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Permit Support Document (16) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN le V it Request for Permit Acton TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: Owner ❑ Applicant ❑ Contractor ❑ City Staff Check V)one ll �f REFUND OR Name: / INVOICE TO: (Business or Individual) '4(5 / (,O Mailing Address: 79 O ti j•-)J�z`��e J S ]" City/State/Zip: � ,OJ A ) a a g '-/P Phone No.: 5 3- q 7L9 -a (c2 S PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCE ,VOID PERMIT APPLICATION. UND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: E(S b 15-. 0 c" ).0( Site Address or Parcel#: 79 v S Lv il ✓n Z l.1-c-- .D/4-() i a Project Name: Subdivision Name: Lot#: EXPLANATION: �j� ',��Z �� `« t4).- .i 4tc..,) tae-r",f ivI e Signature: Date: 5- e Print Name: Lc Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date 2 2,/j _-By Refund Processed: Date Ai /4 By Invoice Processed: Date By Permit Canceled: Date k 2z/,e- By .i" arcel Tag Added: Date By I:\Building\Forms\RegPermitAction_ 92314.doc \\I" ';''''''‘Ak, PI ' Building Permit Applica , � Z7, �- Fire Protection System ' Efri.{ , Y FOR OFFICE USE ONLY Ilk 0ity125 of Tigard Received �� 45;a5=-0::).„96 /�g'^,5 � _ DateB /7 Permit No.: ,/ /K 13125 SW Hall Blvd.,Tigard,OR 9.'1 2 Id 4, 2 i 1 Plan Re iin � Phone: 503.718.2439 Fax: 503.598.1960 Date/B �' Other Permit: T I G A R D Inspection Line: 503.639.4175 ¢ Date Rea. mils: Internet: www.tigard-or.gov �'' � 3 A t i 1. -` Notified/Method: 0 See Page 2 for ` BUILD" Information t r` V Supplemental -,- .--,< /, T � . ij,.-- , ,, ,A//' j is , . . . , ,„„ . . / _ . ,‘ ,',. : „ , ❑New construction 0 Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all Eg Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the ram � '� i R T � � ir�S �� / ' /E .y �1 work indicated on this application. ' . y '' [II 1-and 2-familydwellingValuation: $ [�Commercial/industrial ❑Accessory building 0 Multi-family Number of bedrooms: ElMaster builder ❑Other: Number of bathrooms: Total number of floors: sw M•U.,Zt kcr ST New dwelling area: square feet Job site address: 110,1 City/State/ZIP: —C1 V A,r P O Q c i-7:2-3 Garage/carport area: square feet Suite/bldg./apt.no.: Project name: R G."‘1,./x. (n r,Q Covered porch area: square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet l (1 'I11<.1rYI 'O(3 < C K ”, ® 'l 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© OF # ?"'Ab work indicated on this application. ' 'fi . W4 qq 1.-1 yr q0\ ►0.� co STcrA A-(-'rf f-A-r7D Valuation: $ SQ Q y/ Existing building area: square feet New building area: square feet V t) ER' l; ., , ' ;, E10 , ,, Number of stories: Name: Type of construction: Address: Occupancy groups: City/State/ZIP: Existing: Phone:( ) Fax ( ) New: Business name: All contractors and subcontractors are required to be Contact name: licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: jurisdiction in which work is being performed.If the City/State/ZIP: applicant is exempt from licensing,the following reasons apply: Phone:( ) Fax::( ) E-mail: C?l'' dil B�) O �� l� >l� IT , Business name: r dylr Gc.\-Ncs..4 p is G lea reje o Permit fee: Address: 7.4 vz_ 5 w .0u r‘,4*,,,,,, R o City/State/ZIP: State surcharge(12%of permit fee): To. 1%.P 'D 0CL. C 1'L►`' FLS plan review(40%of permit fee): Phone:(Col)) ttd t_5--7 8$ Fax:(664) ZZ.3. I i z s- (Due upon application submittal.) CCB lie.: Total permit fees: Authorized signature:7 ,.s Amount received: ___ —'— This permit application expires if a permit is not obtained Print name: *I 0.\r+H da rxo., Date: fL/Z2ii ewithin 180 days after it has been accepted as complete. * Fee methodology set by Tri-County Building Industry Service Board. I\Building\Permits\FPS-PermitApp_071514.doc 440-4613T(1i/02/COM/WEB) r City of Tigard: Fire Protection Permit Checklist Page 2- Supplemental Information 1.) Type of Work;-°/'2.)—Ad-di- ork: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices: [5d New system Number of sprinkler heads: Number of alarm devices: ❑ Addition or ❑ 1-10 heads: Affidavit required and ❑ 1-5 devices: Affidavit required and Alteration (3) copies of sketch showing area (3) copies of sketch showing area to existing of work within building structure of work within building structure system 11+ heads: Plan review required and ❑ 6+ devices: Plan review required and 3) sets of plans. (3) sets of plans. Additional description of work: Type f.Sys ' ( Iet"A B, r I7► s ap � able ' ......,,,,,avreagangAmoometilIVINIMERNOVIEK afx >inerftSpAtier ,. ❑ Wet ❑ Dry Additional Standpipes Information: Hazard Group Density Design Area K. Factor Sprinkler Project Valuation: $ Hood Project Valuation: $ -sow* moir,. .52111 71111 :411144411 gkAANktritillA 11* AMMO' tiaregatagMatininanaiiiignangni / ,� % � '�''" \ Submittal shall Battery Calculations If Yes include: Individual Component ® Yes Cut Sheets Fire Alarm Project Valuation: $ relent Sp er hone; t Square Footage: Permit Fee: 0 to 2,000 $198.75 Aging' Jill?' ,villoombillEmmet% 2,001 to 3,600 $246.45zam-44, Amu 3,601 to 7,200 $310.05 7,201 and greater $404.390 % j' �� Sprinkler Project Square Footage: sq. ft. - mow \ ;s . MERNMERREE.. ,. "'�LfktCrtYi1 et5 ✓°C �\ Project valuation subtotal (see A,B &C above): $ Permit fee based on project valuation (see fee schedule): $ Permit fee based on square footage (see D above): $ State Surcharge (12% of permit fee): $ FLS Plan Review(40% of permit fee): $ TOTAL: $ C:\Users\nmurphy\Downloads\FPS_PermitApp.doc 2