Permit • A A Y OF TIGARD MASTER PERMIT
PERMIT #: MST2004 -00199
DEVELOPMENT VELOPMENT SERVICES DATE ISSUED: 7/21/2004
%I , 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 12298 SW ANTON DR PARCEL: 1S134CB-17500
SUBDIVISION: ANTON PARK NO. 2 ZONING: R -7
BLOCK: LOT: 102 JURISDICTION: TIG
REMARKS: 318 sq. ft. bedroom addition and 79 sq. ft. bathroom remodel. Other mechanical is duct work.
BUILDING
REISSUE: CUSTOM STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: 22 FIRST: sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 318 sf GARAGE: sf FRONT: PARKING SPACES : 2
TYPE OF CONST: 5N ' DWELLING UNITS: 1 TWO sf RIGHT: 5
VALUE: 29,383.20
OCCUPANCY GRP: R3 BDRM: 1 BATH: 0 TOTAL: 318 sf REAR:
PLUMBING
SINKS: WATER CLOSETS: 0 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 1 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS:
TUB /SHOWERS: 1 GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN <100K: BOIL/CMP < 3HP: VENT FANS: CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: 1
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS:
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 FDR: 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: 1.00 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: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner: Contractor TOTAL FEES: $ 769.36
F, MUSTOPHA J + MARY FRANCIS OWNER This permit is subject to the regulations contained in the
HOFF, Tigard Municipal Code, State of OR. Specialty Codes
12298 S S W ANTON T ON N DR and all other applicable laws. All work will be done in 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 - 579 - 9215 Phone: ATTENTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those
Rea #: 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
PLM /Underfloor Shear Wall Insp Plumb Final
Mechanical Insp Exterior Sheathing Ins F Final inspection
Plumb Top Out Insulation Insp
Electrical Rough In Electrical Final
Framing Insp Mechanical Final
Is ed By : � '� ■ ∎ , �# 6 4 • Permittee Signature : i /� �
IF
Call (503) •39 -4175 by 7:00 p.m. for an inspection needed the next busin •fs day
l uilding Permit Ap lic_at o> �. F OR OFFICE USE ONLY -. •
City of Tigard Date/By: 7 ¢ 0 /ySrak005 �i /
Permit No.
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie
Phone: 503.639.4171 Fax: 503.598.30L 6 2004 , s , ,, , l i Date/By: ,3i 7-?-.1- o' i + 'r OtherPernut 0,
Inspection Line: 503.639.4175 � Date Ready/By: � See Attached Checklist for `N
Internet: www.ci.tigard.or.us Notified/Method: l � S upplementalIntormation tJ
CITY OF GARD '-k,
,,���:. { � ; ':k.. °� ��r"' ,� �# :. ": a� z�. ;+riK "� � n,. : �-? ; �a�s<cz.= .� :..»�:: M t.���.��.,,, g ? : � ;..� „ .vu + w� r „� ..w .�: rz = °:-.•
git ” . ?; *,,. ;' ' `em PE id WO RT, kf**�, ” ¶ } ", >€ w' ' ? � ;RR; = U TRE D DATA:- :1 ; 1 ?iND- 2 z RA 1VII I Y DWELLING
�Q4'•, 1 ,'•. : ,H.. . > ,. eam'x. RV.. A , ..: _„ ., m A n. "4.t` ;?if -, a,�3:'- .wilt "lai... r,:a,; 3. kw.4,.. &xo,' . , 1 , 0 71.4 ;41,4 > ;,,, _ .26
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all )`"
g Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the . ' -, ..�%- ''", . >_: , a' =;�a�a�°^iy''= +,; _u-r: r.,=s,.:'�*°..r=a3:°i:zX;°a.;., _E,�;4;�.�� "rr`;:'• -,.
�� work indicated on this a
. �"� 4J„'Y -� s ":.s, ����" � S a- x r t 4�'.:, .^ t a 4¢ s� iY�?'. ..:�•�;€�F3..,'...�•� -.a �; application
a q . :. „ C?iTEC�ORY OE "`GONSTrRifGTION. it :. . ir <:�•,
r.3;�:..�s,� ��r���.H ��,. �.:,., �: a �. �; �* at' .:, t�, e^°. s. �:; 4*:•.=:,,: tir :to,;._,'
Si 1 - and 2-family dwelling Valuation: e (� `��_
y g ❑ C ommercial /industrial
❑ Accessory building El Multi-family Number of bedrooms:. I Qd'�
❑ Master builder ❑ Other: Number of bathrooms: k
° ,.�t� yr ° r".?� " �'. - 4` �` � ;��+ ".3e''�':s'�:'.,�a` ` „��^a ��'�. ^�,s"=== �`�":; y.= :�.;� ^, "- - - _
-` 'rt ' = "�":i O ''' Total number of floors:
g a " '� .. 4 ; 11 14, , 4. .,JO S ITEy; :4 R�IVIATI °" AN'D "I QGATI,,, . ,, �,=,
ar� :� - � � � - �..�._�:.;, � „,, �,. �. � . �,r =air .c +. <. ;� , , .____ �. _,_,�,.
Job site address: ' ¶ a r s„ f N 1 D „, � New dwelling area: ..—.. square feet
City/State /ZIP: T 1 , b K . ( 1q ZZ � Garage /carport area: square feet
1
Suite/bldg. /apt. no.: Project name: Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
N D 1- ‘)&Y (7 ` A Other structure area: square feet
'_.; R- VE R D D' , =; O1 ikIERCIAli =US °E C-HECICLISTT-
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
o-€c .h” s°,� ��� �� s^ �.: � `ka.';��dr° *': r �..x, 4"€ - z . °" ' �,
equipment, materials, labor, overhead, and the profit for the
�' D B t iregt P,�TgIU ' OLi initK IW I. ` Y A work indicated on this application.
R I - I D n) ( 0 ) P L eo , � ° 7C Valuation: $
.3/ 0 29 Existing building area: square feet
O New building area: square feet
." " . cc 6; OWN R W '' t k �® NANt , i .." R;� L
?, ". P� 4,' , ;e . - "..1. , , : g: , ..,,E . 4 1 ,011 ,, , , ytiV s.,;. A,s .,. Number of stories:
Name: '
,-- A ' i �� Type of construction:
Address: 1229 � * K) row V Occupancy groups:
City/State /ZIP: Ti �j �,^ ' l C) K . ` 9 `� 3 V Existing:
Phone: (5D3 5 R- 7.4 r e Fax: ( ) New: '
• �; «.: } .. ts�..�. o.s- -�; £fix '=aH " '� �c = s' - =- R " "... *�.;:,'-r� -,:r' 'rr<,:at ,
�'� ., „ PPI,I PANT, ° : ^ CONGA <T�PERSON .4 t �ieE , ° a ' .: ^. s. ; _, n-. -0-- .t,. .
`:".", `- �; T `" 1 .r'= :., r, % .. ,s -° , . :i .a , W.. v , � 'Yr ;x;"�£Sa: : �'S:° rte.,. %..hr r ,� , , , w , : ..
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:
L ` k " , ' .,COIV RACE OR «, 7= , 44 ,'
Business name: A A J .�;" r.P . o,.;:b�.< '., '�,.,r� :. i:. «a �;�.�," ern "`e:^
, r° � 1a z•JI,, DIN P?ERNTwT FE ES* , 1
Address:
Please refer to fee schedule.
City/State /ZIP: /
Fees due upon application / a odiP, .57,2_,
Phone: ( ) Fax: ( )
CCB lic.: Amount received o2 7 J - _ j
•
Date received: yV.0 /
,
Authorized signature: ( ° This permit application expires if a permit is not obtained
_ , � � �, • • within 180 da after it has been a as complete.
Print name: / q (/ 4 (� ) l I�Ir Date: a •~ * Fee methodology set by Tri -County Building Industry
11 Service Board.
i:\ Building \Permits \BUP- PermitApp.doc 12/03 440- 4613T(I I /02/COM/WEB)
One- and Two - Family Dwelling i .4,
Building Permit Application Checklist FOR OFFICE USE ONLY - .
City of Tigard Received
Permit No.:
Date/By:
13125 SW Hall Blvd., Tigard, OR 97223 Associated permits:
Phone: 503.639.4171 Fax: 503.598.1960 �nirNi +\
24- Hour Inspection Line: 503.639.4175 `� ❑Electrical CI Plumbing 0 Mechanical
Internet: www.ci.tigard.or.us "� Cl Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR 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. ❑ ❑ Cl
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. _ CI CI
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
(1. 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 CI CI CI
building codes. Lateral design details and connections must be incorporated into the plans or 6n 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.
Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if 111 ❑
11 ❑ CI 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 Oregon and.shall be shown to be applicable to the project under review.
JURISDICTIONAL SPECIFICS
ep Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
4 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 tree protection measures as required by conditions 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.
i:\Building\Permits \One- Two - FamilyChecklist.doc 12/03
Electrical Permit Application - FOR OF F I CE USE ON • - .
Received S�� Gd r / � ` 9.
City of Tigard
Date/By:
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 kos i pi�" ( Date/13 : Other Permit:
Inspection Line: 503.639.4175 . ; ,al� CI Date Ready/By: a See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information
. ° - P L ?4� >'•� ° ="' y ='44 i " +, �.'. 4 :. x'k'% :':3h .`:+O3.'-_$1. -;nF'�c""Sm ".•A ' y YF._ »`- `a":. « R: : Xig; , x :g, • . .. _
'. .rte "� j: . "
§.g ". #. «2*.u -«. 3v..Y'k:,n'.'. i '£ t.: ,';,S" 'y= , ;R ;.`.. , u , °3� ''. .w... b �n fr..
..K': �', k =t . ,�A . s� i 4 � ' "� w.� . } • 1' v � Icy: :::.P.'r �'Y.e'.' : "A :'. x S..'.'. ?�,.
a,, . ° ..°'- gip•. „e... ,':.T2Y�P . 4 . .OF WORK -�: � ,-� � . .,r.'- �°{ ,. . , . _''. : ��.X "'.2,. =E ' A N rI ,,' ' , .
"'7?� "x w..i b>y... .k.'�� Y.. s. �'._:° . `i. - .�.. ',�:.:.4� " _ :., !]:�� �": "� 'u'� ...a $'. . ..,. . .." i., .... _ ._ ..., .. _ . .. . .
i,-�„ � _ a_�..2 Vr�: �,�.,,.."�$i' ?�'r n tter. `�ar`.+a�ray.ze. < . _ ....:��' . ..c -k... .,
❑ New construction Addition/alteration/replacement Please check all that apply:
❑Demolition ❑Other: ❑Service over 225 amps, comm'l EHazardous location
,. <,�. as <r "_,,,, y Wit ,,, ❑Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
:¢ ' 4 . - t GATEG {OR OF GONST,RTJCTION .ia yg _ z � - " of 1- and 2- family dwellings 4 or more new residential
I and 2 family dwelling ❑ Commercial /industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi - family ❑Master builder ❑Other: CI Building over three stories ❑ Feeders, 400 amps or more
CI Occupant load over 99 persons CI Manufactured structures or
? i - - r ^hb -...,. - .,?}�..' - a:.� ^k ;s+: �_ - �,:�:�'si•. ::�. •.x +ba�,5:,::v -tc::, �Zdzr� atsa�,:;� "`` £ = `�`
6 V V1 nt41E I ibis Tito ifoifi arTE ''" , - j F { a ❑E gress /lightingplan RV park
❑Health -care facility ❑Other:
Job no.: Job site address: 22. l j J A � �Oy �)', Submit 2 sets of plans with any of the above.
City /State /ZIP: T Q The above are not applicable to temporary construction service.
� .
Suite/bldg. /apt. no.: Project name: ,k ,...s, F.EE* < °SGHED,UL . '::' ',
Description Qty. Fee. Total
Cross street/directions to job site: New residential single - or multi - family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
Limited energy, non - residential 75.00 2
;%tr.,i:: �:��,� ,.,r� „'� <;� �:,:KK. ='�'� - : -- a ',' w,n Y „''� �"� =its”. <,�3 "� `�,.;at •
' :- 1 v t = " ;r t E " " DESCRIPTION O �.. )RK .�. wf =sk cj Each manufactured or modular
dwelling, service and /or feeder 90.90 2
Services or feeders installation, alteration, and /or relocation •
200 amps or less 80.30 2
ti � " ;., „ .:.F ER�, .,; .; ,. Q RIVAZ t ° .,9 m am 201 a s to 400 s 106.85 2
0; "PROPERTYWN;- nkTENAN , t P P
401 amps to 600 amps 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City /State /ZIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( ) Fax: ( )
200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
€ � 3 PI# , _ _ ,,,,V.!:4., = ; e ]Vr A C T ' iP ER ON i . A. Fee for branch circuits with
service or feeder fee, each
� � �,� 6.65 2
Business name: lS ( I a. )P1v C oviz ' s 6 (� branch circuit
r l B. Fee service f circuits
Contact name: l without service or feeder fee,
r • � l each branch circuit 46.85 2
Address: b 6 "(. c___Lt.eA , n/v) 4, Each add'l branch circuit 6.65 2
City /State /ZIP: �1'�l „" n (') / 1Q t /5 Miscellaneous (service or feeder not included)
/ c_ Pump or irrigation circle 53.40 2
Phone: �t J//Y� fit_
(5 ) F, 16 - 05 Fax: ( ) 244/14°.
Sign or outline lighting
2
53.40
E - mail: — Signal circuit(s) or limited -
;��:ER ;�: = 1 � *' It - ,.= „` "; _ : ;.pv'�> =ri :�y�r',,,I, energy '
���<�?�.:.��. '�.� �,', a���..,�COPITRAG`I'�OR.�":�;i�' :��£ '��; .. �� ��,��.t�iz�' P
anel, alteration, or
1:-.,-/ s/_ 1 i extension. Describe: Page 2 2
Business name: rG - t Yl C 1 , �YI
Address: 66 `1' ( ` ,� - / AA.. 4 y '. Each additional inspection over allowable in any of the above
0--/ ' Per inspection 62.50
City /State /ZIP: j
1 l� Investigation per hour (1 hr nun) 62.50
r� Industrial plant per hour 73.75
Phone: (�j�) c - 6" 6-) Fax: (
5 6
=e:'EI E`C17RICAt P =EIt1V1IT a _ ;
CCB Lic.:l 5 S Electrical Lic.: 3. �.5 G S uprv. Lie.:/4 7� 7 s Subtotal
Suprv. Electrician signature, required: A . V ��� 10 Plan review (25% of permit fee)
l � ��IXIX
Print name: IJ t Se � Dat e li e - - // / - 61 State surcharge (8% of permit fee)
l / / v� l i / TOTAL PERMIT FEE
Authorized signature: This permit application expires if a permit is not obtained within 180
'�( l � days after it has been accepted as complete
Print name: �� 44,v, Date: 0 -6/4 * Fee methodology set by Tri- County Building Industry Service Board
** Number of inspections per permit allowed.
i'\ Building \Permits\ELC- PerniiApp doe 12/03 440- 4615T(10 /02 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
'�`CO _. , 1WM WOR>C ONLY..' :
Fee for each commercial system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
\Building\Pemtits\ELC- PermitApp.doc 04/03
Mechanical Permit A h Ti`J ED FOR OFFICE USE ONLY
Cl of Tigard a Received G , 9
City g J UL 6 2004 Receive PernutNo.�y��QOy - �(��
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 //h k Date/By: Other Permit:
Inspection Line: 503.639.4175 CITY OF TIGARD ' 1' Date Ready /By: Juris, PI See Page 2 for
Internet: www.ci.tigard.or.us BUILDING DIVISION Notified/Method: Supplemental Information
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?f "w,st} ,.+w,t „^z'°,z, a.:i'.N::, x� ,nAr.„i 4�s; '�".: =1�.a.. ,:,�°! �f.a`a'��.» s`:s,,. .. ,`,4°�,,.w�'.: *.,
as { . � :Y°� ., ,.i.,raa Via;[„„ ,.- , J: : = ", " , s p z �, 4E1'= �<US3CH'akIAST
.,. tli,- :�. >a�� � < ;•, ..,�, �` ='1-> c� t, `3 W "�{i1" .,��:r i'; ; :, i ., �" t' i s C.OIVIIVLERCI�AI: °.;FEE .,SC . DIIL- ,.
. �S�p `mss .?, �, "" ;Y ; S: � ^. : �&n y . TSi�'E 0�., O ..R� "i:Mikwtb:, v * , _�,::Sr ";. y ..Cak:C�H' t. �%n� f^maY`. -..: _ ^, -: > < d 1'� � .. .: iJ. �, �'
�_ ^'r` a ir, ��-:_, i„ ��.%ae9;.,ue.,..,nt.,x,.,P ±x`ds damp§ s��s�= r:+ �n4. �cY: �r. �_sr..,Y.L�.i"r_x�,__o_u'k�.3 -, .. "'jt �. >__,s
❑ New construction [ Addition /alteration /replacement Mechanical permit fees* are based on the value of the wort:
performed. Indicate the value (rounded to the nearest dollar) of all
El Demolition ❑Other: mechanical materials, equipment, labor, overhead, and profit.
s t „ - ,. ,, . r ., Value: $
�� � ��� 4 ;- tt�n�>a_,i , �' � ` T 4 � t �� 11/ 1i.ta.11 , e --- ., � e,,; ,.. - �, . .
111 M and 2- family dwelling I=1 Commercial /industrial El Accessory building ..
R_ ESIDENTIAL�EQUIPMEN "7 SYSTEMS.FEES*
For special information use checklist.
❑ Multi family 1:1 Master builder El Other: Description Qty. Ea. Total
�i. "'° rw. ���A: ...ivr °- y�\r"ru�'�k,.;;,...�ma; rues °xesv,rxi�: ° -;:, - .�rcae,= �' ".,;�•.:!.: g� + , >�;e • =: �, ?;�..
a '1 �,`,g
t", r " �"°' ih '`"s i JOB ESITE 3INFpR IATION. AND ; . s ^ Heat
Job site address: C
ZZ9 A) b? Air conditioning or heat pump
S J l' J - AAA A v �J • (requires site plan showing placement) 14.00
City/State /ZIP: "D q 1 4 D E. q.ZZ 3 Furnace 100,000 BTU (ducts /vents) 14.00
l Furnace 100,000+ BTU (ducts /vents) 17.90
' Suite/bldg. /apt. no.: Project name: Gas heat pump 14.00
Cross street/directions to job site: Duct work p_ 14.00 ,‘1.0,b
1 i 7/ Hydronic hot water system 14.00
♦ /241 Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 10.00
•
Flue /vent for any of above 10.00
Subdivision: Lot no.:
Other: 10.00
Tax map /parcel no.: Other fuel appliances
:a : °> :,:4 . - .,_,::•_:,,.: - ... ^ = s a, « w`.i as Water heater 10.00
° _ A . a, s�DESC t ,iW -6 it `,�"i .
.1 ;L�., �3 �. ..,', sar4aus ,,�.-..t _ 11_`sa,__.d: o,' r:' aawt,..m.-
� � � • � Gas fireplace
foe 10.00
;� �� IILO r� e u / O Flue vent for water heater or gas
Tit pu I VV 1 u Log l igh 10.00
Log lighter (gas) 10.00
. Wood /pellet stove 10.00
Wood fireplace /insert 10.00
,. °::, mss. r� ,,, ; ,u;a, < .« x; -, - :: W,3,:; : Chimn /liner /flue /vent 10.00
f., a ' e ilOPERTYi.®W,NE ai y t � ",.W . w 4 "w "� ® T =T� r , ,, ,
. w.�x ,„ r y x.w_. ., ...,'s,,r ?� ,- ., «..ii Other: 10.00
US r q
Name: (f N E nvironmental exhaust and ventilation
� � e-- � Range hood /other kitchen
Address: 1229 ( ? ( , u in, I Ol(YY } ' ✓'C , equipment 10.00
II
City/State /ZIP: cl b k U z z 3 Clothes dryer exhaust 10.00
�� ) ( Single -duct exhaust (bathrooms,
Phone: 5- 1 2 Fax: ( ) toilet compartments, utility rooms) 6.80
x ck, ,,: r w' +' ,t� W -V I: ^ 1 G,as , x .a
� � � �` � � � g °�� �,�. � � ='�?- � �N t a , ' Attic /crawlspace f ans 10.00
u x IOM "I AP PL I CANT� € it 1s,^ . . ;; .e" , . : k .'.�. "" ® VW := P 0 * " ^,
7 ` .,. w Other: 10.00
Business name:
Fuel piping
Contact name: $5.40 for first four; $1.00 for each additional
Furnace, etc.
Address:
Gas heat pump
City/State /ZIP: Wall /suspended /unit heater
Phone: ( ) I Fax: : ( ) Water heater
Fireplace
E -mail: Range
,
^`.F` ; 5` ..:^ _:: t . : W ar , r,�„�;,.r'-;�'_.: <.x...�,s:..;a -r„ar. lnt '; ' ^".° - ;;'t '"tgtis "ie � %k9: ;ti:. ',�„ ::
i3� �?t. CONTRACTOR a ? t Barbecue
.3 K���e`'�4#�'� �. ..izt, : .-. v. -.� - _aar..�..eP.L.: .ae+y*.r „r,_, r? __. 3.'�.vsla"as �: .a9r,r'
Business name: 02---(L/1-11-6-1„..- C o es dryer (gas)
Other:
Address: ' APt' °V L ' MECHANICAL' PERMIT FEES* '
City/State /Z1P: Subtotal '
Minimum permit fee ($72.50) 7„,2, , ,„5
Phone: ( ) I Fax: ( )
/ Plan review (25% of permit fee)
CCB lie.: State surcharge (8% of permit fee) .S. .4
/
TOTAL PERMIT FEE 7,p, lo 40 This permit application expires if a permit is not obtained within 180
Authorized signature: 2 .‘e / _ days after it has been accepted as complete.
Print name: , / ` g y � / � � � ,� ate: `... r * Fee methodology set by Tri- County Building Industry Service Board
i' \Building \Permits \MEC- PernutApp.doc 12/03 440 -4617T (11 /02 /COM /WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
•
Commercial Fee Schedule:
rgTOtal Valuation 1' ermat
$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.
$100,000.01 and up $1,396.50 for the first $100,000.00 and
$1.10 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
•
•
•
i:\ Building \Permits\MEC- PermitApp.doc 12/03 2
Building Fixtures 9 ��®
` Plumbifi Permit Appli ib _._ . FOR OFFICE' USE ,ONLY: _'. ;
City of Tigard JUL 6 2004 Date/By: Permit No NST�D DO /�
13125 SW Hall Blvd., Tigard, OR 97223 y
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 / /tas �; p k Date/By: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 CITY OF TIGAr . E .iI± D ate R ead y
By: Jur 0 See Page 2 for
Internet: www.ci.tigard.or.us BUILDING DIVI 'l N Notified/Method: Supplemental Information
^•� ": n ° y . TR , +. "n:z n`v3? ": ..:,s�aa: aek,X.�` -'.;. �.y ',zK_`. mti� `�•;. .
`-:* `xa^ 'x>I "•.s + # ; i Ti ', ;^ , : ' r « ' .°'its.:^ ;ig„i a , 'i; � c « `- , ,,ss �'•.i ".:: �; . i `' pJ g ` '"-,s . .
� e ik4I _< :?t. . i rr - �' . : ORI{ -.#` ,., ;' �+" . e s ` ,' `t iiot S , . . `'A- +. - EEE: �S C,H E DIT t;E
„?'� �,��� a ,n��`' =�"� .� °�-u *,t�;e.�,�. �''- Viz..., ,� _,�_, A�:d"�tw i� ,., a`�:: °�;'� .� . _..,,_.. ^ "( s .> .,._. ._.s, ..
❑ New construction ❑ Demolition For special information use checklist.
Description Qty. I Ea. Total
[2, Addition/alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
.1,� "1;" 1 C:ATEGORI OFC010\`ST12 C. z;s: f <, SFR (1) bath " 249.20
a�a.' x:3r � ..�._ #w...;.. w�`v a �t rte_... -^ -�z�is w'� Yu�s.xz,�a
1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building I=I Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
+z r msµ„ Fire sprinkler ( sq. ft.) Page 2
g w� trO STLE INF IA7'ION , I3 tit)Ctt . ". „k, a ,
°t;� ! Si utilities
Job site address: 1229 ' � i a 6U D 2 Catch basin or area drain 16.60
City/State /ZIP: 11G co ?,?, 3 Drywell, leach line, or trench drain 1 6.60
Suite/bldg. /apt. no.: b I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
s r n Manholes 16.60
10D K. Der .o I A I / 2 1 ) 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.:
:< r - t 3 Absorption valve 16.60
,,, - , �` _ DES R�IPTIO,' gF ORK � _ a l,0 - „, . Backflow preventer Page 2
EMAI et 'porn l i l bb' i i, Backwater valve 16.60
Q,, 'tilt i k , Clothes washer 16.60
• Dishwasher 16.60
tt - ` .: . iN NA r '1 Drinking fountain 16.60
` PRO RTY O Y . ` l ' ,`` ..114 , "''''N''',' ' . ' . T ENANT z
, /J � C i - , - - -, . - r � --a g • 4` -- E /sump 16.60
Name: )`l ) " ( ?J 0 ` Expansion tank 16.60
Address: 1 Z Z.98 S w k 414, D� Fixture /sewer cap 16.60
City/State /ZIP: t f� Y' 1 J 0 ec 9 Z7 Floor drain/floor sink/hub 16:60
( 5 2 ) S� l q _ 9 rG I
Phone: l 9 Fax ( ) Garbage disposal 16.60
,_ e z -a- Hose bib 16.60
',4.'
Er A A('PIICvANT -.. -, GONTAC PERSQ
"� ""�'' �" "ecalu` A' "" -
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: Roof drain (commercial) 16.60
Phone: ( ) I Fax: : ( ) Si .a vatory 16.60
0 shower .hower pan ( 16.60 3?)2D
E -mail: NI nn. 16.60
'`'?°`1 i t ?. T ta_. 4 .: a `; a v �;•�.�_' s:.- ` : a �,. M ,;o „, na ° , : i ;i:� ?,',
'n:, � 1 ` d.<�k O TOR': ` e � g
�:�".��„ �?�t0� r Si _ '�:��:...= .. i. .�.t =� n� z ._ ._ �_�r,,,fi .0 . r r.� .�ix ��- Water closet 16 �.��.�•
Business name: 6 9_ ? ` C ^ Water heater 16.60
Address: r Other:
City/State /ZIP: Subtotal
Minimum permit fee: $72.50 za , SO
Phone: ( ) Fax: ( ) - Residential backflow minimum permit fee: $36.25
/,��i-' Plumbing Lic. no.: Plan review (25% of permit fee)
/- � P State surcharge (8% of permit fee) s, a Authorized signature: i / /�i ' TOTAL PERMIT FEE 7,, J')
Print name: , ' f IT''' 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
i \ Building \Permits\PLMF- PermitApp.doc 12/03 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard .
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
tY Fee eat *furl
.., . =
Site §Util><ties : � Q x= � k 4 ;) . _ xn ° Square E,aotage: 6,4. . erit;ee:;£ : .
Footing drain - 1 100' 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
�: :° Pernut.
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
Fixture Or��tCIT � L x = Q ".;.10- at , "Tota additional
$I 0 00 or
.fraction thereof, to and
including
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.
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
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
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 * .
h� a� 1 Qu4nn y iSg0xiraski P,erfo uie�d
Ii re ype °S tAt ` Replace " �
g < � / o ea a lgiA 45-409-t
i C omments regarding fixture work:
,� �J z � �a_ ��r�.�.r� _ � �ekv„� r ...,�. ,„ �...,u ; «
;� g g
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"
-4 "
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial
Ice Mach. /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory
Quantity Total
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
- Service total is >9.
•
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
•
i.\Building\Perrnits\PLM- PermitApp.doc 3/03
CITY OF TIGARD
. 13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
TESLA ELECTRIC CONSTRUCTION IN
664 CHARMAN STREET
OREGON CITY, OR 97045
Electrical Signature Form
Permit #: MST2004 -00199
Date Issued: 7/21/2004
Parcel: 1 S134CB -17500
Site Address: 12298 SW ANTON DR
Subdivision: ANTON PARK NO. 2
Block: Lot: 102
Jurisdiction: TIG
Zoning: R -7
Remarks: 318 sq. ft. bedroom addition and 79 sq. ft. bathroom remodel. Other mechanical
is duct work.
Your company has been indicated as the electrical contractor for the permit indicated above. In order for
the electrical permit to be valid, the signature of the supervising electrician is required. Please have the
appropriate individual from your company sign below and return this Electrical Signature Form prior to the
start of the work to the address above, ATTN: Building Division.
No electrical inspections will be authorized until this completed form is received
OWNER: ELECTRICAL CONTRACTOR:
HOFF, MUSTOPHA J + MARY FRANCIS TESLA ELECTRIC CONSTRUCTION IN
12298 SW ANTON DR 664 CHARMAN STREET
TIGARD, OR 97223 OREGON CITY, OR 97045
Phone #: 503 - 579 -9215 Phone #: 503 - 656 -0503
Reg #: LIC 151265
ELE 3 -540C
SUP 4767S
AN INK SIGNATURE IS REQUIRED ON THIS FORM
X " 0-
Signature of Supervising Electrician
If you have any questions, please call 503.718.2433.
CITY OF TIGARD • 24 -Hour ,
BUILDING Inspection Line: (503) 639 -4175 Av y' — Od /9 y
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Reque ted / 0/�- 7 AM PM BUP
Location / .)--Q A I f z /\ • Suite MEC
Contact Person A.- ' S Ph ( ) 7 " - 7 / 3 7 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing , ELC
Foundation Access: 2,66tef �/ F tg Drain 30 — 'Lc�,.. l 8- `2. ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam •
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS -RE■RT FAIL
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains -
Catch Basin / Manhole
1 Storm Drain
Shower Pan
Othe •
in
P ART FAIL
CHAN
Post- & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
' Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final ❑ Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE . ❑ Please call for reinspection RE: El Unable to inspect — no access
Fire Supply Line
ADA - L
Approach/Sidewalk Date A Inspector Ext
v. Other:
Final DO NO REMOVE this inspection record from the Job site.
PASS PART FAIL
CITY OF TIGARD .. .24 -Hour _
BUILDING Inspection Line: 13) 639 -4175 MST DO - 0 a / 9 q
INSPECTION DIVISION Business Line: 503) 639 - 4171
BUP
Received Date Requested / 6 `" AM PM BUP • Location t _ &ILA W Suite MEC
Contact Person C flA : h ( ) ?a 6 — 7/ 37 PLM
Contracto •h ( ) SWR
D I D Tenant/Owner ELC
ELC
ounda ounda on Access: I Z-/ S i rJviec Kb`i
tg Ora ELR
rawl I rain .
'.lab Inspection Notes: SIT
"ost & :eam
• hear Anchors
Sf eath/Shear
I t S eath/Shear
F • ng
In . ul: tion
D -all Nailing
Fir all
Fir :. Sprinkler
Firi
Alarm
Su d Ce iling
Ro •
Ot
S' PART FAIL
PLUM : ING .
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
CHAL - . -
ros & Beam
Rough -In
Gas Line
-. • e Dampers
'Ii
•AS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
l PAS PART FAIL 0 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
SITE . _ 0 Please call for reinspection RE: 0 Unable to inspect – no access
Fire Supply Line X f
ADA
Approach/Sidewalk Date / I nspector _ – � — %� Ext
Other:
Final DO NOT REMOVE this inspection r - from the job site.
PASS PART FAIL