Permit `I = - - a te:
O7.
.y
A C 1 TY 0 TIGARD
MASTER'PERMIT
PERMIT #: MST2003 -00531
..�If" DEVELOPMENT SERVICES DATE ISSUED: 12/29/2003
.T 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171
SITE ADDRESS: 11500 SW 115TH AVE PARCEL: 1S134DB-01900
SUBDIVISION: ZONING: R - 4.5
BLOCK: LOT: JURISDICTION: TIG
REMARKS: Remodel and addition of 906 square feet of habitable space to include relocating (1) bathroom.
5/24/04, adding (1) service and (10) more branch circuits.
BUILDING
REISSUE: CUSTOM STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: 22 FIRST: 440 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 460 sf GARAGE: sf FRONT: 20 PARKING SPACES : 2
TYPE OF CONST: 5N DWELLING UNITS: 1 THIRD: sf RIGHT: 5
VALUE: 83,714.
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 900 sf REAR: 15
PLUMBING
SINKS: WATER CLOSETS: 2 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 2 DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: 2 CATCH BASINS:
TUB /SHOWERS: 2 GARBAGE DISP: 1 WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: 1 BOIL/CMP < 3HP: VENT FANS: 1 CLOTHES DRYER:
GAS FURN > =100K: UNIT HEATERS: HOODS: 1 OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: 1
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 - 200 amp: 1 0 • 200 amp: W /SVC OR FOR: 00 PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/O SVC/FDR: 00 SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EA ADDL BR CIR: 0 o SIGNAL/PANEL: IN PLANT:
MANU HM/SVC /FDR: 601 - 1000 amp: 601 +amps- 1000v: MINOR LABEL:
1000+ amp /volt :
PLAN REVIEW SECTION
Reconnect only:
> =4 RES UNITS: SVC /FDR > =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL - RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 1,593.01
This permit is subject to the regulations contained in the
JASON SCHLEICHARDT OWNER Tigard Municipal Code, State of OR. Specialty Codes
11500 SW 115TH AVE and all other applicable laws. All work will be done in
TIGARD, OR 97223 accordance 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.
Phone: 503 341 - 1335 Phone: ATTENTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those
Reg u: rules are set forth in OAR 952 - 001 -0010 through
952- 001 -0080. You may obtain copies of these rules or
direct questions to OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Footing Insp Crawl Drain /Backwater Electrical Rough In Exterior Sheathing Insr Rain drain Insp
Foundation lnsp Crawl Drain /Backwater Framing Insp Gas Line Insp Electrical Final
Post/Beam Structural PLM /Underfloor Shear Wall Insp Insulation Insp Mechanical Final
Post/Beam Mechanical Mechanical Insp Shear Wall Insp Rain drain Insp Plumb Fin -
Unde I ' - - ion Plumb Top Out Exterior Sheathing lnsr Rain drain lnsp Final ins. -ction
Issue • ; : / l' ...vL_LLi Permittee Signature : Si.. •,6. L. ■ 0 '� � •
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the e t busine . ay
�3.
CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2003 -00531
p.. DEVELOPMENT SERVICES DATE ISSUED: 12/29/03
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 - 4171
SITE ADDRESS: 11500 SW 115TH AVE PARCEL: 1S134DB
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
REMARKS: Remodel and addition of 906 square feet of habitable space to include relocating (1) bathroom.
BUILDING
REISSUE: CUSTOM STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: 22 FIRST: 440 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 460 sf GARAGE: sf FRONT: 20 PARKING SPACES : 2
TYPE OF CONST: 5N DWELLING UNITS: 1 THIRD: sf RIGHT: 5
VALUE: 83,714.40
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 900 sf REAR: 15
PLUMBING
SINKS: WATER CLOSETS: 2 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 2 DISHWASHERS: 1 FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: 2 CATCH BASINS:
TUB /SHOWERS: 2 GARBAGE DISP: 1 WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: 1 BOIL/CMP < 3HP: VENT FANS: 1 CLOTHES DRYER:
GAS FURN > =100K: UNIT HEATERS: HOODS: 1 OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: 1
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 - 200 amp: 0 - 200 amp: W /SVC OR FD R: PUMP /IRRIGATION: PER INSPECTION:
EAADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/O SVC/FDR: 00 SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EAADDL BR CIR: 3.00 SIGNAL/PANEL: IN PLANT:
MANU HM /SVC /FDR: 601 - 1000 amp: 601 +amps- 1000v: MINOR LABEL:
1000+ amp /volt :
PLAN REVIEW SECTION
Reconnect only:
> =4 RES UNITS: SVC /FDR> =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL • RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPEJIRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 1,506.60
This permit is subject to the regulations contained in the
JASON SCHLEICHARDT OWNER Tigard Municipal Code, State of OR. Specialty Codes and
11500 SW 115TH AVE all other applicable laws. All work will be done in
TIGARD, OR 97223 accordance 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
Phone: 503 - 341 - 1335 Phone: Oregon Utility Notification Center. Those rules are set
forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
Reg #: may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Footing Insp Crawl Drain /Backwater Framing Insp Rain drain Insp
Foundation Insp PLM /Underfloor Shear Wall Insp Electrical Final
Post/Beam Structural Mechanical Insp Exterior Sheathing Ins Mechanical Final
Post/Beam Mechanical Plumb Top Out Gas Line Insp Plumb Final
Underfloor insulation Electrical Rough In Insulation Insp Final inspection
ip A •
I
Issued By : `� ■- %� P ermittee Signature : , i►it a .�` .�.. 1 'i
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the ext 141116-s day
Building Permit A ' k FOR OFFICE USE ONLY
R eceived Building
,1 Date /B : / ' 0,9 W Permit No.: ' ' 7 /jp./ 'co 5 /
City g
Cit of Tigard " 4.' !, Planning Approval Other
:
Date /B Permit No.:
13125 SW Hall Blvd. Plan Review Other
CITY OFTIC-:A.--;
o 3
Tigard, Oregon 97223 Date /B y S Permit No.:
Phone: 503- 639 -4171 Fax: 5( - l A��Y1 ' (Q ' ` Post - Review Land Use
Internet: www.ci.tigard.or.us Al.' - �
g C ontact Date /B : Case e : No. ®See Page 2 for
24 -hour I ection Request: 503- 9 -4175 Name /Method: Su lei! ntal Information c�
0 c,.„,.), (..,-)42., Ad,, Mo D/� 'P v.,
--fg TYPE OF WORK REQUIRED DAIW
❑ New construction ❑ Demolition 1 & 2 FAMILY DWELLING N
Addition/alteration/replacement ❑ Other:
CATEGORY OF CONSTRUCTION Note: Permit fees* are based on the total value of the work performed. Indicate
24 1 & 2- Family dwelling ❑ Commercial/Industrial the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
❑ Accessory Building ❑ Multi- Family
❑ Master Builder ❑ Other: Valuation S $3 740 ,-,.,i
JOB SITE INFORMATION and LOCATION
No. of bedrooms: No. of baths: '
�••� • New dwelling area (sq. ft.) Total number of floors ci
Job site address: f
IISOO $t,J 1 IS A - 0 '!
Suite #: Bldg. /Apt. #: 11 Garage /carport area (sq. ft.) ,\,
Project Name: Sc-�, \.�t` e fe I2ernorerl Covered porch area (sq. ft.)
Cross street/Directions to job site: Deck area (sq. ft.)
k Other structure area (sq. ft.)
IA . .c1,
U
REQUIRED DATA:
COMMERCIAL - USE CHECKLIST
Subdivision: Lot #:
Tax map /parcel #: moo 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,
1 overhead and profit for the work indicated on this application.
a ;�;o�. Rew•cO Qt t $ - 1;,. 2e-it o ce—
h&L h .JI -Jel e-I -> _ Valuation S
1. Existing building area (sq. ft.)
�Cl p. b. Y New building area (sq. ft.)
Number of stories
cg PROPERTY OWNER • 1 ❑ TENANT Type of construction
Name: jAs S e .,1,\ / * A c,t,00..r'17 Occupancy group(s): Existing:
New:
Address: llsoo Si...3 IISits 1
City /State /Zip: jq a , cQ. co 22.3
1 , - 1 NOTICE: All contractors and subcontractors are required to be
Phone: Sod -3y1 _ 1335 Fax: licensed with the Oregon Construction Contractors Board under
! g APPLICANT ❑ CONTACT PERSON provisions of ORS 701 and may be required to be licensed in the
Business Name: jurisdiction where work is being performed. If the applicant is exempt
Contact Name: JIN »,,l Sc IN le1t;,i.xo,,Cdi from licensing, the following reason applies:
Address: I ISOO St,) it P.
City /State /Zip: "7, q o ,..4., i pg. °
Phone: So3 -3'k - 1335 ``,, Fax: I BUILDING PERMIT FEES*
E -mail: J Sc.�`e.1 c,�.a t'dfi e. w co Ac.re-ie -. C.owA. Please refer to fee schedule.
CONTRA T OR
Business Name: Qwne.2 C ^ o∎.c- ve_ Fees due upon application S
Address:
City /State /Zip: Amount received S
Phone: - _ Fax: Date received:
CCB Lift,:
Authorized i / Notice: This permit application expires if a permit is not obtained within
Signature: n!'; ., ., '.ate: I2- 2•-o3 180 days after it has been accepted as complete.
JArS 014 '0_ 2.t c. : 14 *Fee methodology set by Tri- County Building Industry Service Board.
(Please pri name)
is \Dsts \Permit Forms \BldgPermr • ::.. • 11/03
A li li One - and Two-Fa Two-Family Dwelling ., ,.:,a , „ a
u I'? Building Permit Application Checklist Reference no.:
7 Associated permits:
City ofTigard City of Tigard
b O Electrical ❑ Plumbing rJ Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 O Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960
rr L. ` ;>CIIh FOLLOWING ITEMS?! ARE- REQUIRED, FOR ; PLAN REVIEW, i ;,`rµ y, `it 1 Ar Ye 's i No i NIA ?;
1 Land use actions completed. See jurisdiction criteria for concurrent reviews.
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district. etc.
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
8 Soils report: Must carry original applicable stamp and signature on file or with application.
9 Erosion control 0 plan 0 permit required. Include drainage -way protection, silt fence design and location of
c basin- protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state
b ding codes. Lateral design details and connections must be incorporated into the plans,or -on a separate full- size .
sheet attached to the plans with cross references between plan location and details. Plan review cannot be 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 area; existing structures on site; and surface drainage.
12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent. •
size and location.
13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ,
furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above•grade, etc : .,,
14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor bear headers, joists, sub -floor,
wall construction, roof construction. More than one cross section may be 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, etc.
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 greater than four foot at building envelope. ,
Full -size sheet addendums showing foundation elevations with cross references are acceptable.., . , . . . • , ,
16 Wall bracing (prescriptive path) and/or lateral analysis plans. Must indicate details and locations; for , .
non - prescriptive path analysis provide specifications and calculations to engineering standards. • • , - " ,
17 Floor /roof framing. Provide plans for all floors /roof assemblies, indicating member sizing, spacing, and bearing'' ,. . • . . •
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered
systems, see item 22, "Engineer's calculations." .
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists
. over 10 feet long 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) shall be stamped by an engineer or • ' ,
architect licensed in Oregon and shall be shown to be applicable to the project under review.
`' 1 ' - JURISDICfIONALSPECIFICS s , ;, ' � ,
iff i Five (5) site ,, 4444. r .; j_ �� _ ,:.,- .._�, ..•,� , . ; . . � .�. ? �' �
ite plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11 x 17 ".
4.
4 wo (2) sets each are required for Items 16. 19, 20 & 22 above.
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will be not accepted.
26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document.
27 "Drawn to scale" indicates standard architect or engineer scale.
28 Site plan to include tree size, type & location per approved project street tree plan (if applicable), and COT Street Tree List. '
Checklist must be completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 440 -4614 (6 /0O /COM)
Building Fixtures l�
Plumbing Permit Application FOR OFFICE USE ONLY
F r Received Plumbing
u „ 1 �U� ' u ✓ . rte �� Date/By: f WO • Permit No. (�0�/ �' J/�
City of Tigard Planning Ap roval Sewer
Y g Date/By: Permit No.:
13125 SW Hall Blvd. '_ -, /,' Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503-639-4171 Fax: 503-59819600: "' Post - Review Land Use
• /*"' ' ' �. Date /By: Case No.:
Internet: www.ci.tigard.or.us BU!LLiG (�a I R ;y i I) Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 " "" ' " Name /Method: Supplemental Information.
TYPE OF WORK FEE* SCHEDULE (for special information use checklist)
❑ New construction ❑ Demolition Description 1 Qty. I Fee(ea.) I Total
Addition/alteration/replacement ❑ Other: New 1 - & 2 - family dwellings
CATEGORY OF CONSTRUCTION (includes 100 ft. for each utility connection)
1E1 1 & 2- Family dwelling ❑ Commercial /Industrial SFR (I) bath 249.20
SFR (2) bath 350.00 •
❑Accessory Building ❑ Multi- Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION _ Fire sprinkler - sq. ft.: _ Page 2
Job site address: I\5 11 S Ave.. Site Utilities
Suite #: 1 Bld /Apt. #: Catch basin/area drain 16.60
Drywell /leach line /trench drain 16.60
Project Name: S,
t^`e.\ c_t. a�" Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110.00
/N � . b&_16-31-o- Manholes 16.60
�� °° Rain drain connector 2, 16.60
Sanitary sewer (no. linear ft.) Page 2
Subdivision: I Lot #: Storm sewer (no. linear ft.) Page 2
Tax map /parcel #: mop
Water service (no. linear ft.) Page 2
DESCRIPTION OF WORK Fixture or Item
- Absorption valve 16.60
u.- - e . uoce Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher l 16.60
Drinking fountain 16.60
NIPROPERTY OWNER 1 ❑ TENANT
11 Ejectors/sump 16.60
Name:Jpso►�L so/At,1 G( &t Expansion tank 16.60
Address: 1\So0 5 1‘5 4e . Fixture /sewer cap 16.60
City /State /Zip: j t A .(4. 0(Z. ct-12 Floor drain /floor sink/hub 16.60
t Garbage disposal 1 16.60
hone: 503-.3,A\ - \ 335 I Fax: Hose bib , 1 16.60
APPLICANT 1 ❑ CONTACT PERSON Ice maker 16.60
� \
Name: J Aso N S.e\ G A Interceptor /grease trap 16.60
Address: 11500 s_3 1154.4."- �-‘)+z-• Medical gas - value: $ Page 2
City /State /Zip: - c 0 81223 Primer 16.60
t Roof drain (commercial) 16.60
Phone: 503-3, \-1 335 l Fax: Sink/basin/lavatory 2 16.60
E -mail: s. t G -.04 --lk e t 0 c n. or re 11 .cow Tub /shower /shower pan 2 16.60
�. cv \e; e. CONTRACT R Urinal 16.60
Business Name: Q WAE(_ emu- -rp� water closet 16.60
Water heater 16.60
Address: Other:
City /State /Zip: Other:
Phone: Fax: Plumbing Permit Fees*
CCB Lic. #: Plumb. Lic. #: Subtotal $
Minimum Permit Fee $72.50 S
Authorized Residential Backflow Minimum Fee S36.25
Signature: Date: Plan Review (25% of Permit Fee) $
State Surcharge (8% of Permit Fee) $
(Please print name) TOTAL 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
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri -County Building Industry Service Board.
is \Dsts \Permit Forms \PlmPermitApp.doc 01/03
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - l' 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 S220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40 Valuation: Permit Fee:
Storm & Ram Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 55,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
additional $100.00 or fraction thereof, to and
Fixture or Item Qty. Fee (ea) Total including $10,000.00.
Commercial Back Flow Prevention Device 46.40 510,001.00 to $25,000.00 5148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional S100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including 525,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees *.
Quantity by (Fixture) Work Performed Comments regarding fixture work:
Fixture Type: Replace
New Moved Existing Capped
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
- 3"
Car Wash Drain
Garbage Domestic *Note: If the fixture work under this permit results in an
Disposal - Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice Mach. /Refrig. Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
is \Dsts \Permit Forms \PlmPermitAppPg2.doc 01/03
" Electrical Permit Application FOR OFFICE USE ONLY
Received Electrical
Date/By: /8" a' /0 3 Permit No. 70 --0 05 3)
City f Ti and Planning Approval Sign
y Tigard Permit No.:
13125 SW Hall Blvd. J EC E Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax• 503 -59 Xfj,Q,3 Post - Review Land Use
$ � 1 UU � 1 i'� Date/By: Case No.:
Internet: www.ci.tigard.or.us �" A I 1 Contact Juris.: ®See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name/Method: Supplemental Information.
CITY OF TIGARD
BUILDING DIVISION
1 . t .. : ;:, .. : ; ? a ,;;.TYPE ;;OE WORK - , -'7 " 4, �... ,': ,'. '.,PLAN EV )EW;(Plea s ercheck all;tnat apply) " ,
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
21 Addition/alteration/replacement ❑ Other: ❑ Service over 320 amps -rating of ❑ Building over 10,000 square feet,
j; _ , .. ;: ''C ITEGORYiOF CONSTRUCTIONS :-; 1 & 2 family dwellings four or more residential units in
,g( 1 & 2- Family dwelling ❑ Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
.
1. �;- .: ",„ JQaSITE'IN and LOCATION' iti,. -.. ; � e, Submit sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: 11' JO 34„.3 its* pi,h • _ " ; , r c.., ;FEE* SC} EDU-LE __ { :,` . .
Suite #: Blda, /Apt. #: Number of inspections per permit allowed
Project Name: Description Qty Fee (ea.) Total
Cross street/Directions to job site: New residential - single or multi - family per j
1 dwelling unit. Includes attached garage.
I v E,J0. Service included:
1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Subdivision: Lot #: Limited energy, residential 75.00 2
Limited energy, non residential 75.00 2
Tax map /parcel #: , clip 0 Each manufactured home or modular dwelling
DESCRIPTION OF`-WORK . ?'i • Y service and/or feeder 90.90 2
//�� 1 ` ' ` !� J Services or feeders - installation,
►-i t t i1 OA. I ac 2 CXIS Ice s esnce- alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
< . 601 amps to 1000 amps 240.60 2
.PR ......OWNER f TENANT, :._. 6 P P
11 _ 11 Over 1000 amps or volts 454.65 2
Name:, j ASotS Sc_�12,t c.Lo cTX?t Reconnect only 66.85 2
Address: 11 soo s,.J 115'• A e, . Temporary services or feeders - installation,
Clt City/State/Zip: alteration, or relocation:
y p: 1y �c\. .O R . 9 1 22 200 amps or less 66.85 I
P one: 503-N1 -113S Fax: 201 amps to 400 amps 100.30 2
401 to 600 amps 133.75 2
IAP.PLTCAINT . ),: :' . ° 1 ® CON CT :PERS . ' „ ' j ;,. Branch circuits - new, alteration, or
��Q
Name: , J R SON S,tc -L•r Y1 extension per panel:
AA A. Fee for branch circuits with purchase of
Address: ‘15 Oo 5,3 1 is FFV e• service or feeder fee, each branch circuit 6.65 2
City /State /Zip: , Q p ( A Qp , g 1 Z.Z 3 B. Fee for branch circuits without purchase of
1 t service or feeder fee, first branch circuit ) 46.85 2
Phone: 503- 341 -1335 F ax: Each additional branch circuit 3 6.65 2
E SinIQ;t clp.r.1{- e vJQ,-- Goners -. Cows Misc.(Service or feeder not included):
^F „ , C RACTOR - -_ - Each pump or irrigation circle 53.40 2
_ Each si gn or outline lighting 53.40 2
Job No: Q rke ... j Co 4ro.e. -L2 Signal circuit(s) or a limited energy panel,
Business Name: alteration, or extension Page 2 2
Description:
Address:
City/ State/Zip: Each additional inspection over the allowable in any of the above:
y p Per inspection per hour (min. 1 hour) 62.50
Phone: Fax: Investigation fee:
Other:
CCB Lie. #: Lic. #:
:- .; •` Electmcaliferi>cit Eee's *' .. >. ,. , .. A
Supervising electrician Subtotal $
signature required: Plan Review (25% of Permit Fee) $
Print Name: Lic. #: State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set, by Tri- County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms \ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard ,
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
Audio and Stereo Systems
❑ Burglar Alarm •
n Garage Door Opener
El Heating, Ventilation and Air Conditioning System
El Vacuum Systems
0 Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918- 260 -260)
Check Type of Work Involved:
Audio and Stereo Systems
E Boiler Controls
0 Clock Systems
Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
ri Instrumentation .
Intercom and Paging Systems
n Landscape Irrigation Control
E Medical
E Nurse Calls
T1 Outdoor Landscape Lighting
E Protective Signaling
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
• i:\Dsts\Permit Forms \ElcPermitAppPg2.doc 01/03
Mechanical Per Ajw Application FOR OFFICE USE ONLY
Received d ., Mechanical
Date /By: / . 43 Permit No.�7��a0 ,o53/
City of Tigard Planning App oval Building
Date/By: Permit No.:
13125 SW Hall Blvd. C:' 1"Y OF l': .'.;?:7, Plan Review Other
Tigard, Oregon 97223 BUILDING DiVISO.l Date/By: PermitNo.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use
•f�i Date/By: Case No.:
Internet: www.ci.tigard.or.us 419 Contact : Juris.
24 -hour Inspection Request: 503- 639 -4175 El See Page for
p 9 N ame /M et h o d : Supplemental Information.
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
❑ New construction ❑ Demolition Mechanical permit fees* are based on the total value of the work
Addition/alteration/replacement ❑ Other: performed. Indicate the value (rounded to the nearest dollar) of all
CATEGORY OF CONSTRUCTION mechanical materials, equipment, labor, overhead and profit.
A l & 2- Family dwelling ❑ Commercial/Industrial Value: $ See Page 2 for Fee Schedule
❑ Accessory Building ❑ Multi- Family RESIDENTIAL EQUIPMENT /SYSTEMS FEE* SCHEDULE
Description Qty Fee(ea.) Total
❑ Master Builder ❑ Other: Heating/Cooling
JOB SITE INFORMATION and LOCATION Furnace - add -on air conditioning ** I _ 14.00
Job site address: lisp O S i.J / / 5 ' Able . Gas heat pump 14.00
Suite #: Bldg. /Apt. #: Duct work + _ 14.00
Project Name: ifZl�e,� _ Hydronic hot water system 14.
�� r Residential boiler
Cross street/Directions to job site: (for radiator or hydronic system) 14.00
/,/, ai(o4 Unit heaters (fuel, not electric)
(in wall, in -duct, suspended, etc.) _ 14.00
Flue /vent (for any of above) 10.00
Subdivision: I Lot #: Repair units 12.15
Other Fuel Appliances
Tax map /parcel #: MOO Water heater 10.00
1 II
DESCRIPTION ESC RIPTION OF WORK Gas fireplace 10.00
�?M10 1e.` 44c.; " o h EX.i 5-1 l keSr e4+c.e_ Flue vent (water heater /gas fireplace) 10.00
Log lighter (gas) 10.00
Wood/Pellet stove 10.00
Wood fireplace /insert 10.00
Chimney /liner /flue /vent 10.00
[ PROPERTY OWNER 1 ❑ TENANT Other: 10.00
' ame: 3 A SOg SU.,I�t cla-021.4 Environmental Exhaust & Ventilation
Range hood/other kitchen equipment ' 10.00
Address: 1 k yo p Sc„. 115 Ave . Clothes dryer exhaust 10.00
City /State /Zip: 7, O g.. 9/2.23 Single duct exhaust
P one: 5-p- - 3441 _� 3 S Fax:
0 (bathrooms, toilet compartments, 1
APPLICANT ❑ CONTACT PERSON utility rooms) 6.80
ame: prsot� S��le Imo Attic /crawl space fans J 10.00
Address:11S0o Sc,-) / 15 Ave • Other: 10.00
Fuel Piping
City /State /Zip: - r; p12. 81 223 * *($5.40 for first 4. $1.00 each additional)
Phone: 5b3-3(41- S Furnace, etc. ' ** I Fax: Gas heat pump **
E -mail' Wall /suspended/unit heater **
CONTRAC R Water heater **
Business Name: f�(,t,tiiE2 C p 7 -p,e_ Fireplace **
Address: Range **
City /State /Zip: BBQ **
Clothes dryer (gas) **
Phone: Fax: Other: **
CCB Lic. #: Total:
Authorized Mechanical Permit Fees*
Subtotal: $
Signature: Date: Minimum Permit Fee $72.50 $
Plan Review Fee (25% of Permit Fee) $
(Please print name) State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Notice: This permit application expires if a permit is not obtained within *Fee methodology set by Tri-County Building Industry Service Board.
180 days after it has been accepted as complete. * *Site plan required for exterior A/C units.
is \Dsts \Permit Forms\MecPermitApp.doc 01/03
Mechanical Permit Application - City of Tigard
•
Page 2 - Supplemental Information
Commercial Fee Schedule:
TOTAL VALUATION: PERMIT FEE:
$1.00 to $2,000.00 Minimum fee $72.50
$2,001.00 to $5,000.00 $72.50 for the first $2,000.00 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 fraction •
thereof.
All New Commercial Buildings require 2 sets of plans.
i:\Building\Permit Forms \MecPermitAppPg2 09- 01- 03.doc
RECEIVED
DC E 2 2003
Permit #: -- 11 i ,9oo3 -6n 53 !
CITY OF TIGARD (
,.., P, BUILDING DIVISION 1 r \.F1' < r Address: 1 1 500 cat 1, 5 At/
� \ : ii�� ui 4,.., Date: / oZ /6 41
/: g9 Issued by
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(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 required
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:
Al 1. I own, reside in, or will reside in the completed structure.
•
IV, 2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
I II before or upon completion.
i r 3A . My general contractor is (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.
1
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.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Proper ners abo Construction Responsibilities on the reverse side of this form.
, ,, 12. - 2 -0 3
1 (Signature of permit applicant) (Date)
s
(White copy to issuing agency permit file,
pink copy to applicant)
- Information Notice to Properly Owners
About Cs-nstr.uction RiesponsbillKies
Note: This Information Notice to Property Owners about Construction Responsibilities
- was developed by the Construction Contractors Board in accordance with ORS 701.0.5.510.
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent manv problems by being aware of the following responsibilities and areas of concern.
• - - EMPLOYER RESPONSIBILm S:
if you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement of a residential structure, you will, in most instances, he ruled to be an employer and the people
you hire will be employees. As the employer, you must comply with the following.:
•
Oregon's withholding tax law: As an en ployer, you must withhold income taxes from employee v'ages at the time employees
are paid. You will he liable for the tax payments even if you don't. actually withhold the tax from your employees. For more
information, call the Oregon Dept. of Revenue at 945 -8091.
Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information call the Oregon Employment Division at the Department of Human Resources
at 378 -3524.
•
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must
obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject to penalties and will be liable for all claim costs if oneof your employees is injured on the job. For more information,
call the Workers' Compensation Division at the Department of Consumer and Business Services at 945 -7888.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be
liable for the tax payment even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1- 800 - 829 -1040.
OTHER RESPONS1- !LITIES AND A'EAS OF CONCERN:
Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections.
•
Liabilit:i and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accident:3 and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
re -done.
Time to supervise employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough -in and finish
trades, and to notify building officials at the appropriate times so they can perform the required inspections.
If you have additional questions, write or call the Construction Contractors Board (PO"Box 14140, Salem, OR 97309 -5052,
503/378- 4621). The Board is located at 700 Summer St. NE Suite 300, in Salem.
prop- own.pm4
1/94