Permit CITY OF TIGARD MASTER PERMIT
IN 4.
= °: COMMUNITY DEVELOPMENT Permit #: MST2010 -00206
TI.GARD' 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/01/2010
. Parcel: 2S111CB01703
Jurisdiction: Tigard
Site address: 10128 SW LADY MARION DR
Subdivision: HOOD VIEW Lot: 3
Project: Corrigan
Project Description: Create 740 square feet of habitable space in unfinished basement.
BUILDING
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 2 First: 0 sf Basement: 740 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 1 Third: 0 sf Right: 0
Detectors: Yes
Total: 740 sf Value: $72,483.00 Rear: 0
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
0 Tubs /Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 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 Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 3
Furn <100K: 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'I 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 4
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 -3 740
Owner: Contractor:
CORRIGAN, PATRICK H & KAREN A OWNER Required Items and Reports (Conditions)
10128 SW LADY MARION DR
TIGARD, OR 97224
PHONE: 503 -598 -4732 PHONE:
FAX:
Total Fees: $2,563.33
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.-aecordance 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. TENTION: Ore• •n requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are se)orth in OAR
952 01 -0010 through OAR • •2 -00 r I • r. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.3..23 4
Is ued By: ��..... 11_ / Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for the next available inspec . • n 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.
Buildinig'Permit Application �
Residential N \ FOR OFFICE USE ONLY
City Of Tigard Received Date/By: 1/ /b 0 ,. i PermitNo.: AI /0 -eo
1111
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie p �_ TT
111 Phone: 503.639.4171 Fax: 503.598.1914OV 1 6 2010 Date/B (, w (1 7 l o Other Permit:
TIGARD Inspection Line: 503.639.4175 Date Ready /By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov CITY OF TIGARD Notified//Method: � 1 ' I MD Supplemental Information
TYPE OF REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ 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 ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1 - and 2- family dwelling ❑Commercial /industrial Valuation ( ii� 17 7 pb °
❑ Accessory building ❑ Multi- family Number of bedrooms: 2,
❑ Master builder El Other: Number of bathrooms: O
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: ; r) i Z 1-1 a r /t) tr New dwelling area: 7, square feet Li City /State /ZIP: / r , v � - 7 q / 2 Z Garage /carport area: square feet
Suite /bldg. /apt. no.: P roject name: QQ Cl - 11 R Frv, D ) Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL - USE CHECKLIST
Subdivision: I 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
t DESCRIPTION OF WORK work indicated on this application.
k n c 1. a tv(a C1 pos5 ,-✓ I ../t d J w S h J -1-,..., 0 l / c � Valuation: $
�� ; � Existing building area: square feet
New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: P t r-, c (< a . ira A< 1., C v r i i r 0 y Type of construction:
Address: / 0 / L c ) y /4 0. A , D s' .0/\ Occupancy groups:
City /State /ZIP: Tr R.N J 0 iL. 5 9 a Z Li Existing:
Phone: ( O) 4 ?"— 4 9 3.2_ Fax: (S ) 0T 1/ 2 ,r New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
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:
CONTRACTOR
Business name: ^ B PERMIT FEES*
Address:
City /State /ZIP: `' UAV) } l (Please refer to fee schedule)
Structural plan review fee (or deposit):
FLS plan review fee (if applicable):
Phone: ( ) Fax:( )
CCB lic.: Total fees due upon application: �
Amount received: 'r q f / 1 -ke ,
Authorized signature: ='fir` This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: r'jr2 8, d r- IQ il Date: /'I "Z 6" D * Fee methodology set by Tri -County Building Industry
Service Board.
1: \Building \Permits\BUP -RES PemiitApp.doc 10/01/09 440- 4613T(11 /02 /COM/WEB)
•
Building Permit Application Checklist •
One- and Two - Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received
Permit No.:
IN v 13 125 SW Hall Blvd., Tigard, OR 97223 Dated t
0 ' Phone: 503.639.4171 Fax: 503.598.1960 Associated permits:
TIGARD
24 Hour Inspection Line: 503.639.4175
El Electrical ❑Plumbing ❑ Mechanical
Internet: www.tigard - or.gov ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVI Yes No N/A
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. Name of district: El ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity ❑ ❑ ❑
6 Sewer permit. ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
9 Erosion control LI plan ['permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑
building 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 corner 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 beams, 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 Ore:on and shall be shown to be a• .licable to the .ro'ect under review.
JURISDICTIONAL SPECIFICS
23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be 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 and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
1 : \ Building \Permits\BUP- RES- PermitApp.doc 03/21/06 440- 4613T(11 /02 /COM/WEB)
Electrical Permit Application ' et‘firn FOR OFFICE USE ONLY
City
i ; n • Received
/ Permit No.: ^^ /j
`J of Tigard g Date /B : it i /0 (. �r li� ^ (/(/OCJ
° 13125 SW Hall Blvd., Tigard, OR 97223 kAt' �y Plan Review
1114
a Phone: 503.639.4171 Fax: 503.598.196BV 2D Date/B : Other Permit.
TIGARD Inspection Line: 503.639.4175 Date Ready/By: lid See Page 2 for
Internet: www.tigard - or.gov CITY OF TIGARD Notified/Method: M Supplemental Information
YPE .OF Atiiii9LUIIVG DIVISION PLAN' REVIEW
❑ New construction Addition /alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
El Demolition El Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
,i less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
Orr- and 2- family dwelling ['Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION
0 Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "l -2 ", "I -3 ",
Job no.: Job site address: 10/ 2. L,/ L 100HP or more. occupancy.
" ` _ % i(/ r ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: ? VVV 4 i , ;7.X.__ L g 9 2-2- Liz ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: QSc P, I R. 44J d ti ❑ Service or feeder 600 amps or more.
.FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. 1 Fee. 1 Total 1
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
t^ Limited energy, multi - family
l A t <<✓ 2 !/ q, C I ✓t e +.4 0,4 residential (with above sq. ft.) 75.00 2
! Services or feeders installation, alteration, and /or relocation
"I ' '1 4 l l ! -)..4.1./ 200 amps or less 100.70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Z ` 401 amps to 600 amps 200.34 2
Name: Pat, i t -i R. ^ o f K t in, Cot t f1 y� 601 amps to 1,000 amps 301.04 2
Address: Z a / ZSr"' L✓ Z_ . U 7 14 4.441D l �' "r Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: T q i`-� t Cl / fL- 7 9 a ..L q relocation
r
4
- ` 7 L 141_ Fax: (s� > 2 ) 1 - 97-6/ 200 amps or Tess 59.36 1
Phone: (6 )
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
•
intended for sale, lease, rev ert han • ecording to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
g / / > ��C� Branch circuits — new, alteration, or extension, per panel •
Owner si nature: �° Date: A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee 7.42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first / 56.18 1 5t,, i e 2
Contact name: branch circuit
Each add'I branch circuit 3 7.42 'OZ.' 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: !State /ZIP: Each manufactured or modular 67.84 2
tY dwelling, service and/or feeder
Phone: ( ) Fax :: ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited-energy
Business name: panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address:
()Lipid EP Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr
, specifically listed (V2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES .
Suprv. Electrician signature, required: Subtotal: 4.4
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): C . 4. (
TOTAL PERMIT FEE: 57 s 8
Authorized Signature. This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: • Number of inspections allowed per permit.
1:\Building\Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(11/05/COM/WEB
•
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
n Audio and Stereo Systems*
❑ Burglar Alarm
n Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
n Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
n Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
n Medical
n Nurse Calls
n Outdoor Landscape Lighting*
n Protective Signaling
n Other _
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1: \ Building 'Permits\ELC- PermitApp.doc 07/01/10
Mechanical Permit Application i ' . ' roR OFFICEWS , .
Cl of Tigard REC p-'-�' r'Received a e
P No.:
n 131 Hall lvd., Tigard, OR 97223 NOV e Date/By: / / . /0 �'7" / n0 ig
C Date/By: ' Phone: 503.639.4171 Fax: 503.598.1960 IV ®���� Plan Review
D Other Permit:
TIGARD Inspection Line: 503.639.4175 Date Ready /By: Ed See Page 2 for
Internet: www.tigard- or.gov CITY OF TIGARD NDotified/Method:
EMI BUILDING DIVISIO' Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE – USE CHECKLIST
El New construction Mechanical permit fees* are based on the value of the work
❑ Addition/alteration /replacement performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ 1 and 2 family dwelling ❑ Commercial /industrial ❑ Accessory building
For special information use checklist.
❑ Multi - family ❑ Master builder ❑ Other: Description Qty.
Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Air conditioning
Job site address:
Di )- lc , t L. Ca r) • / /l ji j et. / t IV 4/ 1) r (requires site plan showing placement) 46.75
City /State /ZIP: 1 , q t- V . D p 1 � 2....../y Furnace 100,000 BTU (ducts /vents) 46.75
f Fumace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: Project name: 6G . e,u„e3, ,iT/ it( :rat J e-( Heat pump � 1I61.06
L'U Cross street/directions to job site: Duct work 't,U23.32
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
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: O 21 LL`L 3 23.32 (p9,(L,
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 23.32
/ Gas fireplace 33.39
iq, 5 t"t1 / Z /'\ eckt molls- 1 / ') _ l s- et v ,. 1 ,) It° Flue vent for water heater or gas
v fireplace 23.32
ct t 1' n C f V f rt Ci 1---, 1/ / VI i C')e 1.5 T 1 / - Log lighter (gas) 23.32
d J iris U Wood /pellet stove 33.39
Wood fireplace /insert 23.32
Chimney /liner /flue /vent 23.32
PROPERTY OWNER ❑ TENANT Other: 23.32
Name: �� ft-K(0 ,.t u " "1 �' ✓`e A, Co r ('-/ (� c) Environmental exhaust and ventilation
\ ( J Range hood/other kitchen
Address: ` r— 5 t ,,/ /r J
et ` e ,, / t / �, ' / / e equipment 33.39
City /State /ZIP: T/ r j v X_ �? ,Z y Clothes dryer exhaust 33.39
7 � Single -duct exhaust (bathrooms,
Phone: (3 ) 5- _ C.r'? z I Fax: (S d3) 5' u -- 4 7 "f toilet compartments, utility rooms) 23.32
❑ APPLICANT J ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Other: 23.32
Business name:
Fuel piping
Contact name: $14.15 for first four; $4.03 for each additional
Address: Fumace, etc.
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax:: ( ) Water heater
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: Clothes dryer (gas) 0 a) A) E Other:
Address: MECHANICAL PERMIT FEES*
l btota q
City /State /ZIP: Subtotal 7 l
Minimum permit fee ($90.00) 70 ,04._
Phone: ( ) Fax: ( )
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee) 110, T -_,„)
�i TOTAL PERMIT FEE (QC ,
Authorized si attire' ` ( This permit application expires if a permit is not obtained within 180
1 ' 7 days after it has been accepted as complete.
Print name: c: c n �c fc q A Date: d j * Fee methodology set by Tri- County Building Industry Service Board
(:\Building ermits\MEC- PermitApp.doc 10/01/09 V 440- 4617T(11 /02 /COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi- Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
• fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
$2.54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
I:\ Bui lding \Permits\MEC- PermitApp.doc 10/01/09 2
R E CE IVED
Property Owner Statement NOV 16 X010
Regarding Construction Responsibilitieeny
Oregon Law requires residential construction permit applicants who are not licenailivOINOIDIVISION
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
X : I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
V Qtf - k G 1 v
Print Name of Permit Applicant
z v
Signature of Penljt -A• • can Date
Permit #: " 901 - P a F
Address: COI L -DY M/
Issued Date: r1 // u-:
This Copy for Permit Offices