Permit n CITY OF TIGARD MASTER PERMIT
"!'' COMMUNITY DEVELOPMENT Permit #: MST2009 -00090
TIGARD, 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 04/29/2009
Parcel: 1S136DB01800
Jurisdiction: Tigard
Site address: 10880 SW 74TH AVE
Subdivision: Lot: 0
Project: Mickley
Project Description: 420 sq ft addition and remodel.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 0 First: 4 9 7 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 12 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 1 Third: 0 sf Right: 0 Detectors: Yes
Total: sf Value: $52,194.52 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Other Fixtures: 0
Tubs /Showers: 0 Garbage Disp: 0 Water Healers: 0 Water Lines: 0
Bckflw Prevntr: 0
MECHANICAL
Fuel Types Air Conditioning: Vent Fans: 0 Clothes Dryers: 0
Heat Pump: Hoods: 0 Other Units: 0
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: 1' 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea add'I 500 sf: 0 20 1 -400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr:
Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add'I Br Cir:
601 -1000 amp: 0 601 +amp- 1000v: 0
1000 +amp /volt: 0
ELECTRICAL - RESTRICTED ENERGY
SF Residential
Audio & Stereo: HVAC: Security Alarm: Vaccuum System: Garage Opener: All
Other: Other Description: Ecompasing:
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
Owner: Contractor: Required Items and Reports (Conditions)
MICKLEY, WILLIAM NW CONSTRUCTION & DEVELOPMENT
10880 SW 74TH AVE INC
TIGARD, OR 97223 7456 SW BASELINE
PHONE: PHONE: 503- 268 -2549
FAX:
Total Fees: $1,257.17
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 you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through R 952- 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: =sw' v- Permittee Signature: ZA-ke ",/ "
v
CITY OF TIGARD MASTER PERMIT
•:•, COMMUNITY DEVELOPMENT Permit #: MST2009 -00090
13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/29/2009
i f Parcel: 1S136DB01800
Jurisdiction: Tigard
Site address: 10880 SW 74TH AVE
Subdivision: Lot: 0
Project: Mickley
Project Description: 420 sq ft addition and remodel. 12/7/10, Reprint to change general contractor.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 0 First: 497 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 12 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 1 Third: 0 sf Right: 0
Detectors: Yes
Total: 497 sf Value: $52,194.52 Rear: 0
PLUMBING
Sinks: 2 Water Closets: 3 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 3 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Drains: 0
Tubs /Showers: 1 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 Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp SrvclFeeders Branch Circuits
1000 sf or less: 0 0 -200 amp: 1 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea add 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 -3 497
Owner: Contractor:
MICKLEY, WILLIAM OWNER Required Items and Reports (Conditions)
10880 SW 74TH AVE
TIGARD, OR 97223
PHONE: PHONE:
FAX:
Total Fees: $1,257.17
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 a 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
da . ATTENTION: e egon Ia, requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
9 2- 001 -0010 through OA" 9 - - 001 -00• ou may obtain a c-.py of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
l • 4 i 4 - :.if
Is ed By: P ermittee Signature: A. czA
Call 503.639.4175 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
Residential Permit Application CE 1)
FOR OFFICE USE ONLY
City of Tigard DEC 7 2010 Received 5T ! O O 4i
Permit No.:
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
2. • Phone: 503.639.4171 Fax: 503.598.1 oF'FIG Date/B : Other Permit:
l' t G A It D Inspection Line: 503.639 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov UILDING DIVISION Notified/Method: Supplemental Information
TYPE OF WORK 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.
❑ I- and 2- family dwelling ❑ Commercial /industrial
Valuation: $
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: / Q g $ D .
�, " i' , 71/ A, New dwelling area: square feet
City /State /ZIP: Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: 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: 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
DESCRIPTION OF WORK work indicated on this application.
Valuation: $
t s — 3 Existing building area: square feet
New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City /State /ZIP: Existing:
Phone: ( ) Fax: ( ) 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:
'CON RACTO _J
Business name: n() BUILDING PERMIT FEES*
Address: (Please refer to fee schedule)
- Structural plan review fee (or deposit):
City /State /ZIP:
Phone: ( ) Fax: ( ) FLS plan review fee (if applicable):
Total fees due upon application:
CCB lic.:
Amount received:
Authorized signature: ■ICG��Y�� This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: 1C u) iI(i t) / �- C1LL,L. Date: - 7- /4) * Fee methodology set by rt- county B ildi Industry
/ Se kce Boar 5,
I:\Building\Permits \BUP -RES PermitApp.doc 10/01/09 440- 4613T(11 /02 /COM/WEB) �`� I "a-A- "`���
•
Building Permit Application Checklist
One- and Two - Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received Permit No.:
a 1 3125 SW Hall Blvd., Tigard, OR 97223 Date/By:
III • Phone: 503.639.4171 Fax: 503.598.1960 Associated permits:
TIGARD
24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑Plumbing ❑Mechanical
Internet: www.tigard - or.gov ❑ other:
THE FOLLOWING ITEMS ARE REQUIRED jFOR PLAN REVIEW 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: . ❑ ❑ ❑
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 ❑ 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 as •licable to the •ro'ect under review.
JURISDICTIONAL SPECIFICS 1
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:'Buildineermits \BLIP- RES- PermitApp.doc 03/21/06 440- 4613T(11 /02 /COM/WEB)
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
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:
1 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.
'-
'* I w' be performing work on property I own, a residence that I reside in, or a residence that I will
side 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 1 hereby certify that the information on this homeowner statement is true and accurate.
1(.41I
Print Name of P'ermitAppiicant
tlam-
Signature of PermitA licaan Date
9 PP
Permit #: L 9' - (X 0 o f
Address: In SO rat✓ �. '• �wmi�/r, `�
ti' O- T) t✓ ! 7
Issue by: ),=- � Date: iJ
This Copy for Permit Offices
0
RECEIVED
m _ m m m v m m e o N 89° W 180.45'
4 APR�3 �T10g °°
En CITY OF TIGARD
t Gravel Driveway ( CITY F TIGARD - SITE PLAN REVIEW BUlt DING DIVISION
t — — — BUILDING PERMIT O: Mepr -oG6 oGYSFO(j -D)
20' -0" ff
_ f Street Trees: 12§ Approved ❑ Not Approved
(E) 3/4'0 Gas Line _ _ - + ::: A pproved I I
I GMI � re c`� rt y wr
raw
-.
r -- r a1 - I ` tom — I
i'0:'
ti t I I / /j \
t I �j //7 • \ Exist. Storage room to be
Line of (E) fnd. wall / ' I converted to MBR closet
- 125 SF
_ i / // %� CITY OF TIGARD ARD - SITE PLAN REVIEW
(E) 4 "P3 Sewer Line -� I ! 4 ` EL AO :rA ' , roved
I Area of New Addition / /, I Side: = Street Side: :' Approved
+372 SF I i /// Front. � �l
/ I Garag l'
� /r,...----7 / / I v i Rear. _ ____
„ sual Clearance: [ � A WM ' I �� �� / P i I c Maximum Building Height p y feet ❑ N ot Approved Ex
u"/
Residence j f CWS S
{' ' � 6 j � /� /' / I Provid Lwtr quired: Yes ❑ No s 7C -4— I (E 3/4 "0 Water Line /i� I I�j __951:1 �" �� %�� �� ,4 El-4 ° B�
I ± Date; ❑ Received
h. N II ; -. ,. .. , , ,.� 1 ENGINEERING
,_ �/� I
��' 1 ERIN DEPART NT:
A ctua l
Slop e:-,,7 t
N / I I prov
a; . � „ . / ed Not A
Area of New Porch & ;. ?� I Site Plan: ,,,, pproved
. , ,, / I L�1'�" Not AA roved
steps 7 SF ``,`. ` ” /�.
+7 // 1 I I By Di/ in f � _ Date: J ill° - 1. ,
„ ;,:. Notes: Q
1:
• r
(E) Overhead Power ,,
1 1 1
Line 11 I I 3
I I I
1 I I /v
I 1
Concrete I 1 1 f
Parking Area II . - -___ -- ..- - 1 - ~ J
Roof eave above (typ.)
I
t I I I I
1
I Q
\
1 8 0 . 4 5 ' so en nonosonen
en o= onnonenno on no onninonna
, /
I
Property Owner Statement RECEIVED
Regarding Construction Responsibilities MAY 2 2 2012
Oregon Law requires residential construction permit applicants who are not licensed dv • FT1GA9D
Construction Contractors Board to sign the following statement before a building perm
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
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.
1/ I'll ,.•.) I <L£y
Print Name of Permit Applicant
Signature of Permit Appli t Date
Permit #:
Address: DISCI 5143 r 4,/ AA, Am7r4
frd--7) OR T 7.-V 3
Issued Date: ,15/0-09/1.2"- /a
•
This Copy for Permit Offices
}
Building Permit Application
Residential RECEIVED , FO R OFFICE USE ONLY
City of Tigard • Received '/ /3 o y l t —
r —e... 9p
q Permit No.:
14
13125 SW Hall Blvd., Tigard, OR 95i 1 .i 1 2009 Plan Review / ,
G Phone: 503.639.4171 Fax: 503.598.1960 TIGARD Date/By: ' 2 07 Other Permit:
T'I GA R Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready /By: lu ® See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: i t /. Supplemental Information
. TYPE OF WORK, ' " .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 o c a
k n this application hon
❑ 1 and 2-family dwelling Valuation: � 2. ) 4: - s W ?
y g ❑ Commercial /industrial \
❑ Accessory building ❑ Multi - family Number of bedrooms: ( ��
❑ Master builder ❑ Other: Number of bathrooms: / J
JOB SITE INFORMATION 'AND LOCATION'' . ' ` . ' Total number of floors:
Job site address: kW() Stk.) ''� ltt- New dwelling area: ;' square feet t.5
City /State /ZIP: fi �rGy- (fZ '7Z . Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: 74 O; Covered porch area: square feet 7
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA COMMERCIAL- USE,CI{ECKLIST'
Subdivision: Lot no.: Permit fees* are based on the value of the work perfo d.
Indi- .te the value (rounded to the nearest dollar) of
Tax map /parcel no.: equip t, materials, labor, overhead, and the pr t for the
DESCRIPTION OF WORK .. work indict. ed on this appl , tion.
.4 h Valuation: c, , ' ,,, ,/L A____
Existing building : ea: square feet
New building area: square feet
,', ❑ PROPERTY OWNER ❑ TENANT ; ' ° .. Number of stories:
Name: `Fil tL Type of cons .,. ction:
Address: / ( } " t ' ( / i J /J I / .../6 Occup. -cy groups:
City /State /ZIP: 71/ " ,rd Z q " isting:
Phone: (I0 d'� 3 .) g -2 (f� ( 2 . Fax: ( ) New: •
- ❑ APPLICANT ," 0 CONTACT PERSON.' E
NOTIC
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: ( ) j Fax:: ( )
E -mail:
CONTRACTOR ": •
Business name: BUILDING'PERMTT FEES* '
(Please refer to fee schedule) ° '
Address: 7 '�,�,5"� %J Structural plan review fee (or deposit):
City /State /ZIP: dredir az cr
) Fax ( ) FLS plan review fee (if applicable):
Phone: (
v Z " 7 747. 3
/- � p� p Total fees due upon application:
CCB lic.: /67506 -/ C n�-�-i A- `.�4P.C.T
12 .5.0 ct Amount received:
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: f /3 2 / * Fee methodology set by Tri- County Building Industry
Service Board.
1: \Building \Permit. BUP -RES 'ermitApp.doc 11/6/07 440-4613 T( 1 1 /02/COM/WEB)
A,
Plumbing Permit Application
Building Fixtures '
FOR OFFICE' :USE', ONLY ,
����� Received / Al /
City of Tigard Date /By: 7I 7 Permit No.H6rA40 9-eao Fe
v 13125 SW Hall Blvd., Tigard, OR 972
IN
f Plan Review
Phone: 503.639.4171 Fax: 503.5 01 3 2009 Date /By: Other Permit No.:
TIGARD Inspection Line: 503.639.4175 Date Ready /By: Juris: HI See Page 2 for
Internet: www.tigard - or.gov CITY OF TIGARD Notified /Method: Supplemental lnformation
TYPE - Ot3%41i NG DIVISION. - - . FEE* SCHEDULE -
❑ New construction ❑ Demolition For special information use checklist
Description Qty. 1 Ea. Total
❑ Addition /alteration /replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
. • CATEGORY OF CONSTRUCTION K:. °` SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
' ... JOB SITE INFORMATION' AND LOCATIO . ' ' ` „' Site utilities
'✓
Job site address: /O o . ye Catch basin or area drain 16.60
City /State /ZIP: 77a vd f � � Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: 1 Project nam 7g /C Footing drain (no. linear ft.: _ ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: _ ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: _ ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION O W
` Backflow preventer Page 2
Backwater valve 16.60
g
Clothes washer 16.60
Dishwasher 16.60
❑" PROPERTY OWNER Drinking fountain 16.60
❑ `TENANT
- - Ejectors /sump 16.60
Name: (G Expansion tank 16.60
Address: l61S ' � i / ° �(j4j4 , , Fixture /sewer cap 16.60
City /State /ZIP: ' ; O ?72Z? Floor drain /floor sink/hub 16.60
Garbage disposal 16.60
Fax:
Phone: ( ) ( )
. Hose bib 16.60
. ❑ APPLICANT ❑ CONTACT PERSON-
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: R ofdrain (co tal) 16.60
��Slnk asi /I ato 16.60
Phone: ( ) Fax: : ( ) Tub /shower /shower /
an 16.60
P
E -mail: Urinal 16.60
•
. . CONTRACTOR . - n' -.„ , ,, - '''., • Water closet 16.60
Business name: �-M LI h3 E N/_ Aid Water heater 16.60
Address: Other:
City /State /ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25 %ofpermit fee)
State surcharge (12% of permit fee)
I nature:
Aut brizedg TOTAL PERMIT FEE
VPr me: 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.
1:\ Building \Permits\PLMF - PermitApp.doc 12/27/06 440- 4616T(10/02 /COM/WEB)
,
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. •;Fee (ea) ' Total; Square Footage: ° PermitFee:
Footing drain - 1s` 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 $220.00
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 &Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fee ea Total, additional $100.00 or fraction thereof, to and
Fixture Or Item Qty ° ) including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Ram 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
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Commercial Fixture Work: - ` Plan Review for.Plambing Installations. i'..�
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed; • greater, except systems designed and stamped by licensed
Frxture Type Replace engineer.
Previous . Capped Added Existing" ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain IS ®metric Or.Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial " •
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\ Building\Permits\PLM- PermitApp.doc 12/27/06
. ' Electrical Permit Appiicatii1l CEIVED TOR OrFrcl t USE oNL1
° i f ' / Permit No -: 5raez1 �' xo
11312:2 SW Hall Blvd., Blvd., Tinunitl qi,, 9 11 • R I. 4 2009 , P laralevcirta
e" . .
] P l i t e n e : : 563_6319„417711 F a : _ 5035' ..1'' 0 o ' IBuie,llic Other Pandit
- t R!
D . 9 tllieonn Lire: ?016 i941775
OF TIGAi�i/ Dula: 1Ra a: �e ES fee Pale ?for
It : w� �w .,m _ y C ITY 0 �, � r Klirl Sups al iefarritat am
TOPE tit II,I LNG DIVISION
PLAN REVIEW
® Nkny aposinct'io n f Additiomialltetratioingirement Reare check all that apply (submit 2 sets of plans :iv/items checked, below):
I ❑ice or feeder400 amps ormore ❑ Building over three stories.
0 likal Kll)flDhf(4an 0 i--i '_t Other I m where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION { exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground. or exceeds 14,000 ❑ Commercial -use agricultural
cg l- and 2- family dwelling ❑ Commercialiindustrial [l Accessory building amps for all other installations. buildings.
multi-family ❑ Master builder ® Other: ❑ Fire pump. ❑ installation of 75 KVA or
10B SITE INFORMATION; AND LOCATION Emergency system. larger separately derived system
/� ❑ Addition of new motor load of ❑ "A" "E' "I - " "I -
.1 no.: ( Job site adtlrt,>ss: l �8o S t,3 ') ,/ -f/y j 100HP or more. occupancy.
D
T� ✓ G ( f Six or more residential units. ❑ Recreational vehicle parks.
❑Healthcare facilities. ❑ Supply voltage for more than
600 oohs nominal
C:ita ": Stater'ZIP: (CL A/L OIL q7),)3
❑ hazardous locations.
Swtine/bldst_Japt. no.: 1 Pro, name: ,9 `V( A 1 _ ❑ Service or feeder 600 amps or more_
fP -- FEE SCHEDULE
Cmose street/directions to job site: Q Cr.503 1/c C- 4 ve- Description 1 Qrs. I Fee. I roml I .
l
New residential single- or multi - family dwelling unit.
includes attached garage.
Subdivision: I Lot no.: 1.000 sq. ft. or less l 145.15 i 4
- Tian %. ^t l no_: , Ea add'l 500 sq. ft. or portion i 33.40 v 1
P) Limited ener v. residential i
DESCRIPTION OF WORK laeich above sq. ft.) - i--- 75.00 2
n I Limited energy, multi- family 75.00 ?
• (FC Phe-t- Zeavif,�. i residential (with above sq. R.) C q -
/� � Ser or feeders installation, alteration, and/or relocation
I nr5 `41 N. d 2 e4 0 O L r-) F(Sas B & WA/(445 200 amps or less / 80.30 X 0,3 61 2
❑ PROPERTY OWNER i ❑ TENANT P -4' 201 amps to 400 amps , 106.85 2
c: 401 amps to 600 amps 160.60 2
MOD
601 amps to 1,000 amps 240.60 2
Address: Over 1,0(10 atnps or volts 454.65 2
City/State /ZIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 I.
Owner installation: This installation is being made on property- that I own which is not 201 amps to 400 amps 1.00.30 2
itntred sale, lease_ rent. or exchange- according to ORS 447._ 449. 670- and 701. 401 amps to 599 amps 133.75 2
Branch circuits - new, alteration, or extension, per panel
Ovsviirier sig attire: Date: i d
k Fee for branch circuits with
it APPLICANT ❑ CONTACT PERSON 1 above service or feeder fee. .,
each branch circuit 6.6� _
•
,
BURSittlae name: B.. Fee for branch circuits
mrvahout service or feeder fee_ j
Comma name: j 46 2
first branch circuit
Mildness: Fierr{m iadd't branch circuit Il 6.65 11 -
Miscellaneous (service or feeder not included
Cit /'StateiLEP: j Fx h manufactured or modular 1 1
dwelling, service and /or feeder 9
-
0.90 -I, Phone: ( ) i Fax:: (, 1 Reconnect only I P 66.85 1 I 'T
E. - mil Pump or irrigation circle 53.40 2
CONTRACTOR Simi or outline lighting 53.40 2
Business name: Lt J'i fJ ?Jt /t ff/ 2JC, Signal p al er or limited -
enerey p alteration, or
extension. Describe: Page 2 2
Cit' /State /ZIP: Tv0 � -/l„ t O q)04"?' Each additional inspection over allowable in any of the above
Lf Per inspection 62.50 I I --
:Phone: (503 ) ‘,56 56 Z 8 Fax: ( 5 3 ) 63& c1 a 4/) ' Investigation per hour (i hr min) ( 62.50 F •
CC Lie_: ! N -7q LI .El ramiai : , - i, al)( ; Sulam. Lic.: �ga' -.5 I fl Industrial plant per hour i f 7.3.75 t l
- it i ELECTRICAL PERMIT FEES
Stups. Eketti iaa sin' it5t ee. r tssirrd: a 1 Subtotal: I V/.,�i 6
11 Plan review (25 °i, of permit fee): I
Prim name: 3 9G t.- N,Th ,, 1 tt t.._ 7 - 61 n
State surcharge (12% of permit fee): 9 ,t,`'(
Authorized signature: TOTAL PERMIT FEE: g y tq N
This permit application expires if a permit is not obtained within 180
Print name: . Date: days after it has been accepted as complete
w:eenber of inspections allowed per permit.
J'.'ibitaittent'3'emingti 3'xrmits.pp:&c J523'0! , ?5 - 5st5T4 + !r" 4)mi za