Permit City of Tigard 4. COMMUNITY DEVELOPMENT DEPARTMENT EXPIRED
1111 w
Request for Permit Action 0 y, 7
TI G A R n 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 0 City Staff
Check(✓)one
REFUND OR Name: � 1
INVOICE TO: (Business or Individual) N/Pt
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
, 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).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: rp 5 9.0 i°5-- 0 7
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Site Address or Parcel#: t CSOtD `a.U3 N1I H (131.-LS A-J
---ri'Ce A-( t C)2. 9 -7 ?-- 3
Subdivision Name: Lot#:
EXPLANATION: pf,2 CH. I P Pa A R f, cTi l b k r, Gk p,f..ti p€A.,--i,-r ,,,a
Aa.1 i )vey crA)Le• 14su01- r. e_,E_ on. 1A1)-7/,5—
Signature: , CtC . A& . - Date: ;/a9/17
Print Name: �661� 0---. Ortust-i kl
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: Date3 et.? 17 B liffir Route to Records: Date 9 /7 /7 By r.'
Refund Processed: Date V/ By Alf Invoice Processed: Date By
Permit Canceled: Date x//7//7 By ---• Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.doc
CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
COMMUNITY DEVELOPMENT
Permit#: FPS2015-00187
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued:
Parcel: IIS134AD06202
Jurisdiction: Tigard
Site address: 10500 SW NIMBUS AVE T
Project: Solid Rock Fellowship Subdivision: IKOLL BUSINESS CENTER,TIGARD Lot: A
Project Description: Replacing fire alarm control panel,smoke detectors,duct detectors,and sprinkler switches.
Contractor: ACTION TECHNOLOGY SYSTEMS LLC Owner: HANSON, RONALD D
835 SE 17TH AVE ROBINSON, CONSTANCE A
PORTLAND, OR 97214 ROBINSON, CHESTER TRUST ET AL
203604 EAST FINLEY RD
KENNEWICK, WA 99331
PHONE: 503-231-1992 PHONE:
FAX: 503-231-1402
FEES
Description Date Amount
Specifics: Permit Fee-COM 12/17/2015 $177.52
12%State Surcharge-Building 12/17/2015 $21.30
Type of Use: COM Plan Review-Fire Life Safety-COM 12/17/2015 $71.01
Class of Work: ALT Type of Const: VB Info Process/Archiving-Lg$2.00(over 12/17/2015 $2.00
Occupancy Grp: A-3 Height: ft 11x17)
Stories: 1 Info Process/Archiving-Sm$0.50(up to 12/17/2015 $12.50
11x17)
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard:
Density: 0 Design Area: 0
K Factor: 0
Commercial Fire Alarm System:
Fire Alarm Required: Yes Alarm Type: Automatic
Pull Station Required: Yes Smoke Detectors Req: Yes
Battery Calcs Provided: Yes Cut Sheets Required: Yes
Total $284.33
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $9,870.00
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 Notifica to Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direc estions to OUNC b allin 503.232.1987 or 1.800.332.2344.
I ued By: Permitte ignature:
l
Call 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 project.
Approved plans are required on the job site at the time of each inspection.
I
Building Permit Application
Fire-Protection System , OFFICE USE ONLY
CityOl llaand Received
Tigard Date/B �� Permit No.: /
° 13125 SW Hall Blvd.,Tigard,OR 91 ���� 'P® Plan Review 6
Phone: 503.718.2439 Fax: 503.59 . Date/B r �—Other Permit:
Inspection Line: 503.639.4175 Date Ready/ Juris: ® See Page 2 for
Internet: www.tigard-or.gov DEC 12015 Notified/Method: Supplemental Information
TYPE OFQ N REQUIRED DATA: 1-AND 2-FAMILY DWELLING
❑New construction n W. 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
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1-and 2-family dwelling ®Commercial/industrial Valuation: S
❑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: 10500 SW Nimbus New dwelling area: square feet
City/State/ZIP:Tigard OR 97223 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name_-_A=U%1R=9;Pth 501 �IpCovered 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.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Upgrade/Replace Existing Fire Alarm Control Panel,Voice Evac Control/Amp Valuation: SS9,870.00
Replace all existing smoke detectors and addressable devices on existing devices Existing building area: square feet
such as sprinkler switches and duct detectors New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City/State/ZIP:
Existing:
Phone:( ) Fax:( )
New:
❑ APPLICANT ❑ CONTACT" PERSON
NOTICE
Business name: All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed. If the
City/State/ZIP: applicant is exempt from licensing,the following reasons
apply:
Phone:( ) Fax: :( )
E-mail: �J
CONTRACTOR BUILDING PERMIT FEES*
Business name:Action Technology Systems LLC
Please refer to fee schedule
Address:835 SC ITh Avenue Permit fee:
City/State/ZIP: Portland OR 97214
State surcharge(12%of permit fee):
FLS plan review(40%of permit fee):
Phone:(503)231-1992 Fax:(503)231-1402 Due upon application submittal.
CCB lic.: 157630 Total permit fees: ,33
Authorized signature:aoomK
Amount received:
This permit application expires if a permit is not obtained
Print name:Steven A.Barry Date: 1 2 ` �� within 180 days after it has been accepted as complete.
* Fee methodology set by"Fri-County Building Industry
Service Board.
LtBuild ingTernitsTPS-Permit App_071514 doc 440-4613T(11/02/COM/wEB)
". City of Tigard: Fire Protection Permit Checklist
Page 2- Supplemental Information
Describe work to be done:
1.) Type of Work: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices:
❑ New system Number of sprinkler heads: Number of alarm devices:
❑ Addition or ❑ 1-10 heads: Affidavit required and ❑ 1-5 devices: Affidavit required and
Alteration (3) copies of sketch showing area (3) copies of sketch showing area
to existing of work within building structure of work within building structure
system
❑ 11+ heads: Plan review required and ❑ 6+ devices: Plan review required and
(3) sets of plans. (3) sets of plans.
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
❑ Wet ❑ Dry
Additional Standpipes
Information: Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B. Type I - Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
Submittal shall Battery Calculations ® Yes
include: Individual Component ® Yes
Cut Sheets
Fire Alarm Project Valuation: $ 9870
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal see A, B & C above): $ 9870
Permit fee based on project valuation see fee schedule): $
Permit fee based onsquare footage see D above): $
State Surcharge 12% of permit fee): $
FLS Plan Review 40% of permit fee): $
TOTAL: $
C:\Users\Steve Barry\Documents\Dire Alarm Permit and Affidavit I onus\'Tigard Dire Pilarm Permit Application.doc