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LIABILITY: The City of Tigard, Oregon, or it's
employes s, , shall not - be' .- responsible for
�--�----- 2 � --�--� . .- . _ - t-� 31011 —_�--� - discrepanc s which �ma appear Y Y AP ar hereon .
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.._. - ---- -APPROVED FOR CON STRAj0T
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IT IS DUE TO THE QUALITY OF THE
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CITY OF TIGARD MASTER PERMIT
DEVELOPMENT SERVICES F'ERMIT #. . . . . . . : MST99-00&:-,
13115 SW Hall Blvd.. Tigard,OR 97223(503)639-4171 DATE I SSUED: 03/04/99
SITE:: ADDRESE�. . . : 13530 SW ASH AVE FIARCEL: 2S102CD-02714
SUBDIVISION. . . . :FREW.T.NGS ORCHARD -TRACTS ZONING: R-4. 5
BLOCK. . . . . . . . . . LOT.. . . . . . . . . . . . . :026 JURISDICTION: TIG
Remarks: Construction of 192 square foot detached accessory structure.
----------------------------••---------------------------------- BUILDING ------------------------_------------------------------
REISSUE: STORIES.......: i FLOOR AREAS----------- BASEMENT...: 0 sf REQUIRED SETBACKS---- REQUIRED-------------
CLASS OF WORK,:ACS HEIGHT.......,: 9 FIRST....: 192 sf GARAGE.....: 0 sf LEFT..........: 0 SMOKE DETECTRS: N
TYPE OF IISE...:SF FLOOR LOAD..,.: 40 SECOND.,,: 0 sf FRONT.........: 0 PARKING SPACES: 0
TYPE Of CONST,:5N DWELLING UNITS: 0 FINBSMENT: 0 sf RIGHT.........: 5
OCCUPANCY GRP.-.R3 BDRM: 0 BATH: 0 IUTAL------: 192 sf VALUE..$: 3552 REAR..........: 5
-------------------------------•------------------------------- PLUMBING -------------------------
SINKS.........: 0 WATER CLOSETS.: 0 WA5HING MACH..: 0 LAUNDRY TRAYS.: 0 RAIN DRAIN ft: 0 TRAPS.........: 0
LAVATORIES....: 0 DISHWASHERS..,: 0 rLOOR DRAINS.. : 0 SEWER LINE ft: 0 SF RAIN DRAINS: 0 CATCH BASINS..: 0
TUB/SHOWERS...: 0 GARBAGE DISP..: 0 WATER HEATERS.: 0 WATER LINE ft: 0 BCI;FLW PREVNTR: 0 GREASE TRAPS..: 0
------------------------------------------------------------ MECHANICAL --------- ------------
OTHER FIXTURES: 0
FUEL TYPES---------- FURN f 10MK ..: 0 BOIL/CMP ( 3HP: 0 VENT FANS.....: 0 CLOTHES DRYERS: 0
FURIJ )=100!1 ..: 0 UNIT HEATERS..: 0 HOODS.........: 0 OTHER UNITS...: 0
MAX INP.: 0 BTU FLOOR FURNACES: 0 VENTS.......,.: 0 WOODSTOVES....: 0 GAS OUTLETS...: 0
--------------------------------—---------------------------- ELECTRICAL ------------------------------------------------------------------
--RESIDENTIAL
--------------------- -
--RESIDENTIAL UNIT--- --SERVICE/FEEDER--•-- --"rTMP SRVC/FEEDERS-- ---BRANCH CIRCUITS--- ----MISCELLANEOUS---- --ADD'L INSPECTI(?NS--
1000 SF OR LESS: 0 0 - 200 amp..: 0 0 ?00 alp..: 0 W/SVC OR FDR..: 0 PUMP/IRRIGATION: 0 PER INSPECTION: 0
EA ADD'L. 5005F.: 0 291 - 400 amp..: 0 201 - 400 amp..: 0 1st W/O SVC/FDR: 0 SIGN/OUT LIN LT: 0 PER HOUR......: 0
LIMITED ENERGY.; 0 401 - 600 amp..: 0 401 600 amp-: 0 EA ADDL. DR CIR: 0 SIBNAL/PANEL...: 0 IN PLANT...,..: 0
MANE HM/SVC/FDR; 0 601 •- 1000 amp.: 0 691+amps-1090 v: 0 MINOR LABEL -10: 0
1090+ amp/volt.: 0 --___._________.______-._--__- -- PLAN REVIEW SECTION ---------------------------------
Reconnect only.: 0 )=4 RES UNITS.,: SVG/FDR)=225 A.: ) 600 V NOMINAL: CLS AREA/SPC OCC:
-------------------------------------------------- ELECIRICAL - RESTRICTED ENERGY --------------------•----------------------------
A. 5F RESIDENTIAL-------------------- B. COMERCIAL-------------------------------------------------------------— --
AUDIO d STEREO.: VACIAINM SYSTEM..: AUDIO I1 STEREO.: FIRE ALARM.....; INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM..: 0TH: ;: BOILER.........; HVAC...........; LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER..: CLOCK..........: INSTRUMENTATION: MEDICAL........: OTHR:
HVAC...........: DATA/TELE COMM.: NURSE CALLS—.-, TOTAL M SYSTEMS: 0
Owner: -------------------------------------Contractor: ----------------------------- TOTAL FEES:$ !15.66
JOHN B SMITH OWNER This permit is subject to the regulations contained in the
13530 SW ASH AVE SIGHED RESPONSIBILITY FORM Tigard Municipal Code, State of Ore. Specialty Codes and all
TIGARD OR 97223 IN FILE other applicable laws. All work will be done in accordance
with approved plans. This permit will expire if work is
Phone t: 624-5090 Phone 0: not started within 180 days of issuance, or if the work is
Reg #..: suspended for, more than 180 days. ATTENTION: Oregon law
- -- ------ ------ - --- - requires you to follow rules adopted by the Oregon Utility
Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0089. YOU may obtain copies of these rules or
direct questions to OUNC by calling 15031246-1987. f
-----•---- ------- ----- ----------...--- ------- ------ REWIRED INSPFCTIMS ----------------------------------------------------------
Foundation
-- --Foundation Insp —!
Framing Insp --- - _ -�__ ------ - - ---
Building Final -- -- -- — --- —
Issi.red By: ��iQl,'J1� 1�_ F'ermittee Si nate-Ir-e :
++++++++++++++-+++.++++1++++++++++++++++++++++ +++g++ ++++++ +++++++++4+++++4 +t+
Call 639-4175 by 7:00 p. m. for an inspection needed t next bl.rsiness day
L
CITY OF TIGARD Residential Building Permit Application Plan Check A
Recd By —_-
13125 SW HALL BLVD. Additions or Alterations Date Recd
TIGARD- OR 97223 ? Single Family Detached or Attached (Duplex) J Date to P E
V 503-639-4171 r I i.l ; ��3 Date to DST -3-9c12�'
F 503-684-7297 a Permit# �
Print or Type f r Called--3-- IV-;e; ,r—
Incomplete or illegible applications will not be accepted 'e, 0
NameoProject ra h - -- -Name
Job ,e k ai�t4
Address Site Address VArchitect Maiiinq Address
-
r
NamCity/State Zip Phone
------------------ — ''�
e-�C 11 7, 6m7 -- Name --- -- — __
Owner MaiAd
lin dre s
I3 T.?c sly —
C�/State Zip PhonQ ,�- Engineer Mailing Address
97i�3 "S --
General Name
City/Slate Zip Phone
Contractor C)LONC-.c- Describe work Ne9k. Addition O Alteration O Repair O
Mailing Address to be done
Prior to permit _ Additional Description of W I X14
issuance,a copy City/State Zip Phone ;' 3r-t n X� M`'t�if� -F S'Cra7ri�r 9�
of all licenses
are required if Oregon Const Cont. Board Exp Date PROJECT
expired in COT Lic# VALUATION •$ _
database _
Mechanical Name�- -- - NEW CONSTRUCTION ONLY: _
Sub- /' � Sq Ft House 5q. Ft. Garage
Contractor Mailing Addre35 - __
Prior to permit Indicate the restricted energy installation by the electrical
issuance a copy City/State Zip Phone
subcontractor in the followin areas
of all licenses Restricted Audio/Stereo
are required if Oregon Const Cont Board Exp Date Energy _ System Alarms
expired in COT Lic# Inatallations Vacuum Irrigation
__database__ _ System System _
Plumbing Name (check all that Other
Sub- apply) —
Contractor Mailing Address Corner Lot YES NO Flag Lot YES NO
check one (check one)
Has the Subdivision Plat recorded? N!A YES NO
Prior to permit City/Stale Z'p Phone
issuance,a copy -----of all licenses are Oregon Const. Cont Board Exp.Date
required H Lia# I hearb acknowledge that I have read this application,that the
expired in COT Y 9 PP'
database Plumbing Lic # Fxp Date information given is correct,that I am the owner or authorized agent
of the er, and that plans sub mitt 0 are in compliance with
_ __ Oregon S ate laws.
Name '-- natu of ner/A D to
Electrical N/ 3
Sub- Mailing Address - Contact Person Namr e Phone#
Contractor
City/State Zip Phone
Prior to permit
issuance,a copv OFFICE USE ONLY:
of all licenses are Oregon Const Cont Board Exp. Date Plat#: Map/T L#:
required if Lic#
expired in COT _ _ oZ Bioa� el?
database Electrical Lic.# Exp Date Setbacks/ -� Zon Solar:, tl
Electrical Supervisor Lic #� Exp.Date n eeri g Approval: Planning Approval: TIF:
i\dsts\forms\sfaddalt doc 11/20/98
I'�:rmit#: �r9 9—a01r R
OF r o
Address: 0 307'3 0 ,S e4)
ip
1.;5. ISSUCLI hy: t�
Date: 54-1
/8 5 9. "- --
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.0.10(7),
need not submit this statement. This statement will be filed with the permit.
Pill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
I. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
❑ 3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors I', trd.
Q OR
A 3B. i will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Informal ion
Notice to Pr pe ty Owners al juut Co Iruction Responsibilities on the reverse side of this form.
(Signature of permit applicant) (Date)
(White copy to issuing agent► permit file,
pink copy to applicant)
-information Notice to Property Owners
About Construction Responsibilities
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OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
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11 tion have additilln)ll('11le tiol1q. write r)t call (Il(-t, ow trlloioti contniciors hoard(Po► Box 1.11.111,S,icm,OR (17:311 ..tijl,?
50,3/179-462 1 ) The Berard is Inctucd at 700 Sunlrner St, NE Suite 300, to 5ulem.
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CITY CSF TIGARD
COMMUNITY DEVELOPMENT DEPARTMENT IhAL=; fFR PERMIT
13125 SW Hall Blvd.Tigard,Oregon 97223*8199 (503)839-4171 [_i,EliM I T #. . . . . . . : h ST94-0;3933
639- cr171 DATE ISSUED: 1121/14/94
PARCEL: _S 102CD' 0c:''/ l 4 I
`3I TL fiDDRE 7S. . . : 135:30 SW ASH AVI:: ZONING: R-4. 5
SUBDIVISION. . . . - F'REWINGS ORCHARD TRACTS
OLOCK,. . . . . . . LOT. . . . . . . . . . . . . :� 6
BUILDING
kr I SSUE s DWELLING UN T T S:1n BASEMENT. . . . . . . . :0 s f
CLASS OF WURK. :ALT BE:DRMS:O BA THS OA GARAGE. . . . . . . . . . :0 x f
1 Y!-Ir: OF UPC._ -9F.' I"I..001R A14EAS-- ---- _._...__. RLUU I RED SETBACKS_.._._--------
.11.YPE
-_._.__-..r.YPE OF CONST. :5N FIRST. . . . :E50 S f L EF 1. . :1n ft R tyH I . :6 Ft
CJCCIJr)ANCY G3RP. :1`43 SEC:OND. . . :0 sf FRONT. :0 ft REAR. . :0 ft
STORIES. . . . . . . : 1 F I NB5ML NT:0 5f RE.[QUIRE:D-___---___.______.__.._._
_t:J0 s f SMOKE. DE TE.I:;TC_'1RS.
FiE:1GHT. . . . . . . . : 10 Pt TCJTAL ..__- .:C'
FLOOR LOAD. . . . :40 ps f VOLUE. . . . . $1 4067 PARK I NG SPACES- 0
Remarks : REI='LACING DL:C:.'K W1TH SUN ROOM
-
PLUMB NG
BACKFLOW PRE�VNTRS. 0
CiINlia. . . . . . . . . . .111 FLOOR DRAINr. . . . :121 . :
'TRAPS. . . . . . . . . . . . . . :
LAVATORIES. . . . . :0 WATER HEATERS. :0 CATCH BTS. . . . .— :0
TUB/SHOWF'IRS. . . . :0 LAUNDIRY TRAYS. . . :0 GREASE RAP: . . . . . . . :0
WATER CLOSETS. :O SEWER LINE (f t ) . ; 2
DT5HWAGHER5. . . .. :0 WATER LINE (ft ) . :0 L'IfHER FIXTURES. . . . . :171
GARBOGE DISF'. . . :0 RAIN DRAIN (ft ) - :0
WASHING MACH. . . 0 SE 141 I N DRAINS. . :0
SF
F"E:ELI _..__...__.
IhECNANICAL
FUF.I._ TYF'JE`'� _�.__.._.._ ...-_ UNIT HTRS. . :0 tyloe amr.11.1nt by date rec.-Pt
VENTS . . . :0 BPRT $ 50. 50 JF 10/14/94 _
MAX. INPUT:O BTU VENT FANS. . :0 BP'LC $ 32. 83 T:Ci 1V1/ 1c; 34 94-•-257.71
10�1N, .
FURN r . .0 HOODS. . . . . . :0 B5P'C $ 2. 53 JF' 10/ 14/94 -
F URN ) =100K . . 0 WOODS I OVE:'S. :(A
F=LIJUR T=URN. . . . :0 CLO DRYERS. : 0
BOIL/C;IrIP ( 3HP-0 OTHER UNITS-0
GAS OUTLETS:0
Uwr,pr. . .
JOHN SMITH
1351317' SW ASH AVE:
T I GARD OR 97223
phone
ont r^act or:
1WNER
!gone #:
,eq #. . -. -
A Ei`:.i. 86 'TOTAL
his permit is Issued subject to the regulations contained in the ---- REUUIRED INSPECTIONS
igard Municipal Lode, State of Ore. Specialty Cooes and all other Framing Ir.sp
=pplicable laws. All work will be done in accordance with approved 111 s 1.11 at i on I n s p �_.--
plans. This permit will expire if work is not started within 1
Gyp Board Insp
gays of is,uance, or if wore is suspe for re tha Ei d w Rain drain I n s p
r' 8+.1ilding Final.
r m i t t;e h '.c;i.a r 1 a t r_t r^e : Erosion Control
...ted By _. .. . __ _.._.
Residential Building Permit Application.
City of Tigard L VV1`
13125 SW Hall Blvd. ? '
Tigard, OR 97223
(.503) 639-4171
Jobsite Address: C, j, �" (r�•�',cf�
_j4c-
Subdivision: f y_eL -'. rl's Op-djagd Tiaci Lot# �' rn Office Use Only
Planck/Rec #
Valuation: ��
Corner Lot? Y
Reissue of
Flag Lot? Y
Map & TL# �0� =yy271 `�
Owner: T
An Q,
,, �11 �N 1�' V Approvals Required
Address. l d S w S n l� Planning �rl'°—
okE6 c Aj
Engineering _
Phone: _ �~ '�p�� --- Other -- -
Contractor: �� EL F -- Items Reaulred
Address: — Subcontractors
____� ----- Truss Details
Phone. Other
Contractor's License # _
(attach copy of current Oregon license)
Contact Name & Phone
Subcontractors: Architect/Engineer:
Plumbing: --- - Address: --- ----— — —
Mechanical-
(attach
echanical("attach cop;, of current OR Contractor's License)
Phone.
.JOB DESCRIPTION:
plicant Signature & Phone number
Received by:.l
L. / k��' Date Received:
N 1WORU�COMOE\ARESAPP
Permit# Account Description Amc"nt Amt. Pd. Bal. Due
Bldg. Permit (BUILD)
Plumb. Permit (PLUMB)
Mesh. Permit (MECH) _
State Tax (TAX) � • � �✓ -.
Bldg. _
Plumb:
Mech:
Plan Check (PLANCK)
Bldg:
Plumb:
Mech:
Sewer Connection (SWUSA) _
Sewer Inspection (SWINSP)
Parks Dev Charge (PKSDC)
Storm Drainage Chg (SDSDC)
Residential TIF (TIF-R)
Mass Transit TIF (TIF-MT)
Commercial TIF (TIF-C)
Inr ustrial TIF (TIF-1)
Institutional TIF (TIF-IS)
Office TIF (TIF-0)
Water Quality (WQUAL)
Water Quantity (WQUANT)
Fire District (FIRE)
Erosion Cntrl Permit (ERPRMT)
Erosion Planck/USA (EPPLAN)
Erosion Planck/COT (EROSN)
TOT
ALS: � � 3
SEE 35MM
ROLL# 22
FOR
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WASHINGTON COUNTY ELECTRICAL. PERMIT
Department of Land Use & Tra;Isportation
i-0 Electrical Inspection Section
155 North First Avenue. t:s50-12 APPLICATION
Hillsboro, Oregon 97124 U �/�
Information: 503 640,217-2Fax 503 693-4412 -/ 0a)Z
• PRINT Project/Permit
• Complete all Number ST`1�• . Date
.
1. Location of Inst.1llat/ n 4. Complete Fee Schedule below
Address �5 H C, Number of Inspections per permit allowed
---;- Buildingg
City S -
A Suite Na Service included: Items Cost(ea.) Sum
Tenant Narne `� A. Residential-per unit -
(if commercial) r) /19'�— 1000 sq.ft.or less $110.00
Tax Lot . �� 1 O 7_ Q Ma N0. Each additional 500 sq.ri -- 4
Map —"- ----- - or portioi I thereof $25 00
Thomas Map Book: Page: Section:_ Limited Energy $25.00 1
Each Manufd Home or Modular
Direct.ins-__ _ Dwelling Service or Feed9r
$6e.00 _--_-
Commercial B. Services or Feeders
1 Residential Installation,alterations or relocation
200 amps or less $60.00 2
2a. Contractor Installation only: 201 Gmps to 400 amps $8000 2
Electrical Contractor
401 amps to 600 amps $120.00 2
601 amps to 1000 amps - $18000 __
Address Over 1000 amps or volts _— $340.00 2
Date--__ Job Number — ---- Reconnect only —� $50.00 u _. 2
Property Owner -- -�—
Contractor's License No. _ _—� C. Temporary Services or Feeders
Contractor's Board Feg. No. Installation,alteration or relocation
200 amps or less $50.00 _ 2
Signature of Supr. 201 amps to 400 amps $7500 2
- 401 amps to 600 amps $100,00 2
License NO. Phone No. _ Over 600 amps to 1000 volts see W above
2b. .For owner installati ns: D. Branch Circuits
-J L•11n �j `�yp , b��-�CI� New,alteration or extension per panel
rint Owner's!,ameG one o. -- , a) The fee for branch circuits with
-5�,t.11, 5 �`Q, --1-- purchase or service or feeder fee.
Each branch circuit $500 2
:- �( /2-2- 3 b) The fee for branch circuits without
Ity T Fete 'Ip purchase of service or feeder fee. �1
First branch circuit 1_ $35.00
The installation is being made on property I own Each add nl branch circuit_ $5.00 "Z1-), �}
which is not intended for sale, lease or rent. E Miscellaneous (Service or Feeder not included) 2
Each pump or irrigation circle $40.00 _ 2
Owner's Signature —__ _ Each sign or outline lighting $40.00
Signal circuits)or a limited 2
3. Plan Review section (if required) energy panel,alteration
Please check appropriate hem and enter fee In section 5B. or extension $40.00
_ 1 &2 family dwellings over 320 amps s/c meter F. Each additional inspection over the allowable
4 or more residential units in one structure in any of the above
Service over 225 amps; feeder 400 amps or more Per inspection $35.00
Per hour $55.00
System over 600 volts nominal In Plant --` $5500 -A-
- Building over 3 stories in height -
_ Building over 10,000 sq, ft. 5. Fees 00
__- Occupant load over 99 persons A. Enter total of above fees $ —�-�,�
_ Manufactured Structures Park or Recreational 5% Surcharge (,05 X total fees) $ --�-7
Vehicle Park; new, addition or alteration Subtotal $
Classified area or structure containing special B. Enter 25% of line A for
occupancy as described in N.E.C. Chapter 5 Plan Review if required (Section 3) $ _- _-
Submit 2 sets of plans with application where any of the Subtotal $
above apply. Not required for temporary constructicn Less Bulk Label Fee $ `\
services. Balance Due. r $ ±iIs -75-
For Inspections call
Thin Pormff becomes null and Vold It the work sufhnrlred by rmRjJj7
64n-3561 or 693-4415 within 100 days from date of issuance of such perm"or M the work authorized
is
suspended or abandoned of any time Offer work Is commenced for a period of Igo days.
24-hour recorder,one working day In advance of need
Flechlcal Parn:"a are nonrefundable and non-tranaferable.
5'43
CITY OF T I GARD
COMMUNITY DEVELOPMENT DEPARTMENT PLUMBING PERMIT
13125 SW Hai!Blvd.Tigard,Oregon 97 223 0 81 99 (503)839-4171 F'CRMI'T #. . . . . . . : PLM973 -0141
DATE ISSUED: 06/19/95
PARCEL: `13,102CD- 02714
'3ITL ADDRESS. . . : 13330 SW ASH AVE
SUBDIVISION. . . . . F'REWINGS ORCHARD TRACTS ZONING: R--4. 5
BLOCK. . . . . . . . . . : LOT. . . 26
uLn5i OF WORK. . :AI-.T GARBAGE DISPOSALS. . : MOBILE HOME SPACES. :
TYPE: OF USE. . . . :SF WASHING MACH. . . . . . . : 1 BACKFLOW PREVNTRS. .
OCCUPANCY GRP. . : R.3 FI_flt]R DRAINS. . . . . . . . TRAPS. . . . . . . . . . . . . . .
:3TOR I ES. . . . . . . . . 1 WATER HEATERS. . . . . . : CATCI4 BASINS. . . . . . . .
LAUNDRY TRAYS. . . . . . : SF PAIN DRAINS. . . . .
SINKS. . . . . . . . . . : URI NAL S. . . . . . . . . . . . s GREASE TRAPS. . . . . . . s
L.AVATC i OTHER f I XTURE S. . . . . :
TUB/r'HO1: . , SEWER LINE (ft ) . . . . :
WATErI C'_ .. .TS. . : WATF_R I_-INE (ft ) . . . .
DISHWASHERS. . . . RAIN DRAIN (ft: ) . . . .
R e m ar•k.s : PEPLACL WASHING MACH I NC-:. FROM GARAGE TO HEW ADDITION.
Owner: _._..._ __.______.____.____-..- --_------- ._...__._.___. ... _._..._.._..__._...._._.__.__._. FEES - --------
,JOIN SMITH type amount by date r-ecpt
13530 SW ASH AVE PRMT $ es. 00 SW 06/19/95 -
5PCT $ 1. 25 SW 06/1')/95
I IGARD OR 07 L:.;'s
:'hone 1!: 624-5090
(.::anti-actor:
:)WNI'
.'hone 26. ='5 TOTAL
Reg 00000
REQUIRED INSPECTIONS
'his perait is issued subject to the regulations contained in the Rol_lgh - in Insp
Tigard Municipal Code, State of Ore. Specialty Codes and all other Misr.. Inspect ion
applicable laws. All worti will be done it accordance with Firia I Inspection
approved plans. This perait will expire if work is not started
withle 180 days of issuance, or if work is suspended for more W
than 180 days.
'".1er-m.ittee :Siynat:.rr-e - !
I s,s .r e d By
C a I I for ins pecetio11 - 639 4175
Permit#: R yy1 5 Qu Ll I
bF O
.44
X.44A 4 Address:
Issued by: �W Date: _
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are :,ot registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, elertr►.;al, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
Flik1. 1 own, reside in, or will reside in the completed structure.
2. 1 understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
313. 1 will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I here7qm
r at ion is correct and that I have read and do understand the Information
Notic ,=trucllon Responsibilities on the reverse side of this firm.
Ci
�Lper applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
information Notice to Property Owners
About Construction Responsibilities
Note; %'his itVormation Noir, , r,, 1,roperr\ !tr ners awut Construction Responsibilities
11,11A developed by the Construction Contractors Board in accordance with URS 701.055f 5),
I'*you arc acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent awy.,,pmblems by being aware of the following responsibihm- -rod arc, A -M- rn
EMPLOYER RESPONSIBILITIES:
If year hire persons not registered with the Construction Contractors Board to do labor in constm ting or assisting in the
construction or improvement of a residential structure,you will, in most instances,be ruled to be an employer and the people
you hire will be employees. As the employer, you must comply with the following:
Oregon's s%ithholding tax law: As an employer,you must withhold income taxes from employee wages at the tin.:employees
are paid. You will he liable for the tax payments even if you don't actually withhold the trot from your employees. For more
information,call the Oregon Dept.of Revenue at 945-9091.
Unemployment insurance tax: As an employer,you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information,call the Oregon Employment Division at the Department of Human Resources
at 378-3524.
Workers'con,pensation Insurance: Asan employer, you are subject to the Oregon Workers'Comrwnsation I.aw,and must
obtain workers'compensation insurance for your employees. If you fail to obtain workers'compensation insurance, you may
he subject to penalties and will be liable for all claim costs if one of your employees is injured on the job. For more information,
all the Workers'Compensation Divisional the Department of Consumer and Business Services at 945-7999.
U.S. Internal Revenue Service: As an employer,you must withhold federal income tax from ernployees'wages You will he
liable for the tax payment even if you didn't actuall% withhold the tax. For more information,call the Internal Revenue Service.
at 1-8(N)-929-10411.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the permit holder for till.I rojeri. ;, r,us,resprmsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections.
Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such its falWig tools,paint overspray,water damage from pipe punctures, fire,or work that must he
re-done.
Time to supervise employees: Make sure you have sufficient lime to sul ervise your employees.
Expertise: Make sure yon have the expertise to act as your own general contractor.to coordinate the work ofrongh-in and finish
!lades. and to notify building officials at the appropriate times ao they call perform the required inspections,.
If you have additional questions, write or call the:Construction Contractors Board(PO Box 14140,Salem,OR 97309-5052,
503/378-4621). "The Board is located at 700 Summer St. NE Suite 300,in Salem.
prop-o%n.pm4
1/94
City of Tigard PLUMBING PERMIT APPLICATION Planck/Rec. #
13125 SW Hall Blvd. Permit # ,97an- `l1
Tigard, OR 97223
(503) 639-4171
MINIMUM $25.00 PERMIT FEE + ST. SURCHARGE
�....a.....•.+ New Single Fami!j Residences Only -
❑ 1 BATH HOUSE$140.00 ❑ 2 BATH HOUSE$195.00
Job 3 r W, s ❑ 3 BATH HOUSE$225.00
Address CIO~ ar Kee includes all plumbing flxturr . t.q dwelling and the first 100 feet
74; of water service, sanitary sewer and storm sewer. Sea fees below.
Nr (Wa of Dorm" FIXTURES QTY PRICE AMT
',D h Yn lG Sink -� 9.00
a..e Ad*M Q o Lavatory 9.00
Owner Tub or TubrShower Comb. 900
crww Shower Only 9.00
7Z 2,3 1 Water Closet 9.00
Nw (w n w Ww"" Dishwasher 9.00
(�) Garbage Disposal 9.00 -
Occupant ,�,, Washing Machine ( 9.00
Floor Drain 9.00
ur+sw
Water Hester 9.00
Laundry Room Tray 9.00
NNW 1 G / Urinal 9.00
Other Fixtures (Specify) 9.00
wry.es.. Rwn. 9.00
Contractor
9.00
aMsw vo -� 9.00 -
Sewer 1 st 100' 30.00
s...wv.r..en ... Cnr T.ft Sewer-ea. AddtL 100' 25.00
Water Service 1st 100' 30.00
I hereby acknowledge that I have read this application, that the W^•er Service ea. AddlL 200' 25.00 +
,nforrnation given is correct that i am the owner or authorized agent of Stone & Rain Drain 1st 100' 30.00
the owner, that plans submitted are in compliance with State la'Ns, that
I am registered with the Construction Contractor's Board, that the Stone &Rain Drain Addit 100' 25.00
number given is correct. (if exempt from State registration, please ---
give reason below.) e
Mobile Home Space 25.00
Baric Flow Prevention
o �� Device or Anti-Pollution Device 9.00
Any Trap or Waste Not
Conneded to a Fixture 9.00
Oescnbe work new 0 addition *alteration repair O Catch Basin 9.00
to be done residential 9 non-residential O Insp. of Exist Plumbing 40.00/hr
Specially Requested Inspectio.(s 40•001hr
Existing use of f Rain Drain, single family dwelling 30.00
building or property N � ���-' _
Residential backflow prevention
devices 15.00
Froposed use of N�) ����
building or property » dux •(Except residential backflow I
prevention devices)
NOTICE *Minimum Fee $25.00 SUBTOTAL
PERMITS BECOME VOID IF WORK OR CONSTRUCTION 5% SURCHARGE
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED
FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS
PLAN REVIEW 25% OF SUBTOTAL
COMMENCED. -
Gr/
TOTAL
Special Conditions
Date issued i C\ cl 5 by
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line: 639-4175 Eusiness Phone 639-4171
Footing Rain Drain Cover/Scrvice IN
Foundation Water Line Ceiling umb
Post/Beam Mach. Shear/Sheath Framing -Mach.
Plbg.Und/Flr/Slab Pltg. Top Out Insulation ect.
Post/Beam Struct. Mech. Rough-in =GypBd
San. Sewer Ga., Line Appr/Sdwlk Reins.
Other: Ago 11
Date: A. i' P.M. Entry:
Address. ( � ,, -� - --.�
Tenant: Ste: MST: -aJ
BUP-
Con _V/d 2V7_a (adejljlgfe' MEC: --
PLM:
ELC: _
THE FOLLOWIN,3 CORRECTIONS ARE PEOUIRED: ELR:
Ins ector. Date
APPROVED — DISAPPROVEMCALL FOR REINSP. CF CO
I