12625 SW KATHERINE STREET N
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12625 SW KATHERINE ST
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CITY O F T I V^R® --.- iwASTFR pEitMIT
P' RMIT #: MST2003-00L105
DEVELOPMENT SERVICES DATE ISSUED: 11/7/03
13125 SW Fill Blvd Tigard, OR P 7223 (503) 6394171
SITE ADDRESS: 12625 SVJ KATHERINE ST PARCEL: 2S104AA-08200
SUBDIVISION: BELLWOOD NO. 2 MIING. P
BLOL:K: LOT: 10'i JURISDIC fION• III,
REMARKS- q1A sJ. addition over garage. (mother-in-law)
BUILDING
--REISSUE. CIISTUt.I STORIES FLOOR AREAS Y REQUIRED SETBACKS _�—REQUIRED
CLASS OF WORK: ADD HEIGHT: :I! FIRST: sf BASEMENr: sl LEFT: 5 SMOKE DETECTORS:
TYPE OF USE: SF FLOOR LOAD. 4': SECOND- 1,38 st GAf,1CF: sf FRONT PARKING SPACES
TYPE OF CONST: 5N DWELLING UNITS: IHInO st RIGHT.
,�. ,11
OCCUPANCY GRP: R3 BDRM: BATH. TOTAL: 538 of VALUE: REAR: 15
PLL'1BING
SINKS. WATER CLOSETS: I WASHING MACH: 1 '.AUNDRY TRAYS: RAINDR-IN- TPAPS.
LAVATORIES: DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: 2 CATCH BASINS:
TUBISHOWERS: ! GARBAGE DISP: I WATER HEATERS WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER 1 WTURES:
MECHANICAL _
FUEL TYPES FURN<1COK: Soluc61P<3HP: VENT FANS- 1 CLO,NES DRYER:
;AS F1JRN>=100K: UNIT HEATERS: HOODS: 1 OTHER IINIrB:
MAX INP: btu FLOOR F URNIANCES: VENTS: I WOODSTOVES: GAS OUTLE fS:
ELECTRICAL
RESIDENTIAL UNIT _SERVICE FECD_FR_ TEMP SR'/CIFEEDERS BRANCH CIRCUITS MISCELLANEOUS ADVL INSPECTIONS
1000 SF OR LESS 0 -200 amp i n •100 amp: W/SVC OR FOR PUMP/IRRIGATION; PER INSPECTION:
EA ADD'L 9005F: 201 - 400 amp: 201 400 amp: 1st WA)SVCIFDRSIGNIOUT LIN LT: PER HOUR:
LIMITED ENERGY 401 800 amp: 401 000 amp: EAADDL BR CIR: SIGNAL/PANEL: IN PLANT:
MANU HMISVCIFDR: 001 1000 amp: 601+omps-1000v: MINOR LABEL: i
1000.amplvolt:
PLAN REVIEW SECTION I
Ri onnect only: >=4 RES UNITS: 9VCIFOR>=225 A.: >900 V NOMINAL: CLE AREA/SPC OCC:
ELECTRICAL-RESTRICTED ENERGY
A.SF RESIDENTIAL B.COMMERCIAL
AUDIO&STEREO: VACUUM SYSTEM: AUDIO 8 STEREO: FIRE ALARM: INTERCOMIPAGING: OUTLOOR LNDSC LT:
BURGLAR ALARM: 0TH: BOILER: MVAC: LANDSCAPEIIRRIG. PRO"ECTIVE SIONL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR.
HVAC: DATAITELE COMM! NURSE CALLS: TOTAL n SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 1,107.57
This permit Is subject to the regulations contained in the
RANDY WITTEN Tigard Municipal Code,State of OR. Specialty Codes and
12625 SW KATHERINE ST all other applicable laws. All work will be done In
TIGARD,OR 97223 accordanr_e with approved plans. This permit will expire If
work is not started within 180 days of issuance,or if the
work is Suspended for more than 180 days. ATTENTION:
Oregon law requires you to follow rules adopted by the
Phony: 50�-524-9500 Pllona: Oregon Utility Notification Center. Those rules are set
forth in OAP 952-001-0010 through 952-001-0080. You
Raq 0: may ootain copes of these rules or direct questions to
OUNC by caring(503)246-1987.
REQUIRED INSPECTIONS
Underfloor insulation Electrical Rough In Rain drain Insp
PLM/Underfloor Framing!nsp Mectrical Final
Mechanira!Insp Shear Wall Inrp Mechanical Final
PlurrL Top Out Exterior Sheathing Insl Plumb Final
Electrical Service Insulation Insp Find Inspection _
Issued By : 1=� L -.rS�I.L _ Permittee Signature
Call (503) 639-4175 by 7.00 p.m. for an inspection needed the next by►S(ne day
Buddin Permit ApplicationF(YROFKI('.E USE ONLY
-- ---- Received Building
DatciB /els*/p Permit No. 100340.57j �\
Cit Of TI aCd Planning Approval Other
Y g Dale/BV: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard,Oregon 97223 Date/s J •c3 Permit No.: (T
Phone: 503-639-4171 Fax: 503-598-1960 * Post-Review Land Use
Date/By: Case No. _
Internet: www.ci.tigard.or.us No,
Jun Ser Page 2 for
24-hour Inspection Request: 503-639-4175 Name/Mcu,od: Supplemental Information i
f
_ TYPE OF WORK REQUIRED DATA:
New construction I ❑ Demolition t&2 FAMILY DWELLING
Addition/alteration/replacement Other:
CATEGORY OF CONSTRUCTION Note: Permit Ices•are based on the total value of the work performed. Indicate
& 2-Family dwelling Commercial/Industrial the value bounded to the nearest dollar)ul'all equipment,materials,labor,
overhead and profit for the work indicated on this application.
El-Accessory Building Multi-Family
❑ Master BuilderE_ RMTION_ _Other: Valuation S
_ SITE I—� FOAand LOCATION No.of bedrooms:_ No.of baths:
Job site addressSG, ! W r I w-� Total number of floors............L
Suite to Bldg./Apt. : -- New dwelling area(sq.ft.)........ 7•s�-••.....•
Garage/carport area(sq. ft.)..........................•.
Project Name: Covered porch area(sq. it.)_...........................
Cross street/Directions to job site: Deck area(sq. ft.)............................................ __
Other structure area(sq. ft.)....................•.......
REQUIRED DATA: —
COMMERCIAL-USE CHECKLIST
Subdivision:
Tax map/parcel — Note: Permit fees*are based on the total value of the work performed. Indicate
DESCRIPTION OF WORK the value(rounded to the nearest dollar)of all equipment,materials,labor,
lit nvLrhead and profit for the work indicated on this application.
0'eValuation.......................... .............................. S
"---- --- Existing building area(sq.ft.)........................
— New building area(sq. ft.).........................•.....
Number of stories............................................
PROPERTY OWNER _ TENANT _ Type of construction................ ......................
Name: IfA A, �y New:
i�Ve ' Occupancygroup(s): Existing: _
Address: t v •-r�-["_ – -
City/State/Zi :
Phone: 4 Fax: a p NOTICE: All contractors and subcontractors are required to he
APPLICANT CONTACT PERSON licensed with the Oregon Construction Contractors Board under
provisions of ORS 701 and may be required to be licensed in the
Busi less Name: fj 14 (�, (� t it fe r< _ jurisdiction where work is being performed. If the,applicant is exempt
Contact Name: from licensing,the following reason applies
Address: --
City/State/Zip: — —-- -- — -
Phone: Fax: --
---�� -- - BUIL.;,�T:v i-r RMIT FEES*
E-mail: Please refer to fee schedule.
YCONTRACTOR
Business Na:ue: _ Fees due upon application.............................. 5
Address: �
--- --
City/State/Zip: Amount received_ .......................................... S
Phone: -- — Fax: ---- Date received:)-�?, (SID j__---_-
CCB LIc. 4:
Authorized
l 5 C� Notice: This permit application expires Ito permit Is nut rhtaincd within
Signature: _ 'lam_ Date _ 180 dais after It has been ac(epted as complete.
*Fec methndnlot;� %et b.% lYi-(bunts NuilmoL,Indurtrs Ser%ice Itox,d
ease print name)
is�Dsts\PermttForms,BldgPermitAppdoe 01103
One-and Two-Family Dwelling
Building Permit Application Checklist Reference no.:
City of Tigard — Associated permits:
City of Tigard J Electrical U Plumbing U Mechanical
Address: 1311.5 SW Hall Blvd.Tigard.OR 97223 J Other:
Phone: (503) 639-4171 —
Fax: (503) 598.1960
1 Land use actions completed. See jurisdiction criteria for concurrent reviews.
2 Zoning.Flood plain,solar balance points,seismic soils designation,historic district,ctc.
3 Verification of approved plat/lot.
4 Fire district__approval required.
5 Septic system permit or authorization for remodel. Existing system capacity
6 Sewer permit.
7 Water district approval.
8 Soils report. Must carry original applicable stutr,p and signature on file or with application.
Erosion control U plan U permit required. Include drainage-way protection,silt fence design and location of
catCll-Ns m protection,etc.
10 3 Complete seta of legible pbms.Must he drawn to scale,showing conformance to applicable local and state —
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-sil_c
sheet attached to the plans with cross references between plan location and details. Plan review cannot he completed
if copyright violations exist,
11 Site/plot plan drawn to scale.The plan must show lot and building setback dimensions:property comer elevations(if
there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft. intervals);location of easements and
driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction indicator;lot
area:building coverage area:percentage of coverage:impervious arca;existing structures on site;and surface drainage.
12 Foundation plan.Show dimension:,anchor bolts,any hold-downs and reinforcing pads,connection details,vent
size and location.
13 Floor plans.Sh,)w all dimensions,room identification. window size,location of smol:e detectors.water heater.
furnace,ventilation fans, dumbing fixtures,balconies and decks 30 inches above grade,etc.
14 Cross sections)and details.Show all framing-mcmher sizes and spacing such as floor heams,headers..loist.,soh-flour,
wall constniction,rout construction.More than one cross section may he required to clearly portray construction.Show
details of all wall and roof sheathing,roofing.roof slope,ceiling height,siding material,footings and foundation,stairs,
fireplace construction, thermal insulation,r!..
15 Elevation views.Provide elevations for new construction;minimum of two elevations for additions and remodels.
Exterior elevations must reflect the actual grade if the change in grade is grcite, than four foot at building envelope.
Full-size sheet addendums showing foundation elevations with cross references are acceptable. _
16 Wall bracing(prescriptive path)rad/or lateral analysis pians. Must irdicatt details and locations:for
non-prescriptive path analysis provide specifications and calculations to enji=ng standards.
17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating memaer sizing,spacing,and hearing
locations.Show att;c ventilation.
18 Basement and retaining walls. Pr,vide cross sections and details shov:n,placement of rebar. For engineered
systems,see item 22,"Engince, s calculations."
1O Beam calculations. Provide iwo sets of calculations using current code Jcsign values for all beams and multiple joists
over 10 feet lung and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. _
21 Energy Code compliance.Identify the prescriptive path or provide calculations. A gas-piping schematic is required
for four or more appliances.
22 Engineer's calculations.When required or provided,(i.e.,shear wall,roof truss i �1,SII he stamped by an engineer or
architect licensed in Oregon and shall be shown to he applicable ni the project undo. iclot
7� 1111111112111 Eel 111;M]C=,
23 Five(5)site plans are required for Item I I above. Site plan.must he 8112' x I I or 1 1_r 1_ _
24 Two(2)sets each are required for Items 16. 19, 20&22 al,oNe.
25 Building plans shall not contain red lin!s or tape-ons. "Mirrored"building plans will be not accepted.
26 "Reversed"building plans must meet i.riterin outlined in the Permit & System Development Fees document. _
27 "brawn to scale" indicates standard atchitect or engineer scale. _
28 Site plan to include tree size,type&location per approved project street tree plan fit applicable),and COT Street Tree List.
Checklist must be completed before plan revie%s start .late. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is resettled for department use only. gut-t 41 6nr,rc'IAt
i
nW-chanical ?ermit Application Received Mechanical
Date/By: _ Permit No.:
CJI} O Tigard Planning Approval V Building
'J Date/By Permit No
13125 SW Hall Blvd. Plan Review Other
Tigard,Oregon 97223 Date/By: Penna No
Phone: 503-639-4171 Fax: 503-598-1960 Post-Review kind l.Ise
—
Date/B : ('ase No
Internet: www.ci.tigard.or.us lanne/Method:
ontact Juns See Page 2 for
Request:24-hour Ins ection Re 503-639-4175
p y j ....W_ , picmental Irtonnation.
TYPE OF WORK _COMMERCIAL FEE'SCHEDULE-USE CHECKLIST
New construction Demolition vlcchanical permit.`ees•are based on the total value of the work
Add i;ion/alteration/re lacement Other: performed. Indicate the value(rounded to the nearest dollar)of all
_
CATEGORY OF CONSTRUCTION mechanical materials,equipment, labor,overhead and profit.
I & 2-Family dwelling U Commercial/Industrial Value: S See Page 2 for Fee Schedule
Accessory Building Multi-Family RESIDENTIAL EQUIPMENT/SYSTEMS FEE'SCHEDULE..__
Descrip,;anty Fee ea. Total
Master Builder Other: � —
_ Heatln Conlin
JOB SITE INFORMATION and LOCATION Furnace-add-on air conditioning" 14.00
Job site address: �, i , n r f n++�. Gas heat pump 14.00
Suite #: Bld ./A t.#: Duct work -- 14.00
Project Name: Hvdronic hot water system 14.00
Residential boiler
Cross street/Directions tojob site:
J for radiator or hydropic system) 1400 _
Unit heaters(fuel,❑ot electric) —
(in wall,in-duct,suspended,etc.) 14.00
Flue/vent for any of above 10.00
ri
unts
Subdivision: _ _ Lot #: Rc ai --
Tax map/parcel #: Other Fuel Appliances 12.15
_
_ _ _ Water heater _ 10.00
DESCRIPTION OF WORK Gas fireplace _ 10.00
[E Lc ti 0 Vso v ism 1,y Flue vent(water heater' as Fireplace) 10.00
Log lighter(gas) 10.00
— -- ------- - - — --— Wood/Pellet stove 10.00
Wood fire lacchnsert _ _ _I 0.00
Chimney/liner/flue/vent 10.00
ROPERTY OWNER 1,0 TENANT _ Other: 10.00
Environmental Exhaust do Ventilation
ame: n-r Pe _ Range hood/other kitchen equipm,.nt 10.00
Address: _S .�c�: a,F !�r��-� Clothes dryer exhaust I o.00
Cit /State/Zip: 7-ems ,,.4 _ Single duct exhaust
Phone: Q Fax: _ _ (bathrooms,toilet compartments,
raAEPLICANT I Lj CONTACT PERSON utility rooms) 6.80
Nam �. �., - 10
Attic/crawl spece fans .00
—t�I ��''--'�'--- Other: 10.00
Address: _ Fuel Piping
City/State/Zip: •'(55.40 for first 4.$1.00 each additional
Phone: Fax: V Fumace,etc. __ •'
Gas heat pump •'
E-mail: _ _ Wall/suspended/unit heater •• _
CONTRArTnR Water heater ••
Business Name: Fire lace ••
----LT""„ �----- �� —
Address: Range
_ -- —
BB ••
City/State/Zip: _ _ Clothes dryer(gas) ••
Phone: s Fax_ Other: ••
CCB Lic. #: Total
Authonxe `_ _Mechanical Permit Fees'
�� 3
Signature: Date:f
Subtotal: $
li
r� C.C.�f. __ �:�a+ --- —
_ Minnmum Permit Fee$72.50 S
Plan Review Fee(25%of Permit Fee) S
i Please print Hamel State Surcharge 8%of Permit Fee S _
TOTAL.PERMIT FEE S _
Notice: 110%permit application expires Ira permit is not obtait-ed withir *Fee methodology set by Tri-County Rullding Industry Service Board.
180 da,s sifter it ha,heen accepted as complete. **Site plan required rot exterior A/C units.
i Dsis Pcrmn Fonns,MccPcrnutApp doc 0IM3
Mechanical Permit Application - Cite of Tigard r
Page 2 - Supplemental Information
Commercial Fee Schedule: _
TOTAL VA" UATION: PERMIT FEE: _
$1.00 to$2,000.00 Minimum fee$72.50
$2.001.00 to$5,000.00 $72.50 for the first$2,900.00 and$2.30 for each
additional$100.00 or fraction thereof,to and
including$5,000.00.
$5,001.00 to$10,000.00 $141.50 for the first$5,000.00 and$1.80 for
each additional$100.00 or fraction thereof,to
and including$10,000.00.
$10,001.00 to$50,000.00 $231.50 for the first$10,000.00 and$1.35 for
each additional $100.00 or fraction thereof,to
and including$50,000,00. _
$50,001.00 to$100,000.00 $771.50 for the first$50,000,00 and$1.25 for
each additional$100,00 or fraction thereof,to
and including$100,000.00.
$100,001.00 and up $1,396.50 for the first$100,000.000 and
$1.10 for each additional$100.00 or fraeti„,,.
thereof.
All New Commercial Buildings require 2 sets of plans.
h8uildingMermit Form9lMecPerm1tAppPg2 09.01-03.doc
Building Fixtures
Plumbing Permit n�lieation Received Plumbing
Datcl'B : Permit No.: i0FL40U;'�
Cit of Tigard Planning Approval Sewer
City Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other --
Tigard,Oregon 97223 Date/By: Permit No.:
Phone: 503-6394171 Fax: 503-598-1960 Pest-Review Land Use
Datc[B : Case No.:
Internet: www.ci.tigard.or.us Contact Juris.: See Page 2 for
24-hour Inspection Request: 503-639-4175 Namc/Method: s— Supplemental Information.
TYPE OF WORK _ FEE*SCHEDULE(for special Information use checklist)
❑ New construction _� Demolition _Description — Qly. Fec(ce.) total
New 1-&2-famil dwellings
Addition/alteration/re lacemcnt ❑Other: >'
CATEGORY OF CONSTRUCTION (Includes 100 fl.for each utilil�co�nection
_
&2-Famil dwellin SFR(1)bath 249.20 Commercial/industrial SFR(2)batha _ 350.00
,Accessory Buildin Multi-Family _ SF'R 3 bath _ 399.00 -
EJ Master$uildrr
_I Other: I ach additional bath/kitchen - 45.00
_ JOB SITE INFORMATION and LOCATION 1-ie sprinkler-sq.fl.: Page 2
Job site address: f- n--1 Site Utilities _
St!ite#: Bldg./Apt.#: Catch basin/arca drain 16.60
Project Name:
Dr ell/lcach line/trench drain 16.60
Footing drain no.linear fl. _ Page2
Cross street/Directions to job site: Manufactured home utilities 110.00
Manholes 16.60
Rain drain connector 16.60
_ Sanitary sewer(no. linear fl) Pae 2
Subdivision: _ Et#: Storm sewer(no.linear fl.) Pae 2
-��--- Water service(no. linear fl ) Pa
Tax map/parcel #:�---_�-- _ _—� �e 2
DESCRIPTION OF WORK _Fixture or item _
— Absorption valve I6.60
�`'-'-�`_� �►'� Backflow preventer Pae 2
Backwater valve 16.60
Clothes washer 16.60
— -- __-------____ Dishwasher 16.60
"ZIDrinking fountain 16.60
'ROPF,RTY OWNER r�ENANT
— -�---- Electors/sum 16.60
Name: ra , �.(, (,i-� l ., _-_ Expansion tank _ 16.60
Address: Fixture/sewer ca _ 16.60
City/State/Zip: << t, Floor drain/floor sink/hub 16.60
-1— — ---
Garbage disposal 16.60
Phone: 5 7 Y - Fax: Hose bib 16.60
PPL1C CONTACT PERSON Ire, ker 16.60
Name: — (JJ �C , — - Intercer,t• or/grease trap _ 16,60
Address: Mediml gas-value: $ Pa e2
City/State/Zip: Primer 16.60 _
-- ---- Roof drain commercial 16.60
Phone: FaX: Sink/basin/lavatory 16.60
E-mail: Tub/shower/shower pan 16.60
CONTRACTOR Urinal 16.60 —�
Business Name: CL t;�r"'e_ _ Water closet 16,60 _
Address: Water heater _ 16.60
Other:
City/State/Zip: _ Other: -- _
Phone: Fax: Plumbing Permit Fees"
CCB Lic. #: Plumb. Licsubtotal
.#: $
Minimum Permit Fee$72.50 $
Authorized Residential Backflow Minimum Fee$36.25
Date:
_ Plan Review(25%of Permit Fee) $
_ State Surcharge 8%of Permit Fee) $
(Please print name) TO'rAL PERMIT FEE $
Notice: This permit application expires If a permit Is not obtained within All new commercial buildings require 2 sets of plans with isometric or
Ido days ed,.r It has been accepted as complete. riser diagram for pian review.
*Fee methodology cot by Tri-founts,Building Industry Service Board.
is\D$U\PetmitForms\PlmPermitApp.doc 01101
Plumbinp, Permit Application- City of Tigard
Page 2 - Supplemental Information
Fee SchOule: Residential Fire Suppression Systems
Site Utilities Qly. Fee(ea) Total Square Footage: Permit Fee:_ — —
Footing drain- I" IOW 55.00 —— — 0 to 2,000 $115.00
Footing drain-each additional 100' 46.40 2,1101 to 3,600 __ _ $1 W.00
3,601 to 7,200 _ $220.00 -----
Sewer-I st 100' 55.00 7,201 and greater $309.00 -
Sewer-each additional 100' 46.40
Water Service-Ist 100' 55.00 Medical Gas Systems:
Water Service-each additional 100' 46.40 Valuation: Permit Fee:
Storm&Rain Drain- 1st 100' 55.00 $1,00 to$5.000.00 Minimum I`X$72.50
Storm&Rain Drain-each additional 100' 46.40 $5,001.00 to$10.000.Ou $72.50 li-r the first$5,000.00 and$1.52 for each
additional$1 ONA or fraction thereof,to and
Fixture or Item Qty. Fee(ea) Taal including 10,000.00.
Commercial back flow Prevention Device 46.40 $10,001.00 to$25,000.00 $149 50 for the first$10,000.00 and$1.54 fur
Residential Backflow Prevention Device each additie,a1$11").00 or fraction thereof,to
(minimum permit fee$36.25) 27.55 and includ;ag$25,000.00.
Rain Drain,single family dwelling 65.25 $25,001.00 to$50,000.00 $379.55 for the first$25,000.00 and$1.45 for
each additional$100,00 or fraction thereof,to
Inspection of existing plumbing or and includirg$50 000.00.
seccially requested inspections-per hour 72.50 $50,001.00 and up $742.00 for the first$50,000.00 and$1,20 f'or
Subinral: each additional$100.00 or fraction thereof.
Fixiure work:
Are you cggoing, moving or replacing cxisling lixtrtrus? If
"yes",please indicate work perforated b» lixlure. Failure to
accurately report fixtures could result in increased sewer fees*.
uantlty by Fixti re)Work Performed ('onrtnents regarding fixture work:
Fixturr Type: Replace
New_ Moved RxistinCa Led_ --- -- —
Ba tisuy/Font — - ---- --
Bath -Tub/Shower _
-Jacuzzi/Whits pool _ - ----- —
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water As iretor �" -------- " -
Dishwasher -Commercial
-Domestic: _
Drinking Fountain
E c Wash
Floor Drain/sink -2" —
.4"
Car Wash Drain *Note: If the fixture work under this permit results in an
Garbage -Domestic _
Disposal -Commercial increase of sewer I?blls,a sews:permit will lie issued and
-Industrial fees assessed for the sewer Increase must he paid before the
Ice Mach./Refri .Drain-: plumbing permit can he issued.
Oil Separator Gus Station
Rec Vehicle Dump Station
Shower -Clang
-Stall
Sink -Bar/Lavatory _
-Bradley _
-Commercial _
-Service _
Swimming Pool Filter
Washer-Clothes
Water Extractor
Water Closet-"roilet
Urinal
Other Fixtures:
i:\Dsts\PcniiitFomis\PlnllleniiitAppPg2.doc 01103
Electrical P r E
mitR atl(o Received Electrical
Date/By: Permit No.: Csv'jL
City of TigardPlanning Approval Sign
13125 Ste' Hall Blvd. T1GR Date,By: Pemvt No.:
fir; Plan Review Other
Tigard,Oregon 97223 cYiNG 01\1 Date/By: Permit No.:
Phone: 503-639-4171 Fax: 503-50-1R60 Post-Review Land Use
_
Internet: www.ci.tigard.or.us Date/By: Case No:
Juris.: See Page 2f-
or--24-hour Inspection Request: 503-639-4175 Name/Method Supplemental["formation.
TYPE OF WORK _ PLAN REVIEW Please check all that_aPP Y)I
_---
New construction Demolition Service over 225 amps• I IL 11th-care facility
[Q_Addition/alteration/replaeementOther: commercial D Hazardous location
❑Service over 320 amps-rating of ❑Building over 10,000 si were feet.
_ CATEGORY OF CONSTRUCTION _ I&2 family dwellings four or more residential units in
I & 2-Family dwelling 0 Commercial/Industrial ❑System over 600 volts nominal one structure
❑Building over three stories ❑Feeders,400 amps or more
ACCeSSO Building ._SMulti-Family ❑Occupant load over 99 persons ❑Manufactured structures or RV park
LJ Master Builder Other: ❑Egress,lightinp plan ❑Other:
JOB SiTE INFORMATION and LOCATION Submit _sets of plans with any of the almve.
Job site address:
r
z 61_� S W t" TT The above are not applicable to temporary construction service.
J�,QTNf lr�
FEE"SCHEDULE
Suite #: Bld ./A t.#: _ Number of inspections per permit allowed
Project Name: Description Qt-v I 'Pee(ca.) Total
CCO$S street/Directions t0 job Site: New rrv(drntlal-s(nglc or multi-family per
dwelling volt.Includes attached garage,
Sers ice Included:
1000 3q Il.or less 145.15 4
Each additional 500 sq,n.or portion thereof' 33.41) _ 1
Limited energy,residential 75.00 2
Subdivision: LOt#: Limited energy,non residential 75.00 2
Tax map/parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service andlor feeder 90,90 2
Services or feeders-Installation,
alteration or relocation:
200 amps or less 80.30 2
--- - - 201 amps to 400 amp _ 106,85 2
401 ams to 600 ams _ _ I(A).60 2
PROPERTY OWNEF( � _ TENANT 601 amps to 1000 amps — 240.60 - 2
—'—'— Over I(M amps or volts _ 454.65 2
Name. Reconnect only 66.85 2
Address: Temporary services or feeders-Installation,
Cit /State/Zi alteration,or relocation:
--_�, __ 200 amps or less 66.85 1
Phone: Fax: 201 amps to 400 ams —_,_ IM.30 — 2
APPLICANT RS
CONTACT!'E (IN 401 to 600 ams 133.75 2
— Branch ircufts-new,alteration,or
Name: _ _ _ extension per panel:
A.Fee for branch circuits with purchase of
Address: service or feeder fee,each branch circuit 6.65 2-
City/State/Zip: B Fee fnr branch circuits without purchase of
-- -- service or feeder fee,0rst branch circuit _ 464.5 2
Phone: Fax: _ Each additional branch circuit 6.65 2
F-mail: Misc.(Service or feeder not included)
CONTRACTOR Each pump or irrigation circle 53.40 2
-- -- --- - Each sin or outline lighting 53.40 2
Job No: Signal clrcuitfs)or a limited energy panel,
BusinessName: alteratAL6/EU Cl��jl��
Description or extension Paget 2
Address: P.0, r'?x /bt/p --- nescnpnorr.
Cit /State/Zi , I 7/$ Each additional Inspection over the allowable In on of the above:
p' a+V� t4w Per inspection per hour(min. I hour) 62.50
Phone: yax: 4-�/1/ // Investigation fee:
CCB Lic. #: s, Lic. # f?C.- -
sifter-Electrical Perml.Fees*
Supervising electric ir—) Subtotal S
signature required: PlanReview(25"/0 of Permit Feelts
S
4 _
Print Name:_ - Lic #:. 31et5 5 State Surcharge 8%of Permit Fee) _
TOTAL PERMIT FEE I S
Authorized Notice:This permit application expires If a permit is not obtained within
Signature _ Dater 180 dov%after It has hero accepted as complete.
*Fee mrthodologs set bs Tri-(punts Building Industry Service Hoard.
-- _ (Please print nume) -
i'11sts',Perrmt Forms`•FlcPermitApp.doc 01,03
Electrical Permit Application - City of Tigard
Page 2 - Supplemxntal Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Feefor all systems............................................................ $75.00
Check Type of k�ork Involved:
Audio and Stereo Systems*
Burglar Alarm
Garage Door Opener*
DHeating,Ventilation and Air Conditioning System*
Vacuum Systems*
Other _----
_COMMERCIAL WORK ONLY:
Fee for each system.. ..................................................... $75.00
(SEF.OAR 918.260.260)
Check Type of Work Involved:
DAudio and Stereo Systems
Boiler Controls
Clock Systems
Data Telecommunication Installation
Fire Alarm installation
FIVAC
Instrumentation
F7 Intercom and Paging Systems
❑ Landscape Irrigation Control*
E] Medical
Nurse C'aCs
ElOutdct r Landscape Lighting*
Protective Signaling
n Other
_Number of Systems
* No licenses are required. Licenses are required for all
other installations
i`Dsts'.Permit Forms\ElcPermitAppPg2.doc 01103
Elf,etrical Permit Appli ation Received Electrical
Date/By: Permit No.:
City of Tigard Planning Approval Sign
Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard,Oregon 97223 Dale/By' Permit N/
Phone: 503-6394171 Fax: 503-598- e
op1960 Post-Review Land U
Internet: www. igard.oeDate/By: Case o.:
us Contact 3u .: See Page 2 for
24-hour Inspection lest: 503-639-4175 Name/Method: Supplenivnial Information.
TYPK OF WORK _ PLAN REVIEW lease check all that apply)
New construction 10 Demolition LJ Service over 225 amps- Health-care facility
%,Nddition/alteration/replace. t Other: commercial El Hazardous location
❑Service over 320 amps-ra' g of ❑Building over 10,000 square feet,
CATEGORY OF CON UCTION 1&2 family dwellings four or inure residential units in
1 &2-FamilydwellingCom rcial/Industrial ❑System over 600 volts ominal one structure
ACCeS50 Building Multi-F jl ❑Building over three ries ❑Feeders,400 umps or more
❑Occupantloae 9 persons ❑Manufactured structures or RV park
Master Builder Other: ❑Fgress/lighting p n ❑Other:
JOB SITE INFORMA'T'ION and LOCATIO Su mit!sets or pians with any of the above.
The abov are not applicable to temporory construction service.
Job site.address: -LiFEE"SCHEDULE
Suite#: Bid ./A to Number of inspecti0nsJ)e )ermit allowed
Project Name: Descrt do _ — -Qlq I-Fee tea. toIII
\�cM resid ntlal single or multi-family per
Cross street/Directions to job site: Uxsetnn nil.Includes attached garage.
SeriTic
luded:
1000 or less 145.15 4
EacWiddiftiatial 500 sq.ft.orpornon thereof 33.40 1
Subdivision: _ lot#: Li iced ever residemrral 750) 2
ited cner v r ,residenual__ 75.00 2
Tax map/parcel #: _ ach man t' ed a or modular dwelling
DESCRIPTION OF WORK service c or fe der 90.90 2
Servl s r fee er - t■ tian,
__JA( v� r c alterot elo tion
2 80.30 2
-- -- 201 to 400 _ _ IO6.A5 2
40 s to 600 a 160.60 2
FRROPERTY OWNER TENANT l a to 1000 a s 240.60 2
M
er000 am or o 454.65 2
Name: ,,ca (,tit _ ect only66.85 2
Address: (.' `� orary ser c or s•1n all
-ration,or re ation:
City/State/Zip: tp Y_ ,Z; ampsorless 66.85 1
Phone: Fax: s I 4t ams 00.30 2
PPLICA T CONTACT PE ON 6 1 75 2
Hrancrcuitc-new,alteration,or
Name: L f r` — erlcnsiy`�r er panel:
Address: A I'ce.fu,branch circuits with purchase of'
c or feeder fee,each branch circuit 665 2
City/State/Zip: B ee W branch circuits without purchase(if'
iskVice or feeder fee.first branch circuit 46.85 2
Phone: _ Fax.__^ h tditional branch circuit 6.65
E-mail: (Service or feeder not included):
CONTRACTON. ch pump or irrigation circle 53.40 2
a sign or octiina lighting 53.40 2
Job No: Tom _ ^—/ , gnat circuited or a limited energy panel.
BU51IleSS Name: teration,or extension Pa e 2 2
- � Descripuun
-- —
Address: r _
-- Each additional ins rection oscr the allowable in an}0f the above:
Clt /Stag/ZI : Per inspection inr hour(min. I hour) _ 62.50
Phone: _ aX: Invesugalion fee:
CCB LIC_#: LIC. Other.
Electrical Permit Fees*
Supervising electrician _ _--- Subtotal S _
signature required: _ Plan Review(25%of Permit Feel S
Print Name: Lie. #: Stare Surcharge(8%of Permit Fee) S
7 !-
TOTAL PERMIT FEE S
Authorized ( Notice: This permit application expires if a permit is not obtained within
Signature: 180 dnvs after It has been accepted as complete.
/ -Fee methodoloRs set M TH4 aunty Building Industry Service Board.
(Please print name)
i''DstsvPermit Forna'Flcl'ermitApp.doc 01103
r
• I
Electrical Permit Aaalicatiou - City of Tigard Y
Page 2 - Supplemental Information
LIMITED ENERGY PERMITi FEES:
RESIDENTIAL WORK ONLY:
Fee for 211 systems........................... $75.00
('heck'r%pe of Work Involved:
Audio and Stereo Systems*
Burglar Alarm
I
Garage Door Opener*
LJ Heating,Ventilation and Air Conditioning System*
F1Vacuum Systems*
EJ Other
COMMERCIAL WORK ONLY:
Fee for IAch system.......................................................... $75.00
(SEL OAR 918-260.260)
(heck Type of Work Involved:
Audio and Stereo Systems
Boiler Controls
Clock Systems
Data Telecommunication Installation
Fire Alarm Installation
U HV4C
Instrumentation
Intercom and Paging Systems
L J Landscape Irrigation Control*
L� Medical
Nurse Calls
Outdoor Landscape Lighting*
Protective Signaling
Other
Number of Systems
* No UCenseq are required. Licenses are required for all
other Installations
i'DstOermitForms\ElcPermitAppPg2Aoc 01'03
Permit
pF
Address: -Oas �S W
issued by: ------- Date:
Statement: Information Notice to Property owners
About Construction Responsibilities
Note: Oregon Law, URS 701.05.5(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 requi-ed
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 1 and 2, and either box 3A or 3B:
,I
i. I own, reside in, or will reside in the completed structure.
12. 1 understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
L IA. My general contractor is
t (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
/) 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.
1 hereby certify that the above inform ion is correct and that I have read and do miderstand the Information
Notice to Pr )wners abou ons ction esponsibilities on the reverse sid of this form.
(Signat.� of permit applicant) (Date)
C_ (White copy to issuing agency permitfile,
pink copy to applicant)
Information Notice to Property Owners
About Construction Responsibilitie-o
kote 1hid' N01t, 111 ow ('onstt7wtioi7 R#'.SpO17Sff*iWtivx
It'rI,1 rion'l('tved t'1' ri!),id Is; ,trcrtYifL1nce vvi'th ORS 701.0-55(5');
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 MS : _
INSPECTION DIVISION Business Line: (503)639-4171
BUP
Received Date Requested -� l` <1 AM —PM __ BUP
Location —_ /Z 0 ZS �a4�,_PA_g - z .a2'Suite MEC
Contact Person Ph( —) (� -- •�`'� PLM —
Contractor_. _ Ph(�—) _ SWR
BUILDING Tena wne 4)c.1�L/ L --- _ ELC _
Footing
ELC
Foundation Access:
Ftg Drain b2�j ELR _—
Crawl Drain
Slab Inspection Notes: SIT
Post& Beam -
Shear Anchors - ---
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing --
Firewall
Fire Sprinkler --- - -- -- ---
Fire Alarm
Susp'd Ceiling -----...---- — ---- -- - — --
Roof
E
' PART FAIL -�_ ----- -- ' - --- - --
P
Post& Beam ---- ---_--_____ .—
Under Slab --- -- ---- - - -- -------- - - — .-
Rough-In
Water Service - ------ -- — — -- _-
Sanitary Sewer
Rain Drains -- - -------- --- - -—
Catch Basin/Manhole
Storm Drain ------- ----- -
Shower Pan
Other: --
Final ---._----�-
PASS_ PART FAIL
MECHANICAL
Post& Beam
Rough-in -- ------------- ------ ---- ---- - ----—
Gas Line
Sa Dampers
PASS PART FAIL ______ __.,._ ___---- -- ---------------_._----------._______.
ELECTRICAL -
Service
Rough-In
UG/Slab -
Low Voltage -----_-_-..- - - _--
Fire Alarm
'=final Reinspection fee o1$ _ required before next inspection. PO at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinspection ISE: -`_-_ Unable to inspect-no access
Fire Supply Line �.,
ADA
Approach/Sidewalk Date �`- Inspestor Ext
Other:
FinnI _ DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL
DF TIGARD 24-Hour .,
BUILDING Inspection Line: (503)639-4175 MST
IN';PECTION DIVISION Business Line: (503)639-4171
/ WilBUP
Received ( /Date Requested_-_ -S.�AM_ PM — BUP — —
LocationSuite-- MEC� —__—
�C.'t-rpt �v - OPLM
Contact Person _. .-- --_ ���
Contractor -_------- .___-- l _-___ Ph(_—_--) SWR
BUILDING Tenant/Owner .-.----------_- - - _ _ ELC
Footing _ ELC
Foundation Access: ELR
Ftg Drain ------
Crawl Drain
Slab Inspection Notes: SIT
Post& Beam
Shear Anchors - ---
Ext Sheath/Shear --- ------ -
Int Sheath/Shear
Framing -- --- -_ --- ----
Insulation
Drywall Nailing ------ --- -- - ----- ----- - --- -_
Firewall
Fire Sprinkler
Fire Alarm
Susp'dCeiling --------- ------ __._T__ -_-- - --
Roof
Other: ---------- -- _- -- -------
Final
PASS PART FAIL
Post& Beam ---_._.__--
Under Slab ----- --------- - --- -- - -
Rough-In
Water Service - _. __._ - --..- ..-- --------- ----- - -- - -
Sanitary Sewer
Rain Chains ------ - --- ----------- ------- ----
Catch Basin/Manhole
StormDrain -__------- --_--- -- _.____—___—__---- --_.__
Shower Pan
Other. -- -- --
Final - - ---- --------- ...- --� --- - --_
PASS PART FAIL
MECHANICAL ---- -- - ---- - - --------- - - ----- --- ----
Post& Beam - --
Rough-In - -- - ---- -- ----- _----- _---------- _----
Gas Line
Smoke Dampers -- ------ ----- -- - _ - --- ------ --- - -
Final
PASS PRT FAIL_ ------- ---- . ----- ------------- --- -----_..— -------_____-_
-ELE
CTRIC - - - - ----- - --- - -------
Service
Rough-In ---
UG/Slab
Low Voltage ---...__ ---- - - --- - -- ----- ------
Fin - ` Reinspection fee of$ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
_ AS PART FAIL
SITE _ - Please call for reins pe tion RE: --_�_.___. Unable to inspect-no access
Fire Supply Line /
ADA ! -__ Inspector �^'��_ - -- -- Ext---
Approach/Sidewalk Date -
Other:
Find DO NOT REMOVE this Inspectlon record from the Jo site.
PASS P.`RT FAIL
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 MST 4=0 �Q�V
INSPECTION DIVISION Business Line: (503)639-4171
BUP — —
Received �' 0 1+— Date Requested_ — Z5/ AM— — PM— .. BUP —
Location
Suite__--D� MEC --_—_
Contact Person PLM
Contractor--_-__-- _..-__ Ph(__.-_.) - -_-- SWR -----
BUILDING Tenant/Owner ELC
Footing ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain -
Slab Inspection Notes: SIT
Post&Beam
Shear Anchors
Ext Sheath/Shear --- --------
Int Sheath/Shear
Framing ---- ----_----- --- -- - - - --- _— -
Insulation
Drywall Nailing - - - ----- - -- -- ---- --- ----_-
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other: --__.--- -_ __ - .-.._ ------- ---------- -------
Final -
PAR, FAIL
_ UMBIN
Post& earn
Under Slab ----- ---- -- -- -----------
Rough-In
Water Service -
Sanitary Sewer
Rain Drains - - --- - - - _.. -- --- ------_--- - - -
Catch Basin/Manhole
StormDrain ------- ----- --- ----_--- -----_ --__._.-.--- ------------------
Shower Pan
f
PART FI1IL
ECHI AL - ---- ---- - - -----...-- ---- ----- - -------
Post&Beam
Ron ------
:1
---- _ ._.-- ------ --. - -as Llne
Smoke Dampers __._-..__ --- - - ----- -- ... ----- _ _ -- ----- -----
F
PAS PART FAIL _------- ---------------- ----- ---------ftS. CTRICAL
----- --- ----------_- __ ._ ---------
Service
Rough-In ------------
UG/Slab ----_--- --- --._.---- -----__-
LowVoltage ---...... . _- --- - - - _ ----- - -- ---- ----- --- --
Fire Alarm
Final Roinspection fee of$ _._-- required before next injpection. Pay at City Hall, 13125 SW Hall Blvd.
_PASS PART FAIL
SITE - �-] Please c-11 for reinspection RE: r______--____,--_--.-__ Unable to inspect-no access
---.__-�
Fire Supply Line L
ADA Approach/Sidewalk Data-_- -- /. Inspector Ext --_---
Other
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL