Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT L 4 tin
2 Request q est for Permit Action NOV 2 ii 2018
T I(,A R J) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigared' ( r Tic ARD
TO: CITY OF TIGARD
Building Division \a/ 01
13125 SW Hall Blvd.,Tigard,OR 97223 /,�/ ,'
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigarov
FROM: ❑ Owner M Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) ��l\r ( ,/,1 v-,,,1/4) L. L Lb
Mailing Address: 10 3 V-0/910 VVCA St eyi-.e '510
City/State/Zip: Vol vl (_D(Amy- 1KA. el( ist190
Phone No.: '30 D Q cl( --1-7 00
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL/VOID PERMIT APPLICATION.
❑ REFUND 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#: /7S 7 / - a.3/3 ..r.�Cc_)„ c,2G7l p
Site Address or Parcel#: i U S C1 C7 f 1 i eiv1( ,L; IA 11)1...)
^ �"p�r`�/� �fl
Project Name: -1 V V 1-L-'U r C&(J Ct Ka J
Subdivision Name: VP R`V 1-e\f\CCMiei. C(J i Lot #: \LT )
EXPLANATION: r'
�1\I i 1 i ��� IAA l�. -�IS I C�� (� �1-�l(n71+
't\CANN -V( c
t/71/ici ..,-+ _ e- Iff _ Al ,e-e-Y_ - 't1 --c•b--3 Abeec Zzi/-7 /4k4- 6274/ 7226"-cr;iee 1-, ,,,fii'ITL.-
Signature: / Date: 11 I % 1I )
Print Name: /lr\71(21 M(a-, o V 1 v
Refund Policy
I. 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: DateBy Route to Records: Date /o2 3 / ' By .
Refund Processed: Date ,i/� By„/#17Invoice Processed: Date //,�i�c9" By'TOW,
Permit Canceled: Date /2///�/,� By or Parcel Tag Added: Date / By
I:\Building\Forms\RegPemutAction_0 _31 .doc
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Building Permit Application if'-`' 1
Residential r i - FOR OFFICE USE ONLY
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City of TigardTigard ,i , Received
Date/By: A\ e
Permit No.: �l
III I 14 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review t ��� �,DcA...
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permi cA,_ t .;.
T'[G A it D Inspection Line: 503.639.4175 Date Ready/By: Juris: Vi SeepPage 2for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
., es;.... :;;,.. �a_',,,;: ., . i _ ., ,, 3 1 i 11 / ,
®New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
;,
t k, work indicated on this application.
It �....., .tv, t,. . ".',.,e, -s.:?ria.30 .- EI -"` :...., . . .r. , ..
® 1-and 2-family dwelling 0 Commercial/industrial Valuation: $
IDAccessory building 0 Multi-family Number of bedrooms: 9
❑Master builder 0 Other: Number of bathrooms:
_ ' (B, if L: , a` 9-,: Nll no'I , Total number of floors: 3
Job site address: \l S°1 tk� ,,,,,,-,,,,,,4 ('� ,n Q , New dwelling area: 39.A f n square feet
City/State/ZIP: t.V 1,U�r c V1 n o1A , �i 11 `t/v,w - Garage/carport area: 3y to
square feet
Suite/bldg./apt.no.: Project name: Ve( /f Terrace...,Q l.ea s Covered porch area: `SE square feet
Cross street/directions to job site: Deck area: 4 square feet
Other structure area: square feet
IRE .,1 1, pi old 1 R -„ ,
Subdivision: �d v(,vT,e irra Ct, ct Lot no.: \90 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 theprofit for the
.. �`+- iii l *'16401*::.; 0 -0 1 work indicated on this application.
r
.vi _� , .��: .,:�
Valuation: $
Existing building area: square feet
New building area: square feet
.Ty ,,. ., ,,r-P.i . . i . . .: Number of stories:
Name: A 9V t La,� O\a LUV Type of construction:
Address: OO - O�1\€\*L rj 7 P Occupancy groups:
City/State/ZIP: lf,A42 c 97,-7q� ° Existing:
Phone: (1Z;' ( ` J '33 Fax ( )
AP LIGAN ,, _ ❑ (O t PRS 'i B 1 1 G PPs
:.... .. : »r ,� ? ., x=- t , ;,.,ate - - .° .t
Business name:Polygon WLH LLC � ,, . ... ,. (Peasse,referto`;,Ischedu'' ,. . tai ,,.. . ,.....
Structural plan review fee(or deposit):
Contact name:Amanda Gavin
FLS plan review fee(if applicable):
Address:703 Broadway St.Ste 510
Total fees due upon application:
City/State/ZIP:Vancouver WA 98660
Phone:(360)695-7700 Fax::(360)693-4442 Amount received:
E-mail:permitsubmittals@polygonhomes.com
® # , - Commercial and residential prescriptive installation of
.:. P._ 1 ,.,, -, ,.,, , ,:.. ,::,i E roof-top mounted PhotoVoltaic Solar Panel System.
Business name:William Lyon Homes,Inc. Submit two(2)sets of roof plan with connection details
and fire department access,along with the 2010 Oregon
Address:703 Broadway St.Ste 510 Solar Installation Specialty Code checklist.
City/State/ZIP:Vancouver WA 98660 Permit Fee(includes plan review $180.00
and administrative fees):
Phone:(360)695-7700 Fax:(360)693-4442 State surcharge(12%of permit fee): $21.60
CCB lie.:207247
Total fee due upon application: $201.60
Authorized signature: = This permit application expires if a permit is not obtained
,,,,„0114'.: within 180 days after it has been accepted as complete.
Print name:Amanda Gavin Date:
l 1' RO . l g *Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard ReceivedDate/By: Permit No.:
i - ° 13125 SW Hall Blvd:;Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 501598.1960DateBy Other Permit: (y
��-1y-�V k�_ ck3c),
TI GA RD .Inspection Line: 503:639.4175 Date Ready/By: Juris: H See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Mechanical permit fees*are based on the value of the work
®New construction 0 Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all
0 Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit.
Value:$
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT/SYSTEMS FEES*
® 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist.
0 Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning 1 46.75 46.75
Job site address: . I n`P1 L\ SW 1V i 1 `C ) Furnace 100,000 BTU(ducts/vents) 1 46.75
City/State/ZIP: Fl/L/f V Mu 0\10 Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.: Project name:River Terrace East /l ` l5 Duct work 23.32
Cross street/directions to job site: Hydronic hot water system 23.32
Residential boiler(radiator or
hydronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for any of above 1 23.32
Subdivision:River Terrace East Lot no.: Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert 1 33.39
Flue vent for water heater or gas
fireplace 23.32
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
:4 PROPERTY OWNER 0 TENANT Other: 23.32 I,
Environmental exhaust and ventilation:
Name:ADVL Land Holdings,LLC Range hood/other kitchen
equipment 1 33.39
Address:7600 E Doubletree Ranch Road Clothes dryer exhaust 1 33.39
City/State/ZIP:Scottsdale,AZ 85258 Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) _3 23.32
Phone:(602)694-4031 Fax:( ) Attic/crawlspace fans 23.32
® APPLICANT 0 CONTACT PERSON Other: 23.32
Business name:William Lyon Homes,Inc. Fuel piping:
_ $14.15 for first four;$4.03 for each additional
Contact name:I RYnrctrit, elftV� Furnace,etc. 1
Address:703 Broadway St Suite 510 Gas heat pump
Wall/suspended/unit heater
City/State/ZIP:Vancouver,WA 98660 Water heater
Phone:(360)695-7700 Fax::(360)693-4442 Fireplace 1
pp11��,1nnnn GG�e i�nnnn,-�,r�1 ` 1 In `n��/�,�r `��/1� Range 1
E-mail:_ P- V itt5V��vVt,bl'zilS (@V0t /II� YV a Y VIX,J.W ix Barbecue
CONTRACTOR 1�JI Clothes dryer(gas)
Business name:TBD Other:
MECHANICAL PERMIT FEES*
Address: Subtotal
City/State/ZIP: Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:( ) Fax:( ) State surcharge(12%of permit fee)
CCB lic.: TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: * Fee methodology set by Tri-County Building Industry Service Board
Print name: Date:
I:\Building\Permits\MEC PermitApp_040113.doc 440-4617T(11/02/COM/WEB) . _
m.
Electrical Permit Application .. FOR OFFICE USE ONLY
CityO Tigard Received Permit#:
• f g Date/By:. .
r 13125 SW-Hall Blvd.,Tigard,OR 97223 Plan Review�..- b` -Related Permit#:�'- k .- c
Phone 503.718.2439 "Fax: 503.598.1960 Date/B :
Inspectioh Line: 503.639.4175 Ready Date/By:. : Juris: 0 See Page 2 for
.TIGARD Internet:'www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
®New construction ❑Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition ❑Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
® 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
1(0 sr/LI r AD r t 1 0 Addition of new motor load of system.
Job#: Job site address: }L- 1001IP or more. ❑"A","E "1-2","1-3",
�y
❑Six or more residential units. occupancy.
City/State/ZII �,erAve O 10\10 U� 0 Health-care facilities. ❑Recreational vehicle parks.
�a" 0 Hazardous locations. 0 Supply voltage for more than
Suite/bldg./apt.#: Project name:River Terrace East r 1
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total I *
New residential single-or multi-family dwelling unit.
Subdivision:River Terrace East Lot#: ICAO Includes attached garage.
1,000 sq.ft.or less 3 168.54 4
Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 1 33.92 1
DESCRIPTION OF WORK Limited energy,residential 75.00 2
(with above sq.ft.)
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Renewable Energy 0 See Page 2
® PROPERTY OWNER 0 TENANT Services or feeders installation,alteration,and/or relocation
Name:ADVL Land Holdings,LLC 200 amps or less 100.70 2
201 amps to 400 amps 133.56 2
Address:7600 E Doubletree Ranch Road
401 amps to 600 amps 200.34 2
City/State/ZIP:Scottsdale,AZ 85258 601 amps to 1,000 amps 301.04 2
Phone:(602)694-4031 Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
Branch circuits—new,alteration,or extension,per panel
® APPLICANT 0 CONTACT PERSON A.Fee for branch circuits with
Business name:William Lyon Homes,Inc. above service or feeder fee,
7.42 2
eacT tOtAD W`P V IAA)
Feeh branch circuit
Contact name: Vv B. for branch circuits without
service or feeder fee,first 56.18 2
Address:703 Broadway St Suite 510 branch circuit
City/State/ZIP:Vancouver,WA 98660 Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:(360)695-7700 Fax::(360)693-4442 Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: lWolk0�IS , Reconnect only
67.84 2
CO RAC O
Pump or irrigation circle 67.84 2
Business name:TBD Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy 0 See Page 2 2
Address: panel,alteration,or extension.
Each additional inspection over allowable in any of the above
City/State/ZIP: Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr
Industrial plant(1 hr min) 78.18/hr
Email: Inspections for which no fee is
90.00/hr
CCB Lic.: Electrical Lic.: Suprv.Lic.:
specifically listed(%2 hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal:
Print name: • Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
TOTAL PERMIT FEE:
Authorized signature:
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:Building\Permits\ELC_PermitApp_ELR ERE.doc R-eu06/17/7015 440-4615T(I1/05/COM/WEB
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Plumbing Permit Application
Builc i g.Fixtures FOR OFFICE USE ONLY
Cl of Tigard Rece}ved Permit No.: .
u 13125 SW Hall Blvd.,Tigard,OR 97223 Plana /By;
DatReview Other Permit No.. �7
Phone: 503.718.2439 Fax: 503.598.1960 DatelBy`. ��v�-1�.,016
T I G A R D Inspection Line: 503.639.4175 Date Ready/By: Juris: 0 See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
®New construction 0 Demolition For special information use checklist
Description Qty. I Ea. Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
® 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 1 500.32
❑Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder 0 Other: Fire sprinkler sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: mv'W 5� ► V iv-h 1�Y IV L YCatch basin or area drain 18.76
-+ Drywell,leach line,or trench drain 18.76
City/State/ZIP: 1 Il NI,
VI ono
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: 1 Project name:River Terrace East a teO/3 Manufactured home utilities 50.03
Cross street/directions to job site: ✓✓✓ Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.: ) Page 2
Subdivision:River Terrace East 1 Lot no.: 16'',0 Fixture or item:
Tax map/parcel no.: Backflow preventer 1 31.27
Backwater valve 1 12.51
DESCRIPTION OF WORK
Clothes washer 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name:ADVL Land Holdings,LLC Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:7600 E Doubletree Ranch Road
Garbage disposal 25.02
City/State/ZIP:Scottsdale,AZ 85258 Hose bib 25.02
Phone:(602)694-4031 Fax:( ) Ice maker 12.51
® APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name:William Lyon Homes,Inc Medical gas(value:$ ) Page 2
Primer 12.51
Contact name A
'A w t �1 Roof drain(commercial) 12.51
Address:703 Broadway St Suite 510 Sink/basin/lavatory 25.02
City/State/ZIP:Vancouver,WA 98660 Solar units(potable water) 62.54
Phone:(360)695-77009 ( 'n n Fax::(3+160)693-14^4422 q I'},p/� Tub/shower/shower pan 12.51
Email: 1 V ,k ( 1/1,9 t'V l SIR • O(V� f j 111 9 1 V YV' Urinal 25.02
` ' U Water closet 25.02
CONTRACT
Water heater 37.52
Business name:TBD Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50
CCB Lic.: Plumbing Lic.no.: Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: Date: This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)