Permit Support Document VV 0 I
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT /Y I a, /26
46
1 _ Request for Permit Action `
TIC A R lD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.Agard-or.gov
riECDDVf'D
TO: CITY OF TIGARD MAY 1 8 2020
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223 CITY OF TIGARD
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPeriNl tll1SiION
FROM: ❑ Owner ❑ Applicant ❑ Contractor ACCity Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED V):
li CANCEL/VOID PERMIT APPLICATION.
I. (1 0 MO O REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
I‘' INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: P/)S,Z04.2 - iV 2/Z
Site Address or Parcel#: /Y SJ [/v
Of 7 � Gl 4r 67- (1ii
Project Name:
Subdivision Name: Pr fil 14 rds-7 Lot#:
EXPLANATION: o d&GJc?//,& . e4c/vil?h U/l%cc L p .S -/C,`'/
.54q..,er, I -D 1 - /1.t`lce Arc//y ztr57`iic/p.1I— Hcl Pi
P S l `V`Imo. Tt iie.5 6r r-c, ac a(r.,l /46T.40I g-(5n!V/ 7
Signature: .mot • Atedgreer.*---- Date: ,C.—/7 2.e)
Print Name: j f, {r/i hL t4-asir/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
f, , i '% Aft, % /SSCz-C-6
FOR OFFICE USE ()NIX
Route to Sys Admin: Date c/fd7.L , By /� Route to Records: Date Fj/1,�1 241 B /
Refund Processed: Date J B•4/ ? Invoice Processed: Date / By
. Permit Canceled: Date/Jj i By, ,n Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_7 518 oc
Building Permit Application
Fire Protection System FOR OFFICE USE ONLY
City of Tigardpril RECEIVED Received d1
' 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.19604PR 3 0 2020 Date/B : _a i-'41 a ,S cj Other Permit:47 7
TIGARD Inspection Line: 503.639.4175 Date Beady/By. IIIM ® See Page or
Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information
BUILDING DIVISION
TYPE OF WORK REQUIRED DATA:I-AND 2-FAMILY DWELLING
genlew 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 ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
2'I-and 2-family dwelling 0 Commercial/industrial Valuation: $ 4s0❑Accessory building El Multi-familyNumber of bedrooms:
❑Master builder El Other: Number of bathrooms: 4
JOB SITE INFORMATION AND LOCATION Total number of floors: .-
Job site address: \4 o 661 S,,, W New dwelling area: *364 a square feet
City/State/ZIP: 7jq,r 0 set... Garage/carport area: Lim square feet
Suite/bldg./apt.no.: Project name: 4K 2Ack Q a Covered porch area: 1+4 square feet
Cross street/directions to job site: e,(Lt, Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: f-e*Lh V.N d,re--- Lot no.: *1 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
DESCRIPTION OF WORK • work indicated on this application.
S ?YLV.t.c ir S.i S-4-e,......-s Valuation: $
Existing building area: square feet
New building area: square feet
PROPERTY OWNER L❑ TENANT Number Number of stories:
Name: J./ to 0.—, ,{bra a e.4%cS �I1G--et.. . ... Type of construction:
Address: A"0 too X .25 3 Occupancy groups:
City/State/ZIP: �0 tQ1'�,+., Ir.4 0 �2.. Cl R.2,,`J Existing:
Phone:JJ(C p.3) 2.01 2• q� Fax:( ) New:
0 APPLICANT ❑ CONTACT PERSON
NOTICE
Business name: Sc.\‘‘4. 0-‘"c 1Q,2� V.`C l e..5 All contractors and subcontractors arc required to be
Contact name: E..`� ?V,'2E 2— licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 'Q O 9 It)X 2 !J^T'}j jurisdiction in which work is being performed.If the
City/State/ZIP: D�fly..'2 r\c \ pW Ol.. 2 Gi s applicant is exempt from licensing,the following reasons
Sp3) c T1 Z .y 3 t � apply:
Phone:( O Fax::( )
E-mail: fc\c �G bCl\..-tC'cyLoN1,�p tr>,t,s. o
he
CONTRACTOR BUILDING PERMIT FEES*
Business name: A 11-,',�9 • ��^6 (Please refer to fee schedule
1`�
Permit fee:
Address: P et. eit t2
r
City/State/ZIP: S'r* Qqy` Ok-�4.1,34 State surcharge(12%of permit fee):
FLS plan review(40%of permit fee):
Phone:663) 868 141 Fax:/ p563) 5 Z4 9q 4o. (Due upon application submittal.)
CCB lic.: 't� N}2r Total permit fees:
`'t' l / Amount received:
Authorized signature:
This permit application expires if a permit is not obtained
Print name: fe er_. Revs,Z- Date: 1 I 1 Zv CO within 180 days after it has been accepted as complete.
* Fee methodology set by Tri-County Building Industry
Service Board.
I:tauildi g\Permi181FPS-PermitApp_031016 doc 440-4613T(1 1/02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2-Supplemental Information
Describe work to be done:
1.) Type of Work: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices:
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 of System (Complete A,B, C or D as applicable):
A.) Commercial Sprinkler
Sprinkler"Type El Wet ❑ Dry
Additional Standpipes
Information: Sprinkler Supply Line ❑ Yes ❑ No
Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
•
Submittal shall Battery Calculations ❑ Ye,s
include: Individual Component ❑ Yes,
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit lee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05 r
7,201 and greater $404.39
Sprinkler Project Square Footage: 3 69 6 sq. ft.
Fire Protection Permit Fees
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: $
I:\Building\Permits\FPS_PermitApp_031016.doc - - -