Permit CITY OF TIGARD"s .III MASTER PERMIT
' COMMUNITY DEVELOPMENT Permit#: MST2020-00153
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/09/2020
T I i;,'r 1<L. g Parcel: 2S103CA00207
Jurisdiction: Tigard
Site address: 11590 SW FONNER ST
Subdivision: WOODCREST NO.2 Lot: 29
Project: Alexeev
Project Description: 577 sf second story addition of 1 bedroom, relocate 1 bathroom,study and kitchenette,and
alteration of 1 existing bedroom above garage. AREA IS NOT APPROVED FOR USE AS AN
BUILDING
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 1 First 0 sf Basement: 0 sf Left 5 Parking Spaces: 0
Height: 22 Bathrooms: 0 Second: 577 sf Garage: 0 sf Front: 20 Smoke
Dwelling Units: 0 Third: 0 sf Right 5
Detectors: Yes
Total: 577 sf Value: $84,256.00 Rear: 15
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Drains: 0
Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Other Fixtures: 0
Drywell-Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Tvoes Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Fumc100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc!Feeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add'l 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ADD SF VB R-3 577
Owner: Contractor:
ALEXEEV,ALEXANDER&OLGA LIVING OWNER Required Items and Reports(Conditions)
22578 CANYON RIDGE PL OLGA ALEXAEEV
CASTRO VALLEY,CA 94552 4731 N BORTHWICK AVENUE
PORTLAND,OR 97223
PHONE: PHONE: 510-828-0467
FAX:
Total Fees: $3,540.12
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through 952-001- 90. Yo ay obtain a y of t ules or direct questions to OUNC by calling 503.232. 87 or 1.800.332.2344.
Issued By: Permittee Signature: CV
Call 5 3.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project
Approved plans are required on the job site at the time of each inspection.
Building Permit Application r -dr
Residential FOR OFFICL USE OINL1
City of Tigard RECEIVED Received s /7/� S7:2.9.�—oofs
r� Date/By: ! .�� Permit N�
• 13125 SW Hall Blvd.,Tigard,OR 9 1,,Y 1 Plan Review
a Phone: 503.718.2439 Fax: 503.59 960 4 202C Date/By: 0, - J�� other permit
TIGARD Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready I A. run: ® See Page for
Internet: www.tigard-or.gov Notified/Me� �'/ Supplemental Information
BUILDING DIVISION
TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING
❑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
'Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.,7.3�,i`T
tif I-and 2-family dwelling 0 Commercial/industrial Valuation: z�, $ $s{l -
0 Accessory building ❑Multi-family Number of bedrooms:
❑Master builder 0Other: Number of bathrooms: j Kta��,l�I.1mraT
` JOB SITE INFORMATION AND LOCATION Total number of floors: S.
Job site address: I 1 ei 9 O Sw FOty - 9-- ST-. New dwelling area: A1 lit,4G square feet 571
ACity/State/ZIP: TC--+1 .dat217 O 14 •=1'T 223 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name:A LE.)(EEV Aplo 1-n Of-4 Covered porch area: square feet
Cross street/directions to job site: -ry-r.o L•o re ,EST D P Deck area:+St W t¢ L4.3� square feet [- C.
IN t2SEGT'tOrl �! l TW SW 1 Gj-C1 1 �Q'(£ , O r s mehire Pe 44a13 square feett4-4p
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: w ppy>Gy.z.EG. # Lot no.: 29 Permit fees*are based on the value of the work performed.
°L�J Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: O 3 GL+, O Z7Z `f equipment,materials,labor,overhead,and the profit for the
,` b,e- DESCRIPT[ OF W ttit�r s'prt y. _ work indicated on this application.
rP �tt,'s , °(�'c ��
1) 5t_C.pl-4 STot -yf *49%J1TlOaM OYe✓1_GA y - S77 5F Valuation: $
t-) geet.-4e� goOF Ft4.4r'*AiHCrt•hT' EXIST. B Y4COMI-e,`tto 5F Existing building area: square feet
'A EX 1 r bF c + 5-1--"ire. F✓aor•t Si�o►+t, F-i-0 ot4- 6,4� SF New building area: square feet
pir PROPERTY OWNER 0 TENANT Number of stories:
Name: AI_.EX sf OLCa64 ha-e....-sCa-ENi Type of construction:
Address: 1( 5 9 p Sw I`OIN 1-1v-K s-r-. Occupancy groups:
.1_ City/State/ZIP: -1•\CsAt2 y:7" O tQ .9'7 223 Existing:
1 Phone:(51O) e,LiB- 0467 Fax:( ) New:
0 APPLICANT A-CONTACT PERSON BUILDING PERMIT FEES*
Business name: (Pteese refer to fee schedule)
1�N�JA 1-� ,<S.• �'A C.n 22Gt t I V P C Structural plan review fee(or deposit): 4if< .c/$
Contact name: ..0F.yypy eb,Cen
FLS plan review fee(if applicable):
Address: 47 3 I NI. I ,otz--I-t'I W 1 C-it AYE.
Total fees due upon application:
City/State/ZIP: roK-F-1-/.,1-yr7 , OI- -721-7
Amount received:
Phone:(�jflj) 206,-s{ 3.,4,
0 Fax: ( ) PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
E-mail: r..-q ern of @° vn .I . Govty
U Commercial and residential prescriptive installation of
ONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Business name: e�D,toEJI,•-I-•f 0 VH I.yEI�- �-E,X Al-E-X6-6-1/ Submit two(2)sets of roof plan with connection details
and fire department access,along with the 2010 Oregon
Address: t I Cj 4:1 O 9\a./ F O TI hi a . sr Solar Installation Specialty Code checklist.
City/State/ZIP: -r-1G1'.tFti . Ore- 912, ,J2 Permit Fee(includes plan review $I80.00
and administrative fees):
Phone:(5IO) & - 044,1 Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lic.: Total fee due upon application: $201.60
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
/ Date: 5-4., tot° *Fee methodology set by Td-County Building Industry
Print name: ,��--
I" Service Board.
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
City of Tigard
IIIC COMMUNITY DEVELOPMENT DEPARTMENT
rICARD Building Permit Review — Residential
Building Permit #: /1i-C ad24 — 0e/5.3
Site Address: 115Gf sni &Onner
Project Name: _ AIekeev Lot #:
Planning Review
-
Proposal: MArtin, roof trplzc.arna -LAM cle e--tc--{Dl1K-
91. Verify address/suite # active in Accela. ILS-In River Terrace: IS,No ❑ Yes,River Terrace Review Addendum
Site Plan Elements: lo€rosion Control
X('S copies of site plan on 8-1/2"x 11"or 11 x 17"paper Retained trees with drip line and tree protection measures
KDrawn to scale(standard architect or engineer scale) Footprint of new structure(including decks) and FFE
worth arrow > Utility locations&easements(required for new and additions)
Site address,project or subdivision name and lot number
3idewalk/driveway approach
XApplicant information(name and phone number) NA.ocation of wells/septic systems
PrI.ot dimensions and building setback dimensions A€treet tree size,type and location
Square footage of buildings to be demolished .) Street names
Existing structures on site .Corner elevations(2'contours if more than 4'differential)
NALot area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? 0YesANCTo
impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? 10Yes4o
Z Clean Water Services —Service Provider Letter (lot platted prior to 9/10/1995):
Required: ❑ Yes,applicant was notified X No Kiee fy f� Received: ❑ Yes ❑ No
�, Water Meter Fixture Unit Worksheet—Additions,Remodels and ADUs
Required: ❑ Yes,applicant was notified ❑ No Received: ❑ Yes ❑ No
N, -sDC Exemption for ADU applied for: ❑ Yes ❑ No Received: ❑ Yes ❑ No
Public Facilities Improvement (PH) Permit:
Required: ❑ Yes,applicant was notified X No Applied For: ❑ Yes ❑ No,stop intake
NristrLand Use Case #: 2. Zoning: R-4S
14 Required Setbacks: Front: 2-0 Rear: I S Side: J Street Side: t)/A Garage: 23)
❑ Building Height: Max. Height: 30 Actual Height: 1.22 g-
Landscape Area: % ?Lot Coverage Max:
Entrance et back no more than 8'from street-facing wall ❑ Parallel to street or offset 45 degrees or less
Windows .Minimum 12%of area of all street-facing facades
Garage Garage door is behind widest street-facing wall ❑ Yes ❑ No,one of the following is met:
❑ Door extends no more than 5' from wall and there is a covered porch extending beyond garage.
❑ Door extends no more than 5'from wall and there is a 12 sq ft.window above garage on 2nd floor.
arage door width is ❑ 12'or less 'V. 50%or less of facade ❑ 60%or less and includes 7 of following:
❑ Covered porch ❑ Recessed entrance ❑ Wall offset ❑ 1'Roof eave ❑ Roof offset
❑ Fire shingles ❑ Lap Siding ❑ Roof pitch ❑ Gable,hip,or gambrel roof ❑ Dormer
❑ Accent siding ❑ Window trim ❑ Window recess ❑ Window projection ❑ Balcony
Visual Clearance I/ Urban Forestry Plan
"Sensitive Lands: DiYes X.' No Type:
tew Conditions met prior to issuance of building permit
Notes: /�
i Approved By Planning: & — Date: 5f iP W
Revisions (after Building Submittal onl Reviewer Date
Revision 1: 0 Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
I:\Building\Forms\s IdgPermitRvw_RES_122419.docx
Building Permit Submittal
Original Submittal Date: -.S`y/24
Site Plans: # ,3
Building Plans: #
Building Permit#: [ Enter building permit#above.
Workflow Routing: I Planning IErtngineering $Permit Coordinator ��uilding
Workflow Sign-off: R-Sign-off for Planning(include notes from planning review)
Route Application Documents: I;1--Engineering: (1) copy of permit application, (1) site plan, (1) building plan and
original plan review routing form.
Building: original permit application, site plans,building plans, engineer and
beam calculations and trust details,if applicable,etc.
Notes: S//Z/ZO
By Permit Technician: �� Date: -5`1/Zd
Engineering Review
'lope at building pad: Z.
L Conditions "Met"prior to issuance of building permit N/-
C�7'/Easements (encroachments) per engineering conditions of approval and plat " I
gJ Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: ❑ Yes
Assess Water Quantity Fee in-lieu: ❑ Yes C3'No
LIDA Facility on lot: ❑ Yes El-No
LJ Final Plat Recorded: A/a
❑ NOT Approved by Engineering: Date:
Notes:
Approved by Engineering: j Date: S J/3/ 2U
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Permit Coordinator Review
KConditions "Met"prior to issuance of building permit
❑ Approved,NOT Released: Date:
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant:
Revision Notice 2: Date Sent to Applicant:
12'SDC Exemption: ❑ Received Vi„ Does not apply
SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes N/A
Tigard Trans SDC: ❑ Yes N/A
Parks SDC: 0 Yes N/A
LIDA 0 Yes N/A
OK to Issue Permit
Approved by Permit Coordinator: Date: sf i 3/iD
I:\Bui Iding\Forms\BldgPermitRvw_RES_122419.docx
C 4-ti MS 7 2e7 - 00/S.3
//59eSad ,�
Dianna Ornelas
From: #Building Permit Technicians
Sent: Tuesday, May 12, 2020 5:48 PM
To: Olga Alexeev
Cc: #Building Permit Technicians;Allyson Armstrong; Agnes Lindor; pagernw@gmail.com;
UB Online
Subject: RE: Permit Application for 11590 SW Fonner St - MST2020-00153
Attachments: MST2020-00153.pdf;WaterMeters_070119_Add.pdf
Hello Olga,
The building permit was created today and the balance due for the plan review submittal fee due at this time is$645.45
(see attached invoice). Additional fees will be assessed during actual review of the plans and will be invoiced when the
permit is ready to issue.
The $645.45 fee can be paid online at https://aca.accela.com/TIGARD/Welcome.aspx by searching for the permit record
number MST2020-00153 under the Building tab. It is not necessary to enter the street address or parcel information
when searching by permit record number. Click on the Payment tab,then Fees, to see a list of the fees. Click on the link
to pay fees to be redirected to the online payment vendor. There is a 3%service fee for using a card for payment, and
there is no fee for paying by check (select which payment option you prefer using the drop down arrow).
Please email the permit technicians at TigardBuildingPermits@tigard-or.gov after the plan review fee has been paid
so that the plans can be routed offsite for plan review. Due to the high volume of permit activity, and remote working
conditions due to COVID-19, please expect delays in processing this permit and we cannot provide an estimate of the
permit processing time. The permit technicians will contact you when the permit is ready to be issued and with
instructions to pay permit fees online. There is no need to contact us regarding the status of this permit.
Please see below for additional information regarding this project:
• Description of permit and copy to be provided to Washington County tax assessor: 577 sf second-story addition
of 1 bedroom, 1 bathroom, study and kitchenette, and alteration of 1 existing bedroom above garage. AREA IS
NOT APPROVED FOR USE AS AN ADU. All trade permits to be obtained separately.
• Mechanical, electrical and plumbing permits can be obtained through our online permit system by registered
licensed contractors.
• A water meter fixture unit worksheet is required to be completed and submitted to our utility billing division to
determine if the current water meter needs to be upsized. Please complete the attached form to identify all
existing plumbing fixtures and additional plumbing fixtures and email the form to UBOnlinepay@tigard-or.gov
for their review and approval. This form must be approved by UB and their authorization emailed to
TigardBuildingPermits@tigard-or.gov prior to permit issuance.
Thank you and please let me know if you have any questions.
Dianna L. Ornelas(Howse)
Building Division Services Supervisor
City of Tigard I Community Development
13125 SW Hall Blvd I Tigard, OR 97223
503-718-2430 Direct 1503-718-2439 Permits
From:Agnes Lindor<agnesl@tigard-or.gov>
Sent:Tuesday, May 12, 2020 8:08 AM
To: Olga Alexeev<olga.alexeev7@gmail.com>
Cc:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov>; Allyson Armstrong<AllysonA@tigard-or.gov>
Subject: RE: Permit Application for 11590 SW Fonner St
Olga-
Yes, planning department has reviewed and approved it. Your permit is waiting to be created with the building
department. Due to the Covid-19 situation, permit processing is taking a bit longer than usual.
The building department will notify you once your permit is ready for issuance.Thanks for your patience.
Agnes Lindor I Associate Planner
City of Tigard I Community Development
13125 SW Hall Boulevard
Tigard, Oregon 97223
Phone: 503.718.2429
Email: AgnesL@tigard-or.gov
From: Olga Alexeev<olga.alexeev7@gmail.com>
Sent: Tuesday, May 12, 2020 8:04 AM
To:Agnes Lindor<agnesl@tigard-or.gov>
Cc:#Building Permit Technicians <TigardBuildingPermits@tigard-or.gov>; Allyson Armstrong<AllysonA@tigard-or.gov>
Subject: Re: Permit Application for 11590 SW Fonner St
Caution!This message was sent from outside your organization. Allow sender I Block sender
Good morning Agnes,
I know that planning department should review the application first and than application is going to building
department.
Did planning department already finish the review and sent it to building department? Please Let me know the process
is.
Thank you,
Olga Alexeev
On Tue, May 12, 2020 at 7:52 AM Agnes Lindor<agnesl@tigard-or.gov>wrote:
Olga-
I am copying the building department to reply regarding the status of your building permit.Thanks,
Agnes Lindor I Associate Planner
City of Tigard I Community Development
13125 SW Hall Boulevard
Tigard, Oregon 97223
2
a
Phone: 503.718.2429
Email: AgnesL@tigard-or.gov
From:Allyson Armstrong<AllysonA@tigard-or.gov>
Sent: Monday, May 11, 2020 9:37 AM
To: Agnes Lindor<agnesl@tigard-or.gov>
Subject: FW: Permit Application for 11590 SW Fonner St
Olga,
I am forwarding this to our planner to check that we did receive it. The planning department sees all the additions
prior to the building department.
Agnes,
Could you please check to see if we received this permit application for an addition at 11590 SW Fonner St?
Thank you,
Allyson
From: Olga Alexeev<olga.alexeev7@gmail.com>
Sent: Monday, May 11, 2020 9:30 AM
To: Allyson Armstrong<AllysonA@tigard-or.gov>
Subject: Permit Application for 11590 SW Fonner St
Hi Allyson,
l am sending the screen print of first page of our application (see attachment)
3
a
FOR OFFICE USE ONLY-SITE ADDRESS:
'4 This form is recognized by most building departments in the Tri-County area for transmitting information.
l� Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
111 1 Transmittal Letter
Tic A it I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.f Lard-or.gov
TO: JC'IGta2 1Jult..„,,1 NCa. e£✓ZM 1T7 DATE ' CEIVED:
DEPT: BUILDING DIVISIONis- RECEIVED
MAY 4 2020
~ FROM: /S., i tom( r7.6..csE
CITY OF TIGARD
COMPANY: Kd.r-a1.::),o,t,.l_ A. 1=AGE) /-10Qc--it-r-- -r BUILDING DIVISION
PHONE: t73- 20 c- 4 34 o By:?—
RE: 11 5 9 o Sw F o r►r+ t.--.
IS (Site Address) (Permit Number)
.41,--Ex CI-N.( "At�nrrt 01-4 ^1.--t_ .-n o,-ts,
(Project name or subdivision name and lot .mber)
ATTACHED ARE THE FOLLOWING I MS:
1�
``2 Copies: Description: Copies: Description:
Adda:,,...r}'Set(s) of plans. Revisions:
Cross section(s) and detai .. Wall bracing and/or lateral analysis.
k Floor/roof framing. Basement and retaining walls.
----..._., Beam calculations. Z Engineer's calculations.
Other(explain): IN `sty TvLAV-IS
REMARKS: --E�rs _6,c r- - -t- As-rr --4E- HOC— hnF�ttiTS
.EoWe -nit � T .a.,—t=I-tc e.-rtot-r OF -n-tts 1. 12oJ -.
FOR OFFICE USE ONLY
Routed to Perm' :Technician: Date: Initials: _
Fees Due: es ❑No Fee Description: Amount Due: ,
1 $
$
$
S ecial
nstructions:
Reprint Permit(per PE): ❑ Yes ❑ No ❑ Done
Applicant Notified: Date: Initials:
I:\Building\Forts\TransmittalLetter-Revisions.doc 05/25/2012
RECEIVED
Clean Water Services File Number
MAY 4 2020
CtTY OF TiGARD CeanWater Services
BUILDING rikkiiiitive Area Pre-Screening Site Assessment
1. Jurisdiction: GI-r-r of -1-Ic=.a.a.re s 0�
2. Property Information (example 1 S234AB01400) 3. Owner Information
Tax lot ID(s): 2 S 1 O 3 r��.0o Q.O7 Name: A Ol•-CaA
Company: —
Address: 11 5 c10 SW Forrt-4E -- Sr.
Qj3 Site Address: 11 5.1 o S W FoNnE-42 s City,State,Zip: T1 GAQ p Oro- '(-7 2,23
City,State,Zip: TI vp..en, o. 912L.3 Phone/Fax: (Cj 1 o.) 8 2.&- 04( i
Nearest Cross Street: SW 11 S TTLi AVM• E-Mail: O -c /A-LEXfz-E.V
4. Development Activity(check all that apply) 5. Applicant Information
Ar Addition to Single Family Residence(rooms,deck,garage) Name: 12 .A-Ivry
❑ Lot Line Adjustment ❑ Minor Land Partition Company: 1�rr•a.°a,4_ Ass. tl<acas. co-a rTEr--t-
❑ Residential Condominium ❑ Commercial Condominium
Address: 4 7 31 NI. Esor2lZnv+rcK-.A\r
❑ Residential Subdivision ❑ Commercial Subdivision
la Single Lot Commercial ❑ Multi Lot Commercial City, State,Zip: �OvCTt-�rvro, Ov2 �l
Other Phone/Fax: (5 03) t-06,- 43 40
E-Mail:
6. Will the project involve any off-site work? ❑Yes X No ❑ Unknown �T
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project , --'o.v TQ ,E O V E2
trX\S-r u- c GAJL/�vE , A. Wf.w s.-74 "6•49,o SF OF "am viNC- •
This application does NOT replace Grading and Erosion Control Permits, Connection Permits, Building Permits,Site Development Permits,
DEQ 1200-C Permit or other permits as issued by the Department o1 Environmental Quality, Department of State Lands and/or Department of
the Army COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law.
By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority to enter
the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify that I am
familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name te4z.1---4 -t 1 �i� >= PrintfType Title ere,o, v v c-T
Signature e- .79-7 Date q--ZoZo
FOR DISTRICT USE ONLY
❑ Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report may also
be required.
❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This Sensitive
Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered.This
document will serve as your Service Provider letter as required by Resolution and Order 19-05, Section 3.02.1,as amended by Resolution and Order 19.22. All
required permits and approvals must be obtained and completed under applicable local,State,and federal law.
❑ Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive
area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive
areas it they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 19-05,Section 3.02.1,as
amended by Resolution and Order 19-22.All required permits and approvals must be obtained and completed under applicable local,state and federal law.
❑ This Service Provider Letter is not valid unless CWS approved site plan(s)are attached.
❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE
PROVIDER LETTER IS REQUIRED.
Reviewed by Date
Once complete, email to: SPLReview@cleanwaterservices.org • Fax: (503) 681-4439
OR mail to: SPL Review, Clean Water Services, 2550 SW Hillsboro Highway, Hillsboro, Oregon 97123
Revised 6/2017