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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Niii 0 1 D i --:- -711Re uest for Permit Action i2/45- _ ;, ,,,i. , , 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor (gC City Staff Check(1)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 2gf— CANCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: MST x0115—oo aO7 Site Address or Parcel#: 1O(040 á5T) ci2.12v-bEw Cr Project Name: 11-1-41-1 Subdivision Name: Lot #: EXPLANATION: Pai.4 i-r tis Ta 13 Q I,Je, kit's.)- C+or-+AA s) r ilea Essoe y ‘' -r2uc-r i Q..S_ I t. O CSM PL,A'JCt. ._reit) gac Pe rhe 1,E i.1 je_443 Ce t3te.e. Oi t2. -1: t4 ut *rs Ptere 1 T 7-.e 40Th to. t)tHo at./r I6'St t'E1,To /2411miE. jrgte4Qrwtt♦ H' T t5-00 804-I (0aew1Deb Le4.errdieni.'01' ) Signature: ( t. 4. Date: //4.0S— Print Name: Th AA ig. e4Di t1 t_ Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONLY Route to Sys Admin: Dated/ 83 e Cow_ Route to Records: Date /2./to%. B 1 Refund Processed: Date /If : ! Invoice Processed: Date /2p7is BydfiXt— Permit Canceled: Date /44.07/S By .. • Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_0923oc rCity of Tigard • COMMUNITY DEVELOPMENT pi Building Division 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov TIGARD INVOICE TO: Simon Pham Customer ID: C15-00004 10640 SW Derry Dell Ct Invoice No.: INV2015-00007 Tigard, OR 97223 Invoice Date: 12/10/2015 Date Due: 01/10/2016 Case No. Site Address Subdivision-Lot#or Project Name Amount Due MST2015-00207 10640 SW Derry Dell Ct Development Code Review Fee $88.00 for review completed prior to request to cancel permit Note: Adjustment of original -1.69 surcharge fee paid resulted in overage applied to a portion of development code review fee due Invoice Total: $86.31 ® Please see attached fee schedule for description of fees due. (Detach and return this portion with payment.) Case No.: MST2015-00207 Customer ID: C15-00004 Site Address: 10640 SW Derry Dell Ct Invoice No.: INV2015-00007 Project: Pham Invoice Date: 12/10/2015 Date Due: 1/10/2016 Invoice Total: $86.31 Amount Paid: $ Office Note: Route copy of receipt to Dianna Howse. Please mail payment to: City of Tigard, Building Division Atm: Dianna Howse 13125 SW Hall Blvd. Tigard, OR 97223 I:\Building\Accounting\Invoice.doc 01/14/2011 Ii CITY OF TIGARD FEE AND PAYMENT HISTORY 13125 SW Hall Blvd.,Tigard OR 97223 ' 503.639.4171 TIlGARD MST2015-00234 - 9908 SW MURDOCK ST, TIGARD, OR 97224 Revenue Payment Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due Building Permit-New Construction 230-0000-43104 $1,155.90 $0.00 Plan Review 230-0000-43106 $751.34 $751.34 $750.00 12/1/15 Check 400834 $1.34 12%State Surcharge-Building 100-0000-24001 $138.71 $0.00 Totals for Fees $2,045.95 $751.34 $750.00 $1.34 Receipt# Payment Method Check# Payor: Receipt Date Receipt Amount 400834 Check 5769 Sage Built Homes LLC 12/01/2015 $750.00 Total Payments: $750.00 Balance Due: $1.34 Building Permit Application Ni ( fl f 2./id iS Rewlential ‘Nt-VFOR OFFICE USE ONLY Cl of Tigard Received `J �� Date/B : i - / IMEI 11 ._IIM IN • 13125 SW Hall Blvd.,Tigard,OR 97223 5 Plan Review I' • Phone: 503.718.2439 Fax: 503.598.1960 + �O� Date/B : ! Other Permit: T I G A R D Inspection Line: 503.639.4175 0` 1 y,. Date Ready/By: See Page 2 for Internet: www.tigard-or.gov `,t:,�51/4 'Notified/Method: F�6� Supplemental Information !1 TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING Demolition Permit fees*are based on the value of the work performed. 0 New construction ❑ Demohtton 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. Valuation: $Pr WO //�` I-and 2-family dwelling 0Commercial/industrial ❑Accessory building 0 Multi-family Number of bedrooms: IDMaster builder 0 Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: i it..dC Y -".` New dwelling area: square feet City/State/ZIP: �:t: •,� '� `722_. Garage/carport area: Square feet Suite/bldg./apt.no.: Jest name: . _ Covered porch area: square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet 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. '— Valuation: $ Existing building area: square feet New building area: square feet 0 PROPERTY OWNER 0 TENANT Number of stories: Name: `lid, � i..A Type of construction: Address: l O.c te o z2 t )C w.\-...„f-(i c Occupancy groups: City/State/ZIP: �� /` Z 5 � — -7-2. Existing: Phone:( ) 1 Fax:( ) New: 0 APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES* (Please refer to fee schedule) Business name: cS4 Z S a te Structural plan review fee(or deposit): Contact name: FLS plan review fee(if applicable): Address: ....1 / 70.1 7 Total fees due upon application: City/State/ZIP: Phone:( ) Fax: :( ) Amount received: E-mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* Commercial and residential prescriptive installation of CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System. Business name: Submit two(2)sets of roof plan with connection details LIt"/rUry and fire department access,along with the 2010 Oregon Address: Solar Installation Specialty Code checklist. City/State/ZIP: Permit Fee(includes plan review $180.00 and administrative fees): _ Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60 CCB lie.: Total fee due upon application: $201.60 Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: ` Date: ‘1,1 C.- (1 *Fee methodology set by Tri-County Building Industry 1���.1 �� 1 Service Board. I:\Building\Permits\BUP-RESPetmitApp.doc 02/24/201 I 440-4613T(1 I/02/COM/WEB) , :l Building Permit Application Checklist One- and Two-Family Dwelling FOR OFFICE USE ONLY City of Tigard Received Date/By: Permit No. 74 13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits: 1 Phone: 503.718.2439 Fax: 503.598.1960 TIGARU 24-Hour Inspection Line: 503.639.4175 0 Electrical 0 Plumbing 0 Mechanical Internet: www.tigard-or.gov ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No 1 k I Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ■ 2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. ❑ Cl ❑ 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 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- ❑ ❑ ❑ basin protection,etc. _ I 0 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 0 ❑ ❑ 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 ❑ 0 ❑ and location. 13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, ❑ 0 0 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- ❑ ❑ 0 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. 0 0 ❑ 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 0 ❑ ❑ over 10 feet long and/or any beam/joist carrying a non-uniform load. 20 Manufactured floor/roof truss design details. 0 0 ❑ 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 he shown to be a..licable to the .ro'ect under review. JURISDICTION.,1I. SPECIFICS 23 Three(3)site plans are required for Item II above. Site plans must be 8-1/2"x I I"or 11"x 17". ❑ ❑ ❑ 24 Two(2)sets each are required for Items 16, 19,20 and 22 above. ❑ ❑ ❑ 25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans 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. 0 ❑ ❑ 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, ❑ 0 ❑ 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. 1:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-46 I 3T(11/02/COM/WEB) Electrical Permit Application %CtINVA) Received FOIR OFFICE USE ONLY AlCity of Tigard Date/By: Permit 9: N 13125 SW Hall Blvd.,Tigard,OR 972 Plan Review Phone: 503.718.2439 Fax: 503.598.1960 n`�� 1 2015 Date/By: Related Permit#: ' T I G A R D Inspection Line: 503.63 .4175 N Ready Date/By: Juris: FE See page 2 for Internet: www.tigard-or.gov Ok e.��SAK� Notified Method: Supplemental Information TYPE OF WORK,' ' ,r.rrii i�ri t�'''. PLAN REVIEW ❑New construction 0 Addition/alteratiqpirttlacement Please check all that apply(submit j sets of plans w/items checked): T? 0 Service or feeder 400 amps or more 0 Building over three stories. ❑ Demolition 0 Other: where the available fault current 0 Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10.000 amps at 150 volts or 0 Floating buildings. 0 I-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less to ground,or exceeds 14.000 0 Commercial-use agricultural amps for all other installations. buildings. 0 Multi-family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived Job#: I Job site address: 106 t r—z.s,��CV V C� ❑100H Addition of new motor load of system. 100HP or more. ❑"A","E","1-2","1-3", City/State/ZIP: c,_0 � © 2_ q 7Z Z El Six or more residential units. occupancy. _ ❑Health-care facilities. 0 Recreational vehicle parks. Suite/bldg./apt.#: I Project name: < k \ ❑Hazardous locations. 0 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 Qhs. 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 I DESCRIPTION OF WORK Limited energy,residential 7 _ (with above sq.ft.) 75.00 c...77.2 L`a°� �` 7 1( `�� Limited energy,multi-family 75 00 residential(with above sq.ft.) Renewable Energy ❑ See Page 2 PROPERTY OWNER 0 TENANT Services or feeders installation,alteration,and/or relocation Name: 4L ,.,,,• , 2t �Ne..,k 200 amps or less 1 100.70 2 201 amps to 400 amps 133.56 2 Address: L Q 6 ei., C_e_t__; --p c) - 401 amps to 600 amps 200.34 2 City/State/ZIP: ��t°t CG ` 9722_ 601 amps to 1,000 amps 301.04 2 Phone:(� qq _ v9 k I Fax:( ) Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or Email: 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,le en e=,_ait+•,(according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2 Owner signature_ �t ` Date: ( IC7 C 1' T401 amps to 599 amps 168.54 2 0 APPLICANT I 0 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 Address: service or feeder fee,first 56.18 branch circuit City/State/ZIP: Each add]branch circuit 7.42 Phone: Miscellaneous(service or feeder not included) ( ) Fax: :( ) Each manufactured or modular dwelling,service and/or feeder 67.84 Email: Reconnect only 67.84 _ CONTRACTOR Pump or irrigation circle 67.84 _ Business name: Sign or outline lighting 67.84 '_ Address: Signal circuit(s)or limited-energy 0 See Page 2 panel,alteration,or extension. City/State/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 Industrial plant(1 hr min) 78.18/hr Email: inspections for which no fee is 90.00/hr CCB Lie.: Electrical Lie.: Suprv. Lie.: specifically listed('A 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: Date: days after it has been accepted as complete. * Number of inspections allowed per permit. I:Building,Permits ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 440.4615T(11/05/COM/WEB - Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Description I Qty. I Each I Total I * Fee for all residential systems combined: $75.00 Renewable electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 2 5.01 to 15 kva 133.56 2 n Audio and Stereo Systems* 15.01 to 25 kva 200.34 2 Wind generation systems in excess of 25 kva: n Burglar Alarm 25.01 to 50 kva 301.04 2 ❑ Garage Door Opener* 50.01 to 100 kva 552.26 2 >100 kva(fee in accordance 552.26 2 with OAR 918-309-0040) n Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva: System* Each additional kva over 25 7.42 3 • n Vacuum Systems* >100 kva—no additional charge 0.0 3 Each additional inspection over allowable in any of the above: n Other: Each additional inspection is 6625/hr charged at an hourly(1 hr min) Inspections for which no fee is 90.00/hr specifically listed('V,hr min) COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES Subtotal(Enter on Page I): Fee for each commercial system: $75.00 * Number of inspections allowed per permit. (SEE OAR 918-309-0000) Check Type of Work Involved: n Audio and Stereo Systems Ti Boiler Controls Ti Clock Systems Ti Data Telecommunication Installation n Fire Alarm Installation • n HVAC ❑ Instrumentation Intercom and Paging Systems ❑ Landscape Irrigation Control* Ti Medical ❑ Nurse Calls n Outdoor Landscape Lighting* ❑ Protective Signaling n Other: Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\Building\Permits\ELC_PermnApp_ELR_ERE.doc Rev 06/17/2015 City of Tigard . COMMUNTI'Y DEVELOPMENT DEPARTMENT T I G A R D Building Permit Review — Residential Building Permit #: '1 S1-aotS----0c o7 Site Address: 10610 Srnr Derr\.] Dell C+. Project Name: 414/n Lot #: (New dwelling=subdivision name;Addition or Alteration=last name of owner) Planning Review Proposal: -ACC.Ji OJ b vi 1 G Uv1'j Irtnel0 r^')GALtI— i+ S 12 39Nc,re- C—&F Verify site address/suite#exists and active in permit system. yi River Terrace Neighborhood: 0 Yes $ No Site Plan Elements: Three(3)copies of site plan Existing structures on site Site plan must lie on 8-1/2"x 11"or 11 x 17"paper ,00tprint of new structure(including decks)with finished /Drawn to scale (standard architect or engineer scale) floor elevations North arrow ..--gtitility locations(required for new,may apply for additions) Zite address,project or subdivision name and lot number - T ation of wells/septic systems Applicant information(name and phone number) Vision control(including drainage-way protection,silt fence Lot dimensions and building setback dimensions design,location of catch basin,etc.) --Erni-lira,building coverage area,percentage of coverage and ,Z treet names impervious area(applicable if R-7,R-12,R-25&R-40) t tree size,type and location roperty corner elevations(2 foot contour lines if more than - i ing trees to be retained with drip line,and tree 4 foot differential) protection measures Clean Water Services-Service Provider Letter(lot platted prior to 9/10/1995): Required: 0 Yes,applicant was notified El No Received: El Yes El No -EITublic Facilities Improvement(PH) Permit: Required: El Yes,applicant was notified El No Applied For: El Yes El No,stop intake - t a id Use Case#: (.12' Zoning: (a 3 • S ZSetbacks: Front 7,0 Rear `S Side 5 Street Side 2o 2 Garage - Landscape Requirement: -! vEr Lot Coverage Maximum: — % 2 Building Height Maximum Height 3 0 Actual Height 9C —Visual Clearance sements --El-Sensitive Lands: ❑ Yes 0 No Type -$1:Tfban Forestry Plan -0 Conditions "Met"prior to issuance of building permit Notes: Approved By Planning: /1'1 Oil 17.i CI'1 oLe---CW— Date: LI 112//J Revisions (after Building Submittal only) Reviewer Date Revision 1: 0 Approved ❑ Not Approved Revision 2: 0 Approved ❑ Not Approved Revision 3: 0 Approved El Not Approved I:\Building\Forms\BldgPermitRvw_RES_0709 I 5.docx Building Permit Submittal Original Submittal Date: /1/4d-Ji Site Plans: # 3 Building Plans: # ? Building Permit#: nter building permit#above. Workflow Routing: arrn-iing ( Permit Coordinator g Workflow Sign-off: ff for Planning(include notes from planning review) Route Application Documents: veering. (1) copy of permit application, (1) site plan, (1)building plan and original plan review routing form. L�`Butlding original permit application,site plans,building plans,engineer and beam calculations and trust details,if applicable,etc. Notes: By Permit Technician: -waftDate: ////Y/. Engineering Review ❑ 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 ❑ No Assess Water Quantity Fee in-lieu: ❑ Yes 0 No LIDA Facility on lot: ❑ Yes ❑ No ❑ NOT Approved by Engineering: Date: Notes: Approved by Engineering: Date: ��✓��C)' Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Revision 3: 0 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: 0 Yes ❑ N/A Tigard Trans SDC: ❑ Yes ❑ N/A Parks SDC: ❑ Yes ❑ N/A (84aK to Issue Permit Approved by Permit Coordinator: Date: »/40r I:\Building\Forms\BldgPetmitRvw_RES_0709 I 5.docx Clean Water Services File Number j 15 003686 i CleanWater Services 1. -- y'� �'.+ El) . Sensitive Area Pre-Screening Site Assessment r 1. Jurisdiction: ? `` /,�- 12 Z2015 l�.�^� L �" tom +��" 2. Property information (example 1S234AB01400) 3. Owner Information LIR 01' i11r(�KU ‹,.'i Tax lot ID(s): Name: 64.�^�» � I T til rel jOplr Company: ; , Address: IC C,4rCD S t.>v: 3>Fty=Z \,,`'t.'-\i k OR Site Address: toC/ C)=�Ll✓— .Z..- _ '�\. City,State,Zip: "Ti a b...,.._;;_ ef`4,1-'2,.-Z_ City, 4'1-'2,-'S- City, State,Zip: —C C} Z Phone/Fax: -- .", Nearest Cross Street: uE-Mail: Si .tom: • S e-t...y=n..)e[=t-tA`tL.Ct`)t. ,�,� '�....�S. �"� . 4. D velopment Activity (check all that apply) 5. Applicant Information _ Addition to Single Family Residence(rooms,deck,garage) Name.____ ____A.-L-- --_ C'C 2 - ❑ Lot Line Adjustment ❑ Minor Land Partition Company: ❑ Residential Condominium ❑ Commercial Condominium Address: ❑ Residential Subdivision ❑ Commercial Subdivision City, State,Zip: ❑ Single Lot Commercial i❑ Multi Lot Commercial Phone/Fax: Other —___-.-----___— E-Mail: - 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 need d to underst rid your project V.E1> C—<-Z�/N..> S. ere ►>, Lt( }C1C:t `�-,_..) 3 2. '�k.(' - — 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 Duality,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 arid agrees that employees at Clean Water SeMces have authority to enter the project site at all reasonable times tar the purpose of Inspecting project site conditions and gathering information related to the project site. I certify that 1 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. L fA,c-1 Print/Type Title �.) h') E CZ PrinflType Name +� �'H�'"� — --c-----, S Date \1. i C..3 i k Signature C`-�'' AAA_= -' FOR DISTRICT USE ONLY O 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. It Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report may also be required. ❑ Based or;review of the submitted materials and best available information Sensitive areas do not appear:o exist on site or within 200'of the site.This Sensitive Area Pre-Screening Site Assessment does NOT e'irninate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered.This document wilt serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1. Ail required permits and approvals must be obtained arid completed under applicable local,State,and federal law. Based on review of the submitted materials and best available Information the above referenced project wit 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 ant federal law. U 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. 11/12/15 _ Date_-T Reviewed by G -+t- 4,;.._4�� `"� Once complete,email to: SPLReview@cleanwatersetvices.org • Fax: (503)681-443; 97123 OR mail to: SPL Review, Clean Water Services, 2650 SW Hillsboro Highway; Hillsboro, Or, gOnR'Msed 7G