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Permit v CITY OF TIGA MASTER PERMIT • ' " 2 COMMUNITY DEVELOPMENT 1 Permit #: MST2012 -00016 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.243' W Date Issued: 03/01 /2012 Parcel: 1 S136CA09500 Jurisdiction: TIGARD Site address: 11031 SW LEGACY OAK WAY Subdivision: WHITE OAK VILLAGE Lot: 16 Project: White Oak Village, Lot 16 Project Description: New SF. 3/2/12, reprinted to correct setback information. BUILDING Floor Areas Required Setbacks Required Stories: 3 Bedrooms: 3 First: 670 sf Basement: 0 sf Left: 3 Parking Spaces: 0 Height: 31.5 Bathrooms: 3 Second: 820 sf Garage: 198 sf Front: 10 Smoke Dwelling Units: 1 Third: 560 sf Right: 8 Detectors: Yes Total: 2050 sf Value: $217,566.32 Rear: 13 PLUMBING Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 1 Urinals: 0 Lavatories: 4 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Storm Sewer: 100 Drains: 0 Tubs /Showers: 3 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Catch Basins: 0 Bckflw Prevntr. 0 Footing Drain: 0 Ice Maker. 1 Hose Bib: 2 Backwater Value: 1 Drywell- Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 5 Clothes Dryers: 1 Natural Gas Heat Pump: N Hoods: 1 Other Units: 0 Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4 Furn > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp SrvclFeeders Branch Circuits 1000 sf or less: 1 0-200 amp: 0 0-200 amp: 0 W/ Svc or Fdr: 0 Ea add! 500 sf: 3 201 -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: Y BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: NEW SF VB R -3 2050 Owner: Contractor: WESTLAND INDUSTRIES WESTLAND INDUSTRIES Required Items and Reports (Conditions) 12670 SW 68TH AVE STE #400 12670 SW 68TH AVE 1 Ersn Cntrl 503 - 681 -4444 TIGARD, OR 97223 TIGARD, OR 97223 PHONE: 503 -572 -0746 PHONE: 503 - 245 -9715 FAX: 503 - 598 -9081 Total Fees: $17,205.27 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. A TIO : regon law requires you to follow the rules adopted by the Oregon Utility Notificati n Center. Those rules are set forth in OAR 952-00 -0010 through 0 R - 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by cal' 03.232.1987 or 1.800.3.2344. Issu4ld Bv: Permittee Signat _ ' r 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. 4 CITY OF TIGARD MASTER PERMIT 111 - ' • COMMUNITY DEVELOPMENT Permit #: MST2012 -00016 T !GARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/01/2012 Parcel: 1 S136CA09500 Jurisdiction: TIGARD Site address: 11031 SW LEGACY OAK WAY Subdivision: WHITE OAK VILLAGE Lot: 16 Project: White Oak Village, Lot 16 Project Description: New SF BUILDING Floor Areas Required Setbacks Required Stories: 3 Bedrooms: 3 First: 670 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 31.5 Bathrooms: 3 Second: 820 sf Garage: 198 sf Front: 20 Smoke Dwelling Units: 1 Third: 560 sf Right: 5 Detectors: Yes Total: 2050 sf Value: $217,566.32 Rear: 15 PLUMBING Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 1 Urinals: 0 Lavatories: 4 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Storm Sewer: 100 Drains: 0 Tubs /Showers: 3 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 1 Hose Bib: 2 Backwater Value: 1 Other Fixtures: 0 Drywell- Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 5 Clothes Dryers: 1 Natural Gas Heat Pump: N Hoods: 1 Other Units: 0 Fum <100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4 Fum > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc!Feeders Branch Circuits 1000 sf or less: 1 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0 Ea add! 500 sf: 3 201 -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 8 Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: Y BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: NEW SF VB R -3 2050 Owner: Contractor: WESTLAND INDUSTRIES WESTLAND INDUSTRIES Required Items and Reports (Conditions) 12670 SW 68TH AVE STE #400 12670 SW 68TH AVE 1 Ersn Cntrl 503 - 681 - 4444 TIGARD, OR 97223 TIGARD, OR 97223 PHONE: 503 -572 -0746 PHONE: 503 245 - 9715 FAX: 503 -598 -9081 Total Fees: $17,205.27 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 . uspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notificati• • Center. • •se es are set forth in OAR 952- 001 -0010 through OAR 952- 001 -0090. Yo •. - • • .'• - • • of the rules or direct questions to OUNC by calling • 1 • • flr0.33..2344. Issued B ' r Permittee Signature: ` Z Call 50 c 7:00 a.m. for the next available Inspects • e. This permit card shall be kept in a conspicuous place on the job site until c .• • etlon of the project. Approved plans are required on the job site at the time of each inspection. Building Permit Application /6 Residential' FOR OFFICE USE ONL1' City of Tigard C�'ID Re�Bed imam il5ra/64? mile 1J Permit No.: • 13 125 SW Hall Blvd., Tigard, OR Plan Revie'w 972 ` s : r ■ Other Permit: r Phone: 503.718.2439 Fax: 503.598F1�0 r 4 Date/By: j ` / () 1 :lJekea? ' p� Inspection Line: 503.639.4175 1 4 20 Date Ready /B . Juris: HI See Page 2 for rlcnl:o p 12 � J— Internet: www.tigard- or.gov C fT V O � T I q Notified/Method: Supplemental Information TYPE OF W [VISION REQUIRED DATA: I- AND 2- FAMILY DWELLING yy �� New construction . ❑ Demolition • Permit fees* are based on the value of the work performed. 1`" 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. Valuation: $ 2-17 rj = . 0 . 1- and 2- family dwelling ❑ Commercial /industrial • . ❑ Accessory building El Multi-family Number of bedrooms: ❑Master builder 0 Other: Number of bathrooms: , r y/ JOB SITE INFORMATION AND LOCATION Total number of floors: 3 i Job site address: no 3 / S/) L cuc v OAtx (/t¢ -y New dwelling area: square feet City/State/ZIP: 7 / kfr 0 /2 17 z 23 Garage/carport area: / ! (: square feet 5 Suite/bldg. /apt: no.: Project name: //f /77 '044 0/, ->; Covered porch area 1 square feet efzo Cross street/directions to job site: Deck area: square feet 0 Other structure area: Z t square feet 3)5. ' REQUIRED DATA: COMMERCIAL, USE CHECKLIST Subdivision: MI /T£ a v /G,...6,--e. Lot no.: / 4 Permit fees* are based on the value of the work performed. J . Taxmap/parcel no.: Indicate the value (rounded to the nearest dollar) of all `5 / 36 eh e( be d' e materials, labor, overhead, and the profit for the J DESCRIPTION OF WORK • work indicated on this application. i 6/L5T2(/Cr //t le SM/6eg- � /tu/' E Valuation $ f Existing building area: square feet New building area: 'square feet L ❑ PROPERTY OWNER ❑ TENANT Number of stories: ti Name: Type of construction: Address: . Occupancy groups: City/ State/ZIP: ' Existing: Phone: ( ) Fax: ( ) New: VA PPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES* Business name: itA57 -A/Q --�� (Please refer to fee schedule) d �N/JUj/ S .1� $ Structural plan review fee (or deposit): Contact name: R06 /9 /JlJ v v — J, , 5104-.06,86C/C7 n FLS plan review fee (if applicable): 'Address: l? 670 5-4/ t f._ 4/ ST er WO City/ State/ZIP: o /��/ Total fees due upon application: /�/ Die- / ?Zy3 • Amount received: 11 Phone: CS ) X 72 —a74' , Fax: (en ) t7 'IIB, PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* E -mail: Jr,hei ao /L. 6044 ego I.-cp CONTRACTOR Commercial and residential prescriptive installation of C roof -top mounted PhotoVoltaic Solar Panel System. . Business name: /rvGsT� .7if4USTe /£S Submit two (2) sets of roof plan with connection details and fire department access, along with the; 2010 Oregon Address: ��6 70 '11... 11;; 6- i tife 57 / f07 Solar Installation Specialty Code checklist. Permit Fee (includes plan review $180.00 City/State/ZIP: / d2 - 9 7 Z3 and administrative fees): Phone: ( - D - 5) 7j30 -D62 I Fax: (5 S'W— 9 State surcharge (12% of permit fee): $21.60 - CCB lie.: 0 0 2 " " __ Total fee due upon application: $201.60 — Ill Authorized signature: •4�� This permit application expires if a permit is not obtained �`' , . within 180 days after it has been accepted as complete. ? 2p / ! Date: /� * F methodology set by Tri-County Building Industry Print name: -�/ + �' ,j) N&e... C t. ; — 1O ` Service Board. - l:\ Building \Permits \BUP- RESPermitApp.doc 02/ 24/2011 440- 4613T(l 1 /02 /COM /WEB) - Electrical Permit Application I:ol 01, -FICl usE ()NIA 111 e City of Tigard Received Permit No.: q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review [ tA�' d � - 0 OQ ��// Phone: 503.718.2439 Fax: 503.598.19 LL Date/By: Other Permit: ��� TIC; TIC;ARD Inspection Line: 503.639.4175 Date Ready/By: luris: ® See Page 2 for Internet: www.tigard - or.gov FFB 1 4 7012 Notified/Method: Supplemental Information • TYPE OF WORK :. .•• •. r ra ' • , . . • •. . Pi414''REyIEW `4!:'..-: ew Construction / 1 • ❑ Please check all that apply (submit 2 sets of plans w /items checked below): .ab A /alteratidrilr r' a a. B 0 1NG 1 VISION ❑ Service or feeder 400 amps or more ❑ Building over three stories. . ❑Demolition ❑ other: where the available fault current ❑ Marinas and boatyards. CATEGORY OF • CO_ NSTRUCTION" • • - • exceeds 10,000 amps at 150 volts or ❑ Floating buildings. • L - and 2 dwelling less to ground, or exceeds 14,000 ❑ Commercial -use agricultural y g ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or J ❑ Emergency system. larger separately derived system. OB SITE INFORMATION AND LOCATION k :. ❑Addition of new motor load of ❑ "A ", "E ", "1 - 2 ", "1 - 3 °, Job no.: • Job site address: //Q1/5016 - c(v O y Six or or more. occupancy. ❑ ❑Six or more residential units. Recreational vehicle parks. City/State/ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: 1 4 4 /rp Obi ge-1-4(, - ❑ Service or feeder 600 amps or more. Cross street/directions to job site: FEE SCHEDULE • J Description I Qty. I Fee. I Total 1 • New residential single- or multi- family dwelling unit. /4 Includes attached garage. Subdivision: //#/- - O4 Y1 1-4 Lot no.: /4 1,000 sq. ft. or less 168.54 l 4 Ea. add'I 500 sq. ft. or portion 33.92 0(.7‘, 1 Tax map /parcel no.: Limited energy, residential • DESCRIPTION OF WORK (with above sq. ft.) 75.00 75 2 6/05772-1107-- ,. / Limited energy, multi - family 2 /V�it) 5F4 ��� residential (with above sq. ft.) 75.00 //! Services or feeders installation, alteration, and/or relocation 200 amps or less 100.70 2 ❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2 "- 401 amps to 600 amps 200.34 2 Name: 601 amps to 1,000 amps 301.04 2 Address: Over 1,000 amps or volts 552.26 2 City/State /ZIP: Temporary services or feeders installation, alteration, and/or relocation Phone: ( ) Fax: ( ) 200 amps or less 59.36 1 201 amps to 400 amps 125.08 2 Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. Branch circuits — new, alteration, or extension, per panel Owner signature: Date: A. Fee for branch circuits with ,APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2 each branch circuit Business name: gSTNl) jil/Ov57" ,_ /1✓ 5 B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact name: 1Z06 ANL)l 0.0 /7-1,K5-7-Ateolz.,A.e._ branch circuit Each add'I branch circuit 7.42 2 / Address: ! d_ 6 10 5a) 60_ ,6, 5(1/re- ( '2 Miscellaneous (service or feeder not included) City/State /ZIP: �� / ©� �`� 3 Each manufactured or modular 67.84 2 dwelling, service and/or feeder Phone: (4 )5'79. _0 7i Fax: : (4 )5 l / Reconnect only • 67.84 2 Pump or irrigation circle 67.84 2 E - mail: Sign or outline lighting 67.84 2 • CONTRACTOR ' Signal circuit(s) or limited -energy • Business name: �� E. erg /�l „ s panel, alteration, or extension. Page 2 _ 2 ^� 'L 't//Ur91/!`f Each additional inspection over allowable in any of the above Address: r 145/S3 5c 0' 3 4, Additional inspection (1 hr min) 66.25/ hr City/State /ZIP: £ 5�Cj•• �/�5 s r e 9 )5f Investigation (1 hr min) 66.25/ hr J'-'! .tic F N `' Industrial plant (1 hr min) 78.18/ hr Phone: G 35 - cg-( Fax: ( 871) /1E5-0. Inspections for which no fee is 90.00 / hr specifically listed (%] hr min) CCB Lic.: 01.2_ Electrical Lic.: —b`fic- Suprv. Lic.: 316-115 ELECTRICAL PERMIT FEES f 1 Subtotal: , Suprv. Electrician signature, required: Plan review (25% of permit fee): Print name: r / Date: d , � 0 /y State surcharge (12% of permit fee): 4- l � 1 TOTAL PERMIT FEE: 3R (f:, A- Authorized signature: This permit application expires if a permit is not obtained within 180 Print name: Date: T days after it has been accepted as complete. �'• (0 • ,2,,,, • Number of inspections allowed per permit. I:\ Building \Permits\ELC- PermiiApp.doc 07/01/10 440-4615T(l1/05 /COM/WEB s Mechanical Permit Application , FOR OFFICE USE ONLY Re ceived Permit No.: City of Tigard , ► �i� . tY g Date/By: I� NNW: .� J a^ t Ill n 13125 SW Hall Blvd., Tigard,OR 97223 Plan Review III . Phone: 503.718.2439 Fax: 503.598.1960 r• t 4 2 012 Date/By: Other Permit: &44.4901.9.-000e-'? T I G A R D Inspection Line: 503.639 Date Ready/By: Juris: El See Page 2 for Internet: www.tigard- or.gov r, OC 'TIGARD Notified/Method: Supplemental Information Bull') " iNG DIVISION • .....COMMERCIAL FEE* SCHEDULE - USE CHECKLIST ' . TYPE OF WORK Mechanical permit fees* are based on the value of the work New construction ❑ Addition / alteration /replacement performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit Value: $ van OF CONSTRUCTION l RESIDENTIAL EQUIPMENT /.SYSTEMS FEES*• d 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist ❑ Multi - family ❑ Master builder ❑ Other: Description I Qty. I Ea. 1 Total ' .. JOB SITE INFORMATION AND LOCATION . ' Heating/cooling: //(3 c a) L Z- f Air plan conditioning Job site address: (requires ires site plan showing placement) 46.75 City/State /ZIP: 17 � O R — Furnace 100,000 BTU (ducts/vents) , 46.75 , I , 7.'2% B (ducts/vents) Furnace 100,000+ BTU (ducts/s/venvents) 54.91 Suite/bldg. /apt. no.: Project name: 6 (/ ✓t f,� � Heat pump `�� // (requires site plan showing placement) 61.06 Cross street/directions to job site: Duct work 23.32 Hydronic hot water system 23.32 Residential boiler (radiator or hydronic) 23.32 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 46.75 �/� / ! Flue /vent for an y of above 23 Subdivision: 6k (OK. th I Lot no.: Ili Other: 23.32 Tax map /parcel no.: / 5 1 (:4 ef SQo Other fuel appliances: DESCRIPTION OF WORK • Water heater 23.32 ? Gas fireplace 33.39 � < _ Flue vent for water heater or gas �� 4 `" ' fireplace 23.32 Log lighter (gas) 23.32 Wood/pellet stove 33.39 Wood fireplace/insert 23.32 ❑ PROPERTY OWNER • I 0. TENANT Chimney/liner /flue /vent 23.32 Other: 23.32 _ Name: Environmental exhaust and ventilation: Address: Range hood/other kitchen equipment 1 33.39 City/State /ZIP: Clothes dryer exhaust - 1 33.39 Single -duct exhaust (bathrooms, I Phone: ( )) r ---,, !� Fax: ( ) toilet compartments, utility rooms) 6 23.32 ( I Ek1 PLICANT ❑ C PERSON Attic/crawlspace fans 23.32 Business dame: , � . Other: 23.32 Contact name: /^� � j��� /' (4 j rr Fuel piping: $14.15 for first four; $4.03 for each additional O Address: i , , f) i( Furnace, etc. I ('k, IS Gas heat pump City/State /ZIP: Mee= eY14 qtzOiy WalVsuspended/unit heater Phone: (1T83) Ds - 6'7(3 I Fax: : ( 4----- Water heater 1 Fireplace E -mail: Range CONTRACTOR . Barbecue ' Business name: S MAJ6r- t in Clothes dryer (gas) Other: Address: MECHANICAL PERMIT FEES" City/State /ZIP: Lt � t/ ' ble 7 /UJ Subtotal , /- Minimum permit fee ($90.00) Phone: (5 )3 S7S 73 Fax: ( q-)— Plan review (25% of permit fee) CCB lic.: / State surcharge (12% of permit fee) 1z f ����� t TOTAL PERMIT FEE 3, , I ( Authorized signature: This permit application expires if a permit is not obtained within 180 J days after it has been accepted as complete. Print name: tc ., l,� I Date: ( 9.. ,4• l y • Fee methodology set by Tri - County Building Industry Service Board I:\ Building \PermitsVMEC- PermitApp.doc 09/09/10 440-4617T(I1 /07/COM/WEB) • Plumbing Permit Application 1 �� Building Fixtures �� Folz OIFlcE usi. ONL Cl of Ti and 2012 Received ell n 131 SW Hall Blvd., Tigard ' OR 97223FE 1 Date/By: / /9-- i Permit No.: e- bre:94/0.'-0046 Ili Plan Review Phone: 503.718.2439 Fax: 503.598.1 96 �iG p,RD Pla Re Other Permit No.: /t A �` 9.- O�„ n d-a I . I It a Inspection Line: 503.639.4175 CO i► b Dlvisl� N Date Ready/By: tuns: ® See Page 2 for Internet: www.tigard or.gov vii,10 � Notified/Method: Supplemental Information TYPE OF WORK FEE* SCHEDULE El New construction ❑ Demolition For special information use checklist Description I Qty. I Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath ( 312.70 nd 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 SFR (3) bath ( 500.32 igt02, ❑ Accessory building ❑ Multi - family Each additional bath/kitchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFQRMATION AND LOCATION Site utilities: Job site address: I 7 / �� Si/ u Catch basin or area drain 18.76 � Q Drywell, leach line, or trench drain 18.76 City/State /ZIP: / . ! / � £9 � g ( g / Footin drain no. linear ft.: ) Pa e 2 Suite/bldg. /apt. no.: Project name: di74-2. Cont IY' ` 1 Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: ) ( Page 2 Storm sewer (no. linear ft.: ) / Page 2 v!r � V I /4 Water service (no. linear ft.: ) Page 2 Subdivision: / Lot no.: Fixture e or item: Tax map /parcel no.: / / 7i, Cl- 69 Backflow preventer 31.27 DES IPTION OF WORK Backwater valve 12.51 /() i C lothes washer / 25.02 6ORSa i "- � Dpi 1'4 . -j �G l Dishwasher f 25.02 Drinking fountain 25.02 Ejectors /sump 25.02 ❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 Name: Fixture /sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: Garbage disposal 1 25.02 City /State /ZIP: Hose bib Y 25.02 Phone: ( ) y Fax: ( ) Ice maker ( 12.51 D4PPLICANT ��, %, /�/"r,C� ��`L ❑ CONTACT PERSON Interceptor /grease trap 25.02 Business name: .� -- /vis Medical gas (value: $ ) Page 2 t / �� � � Primer 12.51 _ Contact name: N-�„ �) _ �� Roof drain (commercial) 12.51 Address: ( X76 ,� 4 7 ' 9 / � Sink/basin/lavatory C 25.02 City /State /ZIP: 17�r1 fh Ot- q72- Solar units (potable water) 62.54 Phone: ( - 7 7 - 6 Fax:: ( rnj � S / Tub /shower /shower pan y 12.51 �� ! ' I `�-. q„ 1) /� 1, .I ' _ _^ � ( [ Urinal 25.02 E -mail: WrJI (� 'pV{ / l� (��' 1 Water closet 25.02 CONTRACTOR Water heater 37.52 Business name: Q Pi-4111,1 - �� i Water piping/DWV 56.29 Address: / j Other: 25.2 City /State /ZIP: U D g7/0/ Subtotal 5Zg3Z Phone: ( ) Fax: ) Minimum permit fee: $72.50 J � � Plan review (25% of permit fee) CCB Lic.: q3)14, % i3 Plumbing Lic. no.: x- State surcharge (12% of permit fee) Ci.). 0- Authorized signature: 7/ 4i TOTAL PERMIT FEE 5 Print name: //��� a! / � pp ( Dater to . V This permit application expires if a permit is not obtained within 180 days t/ r-'« � AI, _ //'' after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. I:\ Building \Permits\PLMII- PemtilApp.doe 10/01/09 440- 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: Permit Fee: Footing drain - 1 100' 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' 37.52 2,001 to 3,600 i $169.69 Sewer - 1st 100' 62.54 3,601 to 7,200 $233.20 7,201 and greater $327.54 Sewer - each additional 100' 37.52 Water Service - 1st 100' / 62.54 Medical Gas Systems: Water Service - each additional 100' 37.52 Storm & Rain Drain - 1st 100' / 62.54 Valuation: Permit Fee: $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to p and including $10,000.00. Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to (minimum charge - 1/2 hour) and including $25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to Reinspection Fees 90.00/hr and including $50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge - 1/2 hour) each additional $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping, adding or replacing fixtures? If "yes ", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees * . Plan Review for Plumbing Installations Quantity by Fixture Type Plan review is required for any of the following. Fixture Type for Replace/ Please check all that apply. Work Performed: Capped Added Relocate Baptistry/Font ❑ Any new commercial building with water service 2" and greater, except systems designed and stamped by licensed Bath: - Tub /Shower -Jacuzzi/Whirlpool engineer. t ❑ New exterior plumbing site utilities for any complex structure Car Wash: -Each Stall tall as defined in OAR918- 780 -0040. Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities. Dishwasher. Commercial ❑ Any multipurpose fire sprinkler system. Domestic ❑ Any complex structure as defined in OAR918 -780 -0040. Drinking Fountain Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: - 2" 3" Isometric or Riser Diagram ❑ Isometric or riser diagram is required for new buildings -Car Wash Drain that meet the qualifications above. Garbage - Domestic non -food Disposal: - Domestic food related - Commercial food related - Industrial food related Ice Mach./Refrig. Drains Comments regarding fixture work: Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower: -Gang -Stall Sink: - Lav/Bar non -food related - Bradley - Com/Serv/Util food related - Service *Note: If the fixture work under this permit results in an Swimming Pool Filter increase of sewer EDUs, a sewer permit will be issued and Washer - Clothes fees assessed for the sewer increase must be paid before the Water Extractor Water Closet - Toilet plumbing permit can be issued. Urinal Other Fixtures: I:\Building\Permits\PLMF- PermitApp.doc 08/04/2011 2 j t. Y 60 C 4 4/C III o Building Division C7c 9-14-40 Development Code Provision Review T I G A R D Residential Projects Building Permit No: 12i0 /2--- X 4 ' CWS Service Provider Letter Received: Yes ❑ No El N /At, 1777^'* r ` J f a :, Routed Plans: i :z4/ / Original Plan Submittal Date: ! / 1st Revision Submittal Date: a o1�f /Y ❑ Site Plan Only . 2 ^d Revision Submittal Date: ❑ Site Plan Only To the Applicant: Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies to the Building Division. Only checked (/) items are approved. Items not approved and those listed in the notes must be revised prior to re- submittal. For questions please contact the appropriate staff person(s) listed above each section. Staff: please check items along left only if approved. Planning Review (contact SUiec at 503 -718 - OZ- s) or S @tigard- or.gov) Land Use Case No. 0 -00010 Name _CV* re O4-r— er Zoning �- [a' Setbacks: Front / b Rear / 3 Side 3 Street Side Garage a) ❑ Maximum Building Height 3.S Actual Building Height 3 -S la Visual Clearance - Er Easements it-C pu(F,'P$6 (. S Par( ❑ Sensitive Lands Type: Notes: Original Plan: Approved Not Approved ❑ Date: a-I is/ IL Revision 1: Approved ❑ Not Approved ❑ Date: Revision 2: Approved ❑ Not Approved ❑ Date: Engineering Review (contact Mike White at 503- 718 -2464 or MikeW @tigard- or.gov) 'd gi Actual Slope: i' Notes: Original Plan: Approved Not Approved ❑ Date: Z I S I Z Revision 1: Approved ❑ Not Approved ❑ Date: Revision 2: Approved ❑ Not Approved ❑ Date: (Review Continues on Page 2) Page 1 of 2 Citty Review (contact Todd Prager at 503 - 718 -2700 or todd @ tigard - or.gov) UjStreet Trees El Protected Trees Notes: Original-Plan: Approved `Ll Not Approved ❑ Date: 2-45 'JO td, Revision 1: Approved ® Not Approved ❑ Date: . a b -pvla Revision 2: Approved ❑ Not Approved ❑ Date: Permit Coordinator Review (contact Albert Shields at 503- 718 -2426 or albert @tigard - or.gov) ❑ Conditions of Approval Prior to Issuance of Building Permit Notes : Original Plan: Date Sent to Applicant: Revision 1: Date Sent to Applicant Revision 2: Date Sent to A..licant Okay to Issue Permit: Yes VI N, ❑ Date Routed to Building: • Page 2 of 2 Building Permit Application /' Residential FOR OFFICE USE ONLY R-i City of Tigard ' - E / , Dale/B ved �®imipm Permit No.: /15r�42 +ate /4) Iii . • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Other PermitAie „ Phone: 503.718.2439 Fax: 503.59$-1g6N 1 1 DateB : T 1 G A RD Inspection Line: 503.639.4175 20 12 Date Ready /By: funs ® : See Page 2 for Internet: www.tigard - or.gov Crry Notified/Method: Supplemental Information ^ r ' R I GA, TYPE OF W O' IC 'VISION REQUIRED DATA: I- AND 2- FAMILY DWELLING • jaNew construction El 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. 0 1- and 2- family dwelling El Commercial /industrial Valuation: $ 3 ❑ Accessory building ❑ Multi- family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: , 'S JOB SITE INFORMATION AND LOCATION Total number of floors: 3 Job site address: / Jo 3 > Sit) L c6-Ac v 0, (/If-/ New dwelling area: . ,2„6.56 square feet City/ State/ZIP: ---/-) 1,.R-A Q,e 17 Z 23 _ Garage/carport area: lei q) square feet Suite/bldg. /apt. no.: Project name: GtJ/7 `O4,4 AMC g Covered porch area: 1 square feet Cross street/directions to job site: Deck area: ..--er square feet Other structure area: square feet REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: `J%{,£ 24 v/ . Lot no.: / to Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all Tax map /parcel no.: ` / 36 tf} Q � bC / S6 ti equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK - work indicated on this application. / t �Vr , s ��, . c� .n/ 14/1i Valuation: $ ! / E _ 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 BUILDING PERMIT FEES* /' / _ (Please refer to fee schedule) // Business name: / 5-7 .4-I j .. ,77,06,-7-4 _s Structural plan review fee (or deposit): Contact name: RCfi 4/./0/44-0,0 — ,.%ii 57/1-4i0,e�,c -- �1 FLS plan review fee (if applicable): Address: 42 670 S G / � t - _ - 4 / 6 S ri-V 7 Total fees due upon application: City/State /ZIP: 776 Q 172,2_3 // Cl'' Amount received: `� Phone: (/ D ) .c7 L. -epee Fax: : (6 ) ?3B. /1 , o /� 4 aD 2 (init./ 1. Cow / _ PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* E -mail: J t js�1,yl 2A-,d' cdM Commercial and residential prescriptive installation of CONTRACTOR roof -top mounted Photo Voltaic Solar Panel System. Business name: w657 - ND N/)> 7 ' /£$' Submit two (2) sets of roof plan with connection details and fire department access, along with the 2010 Oregon Address: 0 26 70 ' ill./E— 6:7— r7 Solar Installation Specialty Code checklist. City/State /ZIP: ' / m v2 / f q 7 23 r j Permit Fee (includes plan review $ 180.00 and administrative fees): Phone: (9 ' ) 7E3e2 --Q6 ZA I Fax: (503 ) cV - 9087 State surcharge (12% of permit fee): $21.60 CCB lic.: 0 3r7 35' ' Total fee due upon application: $201.60 - Authorized signature: � This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: j, t (66) , 4v/ Date: 2 — 9 . — 2 * Fee methodology set by Tri-County Building Industry I Service Board. I:\Building \Permits \BUP- RESPennitApp.doc 02/24/2011 440- 4613T(I I /02 /COM /WEB) RECEIVED FEB 2 4 2012 I CITY OF TIGARD BUILDING DIVISION a • I, 1 OA BITE PLAN NOTE6: l I t Wig I. AU. IMMO GRADNG MAMMAL TO OE IMPORTED TO AN APPROVED DISPOSAL LOCATION. 2. ALL PILL AMA, lo tPIDEPt OMANI FLOORS, 61DEILAUCEL DPINIMISYS, ETC.. TO BE COMPACIED GRANULAR FILL A n� ta.i. ea A wow own or AYATION TO roesovIDO CONCRETE POISING ALL Cf) L1.1 MIMIC NEW STRUCTURE. 4 PROMS comwarr APPROVED SEDIMENT FMC1NG AROUND EXCAVATED AMA 0 PRIOR TO IDCAVATICSI AND CONSTRUL'11014. ..< ....... D. POPOV= COUNTY/CITY APPROVED STABILISED GRAVELED CONISTPUCTICN ENTRANCE HOMES 1■1 PRIOR TO EXCAVATION AM OCNIEMILICTICK Sky1ina Homes S . 6TOCICPLES MAT BE COMMIS (GM PPLCH OR PLASTIC NeSITING BEIMISEN =ISE MAGRatkill Ave. OCTOSEP tl AND AM. 80. 19 9 Lfr , Poltlant CM 97242 2' CAL 503 2351810 t CONTRACIMI ele-CONTRACTORI C I WNW LOCATION OP ALL LITILTTESS mew TO wmastylimptara.cem IDCAVATICIN AND CC1461EUCTIO4. AIWA RAISCireir4Adop AL II M & ecoomir AND toroutorwr SPCOMATION 1446 BEN PROVIDED TO BMW HOMES op PLANTED SEEP gill • AtIP MON INC. SIMMS HMIS AHD MAW NC, SELL NOT OE MC LIAISLE FOR TM I 16. AO:MACY C I P MS IPPORMATION, IT lb Me SOUS RESPONSIBILITY CP Tie CONTRACTOR /01PER TO VONA' ALL NM COPIXTIONS INCLUDING PILL PLACED CFI 6011. .'Z''. -4.1 ,-, .'' - '',.:•• ',,•"' '; ...1.' +".,,..-- ',",,,,.,..' ' ''' ;', , „ . , -■ ..7,) . s '` ts ':: ) ',,, me. S. TOPOGRAPHY ELEVATENS Il e111 CCILLECTED FROM ACRIAL 61111 WRAY. 7 1 __11. NO. ELEVATION 1.8201D. .■ i0 _____ _ SE. IDOSTEEI GRADE ELEVATE:PI _ — e .. s■ . PE. p14. GRADE ELEVATICIN 2' CAL FIE. MIMED FLOC* ELEVATION • PLAN 3040 L 11L di FL PROVIDE A tINFILF1 GRAVEL BASE UNDER ALL DISIVIMAY AREAL '.. 2 ti z 2ID50 8O. PT - 1 lir U _ il, a. PROVIDE A 4' PENtIlr GRAVEL BASE UPICER AU. ISEMBUALK ARIL 4 PATIO IA I? u I LL._:..... 38 PAN m cv k M. PIPE ALL STOW 05.43440! FROM Me 5112.0140 TO A CONTY/CITY DISPOSAL ".•-•.• ( A POINT/CCFNECTION. ZI' , OLEA=ItalE118 4 . - ma& 1.141 i, 193 &a PT. v.:" INPATRMIE .,; FL Med•LPI SLOPE OP OM AND FILLS TO ES 1110 (a) HORIECWAL TO de (I) ' --- - HERTIcAL FOR ISULDIEWL STRUCTURE% PONDATIONS, AND RETAINING BALM GARAGE 7 . .:;,:',1,FIg1 ... '.,.: ,. P.VC. OMR P1.434 , - M D. PR0VIDE AND MANTAN MOH GRACE UM poems MAMIE AWAY MO , 611TUCTURE ON ALL NDM3 UtI14 A SLOPS CP •• MIMI II I id-Co. ;n--0 ' i / FLOM, ISM 00' 13.00' A OM CO IMPEIR1OU6 AREA*: / MOM DAM LS PUE / POE WALE, 198 841. FT. DRIVEWAYS 15' -CY 38'.0 22.0 PLM 48 SQ. Pt tDo•c44 96 80. FT. WALK IOD PATIO 160 90. PT. avERNANcle ere SQ. PT. BUILDING COvERAGE VD TOTAL Go. PT. 11 AREA* LOT INFORMATION: i a • si • LOT AREA, 2,349 ea PT. IMPERvIC416 COvBRAGE, I40 SQ. PT. 13UILDM C.OvE72AGE2 00 E. BUILDING HEIGNTs APPROX----31.-6' • • MIN. BUILDING SETBACKS, 1W MONT, we MAR, 3 81PE8. LOT 16 W14ITE OAK VILLAM 11.3 TIA, GRD C71R. 1. a Oregon Residential Specialty Code R318.2 MOISTURE CONTENT ACKNOWLEDGEMENT FORM I, Be /QAc/ f, $O/lI , am the general contractor or the owner- builder at the following address: Site Address: H 5- z G y D4 h 44,' City: 1761V-1) Permit #: / 57 — � , ; _Oonif Subdivision/Lot #: / / 07 / / �� - /� and /or ��/ Map and Tax Lot #: To conform with the 2008 Oregon Residential Specialty Code (ORSC), Section R318.2 and OAR 918 - 480 -0140, I am notifying the building official that I am aware of the moisture content Requirement of ORSC Section R318.2 and have taken steps to meet this code requirement. [Section R318.2 is provided for reference]. R318.2 Moisture Content: Prior to the installation of interior finishes, the building official shall be notified in writing by the general contractor that all moisture - sensitive wood framing members used in construction have a moisture content of not more than 19 percent by dry weight of dry framing members. Signature: „if ll Date: — 0 2 .e G .P r a I Contractor or Owner - Builder I: \Building\Form\RES- MoistureSensitiveWood.doc 09/25/08 Oregon Residential Specialty Code N1107.2 HIGH - EFFICIENCY INTERIOR LIGHTING SYSTEMS Permit No.: / i6 D0.0/ Jurisdiction: / may � 44 Site Address: /763/ b Subdivision/Lot #: A / Q � GLr � h and /or /'� Map and Tax Lot #: By my signature below, I certify that a minimum of fifty (50) percent of the permanently installed lighting fixtures in the above mentioned building have been installed with compact or linear fluorescent, or a lighting source that has a minimum efficacy of 40 lumens per input watt. (Oregon Residential Specialty Code N1107.2) 44 Signature: Er ‘ - 12 O r /General Contractor /Authorized Agent Print Name: 46 / DM 2 O c) ORSC Section N1107.2. High - efficiency interior lighting systems. A minimum of fifty (50) percent o the permanently installed lighting fixtures shall be installed with compact or linear fluorescent, or a lighting source that has a minimum efficacy of 40 lumens per input watt. Screw -in compact fluorescent lamps comply with this requirement. The building official shall be notified in writing at the final inspection that a minimum of fifty percent of the permanently installed lighting fixtures are compact or linear fluorescent, or a minimum efficacy of 40 lumens per input watt. I:\ Building\ Forms \RES- HighEfficiencyLighting.doc 07/01/08 STREET TREE TIGARD CERTIFICATION I, /?)\6 4,ildf5o,ti , owner/ agent for 5r 4 �6 (PLEASE PRINT) (PERMIT HOLDER) do hereby certify that the following location meets City of Tigard land use and development standards for street tree installation and is consistent with the approved site plan. PERMIT NO.: R5T;01 - OOO /6 SITE ADDRESS: // 3/ 5 Z 4Cy Q,Q,_ 4 'y SUBDIVISION: I j ` ,� LOT #: l6 SIGNATURE: / � DA'1 E: 6 - 0 26 - 6 (OWNER/AGENT) RE CEIVED VERIFIED BY - DATE: �CTTY OF TIGARD) ❑ Tree location verified per approved site plan. I:\ Building \ Forms \ ScreetTreeCertificate 04/01/2011 Program Use Only \/% Form 640S FastTrack ID Completion Certification —Site Inspection EnergyTrust New Homes Program —Single Family Data check by of Oregon (initials) To be completed by verifier Portland Energy Conservation, Inc. (PECI) Is a Program Management Contractor for Energy Trust of Oregon. First Ins/section Second Inspection Date: if L1l Z 1 Verifier Name: P,Li j Date: I Verifier Name: Incentive Payee Company Name: 5,q /tt/-- Builder orCom p�STi.,AvuQ ot,s(ZltS Contact Name: Performance Testing Company: Technician Name: Site Information Development Lot Number. REM /Rate SCO Project ID: Name: l I _ File #: (required from verifier it � '�8 ICJ project is ENERGY STAR') Site Address: ) ) o 5 L 5 It b AL � e rkt f City: 1 , � State OR I Zip: ❑ Unattached ❑ Attached Number f Stones: Total Building Square Footage: Number of Bedrooms L3 Basement ❑ None ❑ Full Basement 0 Half Basement Crawlspace Type ❑ Garage/basement combo ❑ Slab on grade Other Electric Provider ( 'f PGE ❑ PAC ❑ Other: Gas Provider ,NWN Q CNG ❑ Other: Electric Meter Number: Gas Meter Number: t J (must apply to permanent meter) �!C �—�l Z3 � - (must apply to permanent meter) ¢Q5e 1 7 Additional Project Information (please mark all that apply) ❑ Code plus Best Practices (meets minimum Best Practice requirements with improvements above code) ❑ Path 1 EPS Best Practices Path 2 ENERGY STAR ❑ Envelope Upgrade ❑ Ducts & HVAC Equipment Inside .Equipment Upgrade ❑ Path 3 ENERGY STAR with ducts inside ❑ Path 4 Performance Plus with ducts inside ❑ Path 5 Advanced Performance ❑ Zonal Electric Efficient ❑ Advanced Electric Resistance ❑ Solar Electric (PV) 0 Solar Water Heating (SWH) ❑ Small Wind Renewable El Solar Ready Electric (SRPV) ❑ Solar Ready Water Heating (SRWH) Energy ❑ Qualifies for Solar Ready Incentive (must attach checklist) Solar Installer: Name: Company: Low Income ❑ Yes ElPiTO Does this project qualify as Low Income? (must provide documentation from builder) Accessory ❑ Yes [ 'lo Is this home an ADU? Dwelling Unit ❑ Yes Ly•Io Is the ADU separately metered? If so, provide meter numbers above Other ❑ Earth Advantage — Certification Level: Certifications ❑ LEED -H - Certification Level: 0 Other (please specify): Form 640S v10 120101 Page 1 of 3 Return completed form to: Energy Trust New Homes Program— Single Family 100 SW Main Street, 81600 • Portland, Oregon 97204 1.877.283.0698 • Fax 1.855.575.4315 newhomes ©e nergytrust.org • Ali Form 640S .ei Completion Certification —Site inspection EnergyTrust New Homes Program — Single Family of Oregon To be completed by verifier Portland Energy Conservation, Inc. (PECIJ is a Program Management Contractor for Energy Trust of Oregon. Verifloatlon Type Actual Value Equipment Details & Notes Category Insulation _ Flat Ceiling R- /� Insulation Type: Framing Type: Vaulted Ceiling R- u" 1 l Insulation Type: ❑ Standard Scissor Truss R- Insulation Type: ❑ Intermediate Above Grade Walls R- �y Insulation T ❑ Advanced - 7 Type: Framing Below Grade Walls R- Insulation Type: Size: • Floor Over Unheated Space R- Insulation Type: Floor Over Garage R- / Insulation Type: Slab Floor (unheated) R- ❑ Full Slab ❑ Perimeter Doors Door R- Windows Windows U- SHGC: !/ Window Frame Material: , f )4 �/� Skylights U- r SHGC: Window Area (Glazing) % Total window area: Lighting Indoor and Outdoor % # fixtures: # of ENERGY STAR fixtures or CFLs: Appliances ENERGY STAR Dishwasher »Yes ❑ No EF i * t Cooling Air Conditioning SEER: Btu/Hr: Primary Heat ❑ Fireplace AFUE: G`�' Brand: F'� 4.. 7 Source $ _ ,lDt►W Tao) I► Outdoor Unit for heat Boiler nace HSPF: Model #: ' bcQA ( (l Pumps) ❑ Electric Boiler +t A. Model #: ❑Gas Heat Pumps: SEER: Serial*: t jL 41 (56 EA 3 ❑ Other: Serial #: ❑ Air Source (ducted) COP: Btu /Hr. ❑ Mini Split (ductless) 6o /.. ❑ Ground Source - Location: ECM: ❑ Yes o Heat ❑ Radiant Floor Heat pump commissioning ❑ Cadets `��. < Electronic Air Cleaner: ❑ Yes I�(No report attached or �, co for ground ❑ Zonal {I� Backup fuel: ❑ Electric�Gas ❑ Other source heat pumps that ❑ Other: manufacturer's start up B ocedure was performed Additional notes on primary heating: Notes on secondary heating: Water Heater ❑ ,,,..._��//// Storage Gallons: Brand: �; 1J Electric yTankless EF: V i S20. Model #:. tr[..Z Location Serial #: i A — 04 -7 //7Q tl � t `G� Btu/Hr. 7Q � fdC7 [" ((J 3 •C�� Form 640S v10 120101 Page 2 of 3 Return completed form to: Energy Trust New Homes Program — Single Family 100 SW Main Street, #1600 • Portland, Oregon 97204 1.877.283.0698 • Fax 1.855.575.4315 newhomeseenergytrust.org i I \f, Form 640S Completion Certification --Site Inspection Energy Trust New Homes Program — Single Family of Oregon To be completed by verifier Portland Energy Conservation, Inc. (PECI) is a Program Management Contractor for Energy Trust of Oregon. Verification Type Actual Value Equipment Details & Notes Category Ventilation Energy Trust Mechanical ❑ Exhaust Meets Energy Trust Mechanical Ventilation Requirements System Ventilation Requirement ❑ Supply 1s ❑ No LI a -612-- Hest Recovery �� ERV /HRV Model it Ducts ❑ Ducts Inside % ducts inside: 9 % eior +f C 5,6 606940-C, Ducts in Conditioned Space If claiming incentives for ducts inside, check one of the following: ❑ Ducts Tested ❑ Visual Inspection per RTF specs Duct Insulation R- Duct Location ( 64, -'„0t,. Duct Sealing w /Mastic Paste Yes ❑ No Performance Testing & Duct System Information Ducts Duct leakage must not exceed 0.06 CFM i 50 x floor area, or 75 CFM@50, whichever is greater. When tested without the air handler, leakage must not exceed 0.04 CFM @50 x floor area, or 50 CFM ©50, whichever is greater. Multiple tests may be required. Duct Cubic Feet Per Minute Duct Leakage Air Handler In �I Yes Air Handler Present ;Yes 1 Leakage: (CFM) r' 50Pa: ' Pass ❑ Fail Conditioned Space El During During Test ❑ No Fan Pressure ❑ DG3 Fan Ring Type ❑ 0 1 Leakage Test la o al Leakage Gauge 9-D0700 Pressure: 3 7 (check one) ❑ 1 ❑ 3 Method ❑ Leakage to Outside Duct Blaster -14 Tap Location: (,,_- Location: gPir i CL)R Z t��Z �r7t r d) Area Tested: Gf - Whole House Air Changes per Hour E velope Tightness Cubic Feet Per Minute Leakage: (ACH) @ 50Pa: 2r$ Pass ❑ Fail (CFM) eb 50Pa: House Volume: 1 Best Practices Requirements (All requirements must be met to receive au Energy Perform wrce Score) l • Thermal Enclosure Checklist Complete 1 Pass ❑ Fail Thermal Enclosure Checklist attached? G' Yes • Insulation Quality Inspection Performed ,mo les ❑ No - (complete insulation verification section below) • Approved Mechanical Ventilation Installed lid^res ❑ No --> (complete mechanical ventilation section below) • Zonal Pressure Relief - All zones comply L! es ❑ No If no, state reason for failure: ▪ Combustion Appliance Zone Testing Net CAZ Pressure: Pa If not applicable, please explain: (required) Forced air system operation must not depressurize Combustion Appliance Zone (CAZ) by mote than 3 Pascals (Pa.) *All shaded sections are required for Best Practices. Applications will not be processed without these sections completed. Technical Compliance Options (please list all that apply) • • If any values on this form do not meet Builder Option Package (BOP) requirements, please indicate which Technical Compliance Option(s) allow the variance and explain which component was traded. TCO #: Explanation: Additional Notes: Signature • By my signature below, I certify that I have performed the tests as described, that the form is complete, and that all information on the form is accu e. Verifier „�% i” Verifier Signature: • Ot." Name: f 1 / 1010 -' ct`'e.__ Date: 6 / 3 .7, z ___ Red.Tag_Inspection (If needed): Signature: Name: Date: Form 640S v10 120101 Page 3 of 3 Return completed form to: Energy Trust New Homes Program — Single Family 100 SW Main Street, #1600 • Portland, Oregon 97204 1.877.283.0698 • Fax 1.855.575.4315 newhom es©ene rgyt rust. org