Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
93
Request for Permit Action
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 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 640*�2
Mailing Address: jf—
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
�ANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
fNVOICE R FEES DUE (attach case fee schedule and provide explanation below).
VE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ,/1/J.57` O9,91f5 ',O�/�1✓ /
Site Address or Parcel#:
Pro)ect Name:
Subdivision Name: �D/ ,{ J3or/r /7. Lot#: 7
414
EXPLANATION:
Signature: Date:
Print Name: a
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: Date I B Route to Records: Date jZ ,V /f B
Refund Processed: Date I ByAW I Invoice Processed: Date ,/f B
Permit Canceled: Date/L /c I B Parcel Tag Added: Date B
:\Building\Forms\Req PemittXcdon_092314.doc
City of Tigard • COMMUNITY DEVELOPMENT
Building Division
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
INVOICE
TO: Polygon WLH,LLC Customer ID: 204238
Attn: Maggie Gordon Invoice No.: INV2015-00009
109 E 13`h St Invoice Date: 12/10/2015
Vancouver,WA 98660 Date Due: 01/10/2016
Case No Site Address Subdivision-Lot#or Project Name Amount Due
MST2015-00184 15045 SW Danube Dr Polygon at Bull Mountain,Lot 7 $941.93
Plan review fees due for plan review
completed prior to request to cancel
permit.
Invoice Total: $941.93
® Please see attached fee schedule for description of fees due.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(Detach and return this portion with payment.)
Case No.: MST2015-00184 Customer ID: 204238
Site Address: 15045 SW Danube Dr Invoice No.: INV2015-00009
Project: Polygon at Bull Mountain,Lot 7 Invoice Date: 12/10/2015
Date Due: 1/10/2016
Invoice Total: $941.93
Amount Paid: $
Office Note: Route copy of receipt to Dianna Howse.
Please mail payment to:
City of Tigard,Building Division
Attn: Dianna Howse
13125 SW Hall Blvd.
Tigard, OR 97223
IA Building\Accounting\lnvoicc.doc 01/14/2011
CITY OF TIGARD FEE AND PAYMENT HISTORY
p 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
a �
MST2015-00184 - 15045 SW DANUBE DR, TIGARD, OR 97224
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due
Plan Review 230-0000-43106 $751.34 $751.34 $750.00 10/14/15 Check 400113 $1.34
Plan Review 230-0000-43106 $852.59 $852.59 $852.59
DC Provision Review, SF-Ping 100-0000-43112 $88.00 $88.00 $88
Totals for Fees $1,691.93 $1,691.93 $750.00 $941.93
Receipt# Payment Method Check# Payor: Receipt Date Receipt Amount
400113 Check 070575 Polygon WLH LLC 10/14/2015 $750.00
Total Payments: $750.00
Balance Due: $941.93
! ua fiin Permit Application
r
. '�esic�'enttal �,��® � • e •
City Of Tigard Receiv
e/B
ed
Permit No.: 0 ��
v 13125 SW Hall Blvd.,Tigard,OR 9722 Q t� Plan Review
C Phone: 503.718.2439 Fax: 503.598.1960 OC� iy �01� DateB : �)J Other Permit
Inspection Line: 503.639.4175 ^P�® Date Ready/By: // Juris 0 See Page 2 for 6�
Internet: www.tigard-or.gov O` �1 1 1 otified/Method:/ IIe I,S Supplemental Information
Cv Div S
'z "Haw
,
iddZdJ. ;.5�
®New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
work indicated on this application.
Valuation: O �-�
® 1-and 2-family dwelling E]Commercial/industrial
❑Accessory building ❑Multi-family Number of bedrooms: 4
❑Master builder ❑Other: Number of bathrooms: .
W"'�"uw " " "` n Total number of floors: 2
SITE�TIVEL�R1}IATION A1'DSI: CATI0N
.1%)WKR _�..,,. .-:._�mow.,
Job site address: (Y` ID W �D ox-�Ub-p— New dwelling area: 5'-'6-2_ square feet
City/State/ZIP:Tigard,OR 97224 Garage/carport area: 1 square feet
Suite/bldg./apt.no.: Project name:-" Tor rrAra27. Covered porch area: ac'square feet i. 7
Cross street/directions to job site: Deck area: square feet 1 6 i
Other structure area: square feet
COh1
I2EQUIi2EDATA 11i>GR£IxSL-i7SECE�CICI;IST x
Subdiv ion:Polygon at Bull Mountain Lot no.: Permit fees*are based on the value of the work performed.
Tax ma no.: Indicate the value(rounded to the t,eajsst dollar)of all
p cel
equipment materials,labor,overhead and the profit for the
61
.,.- -. _ 1} C3tIPTxCl1 Q �A� „u �; <• work indicated on this application.
.{, ,;„q'k°ei3�.:z<;.:',:,:;'.?,.25 '-'S*','.,. ",�-'•;i',�;'a.E,',.,�..,zv- '-`�`- �i x' V3d"
Valuation: $
Existing building area: square feet
New building area: square feet
W1,111UWNERTAfiT Number of stories:211 11-HN I
Name:Polygon WLH,LLC Type of construction:
Address: 109 E 13th Street Occupancy groups:
City/State/ZIP:Vancouver, 98660 Existing:
Phone:(360)695.7700 Fax:(360)693.4442 New:
.y'y-.,F ,.::z.`.si:4..;. _7 :",, ;�-:i3'..,c . ray
<xsa:,,
APP f „ :;. s 01ViACT�PE 1V "= - =., h <xB 7tLbING<l'ER1V11I 1 EES. ,..r,
'� f,Y x,.;t3h. ,h -,g._ .: 9 ✓p, acg»x>r ,v,<',--,ry>. ;.,5 .r 3
,..,:�.. tri -:.
.lav,- «Fm.A.. _ z•,,e
,.,7:>. M ,�'.�n'i ,u ,;€k.,,;i@a srasa.t�ldi ,€ ,> -.. 'Mw;r�Y - "SY'ItCllit
�",fv�fwu '�� �z •z»�,W N*,-,-:nftrj,,.'hv'3''Ps':ae,�l's�W' "
Business name:Same
Structural plan review fee(or deposit):
Contact name:
FLS plan review fee(if applicable):
Address:
City/State/ZIP: Total fees due upon application:
Phone:( ) Fax::( )
Amount received:
,; ..
�PHO'1'UVOL•^TA3. St},LAR"3'A3�TEIiSYSTEl14 FEES*
E-mail:maggie.gordon@polygonhomes.com "� x�� �==--'-� a � �'" s(
IQ Commercial Commercial and residential prescriptive installation of
roof-top mounted PhotoVoltaic Solar Panel System.
Business name: s,. 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 $180.00
and administrative fees):
Phone:( ) Fax:( ) o
State surcharge(12%of permit fee): $21.60
CCB lic.:204238 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.
L
name:
Date: _I *Fee methodology set by Tri-County Building Industry
Service Board.
-ng\Petmits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Eiectrical Permit Application • • •
City-of Tigard RDaceed
Permit#:
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Related Permit#:
Phone: 503.718.2439 Fax: 503.598.WOENotified/Method:
DateBInspection Line: 503.639.4175 Y Ready DateBy: 1�5' ® See Page 2 for
Internet: www.tigard-or.gov Supplemental Information
Ar
TYEEOFWUZK" � °
��£-,..,...aN t . -�asxut3• za9�, �- ��. yrs_ a x�"efa
®New construction ❑❑Add ition/alteration/;eQli} u V1 Please check all that apply(submit 2 sets of plans w/items checked):
C''��Y( ❑Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition Other: where the available fault current ❑Marinas and boatyards.
T_ EGORY OF C( �' exceeds 10,000 amps at 150 volts or ❑Floating buildings.
.tea .. �,...�,_ --.......1,__.:<._ 'kaS• S `�n
® 1-and 2-family dwelling ❑Commercial/industrial [:]Accessory building less to Bound, exceeds [1 Commercial-use agricultural
amps for all other installations.
buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or
z:, '"3 ` '' ❑Emergency system. larger separately derived
- -= }_ ��JOB WSI I E INFORhiA1 ()Pl_AND:LOCATION; ,<; ,,,s. d
` `I ❑ load f
Addition of new motor o system.
Job#: Job site address: ( � "15 5VD IOOHP or more. ❑"A","E","1-z","1-3
❑Six or more residential units. occupancy.
City/State/ZIP:Tigard,OR 97224 Cl
p
LC7 ❑Health-care facilities. Recreational vehicle arks.
Suite/bldg./apt.#: Project name:River Terrace ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions toob site: T ""rw'FEESCIiEDIIi E ' J
j v ;iP�. „. :.
Description I Qty. I Each I Total
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 1 168.54 4
Tax map/parcel#: Ea.add'1500 sq.ft.or portion 33.92 1
-
�r Limited energy,residential
w,.,.=. 75 00 2
with above sq.ft.
Limited energy,multi-family 75.00 2
residential(with above sq.ft.
Renewable Ener ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
Name:Polygon WLH 200 amps or less 1 100.70 2
Address: 109 E 13th Street 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Vancouver,CA 98660 601 amps to 1,000 amps 301.04 2
Phone:(360)695.7700 Fax:(360)693.4442 Over 1,000 amps or volts 552.26 1 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,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
_,... —
r -,,,,,,,r,, ;^�,•.- IM, Branch circuits new,alteration,or extension, er ane
� Al!ELICANT' i 1z�' :❑i'CO' xACT>PERSQI�t'".-
- A.Fee for branch circuits with
Business name:Same above service or feeder fee, 7.42 2
each branch circuit
Contact name: B.Fee for branch circuits without
service or feeder fee,first 56.18 2
Address: branch circuit
City/State/ZIP: Each add'I branch circuit 7.42 1 2
Miscellaneous service or feeder not included
Phone:( ) Fax: :( ) Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Email: Reconnect only 67.84 2
.-?G' _ r'•.eYS wv%; - �r d,a'.4?'Ir,;.,n,�_ao,s: �,,r.<.'-E•s•,,_g�*
z e ick « .•-- -;'� YL^ Vis'.,' Lr,...
MCQN'T1iALTf?It l r ,; f-w� ? .b
xr �x.�:,. Pump or irrigation circle 67.84 2
Business name: Sign or outline lighting 67.84 2
Signal circuits)or limited-energy
Address: panel,alteration,or extension. ❑ See Page 2 2
Each additional inspection over allowable in any of the above
City/State/ZIP:
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 Lic.. Suprv.Lic.: specifically listed(%hr min
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.
C\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(I1/05/COM/WEB ,
M'echa'nical Permit Application • • •
City of Tigard ® ReceivedDate/By:: Permit No.:
e 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 �i Date/By: Other Permit:
a Inspection Line: 503.639.4175 V` Date Ready/By: runS 0 See Page 2 for
Internet: www.tigard-or.gov ^01� Notified/Method: Supplemental Information..,h Mechanical permit fees' are based on the value of the work
®New construction ❑Addition/altera ```` performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: Vv\ I mechanical materials,equipment,labor,overhead,and profit.
CAT lit tRY,O) tONST4itIC Value
:�; -,--:= ..._. T -,. :, ItESIDE3�ITIAI.>QITIPMEI�1TlSYSTEISISFEES*
" -�
® 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist
❑Multi-family ❑Master builder ❑Other: Description Qty. Ea. Total
'- ;- Heating/cooling:
„ clB sITEzIvaRl�rnTTorri.arm o
...
;= „ v .,:� a m
�.fi
E Air conditioning1 46.75
Job site address: J��L��� Furnace 100,000 BTU(ducts/vents) 1 46.75
City/State/ZIP:Tigard,OR 97224 Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.: Project name:River Terrace Duct work 1 23.32
Cross street/directions to job site: H dronic hot waters stem 23.32
Residential boiler(radiator or
h dronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for anyof above 23.32
Z Other: 23.32
Subdivision: Lot no.: T
Other fuel appliances:
Tax map/parcel no.: Water heater 1 23.32
-�,;� „a - :<a Gas fire lace/insert 1 33.39
ES+CRt3>♦T flF�yWQR �: ;y;
Flue vent for water heater or gas
fireplace 1 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: Range hood/other kitchen
equipment 1 33.39
Address: Clothes dryer exhaust 1 33.39
City/State/ZIP: Single-duct exhaust(bathrooms,
Q
toilet compartments,utility rooms) 23.32
Phone:( ) Fax:( ) Attic/crawls ace fans 23.32
Other: 23.32
€ ;
❑; 1PPI:I{11NI F a.. `CDNIAt'I PERSON:';'::
._.
Fuel piping:
Business name:
$14.15 for first four;$4.03 for each additional
Contact name: Furnace,etc. 1
Gas heat pum
Address:
Wall/suspended/unit heater
City/State/ZIP: Water heater 1
Phone:( ) Fax::( ) Fireplace 1
Range 1
E-mail: Barbecue
x _ 3
Clothes dryer(gas)
W101 '1111 ^( - Other:
Business name:
��"I4IEGHf1N1�li�t1L�EEI�NIITFEES*mY a� ;,i�� '�-��-��'.
Address: Subtotal
City/State/ZIP: Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:( ) Fax:( ) State surcharge(12%of permit fee)
CCB lic.: TOTAL PERMIT FEE
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: Date:
1:Building\Permas\MEC_PermitApp_040113 doc 4404617T(11/02/COM/WEB) —,
di ti
ECEI'I����IVE v
Plumbing Permit Application
•
Building FixturesNOV 12 2015 �� p(
,Recaved Permit No
City of Tigard U(sAK Dil
a 13125 SW Hall Blvd.,Tigard,OR YTtls Elan Review Other Permit No
Phone-. 503.7182439 Fax 503 S6'196D� � ��!'����� Dat�Y•
l ¢lulu D I !?ate Reddy/By. )zero ® See Page Z for
Inspection Line: 503.639.4175 DatiSedrNletlwd Supplemental Information
Internet www.tig-d-or.govVii
_ — F,.,pe fn ormation use checkffst ~
Total
New construction E)Demolition Discal tion Ea
❑ New 1-2-family drrelli s(includes 100 ft.for each utility connection)
Additionlalteration/replacement ❑Other►
SFR(1)bath 312.70
SFR(2)bath 437.78
1-and 2-family dwelling ❑Commereial/indrlstrial SFR(3)bath 50032 5�U'
❑Accessory building ❑Multi-family Each additional balh/kltchen 25.02
Other: Fire sprinkler C_sq-ft-) Page 2
[]
Master builder site utilities:
4°= Man—No W IM: mom
Catch basin®raw ca drain 18.76
Job site address: 5`� C�.J p�u�Q Drywell,leach tine,or traneh drain 18.76
CiIP: c'i�L�'AFooting drain(no.linear R: Page 2
ty/StatrJL `�1 '
Q ,� t�,� Manufactured home utilities 50.03
Suitelbldg./apt-no.: Projectnam�: Pb� V�I� 1 rU / 1
Manholes 18.76
Cross street/diteetions to job site: Rain drain connector18.76
Sanitary sewer(no.linear R I r7 Page 2
Storm sewer(no.linear fL: Q Page 2
Wats serfic t(no.linear R:LW Page 2
Subdivision LA no.: �' Fixture or item: 3127 ,2
Backflow preventar
Tax map/paroel no.: Backwater valve ( 12.5] �'Z•�j�,
Clothes washer i 25.Q2 .0
_ Dishwasher 25.02 02
7�Y1 Drinking fountain 25.02
{{.•f7 EjectorsfsumP 25.02
Expansion tank 12.51
Fixture/scwer cap 25.02
Name: !+ Floor drairdfloor sink/hub 25.02
Address: t 1 �f ' 'n Garbage disposal 25.02 2
• W Hose bib 25.02 ,D
City/StatefLlP: 12.51 Z
Ice maker
Phone Q Fax( ) Interoeptor/grease trap 25.02
r
Medical gas(value:S } Page 2
Business!Imre: lie I Primer 12.51
Contact naRoof drain(commercial) 12 S l
me:
Address: Sirtk/basirl4avatory ((J 25.02
,r, Solar,units(potable water) 62.54
City/5tFdelZ1P: U E25.02
'Z (�
Tub/shower/showar pan. 3
Phone:( j) �3 b
Fax::( ) Urinal
Witwolosd Water heater �.
Btrs"lrnss rtetne:
U Water piping/I 56.29
Other 25.02
Address: Subtotal
CitylStatelLiP: RSR Minimum permit fee: $72.50
Phone )•,. j( — b3 Fax( } Pian review (25%of permit fee)
CCB Lic.: Plumbing Lie. State surcharge(12%of permit fx)
TOTAL PERMIT FEE
Authorized signature:
Tbis permit appli--- expires iter permit isnot obtained within 180 days
J Date: after it has been accepted as complete.
Print namel r` r•-- - Fee methodology set by T"ourny Building Industry Scrvice Board.
I:,a.lffiwarad,\PLrdIYPeYmilApp.dot 10/01109 44DA616T(101021COMAVE10
City of Tigard
a COMMUNITY D13V1='LO]'MENT DFPARTMLNT
C
Building Permit Review — Residential
V+
Building Permit #:
Site Address: 15011 'r Sy( 01-An OD-P,
Project Name: G, - 1 Poly qon Qui\ Mauntz-A%'n Lot #:
(New dwelling= subdivision name;. Addition or Alteration=last name of owner)
Planning Review
Proposal: N�/W cS
�erifjv site address/suite# exists and active in permit system. (SKows 1 0� 2 i1'1 Gt(CQ.IQ �dK" ° a
O+'-;c7itic•
River Terrace Neighborhood: � Yes ❑ No
IV�fiv Parcels haf def G+ll��ntd.
Site Plan Elements:
Three(3) copies of site plan � isting structures on site
Site plan must be on 8-1/2"x 1 1"or 11 x 17"paper �l7ootprint of new structure(including decks) uvith finished
Drawn to scale (standard architect or engineer scale) floor elevations
North arrow dUtility locations (required for neve,may apply for additions)
ite address,project or subdivision name and lot number cation of wells/septic systems
Applicant information (name and phone number) iroston control (including drainage-way protection, silt fence
Wot dimensions and building setback dimensions design,location of catch basin,etc.)
/Lot area,building coverage area,percentage of coverage and Atreet names
—/ttnpen,ious area (applicable if R-7,R-12,R-25&R-40) Street tree size,type and location
ropert-\7 corner elevations (2 foot contour lines if more than XI-xisting 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: 1 Yes,applicant was notified ❑ No Received: ❑ Yes ❑ No
Public Facilities Improvement(PFI) Permit:
Required: ❑ Yes,applicant was notified E] No Applied For: Yes El No,stop intake
0rZ/7Land Use Case#: SU 09 '2 0\S;— '00 00'2-
/Z
Zoning: , S
Setbacks: Front -2�o Rear Side Street Side I S Garage
Landscape Requirement. %
Lot Coverage Maximum:
Building Height: Maximum Height Actual Height �
Visual Clearance
�Easements
Sensitive Lands: ❑ Yes No Type
Urban Forestry Plan � "
El Conditions "Met"prior to issuance of buildingermit V)(lA-hO Y-)i V-)
Notes:
Approved By Planning: Date: t O/`7) IS
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
Building Permit Submittal
Original Submittal Date: / ) �j S7—
Site Plans: # 7 —
Building Plans: # 3
Building Permit#: !nter building permit#above.
Workflow Routing: inning �iigineeringrmit Coordinator 5�- u—Ig
Workflow Sign-off: [§ gti-off for Planning(include notes from planning review)
Route Application Documents: E9 engineering: (1) cop),of permit application, (1) site plan, (1) building plan and
original plan review routing form.
D-lTbflding: original permit application, site plans,building plans, engineer and
beam calculations and trust details,if applicable,etc.
Notes:
By Permit Technician: �� Date:
Engineering Review
/FrSlope at building pad:
41.0
® Conditions "Met"prior to issuance of building permit
Easements (encroachments) per engineering conditions of approval and plat
IET-\vater Quality/Quantit>>FacilitX:
Assess Water Quality Fee in-lieu: ❑ Yes .E'No
Assess Water Quantity-Fee in-lieu: ❑ Yes .RrNo
LIDA Facility on lot: ❑ Yes ErNo
❑ NOT Approved by Engineering: Date:
Notes: PIUVC� OOT 94 .e"Xb P&4;�iNE7 Ci,,1 -"59
Approved by Engineering: Date: A) tS�
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:/,0
Notes:
dt
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:
DC Fees Entered: Wash Co'Trans Dev Tax: � 1 es ❑ N/A
Tigard Trans SDC: �;'Yes ❑ N/A
Parks SDC: (-Yes ❑ N/A
POK to Issue Permit
pproved by Permit Coordinator:
1:\Building\Forms\BldgPer iitRvw_RES_070915.docx