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_ 9840 SW INEZ STREET
CIT` Cc TIGARD
COMMUNITY DEVELOPMENT DEPARTMENT
13125 SW Hall Blvd.Tigard,Oregon 97223**'ow (503)639-4171
5 Ll B D I V IS--1L
BLOCK. . . . .
T Y F-',G OF U':
TYPE Or-
3CLUPANCY LOAD:
"OR, . ! IT. :
r "3MT':1 . ^EZZ
FL001-4 'LOril).
fa',!ELLTNS UNITE:
!'.I C'L)R M'."a-. BATHS.
,)ALLJE-*. 1 3000
Pemaai-k!-�: W.')PECTOF, Wl;-i F
'1EQUIRED INSPLLAii
1;; Vr 1'001- IT16 Insp
Tigard MtAcipal Code, State of "re. Specialty Codes and all Ott, Foumdat iun InL:,p
applicable laws. All work will be done in accordance with f;,j,,t -1bvam lrilip
apprcyed plans, this peroit will expire if work is not started F I Am:i 1,Y I I'l C,P
within 186 days of issuance, or if work is suspended fiv lit-ol,-tt iur) 1
days. Gyj., BuLo�cl Iti-
16 10
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Resic'enti4l Building__Permit��plic tion
Call of Tigard 4S
13125 SW{-fall Blvd.
Tigard, OR 97223
(503) 639-4171
Jobsite. Address: _ u S cv r►
Office Use Only
Subdivision: )7'i►Iy^/S Lot #
�.. Planck/Rec #
Valuation: 43twU 0 - --
Permit # ) -t1 3 G Ll
Corner Lot? Y N
Reissue of
Flag Lot? Y N
Map & TL# e���.�� .� �� 003 ,
Owner. �r1`1� r K rbc; r n S _ Approvals Required
Address. _ � J 5 U/ �Q S r ___ Planning
Engineering - ---- -
Phone (l'.�U /� cj - Other-----__— --
Contractor: C�C��n P v - Items Required
Address. Subcontractors
__. Truss Details
Phone Other —
Contractor's License # — —
(attach copy of current Oregon license)
Contact Name & Phone — _-
Subcontractors: ArchitecVEngineer: --
Plumbin _ —_— Address _. ------ --.__----__----
Mechanical: --
(attach copy of current OR Contractor's License)
Phone _____-�--___. -------.- ----
JOB DESC'21PTION ____--- ---- -------.-____-_--
Applicant Signature & Phone number
Received by: _ -- __-�__ Date Received
, 1
Permit# Account Description Amount Amt. Pd. Bal. IGue.
( � c' Bldg. Permit (BUILD)
Plumb. Permit (PLUMB)
Mech. permit (MECH)
State Tax (TAX)
Bldg: 3
—1--y=---
Plumb:
Mech:
Plan Check (PLANCK)
c'
Bldg �_y_
Mech:
Sewer Con;iection (SWUSA)
Sewer Inspection (SWINSP)
Parks Dev Charge (PKSDC)
Residential TIF (TIF-R)
Mass TrM^-i} 'T1F (TIF-MT)
Commercial TIF (TIF-C)
Industrial T"" (TIF-1)
InstitUrtional TIF (TIF-IS)
Office TIF (TIF-0) __—
Water Quality (WQUAL)
Water Quantity (WQUANT) �-
Fire Life Safety (FLS)
Erosion Cntrl Permit (ERPRMT)
Erosion Planck/USA (ERPLAN)
Erosion Planck/COT (EROSN) _
TOTALFi:
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74
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Permit #.
�' ,, , •,.��;, Address•
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;�,. •r. '��z� Issued by:
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 701.010(7),
need not submit this.statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes I and 2, and either box 3A or 313:
EJ 1. I own, reside in, or will reside in the completed structure.
2. 1 un ierstand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
L� 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
a3B. 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 hereby certify ti-at the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
(Signature f permit applicant) (Date)
(White copy to issuing agency permit frle,
pink copy to applicant)
Information Notice to Property Owners
About Construction Responsibilities
/uflli'.` III i.s /111('1 mfIIIf t; 11:'1' if PI;pf'1I; (1�11if,,S itIfma ('tNivt if, itotl RespomsihI/;lla1
II","% dct'r"/„'h Y! l,l //I, 1 111:.,1111('fit II of r,IItI",ll II,t. Bfuro 111 .i, (e d(IrU'N ivith ORS 701.o.55(5),
It Vi LI IfV nt,IIIIL U"YolII alt Il t, )n I.at,lnr I-,t.t,Il,,ow.t ;I !u'1k If owe „I fll:lki: ,1 !lhsianllal improvement to an existing str ouI
}ou can prevent many problems by bunft iMac.;of the II)IIWA IlF respunSihll„It and areas of concern.
EMPLOYER RESPONSIBILITIES:
Ii' you hire persons nut registered with the G.nstructior, Contracltn , Board tel do labor in constructing or assisting in Of
construction or improvement of a re%iciential .structure, you will, in most instances,he reeled to he an employer and the people
YOU hire will he employees. As life employer, you must comply with tile. following:
Oregon's withholding tax low: Asan employer,you roust withhold income taxes from employer wages at the time empl
are paid. You will he liable for the tax payment,,even if yoll(lon't aetL►ally withhold the tax from vollr c rnph yt cs. I-of
icfornlation,call the Oregon Dept. of Revenue at 945-9091.
Unemployment insurance tax: As an employer,gull ;Ire rrquirrd to)pay a lax for unemploynirnt insurance purpo,c" un the
wilges of all employer". I ur more information,call the Oregon larrployment Division at the Depailrrlt:.-nt of Human Resources
at 378-1524.
Workers'compensation insurance: AN an elnplotrr. :til ;Ire subject to the (hkfgon Wo►kers'('on:prnsatlo l I.aw,and trust
obtain workct'f.'cornper)salion insur:mc r Iur our e11lployecs. I1 you fail to obtain workers'compensation in surarlce. you inay
hL' subn
ject to pealtios and wi11 he liable for all t:laim costs iforle of your employees is injured cin the jot). For more information,
call the workers'Con,pensauon CtivisH M :It the fk'parnnent of('onstunl:r:Incl liusiness Services ;,t945 788A
U.S. internal Revenue tit rvite: Asan emplover,you 11111"1 w ilhhuld federal income tax from c mployves'w..ges. You will he
lurblr for the tax palNmerit even if ti leu didn't acu.rallV withIit)hI the two For more information,call the Internal Reventic Sinvice
at I SM-929-1040,
O e E.vR RESPONSIBILITIES AND AREAS OF CONCERN:
(_'ll. limpliance: As the perrml holdel tia Ihh.prltircl von,ut'n spunslhlc f• I It'•,,II Ini,ul� fA11111C to ruCcl code WLli irentents
(hal v br'n111'.hl I1, vl,lll IIIIclitiont Ihloll ) 111"pi" Ilt,ll"
Liability and property damnge insurance: Contact \our insurance agent to see it vnu have adequate nlstinin e coverage fo,
accidents and omissions such as falling tools. paint overspray, water danlagc Roil pipe, punctures, fire, or work rhat Illust ht
re-dome..
Time to cuperi,ise employees: Makc sure you hint- sufficWIll acne ;u 1111VI%Ise \0111 employees.
Expertise: Make sure yott have the ex petlise to act as your own general contractor,to coordinate the work of rough-in and finish
tr.rdc,, and '.o notify httilding officials at the appropriate time~ so they ran perform the required inspections
It still have additional queslruns, write ur call the C'orrstructiun Contractors Board(I'O Box 14140,Salcrll,OR 97109.5052,
501/t78-4h?11 The Board is located at 700 Summer tit. VI'. Suite 1t10, in Salem.
prop era n.prnd
1104
1 CITY OF TIGARD CITY OF TIGARD
Washington County, Oregon
OREGON
NOTICE O __INFRACTION
I
PERMIT # DATE:
ADDRESS: -.ZAz 9 s
TAX MAP:
OWNER CONTRACTOR
i
It has been determined that the following activity(ies) or
condition(s) is/are an infraction(s) as defined by the Tigard
Municipal Code:
You may contact rte by phone at 639-4171 . You must remedy the
alleged infraction within a certain time period or the City will
file a summons/complaint against you.
The following action to remedy the infraction must be completed by
_ yU_ in the following mar:Ler :
D&E TIME
�P(, C i B A-1
uez,77 W
�"S� e
If this remedial action is not taken by the time and date
indicated, a uniform summons and complaint will be issued, and a
penalty of $250 .00 per day per violation, plus heaxing fees, may be
imposed upon you, pursuant to the Tigard Municipal. Code.
CITY OF TIGARD
BY:
Building Inspector. (Print Name)
i[/infrec
13125 SW Hall Blvd. Tigard, OR 97223 (503) 639-4171 TDD (503) 684-2772 --
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspection;
Footing Susp, Ceiling Sprink. Rough-in p r/Sdwl
Foundation Plbg. Underslab Mech. Rough-in Fire
Post/Beam Struct. Plbg. Top Out Elec. Rough-in FINAL:
Post/Beam Mach. San. Sewer Gas Line
Plbg. Underfloor Rain Drain Framing Plumb.
Alarm Water Line Insulation -Mach.
Underflr. Insul. Shear Wall Gyp. Bd. act.
Date Requested: s Time: AM PM
Address:
Builder Permit #: 5-03 c
THE FOLLOWING CORRECTIONS ARE REQUIRED:
Insector: Date:
PPROVED _DISAPPROVED _APPROVED SUBJF_C TO ABO E
__Call For Reinsp.
H
P 003 024 772
a Receipt for
t� Certified Mail
p No Insurance Coverage Provided
a XIg_"S_M, Do not use for International Mail
(See Reverse)
Seg to
x EMERY STEARNS
W Street and No
x 9840 SW INEZ STREET
P 0 Stets and ZIP Code
W TIGARD OR 97223
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Rearrrcted Delivery Fee
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Of to Whom 6 Date Delivered
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Date,and Ad y Abdj
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I CrnnldPte Items t and/or 2 for additional service. I also wish to receive the
to Complete items 3,and 4a a b. following services (for an extra di
• Print your name and address on the roverse of till,form eo thra we ran
roturn this card to you. fee):
y • Attachre form to the rront of the mailpiece,or on the beck If specs 1. ] Addressee's Address d
does net permit.
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L • Write"Rat-on Receipt Requested"on the mallple%•e below the article number.
• The Return Receipt will @how to whom the article nes dellvared and the date 2 Restricted Delivery G
c delivered. d
Consult POStMaster for fee. y
v 3. Article Adsed
dresto __: 4e. Article Number _ ¢
o EMERY STEARNS °>,l, = / / /_E
E 9840 SW INEZ STREET 4b. Service
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U TIGARD OR97223 [A Registered 1:1 Insured c�
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O ' M rchandlae s
O 7. Date of a or
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Q 8. Signature IAgentl
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PS Form 3811, December 1991 nu.8.oro:tees--357714 DOMESTIC RETURN RECEIPT