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Permit y CITY OF TIGARD MASTER PERMIT II ":: C OMMUNITY DEVELOPMENT Permit #: MST2011 -00202 1 3125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/20/2011 TiARD Parcel: 2S1146B04300 Jurisdiction: Tigard Site address: 10390 SW SERENA WAY Subdivision: PICK'S LANDING NO.1 Lot: 20 Project: LEHMAN Project Description: Converting attic to bedroom. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 323 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right. 0 Detectors: Yes Total: 323 sf Value: $7,000.00 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 Drains: 0 Tubs /Showers 0 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: 1 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: 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: 1 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: ALT SF VB R -3 323 Owner: Contractor: LEHMAN, GUY P & HEATHER E OWNER Required Items and Reports (Conditions) 10390 SW SERENA WAY TIGARD, OR 97224 PHONE: PHONE: FAX: Total Fees: $830.23 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 -00 roug R 952-001-0090. You obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 , .2232.1987 or 1.800.332.2344. Issued L �C /i`"'�/l' Perm itteeSignature. C .� L / .-C— L!. /4- ( 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 Permit Application ' Residential FOR OFFICE USE O NLY Received ` permit No.: City of Tigard DateB : J �` I. 14 ii rs. ° 13125 SW Hall Blvd., Tigard, ! i. T` %`3 ` PI.. R- • e v,. C ' Phone: 503.718.2439 Fax: '• ° .1 •• I 01. 11 DateB : I _. &l(L I M® Other Permit: T I G A R D Inspection Line: 503.639.4175 t . Date ReadyBy: Juris: ® See Page 2 for Internet. www.tigard -or.gov � OcC P \Cl O 0. Notified/Method: 1,.? it Sup .,yr _ I nfo y•atid TYPE OF V`' * ,C - o\ REQUIRED DATA: 1 - AND 2,FAMILY I WELLING ❑ New construction [� tion Permit fees* are based on the value of the work performed. ' Indicate the value (rounded to the nearest dollar) of all 'I 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 Valuation: $ 7 yZ2 - ( y g ❑ Commercial /industrial i ❑ 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: 4 0'3c:‘ 0 S _ d ere nrA New dwelling area: _ square feet City /State /ZIP: Z Z 4 Garage /carport area: square feet • Suite/bldg. /apt. no.: Project name: '. • ti j � ��, � ��� A � 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: 1 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. t J Valuation: $ T c> k'<1.SQo r Yfl occ 1. ookYI I' n't-( • . ' _ - . �J 5l o Existing building area: square feet New building area: square feet PROPERTY OWNER ❑ TENANT Number of stories: Name: G txylK e -1,e4-- Le_Lr..c-e\ Type of construction: Address: k v 33Gi 0 30..S ►el.c., Loci Occupancy groups: City /State /ZIP:^ i Q(I` 9 ® t' . t R 1 Z Z I{ Existing: Phone: (503) 518' 0 1 a1 Fax: ( ) New: APPLICANT . ❑ CONTACT PERSON BUILDING. PERMIT FEES* (Please refer to fee schedule) Business name: f, Structural plan review fee (or deposit): Contact name: FLS plan review fee (if applicable): Address: City /State /ZIP: Total fees due upon application: Phone: ( ) I F ( ) Amount received: , �So • �® E -mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* • Commercial and residential prescriptive installation of CONTRACTOR roof -top me nted Photo Voltaic Solar Pane1 m. Business name Submit two : sets of roof plan wi nection details and fire departm=-=, access, a with the 2010 Oregon Address: Solar Installation S 0 Code checklist. City /State /ZIP: Permit Fe- elude -: an review $180.00 and administrati - es): Phone: ( ) ( ) Fax: e surcharge (12% of permit fee): ■ $21.60 CCB lie.: Total fee due upon application: $201.60 Authorized signature: This permit application expires if a permit is not obtained f� � within 180 days after it has been accepted as complete. Print name: .-- 6r / 1- [ i 4 Date: ( Z ji./ f 20 (' I * methodology set by Tri- County Building Industry 6 y ` Service Board. I:\ Building \Permits \BUP- RESPermitApp. oc 02/24/2011 440- 4613T(I1 /02 /COM/WEB) Building Permit Application Checklist One- and Two - Family Dwelling FOR OFFICE USE ONLY City of Tigard Received Permit No.: III 13125 SW Hall Blvd., Tigard 97223 , Date/By: ' ; ._ Phone: 503.718.2439 Fax: 503.598.1960 Associated permits: - HOARD Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical Internet: www.tigard- or.gov • ❑ Other: THE FOLLOWING. ITEMS ARE REQUIRED FOR.PLAN REVIEW " . N /A REQUIRED � Yes � No . 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 ❑ Cl ❑ 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 Ion and shall be shown to be ap plicable to the uo'ect under review. JURISDICTIONAL SPECIFICS t 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 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. I: \Building \Permits \BUP- RESPermitApp.doc 02/24/2011 440 4613T(11/02 /COM/WEB) ' Electrical Permit Application FOR OFEICE_usl o1r_Y City of Tigard DateBed PennitNo.: `� Date/By: 13125 SW Hall Blvd., Tigard,0 ?2 Plan Review ' Phone: 503.718.2439 Fax: y t t0 O�� Re Date/By: Received Other Permit: T 1 G A R D Inspection Line: 503.639.417 h ti Date Ready/By: .runs. ® See Page 2 for Internet: www.tigard oo C C O Notified/Method: Supplemental Information TYPE OF WORK O� �G� S PLAN REVIEW ❑ New Construction ,� Addition/alter qi - ,c e sent 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. ❑ Demolition ❑ Other: tA 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 ,.1- 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 ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ", "1 - ", "1 - ", �}} IOOHP or more. occupancy. Job no.: Job site address: ' t, SI r� :5c/1' I ! . joky ❑ Six or more residential units. ❑ Recreational vehicle parks. City /State /ZIP: T \0014 o ❑ Health -care facilities. ❑ Supply voltage for more than \ 22. 0 Hazardous locations. 600 volts nominal. Suite /bldg. /apt. no.: 1 Project name: ❑ Service or feeder 600 amps or more. i G �� fY 3'Y1 FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total I New residential single or multi - family dwelling unit. Includes attached garage. Subdivision: I Lot no.: 1,000 sq. ft. or less 168.54 4 Ea. add'I 500 sq. ft. or portion 33.92 l Tax map /parcel no.: Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) g tl Limited energy, multi - family _ 75.00 2 1 (‘C/Y1‘701' fl.l, .51 Mi I, 4 Rek92fr51 1 /1 007.1/'�'tayr/ residential (with s installati a Services or feeders installation, alteration, and /or relocation 200 amps or less 100.70 2 El PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: W K i- \te /..h /m 601 amps to 1,000 amps 301.04 2 Address: /0 301 0 ,SW 3ei ve. - ijay Over 1,000 amps or volts 552.26 2 .-- , n Temporary services or feeders installation, alteration, and /or City /State /ZIP: , ,• �J0 JX 0(` c1' 1 2_2 LA relocation Phone: (5o3) 5'96, '1 2 o 2 I Fax: ( ) 200 amps or less 59.36 1 201 amps to 400 amps 125.08 2 Owner installation: This installati n is being made on property that I own which is not intended for sale, lease, ent, orra hange, according to ORS 447, 449, 670, and 70 401 amps to 599 amps 168.54 2 Branch circuits— new, alteration, or extension, per panel Owner signature: Date: 1 2- l J 2 ©1 A. Fee for branch circuits with ❑ APPLIC T I ❑ 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 2 Contact name: branch circuit Each add'l branch circuit 7.42 2 Address: Miscellaneous (service or feeder not included) City/State/ZIP: Each manufactured or modular 67.84 2 Y dwelling, service and/or feeder Phone:( ) I Fax::( ) Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 E - mail: Signor outline lighting 67.84 2 CONTRACTOR Signal circuit(s) or limited- energy Business name: 0 l/° t , l �/ panel, alteration, or extension. Page 2 2 I` Each additional inspection over allowable in any of the above Address: 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: ( ) I Fax: ( ) Inspections for which no fee is 90.00 / hr specifically listed (A hr min) CCB Lie.: 1 Electrical Lie.: I Suprv. Lie.: ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: _ $ 70 A Plan review (25% of permit fee): - Print name: { Date: State surcharge (12% of permit fee): 6 (7 7(1 At TOTAL PERMIT FEE: 604 .q A Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: L- 1 z HtilAM Date: 12/(�� / (J * Number of inspections allowed per permit. P \Building\Permits\ELC- PermitApp doc 07/01/10 440-46 15T(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: ❑ Audio and Stereo Systems* ❑ Burglar Alarm ❑ Garage Door Opener* ❑ 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: ❑ 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 ❑ Outdoor Landscape Lighting* ❑ Protective Signaling ❑ 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 FOR OFFICE USE ONLY 1 " of Tigard Received g � DateBy; �� -!., Permit No.: - a I J _ 11.1 i ,_ '. 13125 5 SW Hall Blvd., Tigard, OR 97223 Plan Review Phone: 503.718.2439 Fax: 503.598.196 Date /By. Other Permit: Eill ' Inspection Line: 503.639 Tl G A R D ^O'\1 Date Ready /By: ® See Page 2 for Internet: www.tigard-or.gov (. Notifi 0 See Page Supplemental 2 Information C A TYPE OF WORK o � os V \5 16. COMMERCIAL FEE* SCHEDULE - USE CHECKLIST �\ ,� ` G �� \ Mechanical permit fees* are based on the value of the work ❑ New construction N, Addition /alteration/re� performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit. Value: $ CATEGORY OF CONSTRUCTION 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. I Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning Job site address: (requires site plan showing placement) 46.75 ( b 3 S� Js1tNA-c.A Furnace 100,000 BTU (ducts /vents) 46.75 City /State /ZIP: Tl ci 0.i`C" 0 k • S 7 2. Z tA Furnace 100,000+ BTU (ducts /vents) 54.91 Suite/bldg. /apt. no.: (/ Project name: Q Heat pump �� �� �+ (requires site plan showing placement) 61.06 Cross street/directions to job site: Duct work j 23.32 )-?_ 3) - 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: 23.32 Tax map /parcel no.: Other fuel appliances: DESCRIPTION OF WORK Water heater 23.32 G p Gas fireplace 33.39 1 frm S c® r Im l Skoc d< tl crv-r) 1 A iri 13 er eroO/rl Flue vent for water heater or gas (� fireplace 23.32 Log lighter (gas) 23.32 Wood /pellet stove 33.39 Wood fireplace /insert 23.32 4 PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32 A i Other: 23.32 Name: (.�Gy/ � r l `.21 Le_L .or ry t Environmental exhaust and ventilation: Address: / [ Range hood/other kitchen ©3RC) (L . =>1r re. i*l equipment 33.39 City/State/ZIP: Clothes dryer exhaust 33.39 y � c �.c�Q t�� . �`� ZZ'-� ry Phone: 4 Fax: Single -duct exhaust (bathrooms, hone: (jc 3) 5c-1/40-.01 Z J ( ) toilet compartments, utility rooms) 23.32 a APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32 Business name: C.�� .e Other: 23.32 Fuel piping: Contact name: $14.15 for first four; $4.03 for each additional Address: Furnace, etc. Gas heat pump City /State /ZIP: Wall /suspended/unit heater Phone: ( ) Fax: : ( ) Water heater Fireplace E -mail: Range CONTRACTOR Barbecue Clothes dryer (gas) Business name: ' f^ Vv✓ / Other: Address: MECHANICAL PERMIT FEES* City /State /ZIP: Subtotal Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) 4 1 - 1) ‘ CO Plan review (25% of permit fee) QQ//`` CCB lie.: State surcharge (12% of permit fee) O. 50 ' ' TOTAL PERMIT FEE 16447j Authorized signatu- This permit application expires if a permit is not obtained within 180 'Ir. . days after it has been accepted as complete. Print name: ! ' 0 - 1.454/14# Date: i Z '`{ '2A) I / * Fee methodology set by Tri- County Building Industry Service Board I:\Building\PermitsVMEC -Permi la oc 09/09/10 440 -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. C \Building\Permits\MEC- PermitApp.doc 09/09/10 2 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 701.325 (2)) 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 a II subcontractors who work on the structure must be licensed with the Construction Contractors Board. o r • I will be performing work on property I own, a residence that I reside in, or a residence that I w ill 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 horn eowner statement is true and accurate. Print Name of Permit Applicant jd / Signature of Permit Applicant Date Permit #: HOT' ( - 6. - • 390ewaf-f, ALoft , Address: � �� �,i %„ f t LOCI &D 62_ [ 7ga-e Issued `Date: / /7 This Copy for Permit Offices