Permit (12) CITY OF TIGARD MASTER PERMIT
2.IN COMMUNITY DEVELOPMENT
Permit#: MST2016-00349
Date Issued: 09/19/2016
TGA RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 2S104AD00300
Jurisdiction: Tigard
Site address: 12775 SW MARIE CT
Subdivision: BELLWOOD Lot: 12
Project: ANDERSON
Project Description: 900 sq.ft. addition of family room, bedroom, bathroom and laundry. This permit covers structural
work only-all trade work being submitted under separate permits.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 1 First: 900 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 16 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 20 Smoke
Yes
Dwelling Units: 1 Third: 0 sf Right: 5
Detectors:
Total: 900 sf Value: $30,000.00 Rear: 15
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain0 Storm Sewer: 0
Tubs/Showers: 0 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
Other Fixtures: 0
Drywell-Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 0 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: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Ecompasing: N
Other: N Other Description:
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ADD SF VB R-3 900
Owner: Contractor:
ANDERSON,JAIMI S&SPENCER D Required Items and Reports(Conditions)
12775 SW MARIE CT 1 Ersn Cntrl 503-639-4175
TIGARD,OR 97223
PHONE: PHONE:
FAX:
Total Fees: $2,081.02
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 Notificatio ter. Those rules are set forth in OAR
952-001-0010 through 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling .232.19 7 or 1.800.332.2
Issued By: "( 1���--� Permittee Signature: -->
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.
Building Permit Application Z-S "3 4/i
Residential FOR OFFICE USE ONLY
City of Tigard ReceivedPennitNo.:
1111 II 13125 SW Hall Blvd.,Tigard,OR 97223 - .•' Date/By:Plan Review a, _ /��
.
Phone: 503.718.2439 Fax: 503 Date/By: 2. 1-C in Other Permit: :
TIGARD Inspection Line: 503.639.4175 ^ 1 D.t-R .d/B•. t;3 See Page 2for
Internet: www.tigard-or.gov 4 Notified/Method: f,',/ o ► Supplemental Information
? it.' if AY-CP J C
k.
C o � QUIREi1� WEL Il`1
..:. \.... � � � ...._ �..� ANA2»FAMIU�If L.,,�.. .
❑New construction ■ P: 1 .• .. Permit fees*are based on the value of the work performed.
rit V - Indicate the value(rounded to the nearest dollar)of all
®Addition/alteration/replacement ill Other: equipment,materials,labor,overhead,and the profit for the
� \ uGORi WilE UCTION work indicated on this application.��\ K ,
® 1-and 2-family dwelling 0 Commercial/industrial Valuation: $30,000
❑Accessory building 0 Multi-family Number of bedrooms: 1
El builder 0 Other: Number of bathrooms: 1
xa \k Total number of floors: 1
�, B SITE �+IF'I.?.�,,TION Al L0�'A�IQ1�I .\\
Job site address:12775 SW Marie Court New dwelling area: 900 square feet
City/State/ZIP:97223 Garage/carport area: --- square feet
Suite/bldg./apt.no.: Project name:Anderson Residence Covered porch area: -- square feet
Cross street/directions to job site:128th Ave.and Marie Court Deck area: --- square feet
Other structure area: ... - square feet
REQUIRED DA."I`A,.COM14IEOt USE CHECKLI T.,,;
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
\�� \!x, I3 TIOIa\�� - -S,'-„-' ,:'7.,,''..1 work indicated on this application.
Additbn of family room,bedroom,bathroom and laundry Valuation: $
Existing building area: square feet
New building area: square feet
�\% ®� IIOPER - ' R \ \TENAN \ Number of stories:
\� �.. ...�_.._ tit ��A y... ���; �
Name:Spencer Anderson Type of construction:
Address:12775 SW Marie Court Occupancy groups:
City/State/ZIP:Tigard,OR 97223
Existing:
Phone:(971)322-6041 Fax:( ) New:
-- - ,l`Ai'I'LiCANT \\• •
\, '� ►i CC• •''P1yRSOl ,k IJ I7lING..I'I1;14ii_, \\._
Business name:
A ;; (Please referrofee a hedule)
Structural plan review fee(or deposit):
Contact name:Spencer Anderson
FLS plan review fee(if applicable):
Address:12775 SW Marie Court
Total fees due upon application:it 3 30.71
City/State/ZIP:Tigard,OR 97223
Phone:(971)322-6041 - Fax::( ) Amount received:
P41
E-mail:spencera7@gmail.com OTO'VOI SOLAR PA1 ELIVSTEA' FEE
\ C,,--P-L744, ,-,-' ""OR \ R Commercial and residential prescriptive installation of
•\•.• ' roof-top mounted Photo Voltaic Solar Panel System.
Business name: G 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
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 signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name:Spencer Anderson Date:8/18/16 *Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\BUP-RESPennitApp.doc 02/24/2011 4404613T(11/02/COM/WEB)
Building Permit Application i-8 h
Residential FOR OFFICE USE ONLY
�imCity of Tigard Received: 0 r Date/B Permit No.: ..
IN13125 SW Hall Blvd.,Tigard,OR 97223 ` Plan Review ��, I
C Phone: 503.718.2439 Fax: 503. ! Date/B : Other Permit:
1I G AR D Inspection Line: 503.639.4175 r�016 Date Ready/By: fa See Page 2 for
Internet: www.tigard-or.gov ! - �� 4 �� Notified/Method: FM Supplemental Information
1 E OF W � REQU DATA 1 AND rE Y I ELLI G
❑New construction ■ n: '.� . Permit fees*are based on the value of the work performed.
S Indicate the value(rounded to the nearest dollar)of all
®Addition/alteration/replacement w Other: equipment,materials,labor,overhead,and the profit for the
work indicated on this application.
®1-and 2-family dwellingValuation: $30,000
❑Commercial/industrial
❑Accessory building 0 Multi-family Number of bedrooms: 1
0 Master builder 0 Other: Number of bathrooms: 1
JOH SITE INFORht1IATION AND LOCA Total number of floors: 1
Job site address:12775 SW Marie Court New dwelling area: 900 square feet
City/State/ZIP:97223 Garage/carport area: ---- square feet
Suite/bldg./apt.no.: Project name:Anderson Residence Covered porch area: square feet
Cross street/directions to job site:128th Ave.and Marie Court Deck area: --- square feet
Other structure area: square feet
REQUIR ,; ATA.CO RCLAL-L C KLIST
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.
Additbn of family room,bedroom,bathroom and laundry Valuation: $
Existing building area: square feet
New building area: square feet
4 PROPERTY OWNER = '" ❑ TENANT Number of stories:
Name:Spencer Anderson Type of construction:
Address:12775 SW Marie Court Occupancy groups:
City/State/ZIP:Tigard,OR 97223 Existing:
Phone:(971)322-6041 Fax:( ) New:
:4 APPLICANT 2 CONTACT PERSO14,.; BSI IN I$J IJ FE *
Ie seri .wfre schedule)
Business name: I
Structural plan review fee(or deposit):
Contact name:Spencer Anderson
FLS plan review fee(if applicable):
Address: 12775 SW Marie Court
City/State/ZIP:Tigard,OR 97223 Total fees due upon application: 330.7/
Amount received:
Phone:(971)322-6041 Fax::( )
E-mail:spencera7@gmail.com PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Ct} TRACTUit Commercial and residential prescriptive installation of
roof-top mounted Photo Voltaic Solar Panel System.
Business name: Submit two(2)sets of roof plan with connection details
�n✓ 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 lic.: 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:Spencer Anderson Date:8/18/16 *Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Pennits\BUP-RESPennitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Information Notice to Owners About
��aggr/i/��
r`.+.4„,,,,,` 11- Constructi n Responsibilities
� ��r°% o Responsibilities
\i„r (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 employer, 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 Employment
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
htto://www.oregon.gov/DOR/BUS/docs/211-055.odf 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 ensure adequate insurance coverage for accidents and omissions,
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
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325(2))
This statement is required for residential building, electrical, mechanical,and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010(7), need not
submit this statement.This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
5p12:-/OA i L-S j
Print Name of Permit Applicant
1 0 f
Signature of Permit Applicant Date
Permit#: "-7c2O/b ODS`/!9
Address: if) /1:172/E. e 7--- ;� r��
r � s a.
at7:.,,'i,4
Issued by: _�� Date: X. /�� f = •
This Copy for Permit Offices
I\.1ra-6/4-063 /9
Clean Water Services File Number
16-003315
C1le.all\k`ater Services
Sensitive Area Pre-Screening Site Assessment
1. Jurisdiction: Tigard
2. Property Information(example 1S234A801400) 3. Owner Information
Tax lot ID(s): 2S104AD00300 Name: `''i F ,,t C441— A%)12 'a
Company:
Address: ! -Ti
OR Site Address: 12.:17 ffl A-/L I t. City,State,Zip: t[. :4 7 C t.� c)7 3
City,State,Zip: "ri (.7 AI c 17 32"'3 Phone/Fax: 6177 ,E —14,6)4i
Nearest Cross Street: LL—c-4 11,4 l- ,v E-Mail: fie,. r- i c e.M 1ti I n
4. Development Activity(check all that apply) 5. Applicant information
Addition to Single Family Residence(rooms;deck,garage) Name: .
Ci Lot Line Adjustment 0 Minor Land Partition Company:
J Residential Condominium IJ Commercial Condominium Address: j ALJ j
6.47
U Residential Subdivision ❑ Commercial Subdivision
r- City,State,Zip:
JD Single Lot Commercial ❑ Multi Lot Commercial a �•
Other Phone/Fax: 'IT) 2-- 6,(> f
E-Mail: e"Itr c'� <a/Vtlt"1 tt
6. Will the project involve any off-site work? U Yes 4No Li Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
k ' t ""2✓+ h d �` ,a ,4 - Vis, s�s
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 Quality,Department of State Lands and/or Department of
the Army CDE. 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 of representative,acknowledges and agrees that employees 01 Clean Water Services have authority to enter
the project site at al reasonable times for the purpose of inspecting project site conditions and gathering irtormation related to the project site. I certify that I are
familiar with the information contained in this document,and to the best of my knowledge and belie`,this inlarrnation is true,complete,and accurate.
Print/Type N. r' C ' i >• _Print/Type Title &to/kik-4_
Signature " — l/f Date q— , ,/(,„
FOR DISTRICT USE ONLY
Sensitive arms 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.
XBased on review of the submitted materials and best mailable information Sensitive areas do not appear to exist an site or within 209'of the site,This Sensitive
Area Pre-Screening Site Assessment does NOT eliminate the reed to evaluate arid protect water quality sensitive areas if they are subsequently discovered.This
document will serve as your Service Provider le.rer as required by Resc ution and Order 07-20, S,ction 3,02.1. All required permits and approvals must be
cbtai;ed and completed under applicable local,Slate,and federal law.
eased on review of the submitted materials and test available intprmation the above referenced project will not significantly impact the basting or potentiahy
sensitive area(s)found near the.site.This Sensitive Aiea Pre-Si.earing Site Assessment does NOT eliminate the need to evaluate and protect additional water quality
sensitive areas if they are subsequently discovered.-his document will serve as your Service Provider letter as required by Resolution and Order 07-20.Section
021. All required aermits and approvals must be obtained and completed under applicable local,state and federal law.
IJ This Service Provider Letter is not valid unless CWS approved site plan(s)are attached.
,J The proposed activity does not meet the definition of development Dr the lot was platted atter 9/9/95 ORS 92.040(2). NO SI''E ASSESSMENT OP SER1,CE
PROVIDER LETTER IS REQUIRED.
Reviewed by ;' • Date 9/7/16
Once complete, email to: SPLRevitwcleanwaterservices.or. • Fax: (503) 681-4439
OR mail to: SPL Review, Clean Water Servi b 550 SW Hill .e s ighway, Hillsboro, Oregon 97123
4�i8;isvd 212015
City of Tigard
114 a COMMUNITY DEVELOPMENT DEPARTMENT
■
T l c A R D Building Permit Review — Residential
Building Permit #: /rj(57'0 /ly-00 11/
Site Address: /Q 9-S . )it) 1/4 ala/-74"-
Project
lar- '
Project Name: /0/7ctiPPS ert "Vort;75c)r_ Lot #:
(New dwelling=subdivision name;Addition or Alteration=last name of owner)
Planning Review
Proposal: CYDC) S' e,,,,,c .??0,-
Verify site address/suite# exists and active in permit/sstem.
1
Il!'°I''ver Terrace Neighborhood: ❑ No 6Q Yes,See River Terrace Review Addendum Attached
Si Plan Elements:
IDi yThree(3)copies of site plan 6isting structures on site
e plan must be on 8-1/2"x 11"or 11 x 17"paper otprint of new structure(including decks)with finished
tit
rawn to scale(standard architect or engineer scale) floor elevations
orth arrow U 'i a ty locations(required for new,may apply for additions)
•to address,project or subdivision name and lot number 'i.:cation of wells/septic systems
pplicant information(name and phone number) II Existing trees to be retained with drip line,and tree
tit dimensions and building setback dimensions .;tection measures
Ott area,building coverage area,percentage of coverage and pd 4-et tree size,type and location
pervious area(applicable if R-7,R-12,R-25&R-40) IF treet names
Property corner elevations(2 foot contour lines if more than
4 foot differential)
❑ Clean Water rvices—Service Provider Letter (lot platted prior to 9/10/1995):
Required: Yes,applicant was notified ❑ No Received: ❑ Yes t No
Public Facilities Improvement(PFI) Permit:
0Required: ❑ Yes,applicant was notified ❑ No Applied For: ❑ Yes ❑ No,stop intake
and Use Case#:
Zoning: 1e— Ste--.
LJ Setbacks: Front. cc?Q Rear /5- Side Street Side NIA. Garage aO)
Okii Landscape Requirement:
❑ of Coverage Maximum:
IV Building Height: Maximum Height Actual Height /3
Visual Clearance
01 Easements
Sensitive Lands: ❑ Yes ❑ No Type
Urban Forestry Plan
Conditions "Met"prior to issuance of building permit
otes:
Approved By Planning: ��may, Date: 'ffil
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved _
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
I:\Building\Forms\BldgPermitRvw_RES 060116.docx
Building Permit Submittal
Original Submittal Date: 7/6/
Site Plans: # 3
Building Plans: # 3
Building Permit#: El--E1--iter building permitit�#above.
Workflow Routing: 11-15.1;7—ming�� ;ngitieering Pt Coordinator Cf"�uilding
Workflow Sign-off i���5i off for Planning(include notes from planning review)
Route Application Documents: IBJ-'Engineering: (1) copy of permit application, (1) site plan, (1) building plan and
,3 ori i al plan review routing form.
'Building: original permit application, site plans,building plans, engineer and
beam calculations and trust details,if applicable,etc.
Notes: /� ��
By Permit Technician: '� ' Date: /.//�
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 ❑ No
LIDA Facility on lot: ❑ Yes ❑ No
❑ NOT Approved by Engineering: Date:
Notes:
Approved by Engineering: 7( fi Date: '/-
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
Permit Coordinator Review
❑ Conditions "Met"prior to issuance of building permit
❑ Approved,NOT Released: Date:
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant:
Revision Notice 2: Date Sent to Applicant:
Revision Notice 3: Date Sent to Applicant:
SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes __ A
Tigard Trans SDC: ❑ Yes I! ' /A
Parks SDC: ❑ Yes N. /A
Z1•K to Issue Permit
Approved by Permit Coordinator: /171 Date: 9 7/6
I:\Building\Forms\B1dgPermitRvw_RES_060116.docx