Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
` ' .,' CATEGORY OF'CONSTRUCTION. -• - rY , exceeds 10,000 amps at 150 volts or 0 Floating buildings.
j dd 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
❑ Multi-family Master builder Other: amps for all other installations. buildings.
y ❑ ❑ ❑Fire pump. ❑Installation of 150 KVA or
"JOB'SITE INFORMATION AND LOCATION ❑Emergency system, larger separately derived
Job#: Job site address: ❑Addition of new motor load of system.
�'lo lall� )M MN l r€5 100Hp or more. ❑ A„ `E" 1.2„ l_3„
City/State/ZIP: f Q (�(2 G�(��3 ❑Health-care It more residential units, occupancy.crreational vehicle
V' \ I ❑Healthcare facilities. ❑ parks.
Suite/bldg./apt.#: j I Project name: ��1� ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total I •
New residential single-or multi-family dwelling unit.
Subdivision: I Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'I 500 sq.ft.or portion 33.92 1
' ' -,` -DESCRIPTION OF WORK ..` Limited energy,residential
h n U\,i L Q. 1 Cc, \ (with above sq.ft.) 75.00 2
"L w( r � '� ` Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
PROERTY OWNER 4 I I . 0 TENANT--
Renewable Energy See Page
` P Services or feeders installation,alteration,and/or relocation
Name: �(,,,,4-.0,, -(,�\1A�r y� 200 amps or less 100.70 2
I V ' ! M� ( j' ` 201 amps to 400 amps 133.56 2
Address: c( I V 1�1\
D l ` 401 amps to 600 amps 200.34 2
City/State/ZIP: 601 amps to 1,000 amps 301.04 2
Phone:( ) I Fax:( ) Over 1,000 amps or volts 552.26 2
n CU C kiG � 1 + C Temporary services or feeders installation,alteration,and/or
Email: v\ ccii)_ \ relocation
Owner installation: II is I sa s r 1 being made on property that I own which is not 200 amps or less 59.36 1
intended f o r sal• 'or exch. !e,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 1(30/( � 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: (� \-/`k- above service or feeder fee,
v �\ each branch circuit 7.42 2
Contact name: .:21 B.Fee for branch circuits without
service or feeder fee,first
Address: branch circuit• 56.18 2
City/State/Z1P: Each add'I branch circuit 1 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax: :( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: Reconnect only 67.84 2
'
. - ` '.' CONTRACTOR . ^ • - -: Pump or irrigation circle 67.84 2
Business name: Sign or outline lighting 67.84 2
Address: Signal circuit(s)or limited-energy ❑ See Page 2 2
panel,alteration,or extension.
CityJState/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr
Email:
Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: Electrical Lie.: Suprv. Lic.: specifically listed('/2 hr min)
ELECTRICAL PERMIT FEES _ .•
Suprv.Electrician signature,required: Subtotal:
Print name: Date: ❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature:
TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Print name: ,. ''0.(•'c,.. F,.�^ Date: Q � /\ days after it has been accepted as complete.
r • Number of inspections allowed per permit.
I:\Building\Permits\ELC_PermitApp_ELR_ERE.dor Rev 06/17/2015 440-4615T(i 1/05/COM/WEB
Mechanical Permit Application FOR OFFICE USE ONLY _
City of Tigard 044. Date/By: Permit No.: e .19= •
a 13125 SW HaII Blvd.,Tigard,OR 9 _. Plan Review
C. Phone: 503.718.2439 Fax: 50 1* 0., V:\C. Date/By: Other Permit:
Inspection Line: 503.639.4175 , (, y
Tl G A RD o Date Ready/By: Jurist ` la See Page 2 for
Internet: www.tigard-or.gov % -\:°
'c\,''' `d'� Notified/Method: Supplemental Information
a TYPE OF OA`` tO\ . . . COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
`�`` \`yG Mechanical permit fees*are based on the value of the work
❑New construction [X(Addition/altSlf replacement 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* 7.".
ljuld 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist.
❑Multi-family ❑Master builder ❑Other: Description Qty. I Ea. I Total
'•: JOB SITE;INFORMATION AND LOCATION Heating/cooling:
Air conditioning 46.75
Job site address: \1 k.C5 C �� cJ(1/V nn CO Furnace 100,000 BTU(ducts/vents) 46.75
City/State/ZIP: -\ ` �U '( 9-79.a.....3 Furnace 100,000+BTU(ducts/vents) 54.91
Suite/bldg./apt.no.: (� Project name: �a Y .r . 0/� Heat pump 61.06
r U r \ Duct work 23.32
Cross street/directions to job site: 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: Lot no.:
Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
. DESCRIPTION OF WORK ` : . Gas fireplace/insert 33.39
Flue vent for water heater or gas
�
k( jC.Lk\ — (-nort,-\_ \W \ 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
PROPERTY OWNER - ' ❑ TENANT - "
Environmental exhaust and ventilation:
Name:: Range hood/other kitchen
,1 ` equipment 33.39
Address: k`%t� `M�Af C� 'S s )T) Clothes dryer exhaust . 33.39
City/State/ZIP:` (i�1 c �g.a5 1^ Single-duct exhaust(bathrooms,
v`\ toilet compartments,utility rooms) 23.32 .3),-
Phone:(5n) CC��� Fax:( ) Attic/crawlspace fans APPLICANT ❑ CONTACT PERSON 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:( ) Fax::( ) Fireplace
` Range
(J J
E-mail:ai X C OM Barbecue
- C NTRACTOR • ' Clothes dryer(gas)
Business name: Other:
J -e MECHANICAL PERMIT FEES* .
Address: Subtotal ;.3.3_2
City/State/ZIP: Minimum permit fee($90.00) ty)-d0
Phone: Plan review(25%of permit fee) —
( ) Fax:( ) State surcharge(12%of permit fee) /Q.80
CCB lic.: TOTAL PERMIT FEE _ /OJ,Fd
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: Q, �,/j • Fee methodology set by Tri-County Building Industry Service Board
Print name: �i`t. -I,,, M Date: I�,3 c
I:\Building\Pennits\ EC_PermitApp_040113.doc 'i \ 440-4617T(Il/02//COM/WEB)
Plumbing Permit Application
'' Building Fixtures ® FOR OFFICE: USE ONI.V
Received
lig City of Tigard �`�
Date/By: Permit No.:MST�(�0O(7
U 13125 SW Hall Blvd.,Tigard,OR ', ^ '
C ' Phone: 503.718.2439 Fax: 503.5'\ ;x';. ^o1C� Date/By:Review Other Permit No.:
Inspection Line: 503.639.4175 o f• Date Ready/By: Juris: ® See Page 2 for
IIC,,RD �p 3 1�P0a� y o g
Internet: www.tigard-or.gov S oti6ed/Method: Supplemental Information•
• `TYPE OF .WORK r%ktic031,, / I�F r.0-j,O "FEE* SCHEDULE
❑New construction ❑ ` , For s'ecio!in ormation use checklist
Descri.tion Q . Ea. Total
4Addition/alteration/replacement ❑ ther: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
.'m.1 d 2-famil y dwelling SFR(2)bath 437.78
g ❑Commercial/industrial
building SFR(3)bath 500.32
❑Accesso ry g ❑Multi-family
Each additional bath/kitchen 25.02
❑ h
Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION ' - Site utilities:�` Catch basin or area drain 18.76
Job site address: 110'Q L �P YVv� Ore S.4-�
` v Drywell,leach line,or trench drain 18.76
City/State/ZIP: \\r/ q-T 9.9,73 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: Project name: "75(,.M(6'SC,1 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: 1 Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
- DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
r vkA ,jk%\ Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
PROPERTY OWNER . ❑ TENANT Expansion tank 12.51
Name: J
�('U\r\tl``�1 f Fixture/sewer cap 25.02
�1 ` \\ Floor drain/floor sink/hub 25.02
Address: \ \U >i' � �WW �� V
��� � Garbage disposal 25.02
City/State/ZIP: 7 1 ( Hose bib 25.02
Phone:(c05) S5�W�� Fax:( ) Ice maker 12.51
APPLICANT ❑ CONTACT:PERSON Interceptor/grease trap 25.02
\\ Medical gas(value:$ ) Page 2
�
Business name: ^ n Ck �
Contact name: \/4�J Primer 12.51
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory I 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan L. 12.51
Urinal 25.02 E-mail: aw u„,,,,,( @ _Yy\G . C CY
Water closet ' 25.02
TRACTOR
' Water heater 37.52
Business name:
U1n/M%(- Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50
CCB Lic.: pi 1• no.: Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: �� 1 > Date: c (� /'C This permit application expires if a permit is not obtained within ISO days
+ \ J after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PermitApp.doc t 0/01/09 440-4616T(I 0/02/COM/WEB)
Or
7' Information Notice to Owners About
a`_.:�_. . construction Responsibilities
� �. N�fJF: + UI
. ��. (ORS 701.325 (3))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure,can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an em ployer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503-378-4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Em ployment
Department at 503-947-1488.
• Oregon's Business Identification Number(BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or go to
http://www.oregon.gov/DOR/BUS/docs/211-055.pdf for the appropriate forms.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503-947-7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1-800-829-4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensur e adequate insurance coverage for accidents and om issions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough-in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
700 Summer St NE, Suite 300, PO Box 14140, Salem,OR 97309-5052
Telephone:503-378-4621 —Fax: 503-373-2007
Website Address:www.oregon.gov/ccb
f/property_owner adopted 9-23-08 This Copy for Permit Applicant
IGAR.D,
City of Tigard
December 3, 2015
Sara Johnson
11810 SW Summer Crest Dr
Tigard, OR 97223
Re: Permit No. MST2015-00172
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 11810 SW Summer Crest Dr.
Project Name: Johnson
Job No.: N/A
Refund: ® Check#219215 in the amount of$146.47.
n Credit card "return" receipt in the amount of$
n Trust account"deposit" receipt in the amount of$
Notes: Refund overpayment of plumbing permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
AgruSstrauW.on I �lr l��,co.! Tigjar6l,�l��.Fgon 97223 • 503.639.4171
1:\Building\Refun rpay.
TTY Relay: 503.684.2772 • www.tigard-or.gov
pri
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Requetfovr Pe/mit Actio n form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Sara Johnson DATE: 11/5/2015
11810 SW Summer Crest Dr
Tigard, OR 97223 REQUESTED BY: Dianna Howse
BT
TRANSACTION INFORMATION:
Receipt#: 202853 Case #: MST2015-00172
Date: 10/05/2015 Address/Parcel: 11810 SW Summer Crest Dr
Pay Method: CreditCard Project Name: Johnson
EXPLANATION: Applicant overcharged for plumbing permit fees,undercharged for mechanical permit
fees, and assessed an additional 545.00 admin fee to change contractor. Refund
difference.
REFUND INFORMATION:; = '- s L ;.,.;.
Fee
Descri tio.n.F.rom Recei t
Revenue A. ccountNo::
Exaiple: 2300000431.04
:Refund'.
::`;' }` $Amount --
Plumbing permit fee 230-0000-43101 $125.96
12% state surcharge 100-0000-24001 20.51
TOTAL REFUND: $146.47
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff • i /��,—,��
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FORTIDEIVIARB.SYSTEM ADMINISTRATION;USE
Case Refund Processed: Date: /.1�3//s By: 4
I:\Building\Refunds\RefundRe,uest.doc x 09/01/2010
CITY OF TIGARD FEE AND PAYMENT HISTORY
IIICII
r: 13125 SW Hall Blvd.,Tigard OR 97223
• 503.639.4171
TIlGA.AU
MST2015-00172 - 11810 SW SUMMER CREST DR, TIGARD, OR 97223
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due
Building Permit-Additions,Alterations, 230-0000-43104 $180.17 $180.17 $180.17 10/5/15 Credit Card 202853 $0.00
Demolition
Plan Review 230-0000-43106 $117.11 $117.11 $117.11 9/30/15 Credit Card 202803 $0.00
12%State Surcharge-Building 100-0000-24001 $21.62 $21.62 $21.62 10/5/15 Credit Card 202853 $0.00
Info Process/Archiving-Sm$0.50(up to 230-0000-43135 $1.00 $1.00 $1.00 10/5/15 Credit Card 202853 $0.00
11x17)
Branch Circuits wo/Purchase Service or 220-0000-43103 $63.60 $63.60 $63.60 10/5/15 Credit Card 202853 $0.00
Feeder
12%State Surcharge-Electrical 100-0000-24001 $7.63 $7.63 $7.63 10/5/15 Credit Card 202853 $0.00
Single Duct Exhaust(Bathrooms,Toilet, 230-0000-43102 $23.32 $23.32 $23.32 10/5/15 Credit Card 202853 $0.00
Utility Rooms)
12%State Surcharge-Mechanical 100-0000-24001 $2.80 $2.80 $2.80 10/5/15 Credit Card 202853 $0.00
SFR-Baths 230-0000-43101 - $312.70 $312.70 $312.70 10/5/15 Credit Card 202853 $0.00
12%State Surcharge-Plumbing 100-0000-24001 $37.52 $37.52 $37.52 10/5/15 Credit Card 202853 $0.00
Totals for Fees $767.47 $767.47 $767.47 $0.00
Receipt# Payment Method Check# Payor:, Receipt Date Receipt Amount
202803 Credit Card Sara Johnson 09/30/2015 $117.11
202853 Credit Card Sara Johnson 10/05/2015 $650.36
Total Payments: $767.47
ov&-4._/,‘,9-.O "-`G 6-az Balance Due: $0.00
.04_kF46in/G fr/6-efie t f. c.aa X- AriT S effencac
3/A ,-7o 37 Sae % . a a /a .1--o YS.o-6 ;,937,4e/ a?, .52
75;0!0 - 9.o/ - g3 3,A o�'Fe� � , �2 -- .,, v?7
rte; �.J 7, 7 1F-- ALE: �" . A "f (P. Gy /7 a0 ,s°/ dr
a. 81 /aS, n
Plumbing Permit Application
'' .. Building Fixtures rc,R orrICI: USEON'l..V.
•
Received •
City of Tigard �`v�® Date/By: Permit No.:/ sr2.0(�0o(7).
a 13125 SW Hall Blvd.,Tigard,OR ',14'' Plan Review
: - e; Phone: 503.718.2439 Fax: 503.5" "-.. 0 Date/By: Other Permit No.:
-
'I'I G n It O Inspection Line: 503.639.4175 !p 3 Q �v Date ReadyBy: Juris: ® See Page 2 for
Internet: www.tigard-or.gov S 0 otified/Method: Supplemental Information
- - `TYPE OF.WORK. ; O' `O`.\- _ ,__,.FEE"_SCHEDULE ' : ' ..'.• .
❑New construction 0 !iv* n., Q For special information use checklist
Description ( Qty. f Ea I Total
4Addition/alteration/replacement 0 I ther: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION . SFR(1)bath 312.70
G'ell t d 2-family dwelling 0 Conunercialrndustrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building 0 Multi-family
Each additional bath/kitchen 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
JOB.SIITE INFORMATION-AND LOCATION Site utilities:
Job site address: k ►71 Q 71. -Ni.,,,,, .S�
C, -( Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76
City/State/ZIP: \\[no CRe T Xa7-3 Footing drain(no.linear ft.: ) Page 2
Suite/bldgJapt.no.: Project name: ---T iktScy) 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 12.5 i
Clothes washer 25.02
rmc:(2,6.A Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
° PROPERTY OWNER• ❑ TENANT' ` Expansion tank 12.51
Name: `,� ,^ Fixture/sewer cap 25.02
�r'��' \ l Floor drain/floor sink/hub 25.02
Address: ,I-10 '� SJV-VW' W ( - Y Garbage disposal 25.02
City/State/ZIP: 7 l C .k c\�a R) Hose bib 25.02
Phone:(5)31 g<j��_�� Fax:( ) Ice maker 12.51
APPLICANT . . ' .0 CONTACT PERSON • Interceptor/grease trap 25.02
Business name: ` w`O \ Medical gas(value:$ ) Page 2
VVV����JJJ Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory t 25.02 c25.0`__
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51 ,25%0 Wit,
C(� \ Urinal
, 25.02
E-mail: aC� ( �G�.� -Y C 1 Y
Water closet f 25.02 mss,e+a-
TRACTOR.
Water heater 37.52
Business name: 1J'Vt,,(--- Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50 75-,d(o
CCB Lic.: illip PI t• • no.: Plan review (25%of permit fee)
State surcharge(12%of permit fee) r1'•,a/
Authorized signature: TOTAL PERMIT FEE - j7
Print name: This permit application expires if a permit is not obtained within 180 days
�(' leti Date: (�d/ 5 after it has been accepted as complete
"Fee methodology set by Tri-County Building Industry Service Board.
I:wBuilding\Permits\PLMU•Permit App.doc l0/01/09 440-4616T(I0/01/COM/WEB)
Mechanical Permit Application ll►I4 OF ICI. US1'.ONLY _
City of Tigard ®�SP Daceiv , .
SE
n 13125 SW Hall Blvd.,Tigard,OR 9 Plan Review •
C Phone: 503.718.2439 Fax: 50 o,� Date/By: Other Permit:
I'I C.n i.i� Inspection Line: 503.639.4175 t�Q�. Date Ready/By: ►uds: ' ® See Page 2 for
Internet: www.tigard-or.gov $C51
1 Oi7��`(-�(�OOIA Notified/Method: Supplemental Information
G V` 'CJ`
TYPE OF',.`+ .,`GDO . . .. COMMERCIAL FEE* SCHEDULE.- USE CHECKLIST
``_IN`s' Mechanical permit fees*are based on the value of the work
0 New construction �Addition/albTf replacement performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,and profit.
Value:$
CATEGORY OF'CONSTRUCTION: • ` • RESIDENTIAL EQUIPMENT`/'SYSTEMS FEES"7..•
KfI�rtd 2-family dwelling 0 Commercial/industrial 0 Accessory building For special Information use checklist
❑Multi-family ❑Master builder ❑Other: Description _Qty. Ea. ] Total
': `. ••;••JOB SITEr;INFORMATION AND LOCATION •••'.•• • Heating/cooling:
Air conditioning 46.75
Job site address: `.t lC�1j�� �M 9f. urnace 100,000 BTU(ducts/vents) 46.75
City/State/ZIP: - `�0Jv--l W Cy'R_ CO_V� Furnace 100,000+BTU(ducts/vents) 54.91
CJS ct �O��� Duct pump 61.06
Suite/bldgJapt.no.: `-) Project name: Duct work 23.32
Cross street/directions to job site: 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: Lot no.: Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
• DESCRIPTION OF WORK . - • Gas fireplace/insert 33.39
Flue vent for water heater or gas .
� n
t, „n.0 \ — r yn� \W \ fireplace , 23.32
v _ v Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
Other: 23.32
PROPERTY OWNER` • •• ' . ❑.TENANT .'`:. '
Environmental exhaust and ventilation:
Name —3 Q1_ , � Range hood/other kitchen
R equipment 33.39
Address: `k%-,-e,) i C M 0._1f-e-S.A- Clothes dryer exhaust 33.39
City/State/ZIP:---K G, a C gNr..K5 Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) I 23.32 ;3.3)-
Phone:( ) ( _q- �')% Fax:( ) Attic/crawlspace fans 23.32
PLICANT 0 CONTACT PERSON. Other: 23.32
Business name Fuel piping:
li 514.15 for first four;$4.03 for each additional
Contact name: Furnace,etc. _
Gas heat pump
Address:
Wall/suspended/unit heater
City/State/ZIP: Water heater
Phone:( ) Fax::( ) Fireplace
! � , Range
E-mail:7l v� 11@___5(yyyk`t) C �^
`'`� O ! Barbecue
- .• NTRACTOR ' • .. . Clothes dryer(gas)
Other:
Business name:
CIIJ kr -e— MECHANICAL PERMIT FEES* .
Address: Subtotal ‘,1.3.3.2
City/State/ZIP: Minimum permit fee($90.00) q4-.pry
Plan review(25%of permit fee) —
Phone:( ) Fax:( ) State surcharge(12%of permit fee) /0_81) •
CCB lic.: TOTAL PERMIT FEE vo,ird
,,J This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: • Fee methodology set by Tri-County Building Industry Service Board
Print name: ` c/ ,.ma .ej/� Date: 3
1:\Building1Permlts M CC_P'ennnit+App 040113.doc 440-46171(Il/OM/WEB)
Electrical Permit Application G� 1.1114 ul•ric1:: ust:u' i.Y -
City of Tigard G Received
a 13125 SW Hall Blvd.,Tigard,OR 19 ��`� + Plan Review
O I i.
:11 IS • Phone: 503.718.2439 Fax: 503.}'°. ••.1 �01� Date/B : Related Permit It:
Inspection Line: 503.639.4175 (,D 3 U Ready Date/By: 1 See Page 2 for
I I C,A R p Internet: www.tigard-or.gov �t^`ric ,^A�Q Notitied/Method: u , ' Supplemental Information
• - _w-y• ^ TYPE OFIW!
11111- 'v.1.:'-. CITY OF TIGARD MASTER PERMIT
4'`. 1. COMMUNITY DEVELOPMENT Permit#: MST2015-00172
n-i. :._.t-..lDate Issued: 10/05/2015
giG ID, 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1S134CD07900
Jurisdiction: Tigard
Site address: 11810 SW SUMMER CREST DR
Subdivision: BURLWOOD NO.4 Lot: 12
Project: JOHNSON
Project Description: Interior remodel:Added interior walls to NE corner of home,and installed(1)sink,(1)tub, (1)
shower,(1)water closet,(2)branch circuits, and(1)bathroom fan.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 1 Third: 0 sf Right: 0
Detectors: Yes
Total: 0 sf Value: $7,000.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
0
Tubs/Showers: 2 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Drywell-Trench Drain: 0 Other Fixtures: 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
Fum>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add'I 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 2
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+a mp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio 8 Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing: Y
BUILDING INFO
Class of Work: Type of Use: Typo of Constr: Occupancy Group: Square Foot:
ALT SF VB R-3 0
Owner: Contractor:
JOHNSON,EVAN L 8 SARA OWNER Required Items and Reports(Conditions)
11810 SW SUMMER CREST DR EVAN 8 SARA JOHNSON 1 Subject to on-site review by
TIGARD,OR 97223 11810 SW SUMMER CREST DR inspection staff
TIGARD.OR 97223
PHONE: PHONE:
FAX:
Total Fees: $767.47
This permit is issued subject to the regulations contained in the Tigard Municipal Cade, 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 -• - Those ules. 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 c- ' e 503.23 . 987 or 1 e.332.2344.
Issued By: it�l�7i�,., Permittee Signature:
a 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 c•mpletion of the pr•
Approved plans are required on the job site at the time of each in •• tion.
Building Permit Application
.
Residential ® I()IbOI l ici: lisl?(hNl.l`
City of Tigard V5 Re«i°ea -y
CO\J y/3 0//S— Permit No.:,s^�- 0!5—_00.1 ! ,
q 1;113125 SW Hall Blvd.,Tigard,OR 9 Wi Plan Review "v
C • Phone: 503.718.2439 Fax: 503.59. 1"."' ,% IS° Date/By: SO l j cOther Permit:
-r I C;Ai;n Inspection Line: 503.639.4175 [Q I) Date Ready/By: kris: ® See Page 2 for
Internet: www.tigard-or.gov S GPD Notified/Method: JUI alp Supplemental Information
•F�-' 0 t. ' .,- n..._.
TYPE OF WO V. a 0 • . REQUIRED DATA:,1-AND 2-FAMILY'DWELLING
❑New construction ■I emolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
RAddition/alteration/replacement El Other equipment,materials,labor,overhead,and the profit for the
'.' •• *, '•CATTEGORY.;OF CONSTRUCTION - . • '; work indicated on this application.
Valuation: $
I1 and 2-family dwelling ❑Commercial/industrial
121Accessory building 0 Multi-family Number of bedrooms:
ElMaster builder ❑Other: Number of bathrooms:
JOB SITE.'INFORMATION:AND,LOCATION. ' - `:•,...
Total number of floors:
Job site address: 1 Q-lC '� Jr yjr , ii- New dwelling area: square feet
City/State/ZIP: \ U- ,Ar . C d • a_ Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: p Covered porch area: square feet
Cross street/directions to job site: iv.�" p 44) AS nII Deck area: square feet
r tf.�'- of koff,€- Other structure area: square feet
TDI, 54`e di J) S i'•1 . 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.
1f'� AC\O-JC_��Q r Valuation: $
1 " ` ` Existing building area: square feet
New building area: square feet
PROPERTY OWNER-. • • .. 0.TENANT , Number of stories:
Name: '' .•)c kJ0\rVikc)f Type of construction:
Address: t l5s-1 a R A) b \ N Crt y•)r' Occupancy groups:
City/State/ZIP: ---1 ��ri
oe, 1-7 9' Existing:
Phone:(S �� C Q' Fax:( 1 ) New: I
APPLICANT 0 CONTACT"PERSON . BUILDING.PERMIT FEES'
Business name: .".G {Please fees to fiv schedule).
-��— G�o�-L....) Structural plan review fee(or deposit): •
Contact name:
FLS plan review fee(if applicable):
Address:
Total fees due upon application:
City/State/ZIP: 1�� II
Amount received:Phone:( ) Fax::( ) .PHOTOVOLTAC SOLAR PANEL
SYSTEM FEES'E-meil:��) l � � Si GI1 G` /ii •
• Commercial and residential prescriptive installation of
- •. roof-top mounted Photo Voltaic Solar Panel System.
Business name: 0-kiivr . Submit two(2)sets of roof plan with connection details
and fire department access,along with the 2010 Oregon
Address: Solar Installation Specialty Code checklist.
City/State/ZIP: Permit Fee(includes plan review $190.00
and administrative fees):
Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lie.:
_ Total fee due upon application: $201.60
Authorized si= ature: , 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
Print name: \^ Date: q/ `RC/A 5 Service Board.
\
I:\Building\PermitsBUP-RESPermitApp.doc 02/24/2011" ` 440.4613T(I 1/02/COM/WEB)
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
11810 SW SUMMER CREST DR, TIGARD, OR,
97223
Residential - Master Permit
615 Mechanical rough-in
FAIL
MST2015-00172
David Young
Provide pictures of mechanical vent to check sizing and exit location.
Instal timer or de humidistat per code for bath fan.
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
11810 SW SUMMER CREST DR, TIGARD, OR,
97223
Residential - Master Permit
699 Mechanical final
PASS
MST2015-00172
David Young
Owner states bath vent is thru the roof, unable to verify due to no access.
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
11810 SW SUMMER CREST DR, TIGARD, OR,
97223
Residential - Master Permit
399 Plumbing final
PASS
MST2015-00172
David Young
Corrections complete.
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
11810 SW SUMMER CREST DR, TIGARD, OR,
97223
Residential - Master Permit
299 Final inspection
PASS - No C of O
MST2015-00172
David Young
All corrections for this permit complete.
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
11810 SW SUMMER CREST DR, TIGARD, OR,
97223
Residential - Master Permit
199 Electrical final
PASS
MST2015-00172
David Young
Note: owner calling in electrical final for panel change for approval.
Violation Summary:
Inspector Contractor