Permit CITY OF TIGARD SITE WORK PERMIT
" Permit #: SIT2011 -00010
COMMUNITY DEVELOPMENT
Date Issued: 09/20/2011
T IGARD 13125 SW Hall Blvd., Tigard OR 97223 503 718 2439 Parcel: 1S136AD06000
Jurisdiction: Tigard
Site address: 11437 SW PACIFIC HWY
Project: Carl's Jr. Restaurant Subdivision: Lot: 0
Project Description: Site work for new Carl's Jr. restaurant.
Contractor: TJ NISBET CONSTRUCTION INC Owner: EJM PROPERTIES INC &
15896 SE 82ND DR MAVERICK DECATUR GEORGIA LLC
CLACKAMAS, OR 97015 -0040 BY MAVERICK INVESTMENTS
3633 E BROADWAY
LONG BEACH, CA 90803
PHONE 503- 257 -0308 PHONE:
FAX 503 - 257 -0309
FEES
Description Date Amount
Specifics: Permit Fee - Site Work 09/20/2011 $1,339.24
Plan Review 09/20/2011 $870.51
Type of Use: COM 12% State Surcharge - Building 09/20/2011 $160.71
Class of Work: ALT Erosion Control 09/20/2011 $80.00
Project Valuation: Erosion Plan Review CWS 09/20/2011 $26.00
1 $217,731.00 Erosion Plan Review COT 09/20/2011 $26.00
Site Specifics:
Excavation Volume: 100 cu. yd.
Fill Volume: 100 cu. yd
Impervious Surface. sq ft
Engineered Fill No Soil Report Required: Yes
Paving. Yes Grading:
Landscaping Yes Site Prep: Yes
Storn Drains' Yes Retaining Wall: No
Fire Underground No Accessible Parking Yes
Fence
Total $2,502.46
Required Items and Reports (Conditions)
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 ou to follow the rules adopted by the Oregon
Utility Notif - - enter. Those rules are set forth in OAR 952 - 001 -0010 through OAR 2- !e -'i••i ou may obtain a copy of the rules
or direct estions to • NC : :llin. 03.232.1987 or 1.800.332 2344.
Issued � :y: ` . / � . Permittee Signature: l
Call 503.639.4175 by 7:00 a.m. for the next available inspacf. n date.
This permit card shall be kept in a conspicuous place on the job site until completion o the project.
Approved plans are required on the job site at the time of each inspection.
Building Permit Application
Site V ork F y u H {3 �, x „ * fix txu �1r 4" kSrm s n "V SAD , lr �-,5 ..
.*,%4N �1 ; aa . m `° fi r s as< FOR OFF US ONLY� t ti '
��l °� Reccncd
`°r�' %iuA �' City f Tigard Pennu No . _
Y g` ��'t Uatels 4 �/t d 0 pm
1 11111 � " 13125 SW H all Blvd., Tigard, OR 97223 l flan Revs 1'r} �I /�
e ' 4 Phone: 503.718 2439 Fax 503 598 1960�"�E�'• � )nte /l3\ a . �
Wil nr� Other f erini( 161 I ,11, _ J
T Inspection Line: 503 639.4175 � �Q .4 *°' , � 7p : iLRea -r`y �+ // tenet El See Page 2 for
,o ... .: .r., , Internet www tigaid- or.gov „`{ y° ,�\ ;;Muffed /Method T / 97/ `� supplemental Information
TYPE OF WORK t+.3° +`y /
— %' REQUIRED DATA: I- AND 2- FAMILY DWELLING
® New construction ❑ Demolitions' Permit fees* are based on the value of the work performed
Indicate the value (rounded to the neatest dollar) of all
❑ Addition /alteration /replacement ❑ Other: equipment. materials, labor. overhead, and the profit lot the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ I- and 2- family dwelling Valuation. $
® Commercial /industrial
❑ 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:44434 -SW Pacific Highway 1l 4 37 New dwelling area: square feet
L City /State /ZIP. 97223 Garage /carport area• squm feet
Suite/bldg /apt. no.• Project name Carts Jr Covered porch area: square feet
Cross street/directions to job site: The project is located on the north side Deck area• squat e feet
of the Highway 99 street frontage on the west side of Busters BBQ Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no : 6000 Permit fees* are based on the value of the work performed
Tax map /parcel no.. 1S1 36AD Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead. and the piolit for the
DESCRIPTION OF WORK ° ' work indicated on this application.
Demo existing Kentucky Fried Chicken on -site and construct Carts Jr in its place Valuation: $$217,731.00
Existing building area: square feet
New building area: 2786 squire f: ct
❑ PROPERTY OWNER ® TENANT Number of stories 1
Naive: KWKG, INC Type of construction:
Address: P 0 Box 1012 Occupancy groups:
City /State /ZIP: Wilsonville, OR 97070 Existing.
Phone: (503)682 -8474 Fax: (503)682 -7035
New, x
❑ ,-APPLICANT ❑ CONTACT, PERSON .
NOTICE
Business name: KWKG, INC All contractors and subcontractors are required to be
Contact name. Dan Gjurgevich licensed with the Oregon Construction Contractors Boai d
under ORS 701 and may be required to be licensed in the
Address: Wilsonville, OR 97070 jurisdiction in which work is being performed. if the
City/State/ZIP: Wilsonville, OR 97070 applicant is exempt from licensing. the following ieasons
apply:
Phone. (503) 682 -8474 Fax • (503) 682 -7035
E -mail: dodgers088 @aol.com
CONTRACTOR
Business name: T.J. Nisbet Construction, Inc. BUILDING- PERMIT FEES*
Address. PO Box 40 (Please refer to fee schedule)
Structural plan review fee (or deposit)'
City /State /ZiP: Clackamas, OR 97015
Phone: (503) 257 -0308 Fax. (503) 257 -0309 FLS plan review fee (if applicable)
CCB be :92315 c0-7// Total fees due upon application: $1,338.00
I Amount received:
Authorized signature:
This permit application expires if a permit is not obtained
Print name: Tom Nisbet Date: 9 /7/11 within 180 days alter it has been accepted as complete.
Fee methodology set by Tri- County Building Industry
Service Boaid
1 \Building \Permits \SIT- PermitApp.doc 10/01/09 440- 4613T(11 /02 /COiM /'S\'FBI
City of Tigard: Site Work Permit Checklist
Page 2 - Supplemental Information
Commercial, Multi - Family and One- and Two - Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way. or wetland, the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below, unless otherwise noted.
Excavation Volume: 100 cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) 100 cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) 100 cu. yds.
Retaining structure? (Check one) n Rock
n CMU
Fl Concrete
Other: not appl.
*Total new impervious area including all buildings,
sidewalks, and paving: 0 sq. ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See "Site Work Permit Application - Plan Submittal Requirements" attached.
The following must accompany this application:
1 1 Site Plan with Vicinity Map showing ADA n *Parking (including ADA) and Lighting
compliance Plan
n Grading Plan and details n *Landscaping Plan
n Erosion Control Plan and details n Soils Report (if required)
n Retaining Structures
*Does not apply to One- and Two - family dwellings.
Plan Submittal: Permit Fee:
TYPE OF SUBMITTAL # of Plans Valuation: Permit Fee:
(New, Additions or Required at $ 00 to $500.00 $51.09 minimum permit fee
Alterations) Submittal $500.01 to $2,000.00 $51.09 for the first $500.00 and
$2.69 for each additional $100 or fraction
Commercial 3 thereof to and including $2,000.00
$2,000 01 to $25.000 00 $91 44 for the Oust $2,000 00 and
Multi 1 amity R- I Occupancy 3 $10 76 for each additional $1,000 or
fraction thereof. to and including
$25,000.00
One - & Two - Family Dwelling 2 $25.000 01 to $50.000.00 $338.92 for the first $25,000 00 and
$8.06 for each additional $ 1.000.00 or
fraction thereof, to arid including
$50,000.00.
$50.001 00 to $100,000.00 $540.42 for the first $50,000.00 and
$5.38 for each additional $1,000 00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and over $809.42 for the first $100,000.00 and
$4 49 for each additional $1,000 00 or
fraction thereof.
I \Budding \Permits \SI'r- PerutApp.doc 03/03/2011 2
Building Division
Development Code Provision Review
T cARD Commercial Projects - No Associated Land Use Case
Building Permit No: ( S i o26// — O 16 CtYExpedited Review
Plan Submittal Date: 91 &WS � // C9 O6'91\VA/IL/ S[..��„` / $/jq%)
W i`ri^ j G p
To the Applicant:
If the proposed use is not permitted within the zone, please contact the Building Division to cancel
the permit application. Building Permit Technicians (503) 718 -2439.
> If a land use is required and for all other questions, please contact the staff person listed above the
Planning Review section.
Staff: please check items along left only if approved.
Planning Review (contact 4 at 503 - 718 - L1aq or @tigard- or.gov)
Et Zoning G • G' Permitted Use Yes -B' No ❑
J ' Land Use Required: Yes El No ❑ (explain below)
Notes: IFAp ec ( mot* e . 4 S 0 a 2o1 C1- 6 /
3 /
lt..,,,6 [ . ii 2. /Y ai '! f ei 41:. 14 e4 4 lrZ 1 ' . -[-.tV v.L.'
PbU 44 tuna r -u - N- 'iv. 1 .to 4 .4,..t RC "4 t 114 7 r Z 6. u' N - l
H - Approved ❑ Not Approved Date: 7' c ?
Permit Coordinator Review (contact Albert Shields at 503 - 718 -2426 or albert @tigard - or.gov)
Notes:
Routed back to Building Division Date: / / p
I. \CURPLN