Permit CITY OF TIGAR MASTER PERMIT
PERMIT #: MST2003 -00375
I 'I DEVELOPMENT SERVICES DATE ISSUED: 11/10/03
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 11875 SW LYNN ST PARCEL: 2S103BA -00142
SUBDIVISION: LERON HEIGHTS NO. 2 ZONING: R - 4.5
BLOCK: LOT: 032 JURISDICTION: TIG
REMARKS: Addition of 1456sf. (2) story plus modification of existing space.
BUILDING
REISSUE: CUSTOM STORIES: 2 FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT: 21 FIRST: 728 sf BASEMENT: sf LEFT: 5 SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: 728 sf GARAGE: sf FRONT: 20 PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: I THIRD: sf RIGHT: 5
VALUE: 136,526.40
OCCUPANCY GRP: R3 BDRM: 3 BATH: 4 TOTAL: 1,456 sf REAR: 15
PLUMBING
SINKS: WATER CLOSETS: 4 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: • TRAPS:
LAVATORIES: 5 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS:
TUB /SHOWERS: 4 GARBAGE DISP: WATER HEATERS: 1 WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: 4 CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS: 2
MAX INP: btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: GAS OUTLETS: 2
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/F DR: 00 SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EAADDL BR CIR: 5.00 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 8 STEREO: VACUUM SYSTEM: AUDIO 8 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: $ 2,110.45
ALAJM I, ABDULHADI M + MARCIA M ARAVE CONSTRUCTION CO This permit is subject to the regulations contained C o i the
all other Municipal r applicable cal a w
la , State work k w Specialty Codes and
11875 SW LYNN ST 12270 SW SUMMERCREST all other applicable l rov All work will be done i
TIGARD, OR 97223 TIGARD, OR 97223 t
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. ATTENTION:
Oregon law requires you to follow rules adopted by the
Phone: Phone: 503 639 - 7380 Oregon Utility Notification Center. Those rules are set
forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
Reg #: LIC 00202967 may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Erosion Control Insp 84 Underfloor insulation Electrical Rough In Gas Fireplace Plumb Final
Footing Insp Crawl Drain /Backwater Framing lnsp Insulation Insp Building Final
Foundation Insp PLM /Underfloor Shear Wall Insp Rain drain lnsp
Post/Beam Structural Mechanical Insp Exterior Sheathing Ins l Electrical Final
Post/Beam Mechanical Plumb Top Out Gas Line Insp Mechanical Final
Issued By : 4i) . , . _ . .41!. _ .. 1 . l- Permittee Signature : Al .- ' /M • Z -
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the 4 ext business day
Building Permit Application FOR OFFICE USE ONLY
Received Building
Date/B : -, -O a 1 Permit No.: 0610 -u4 3 '� _
Planning Approval Other
City of Tigard `' �D Date/B : Permit No.:
13125 SW Hall Blvd. fer Plan Review Other
Tigard, Oregon 97223 r1 Date/B : AA/ /o - 2I -63 Permit No.:
Phone: 503- 639 -4171 Fax 50g 1 i Qt G " � 4� ypF' ile Post - Review Land Use
11.. Date/B : Case No.
Internet: www.ci.tigard.or.us J a �i c• - Contact NM ® See Page 2 for
24 Inspection Request: 5Q, f7 1 V S 1 0N Name /Method: Su i . lemental Information
• TYPE OF WORK REQUIRED DATA:
• ❑ New construction ❑ Demolition 1 & 2 FAMILY DWELLING
- Addition/alteration /replacement ❑ Other:
CATEGORY OF CONSTRUCTION Note: Permit fees* are based on the total value of the work performed. Indicate
.T I & 2- Family dwelling ❑ Commercial/Industrial the value (rounded to the nearest dollar) of all equipment, materials, labor,
overhead and profit for the work indicated on this application.
- ❑ Accessory Building ❑ Multi- Family - t
❑ Master Builder El Other: Valuation �. 1.4-1 $ / `LS Ooo
J SITE INFORMATION and LOCATION No. of bedrooms ' of baths: 4
Job site address: / / r7 5 Su) L,y v,4 S T- Total number a floors -L
New l dwelling area (sq. ft.) 1 </5 6 I
Suite #: I Bldg. /Apt. #: Garage /carport area (sq. ft.) 0 I
Project Name: /QL4.)Al2- Covered porch area (sq. ft.) O Cross street/Directions to job site: Deck area (sq. ft.) 1 2 0
A_ya a ,7-4 is 2.131.- c ICS w F s T to F O/t c A) r Other structure area (sq. ft.) b
oPF /2/T
REQUIRED DATA:
COMMERCIAL - USE CHECKLIST
Subdivision: LL-7 / "#`si.- I Lot #: 3,P-
Tax map /parcel #;_Z__S/0 3 7c-Q0 / c%— Note: Permit fees* are based on the total value of the work performed. Indicate
DESCRIPTION OF WORK the value (rounded to the nearest dollar) of all equipment, materials, labor,
1� overhead and profit for the work indicated on this application.
/ 2 S7ofz y App cr o /u PLus 4E/no Dc- o f
Son1C Cs � (ST1� WD.tcE Valuation $
Existing building area (sq. ft.)
New building area (sq. ft.)
Number of stories
or PROPERTY OWNER • I ❑ TENANT Type of construction
Name: iftai 9- "1RQoA ,64J -Ar/ Occupancy group(s): Newing:
Address: / / 8 ? s s„ . ,„ ? .5
City /State /Zip: j/ 6>-d_O f 8 k. 9 7223
Phone: Fax: NOTICE: All contractors and subcontractors are required to be
APPLICANT ❑CONTACT PERSON licensed with the Oregon Construction Contractors Board under
provisions of ORS 701 and may be required to be licensed in the
Business Name: /W( Co tes j . Co . jurisdiction where work is being performed. If the applicant is exempt
Contact Name: Spe■t.LLE2 4410e- from licensing, the following reason applies:
Address: /2.2 ?e7 SA) S i
City /State /Zip: e' //f,QR D a r2, ?72 23
Phone: SQL 73 8a ( Fax: S >932 /
BUILDING PERMIT FEES*
E -mail: Please refer to fee schedule.
CONTRACTOR
Business Name: ..9i c 45 „4# c-4,.) / Fees due upon application $
Address: , ;
•
City /State /Zip: Amount received $
Phone: Fax: Date received:
CCB Lic. #: 4 , cQ�9 j 1 & - �fC - o ,
Authorized 2 Notice: This permit application expires if a permit is not obtained within
Si 1 p �/�1��� Date: _ °•3 180 days after it has been accepted as complete.
Sys � -4 RA �/ / •Fee methodology set by Tri- County Building Industry Service Board.
(Please print name)
is \Dsts\Permit Forms\BldgPermitApp.doc 01/03
•
One- and Two - Family Dwelling
:l;� Building Permit Application Checklist Reference no.:
Associated permits:
City of Tigard
City of Tigard U Electrical O Plumbing O Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 U Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW
Yes No `/A
I 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.
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 0 permit required. Include drainage -way protection, silt fence design and location of
catch -basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed
if copyright violations exist.
11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if
there is more than a 4-ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements and
driveway; footprint of structure (including decks); location of wells/septic systems; utility locations; direction indicator, lot
area; building coverage area; percentage of coverage; impervious area; existing structures on site; and surface drainage.
12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent
size and location.
13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater,
furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc.
14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub -floor,
wall construction, roof construction. More than one cross section may be required to clearly portray construction. Show
details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings and foundation, stairs,
fireplace construction, thermal insulation, etc.
15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels.
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full -size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing (prescriptive path) and /or lateral analysis plans. Must indicate details and locations; for
non - prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor /roof framing. Provide plans for all floors/roof assemblies, indicating member sizing, spacing, and bearing
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered
systems, see item 22, "Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists
over 10 feet long and/or any beam/joist carrying a non - uniform load.
20 Manufactured floor /roof truss design details.
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required
for four or more appliances.
22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or
architect licensed in Oregon and shall be shown to be applicable to the project under review.
JURISDICTIONAL SPECIFICS
23 Five (5) 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 & 22 above.
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will be not 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 & location per approved project street tree plan (if applicable), and COT Street Tree List.
Checklist must be completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. . 440-4614 (6n0 /COM)
Ele Permit Application FOR OFFICE USE ONLY
Rece Electrical /n
EC � I s , � .� Date/By: Pet�rtit No.: Y / 7ST�(/D 3 —06 '3 `P.- CI of Ti and R V Planning Approval Sign
City g Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 JUL 22 2 i Date/13y: Permit No.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use
DHai: " fi 'i +� Date/By: Case No.:
Internet: www.ci.tigard.or.us CITY OF TI _� L ll a �) Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503 - LNG E' ° "— — Name/Method: • Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
'El-Addition/alteration/replacement El Other: ❑ Service over 320 amps - rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
o Commercial/Industrial & 2- Family dwelling ❑ Comercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
Accessory Building ❑ Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
. p Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit _ sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: // 575 sc.) L pu ,1/41 FEE* SCHEDULE
Suite #: Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: 4c,10-"-e- Description Qty Fee (ea.) Total 1
New residential - single or multi - family per
Cross street/Directions to job site: dwelling unit. Includes attached garage.
2 P CPC 1< S ca E s 7 C) F L.1 /.iLNK T Service included:
A f / / 1000 sq. ft. or less 145.15 4
O Each additional 500 sq. ft. or portion thereof 33.40 1
Limited energy, residential 75.00 2
Subdivision: I Lot #: Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
Services or feeders - installation,
2 57 /- P Z y / 7 /OA-) alteration or relocation:
oft C X / S 7 eV G-
200 amps to or less 80.30 2
p L-� s 2 � C 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTYOWNER I ❑ TENANT 601 amps to 1000 amps 240.60 2
_ Over 1000 amps or volts 454.65 2
Name: 6 L Reconnect only 66.85 2
Address: / / a" 7 5 S e,J Lp urt) S T Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: T/ 6/12D, D D/z, 97 22 3 200 amps or less 66.85 1
Phone: Fax: 201 amps to 400 amps �.
00?0 2
401 to 600 amps
❑ APPLICANT ❑ CONTACT PERSON Branch circuits - new, alteration, or
Name: ,OLQ 'C= COW S % • Co • extension per panel:
A. Fee for branch circuits with purchase of
Address: /2 2 7 o Sc..J S'c hr a E/�C2E g T service or feeder fee, each branch circuit 6.65 2
City /State /Zip: 776 AR D OA - B. Fee for branch circuits without purchase of
/
service or feeder fee, first branch circuit 46.85 2
Phone: S' 5 7370 I Fax:503 572 3 2 / 7 Each additional branch circuit 5 6.65 2
E -mail: J Misc.(Service or feeder not included):
ONTRACTO /'/J Each pump or irrigation circle 53.40 2
GQ YX., Each sign one lighting 53.40 2
Job No: Signal circuit(s) tss) ) o or a limited energy panel,
Business Name: alteration, or extension Page 2 2
Description:
Address:
City /State /Zip: Each additional inspection over the allowable in any of the above:
Per inspection per hour (min. 1 hour) 62.50
Phone: Fax: Investigation fee:
Lic. #: 3 - a a-� C- other
CCB Lic. #:W Electrical Permit Fees*
Supervising electrician Subtotal $
signature required: Plan Review (25% of Permit Fee) $
Print Name: I Lic. #: N 70S State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forms \ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard •
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Burglar Alarm
❑ Garage Door Opener
• Heating, Ventilation and Air Conditioning System
Vacuum Systems
El Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
a Audio and Stereo Systems
El Boiler Controls
Clock Systems
Data Telecommunication Installation
Fire Alarm Installation
HVAC
El Instrumentation
0 Intercom and Paging Systems
•
0 Landscape Irrigation Control
❑ Medical
Nurse Calls
Outdoor Landscape Lighting
LI Protective Signaling
El Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
i:\Dsts\Permit Forms\ElcPermitAppPg2.doc 01/03
Building r fixtures
Plumbing Permit Application . • R FOR OFFICE USE ONLY
ece Plumbing
R ^ Date/By: Permit No. j CO ?,7"
City of Tigard e l E = Planning Date/By: Approval Sewer
v Permit No.:
13125 SW Hall Blvd. Plan Review Other
Date®y: Permit No.:
Tigard, Oregon 97223 III
Phone: 503- 639 -4171 Fax: 503 - 598- 1960""L i 1 Post - Review Land Use
idl ;h4 7, I.1 ?1� Date/By: Case No.:
-,
Internet: www.ci.tigard.or.us CITY . ^•! :' Contact Juris.: El See Page 2 for
24 - hour Inspection Request: 503 639 - MLD _ 8 1V1S1ON Name/Method: Supplemental Information.
TYPE OF WORK FEE* SCHEDULE (for special information use checklist)
- ❑ New construction ❑ Demolition Description . .1 Qty. I Fee(ea.) I Total
❑ Addition/alteration/replacement ❑ Other: New 1- & 2- family dwellings
CATEGORY OF CONSTRUCTION (includes 100 ft. for each utility connection)
I=1 1 & 2- Family dwelling ❑ Commercial/Industrial SFR(1)bath 249.20
SFR (2) bath ` 350.00
['Accessory Building ❑ Multi - Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Fire sprinkler - sq. ft.: Page 2
Job site address: J/ $7 s- 5 w L f/A S T. Site Utilities
Suite #: I Bldg. /Apt. #: Catch basin/area drain 16.60
Project Name: /j-C4 3'/7 / Drywell/leach line/trench drain 16.60
Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110.00
e Be o ,C s c-J E S T o r c- AA- r Manholes 16.60
OF P / il l S ,. Rain drain connector 16.60
• Sanitary sewer (no. linear ft.) Page 2
Subdivision: I Lot #: Storm sewer (no. linear ft.) Page 2
Tax map /parcel #: Water service (no. linear ft.) Page 2
DESCRIPTION OF WORK Fixture or Item
Absorption valve 16.60
gE n20 v E 1ieFG0 CA7'6 tS47r6Coof S Backflow preventer Page 2
G,) f 7E2 /file >q 7E Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
Et- PROPERTY OWN I ❑ TENANT Ejectors/sump 16.60
Name: q 12 / /A7/f kc / 4 4 c ' f 5 Expansion tank 16.60
Address: //a 7S Spa - M .
"' y 5 7 . Fixture/sewer cap 16.60
City /State /Zip: 7761e 0, Olt. 9 ? 2 23 Floor drain /floor sink/hub 16.60
Garbage disposal 16.60
Phone: Fax: Hose bib 16.60
[-'APPLICANT • - ❑ CONTACT PERSON • Ice maker 16.60
Name: 4 Cb/v S 7. C6 • Interceptor /grease trap 16.60
Address: 122 20 .S c,, .S4 i/ Apt FZ C2 C 57' Medical gas - value: $ Page 2
City /State /Zip: j( 6012 0 On c � 72 2 3 P 16.60
Roof drain (commercial) 16.60
Phone: S 7 » 0 1 Fax: S 7? 3.2/ ? Sink/basin/lavatory 5 16.60
C e l l Ermait 74s1-0535 Tub /shower /shower. pan 44 16.60
CONTRACTOR Urinal 16.60
DD,,,, Water closet 1 16.60
Business Name:
ci Q i, 'p ,aA , 4,_.. LUin(� Water heater ( 16.60
Address: A--/S10 S- A Other:
City /State /Zip: (9 C, /e4 9 7a67 Other: --
Phone: c6 3 ° g' Fax: Plumbing Permit Fees*
CCB Lic. #: j sa 5_ Plumb. Lic. #: 3 - 33aTt3 Subtotal $
Minimum Permit Fee $72.50 $
Authorized Residential Backflow Minimum Fee $36.25
Signature: Date: Plan Review (25% of Permit Fee) $
State Surcharge (8% of Permit Fee) $
(Please print name) TOTAL PERMIT FEE $
Notice: This permit application expires if a permit is not obtained withiN All new commercial buildings require 2 sets of plans with isometric or
180 days after it has been accepted as complete. Q riser diagram for plan review.
" Q� *F methodology set by Tri- County Building Industry Service Board.
i :\Dsts\Permit Forms\PlmPermitApp.doc 01/03 1 1 \ S 0
•
•
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' 55.00 0 to 7000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40 Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item additional $100.00 or fraction thereof, to and
Qty. Fee (ea) Total including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00. -
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
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: 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 *.
Quantity by (Fixture) Work Performed Comments regarding fixture work:
Fixture Type: Replace
New Moved Existing Capped
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"
-4 "
Car Wash Drain *Note: If the fixture work under this permit results in an
Garbage - Domestic P
Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice Mach./Refrig. Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
iADsts\Permit Forms\PlmPermitAppPg2.doc 01/03
Mechanical Permit Application . FOR OFFICE USE ONLY
Received Mechanical
DateBy: Permit No.: � l b jg.003 - 6037'
City of Tigard Planning Approval Building
City g `I ;1 Date/By: Permit No.:
13125 SW Hall Blvd. ���j�' V Plan Review Other
Tigard, Oregon 97223 Date/By. Permit No.:
Phone: 503- 639 -4171 Fax: 503 -59W602 2 I Post - Review Land Use
i?ere�� �i�t � DateBy: Case No.:
Internet: www.ci.tigard.or.us - J ,,. I Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503 -63,� 1)753F Name/Method: _ Supplemental Information.
BUILDING DIVISION
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
. ❑ New construction El Demolition Mechanical permit fees* are based on'the total value of the work
❑ Addition/alteration /replacement ❑ Other: performed. Indicate the value (rounded to the nearest dollar) of all
CATEGORY OF CONSTRUCTION mechanical materials, equipment, labor, overhead and profit.
El 1 & 2- Family dwelling ❑ Commercial/Industrial Value: $ See Page 2 for Fee Schedule
❑ Accessory Building ❑ Multi- Family RESIDENTIAL EQUIPMENT /SYSTEMS FEE* SCHEDULE
Description 1 Qty I Fee(ea.) I Total
- El Master Builder El Other:
Heating/Cooling
JOB SITE INFORMATION and LOCATION Furnace - add -on air conditioning ** 14.00
Job site address: 1/ '7S $w 2-. / u Gas heat pump 14.00
Suite #: I Bldg. /Apt. #: Duct work rp 14.00
Project Name: iqC :Jnt1 Hydronic hot water system 14.00
Cross street/Directions to job site: (orid radiator or hydronic system) 14.00
24.0c K 5 W E s% o P c,) ,t e.iv cc I Unit heaters (fuel, not electric)
OFF /2 / s t (in wall, in -duct, suspended, etc.) 14.00
Flue /vent (for any of above) 10.00
Subdivision: I Lot #: Repair units 12.15
Other Fuel Appliances
Tax map /parcel #: Water heater ( 10.00
DESCRIPTION OF WORK Gas fireplace 2, 10.00
2 s'TO e y 1PP /7 /OoU PL' .S Flue vent (water heater /gas fireplace) 2.. 10.00
KEA-r O a E L o , so .•.-+ E &",>( / s7/....c.) G—
Log lighter (gas) 10.00
Wood/Pellet stove 10.00
SPAct ' = , £cTcti DAZE4 O C't 7E Wood fireplace/insert 10.00
gE 6t s ?e /e S /N $774CL NEAT FAN S Chimney/liner /flue/vent 10.00
(PROPERTY OWNER I ❑ TENANT Other: 10.00
Name: tYPIP l /'l 4Qf /,4 6(i /.1 f Environmental Exhaust & Ventilation
Range hood/other kitchen equipment 10.00
Address: I/ Y 75 S C7 •( 57
Clothes dryer exhaust 10.00
City /State /Zip: 7760:020 e a, g7 2 2 3
Single duct exhaust
Phone: 1 Fax: (bathrooms, toilet compartments, J
-APPLICANT ❑ CONTACT PERSON utility rooms) 7 6.80
Name: 4ktvE c S7• CI e Attic/crawl space fans 10.00
Other: 10.00
Address: /'22 20 Sw See-'7c< C/LE sr- Fuel Piping
City /State /Zip: 1 77.4t24 ®o2 / •722 e3 * *($5.40 for first 4, $1.00 each additional)
Phone: sqo 73,r .0 I Fax: 57? 32/ g Furnace, etc. **
Gas heat pump **
E -mail: Wall/suspended/unit heater **
CONTRACTOR Water heater **
Business Name: - p e Fireplace 2 **
Address: Range **
City /State /Zip: Clothes dryer (gas) **
Phone:So 3 -(4 _04 I Fax: Other: *5
CCB Lic. #: i (011 5 Total:
Authorized Mechanical Permit Fees*
Signature: Date: Subtotal: $
Minimum Permit Fee $72.50 $
Plan Review Fee (25% of Permit Fee) $
(Please print name) State Surcharge (8% of Permit Fee) $
TOTAL PERMIT FEE $
Notice: This permit application expires if a permit is not obtained within *Fee methodology set by Tri - County Building Industry Service Board.
180 days after it has been accepted as complete. * *Site plan required for exterior A/C units.
i:\Dsts\Permit Forms\MecPermitApp.doc 01/03
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial Fee Schedule:
Total Valuation: Permit Fee:
$1.00 to $5,000.00 Minimum fee $72.50
$5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52
for each additional $100.00 or fraction
thereof, to and including $10,000.00.
$10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and
$1.54 for each additional $100.00 or
fraction thereof, to and including
$25,000.00.
$25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and
$1.45 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,001.00 and up $742.00 for the first $50,000.00 and
$1.20 for each additional $100.00 or
fraction thereof.
Assumed Valuations Per Appliance:
Value Total
Description: Qty (Ea) Amount
Furnace to 100,000 BTU, including 955
ducts & vents
Furnace > 100,000 BTU including ducts 1,170
& vents
Floor furnace including vent 955
Suspended heater, wall heater or floor 955
mounted heater
Vent not included in appliance permit 445
Repair units 805
< 3 hp; absorb. unit, 955
to 100k BTU
3 -15 hp; absorb. unit, 1,700
101k to 500k BTU
15 -30 hp; absorb. unit, 501k to 1 mil. 2,310
BTU
30 -50 hp; absorb. unit, 3,400
1 -1.75 mil. BTU
>50 hp; absorb. unit, 5,725
>1.75 mil. BTU
Air handling unit to 10,000 cfm 656
Air handling unit >10,000 cfm 1,170
Non - portable evaporate cooler 656
Vent fan connected to a single duct 446
Vent system not included in appliance 656
permit
Hood served by mechanical exhaust 656
Domestic incinerator 1,170
Commercial or industrial incinerator 4,590
Other unit, including wood stoves, 656
inserts, etc.
Gas piping 1-4 outlets 360
Each additional outlet 63
TOTAL COMMERCIAL $
VALUATION:
is \Dsts\Permit Forms\MecPermitAppPg2.doc 01/03
L
CITY OF TIGARD
13125 S.W. HALL BLVD. • •
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
IVO SKORA PLUMBING
1820 SW WYNWOOD
PORTLAND, OR 97225
o\le
Plumbing Signature Form Ckc G 10
Permit #: MST2003 -00375
Date Issued: 11/10/2003 OFD, vP g‘oN
Parcel: 2S103BA -00142 �� �` NGo
Site Address: 11875 SW LYNN ST 8 .0��
Subdivision: LERON HEIGHTS NO. 2
Block: Lot: 032
Jurisdiction: TIG
Zoning: R-4.5
Remarks: Addition of 1456sf. (2) story plus modification of existing space.
Your company has been indicated as the plumbing contractor for the permit indicated above. In order for
the plumbing permit to be valid, please have the appropriate individual from your company sign below and
return this Plumbing Signature Form prior to the start of the work to the address above, ATTN: Building
Division.
No plumbing inspections will be authorized until this completed form is received
OWNER: PLUMBING CONTRACTOR:
ALAJMI, ABDULHADI M + MARCIA M IVO SKORA PLUMBING
11875 SW LYNN ST 1820 SW WYNWOOD
TIGARD, OR 97223 PORTLAND, OR 97225
Phone #: Phone #: 503 - 644 -7373
Reg #: LIC 104845
PLM 34 -297PB
AN INK SIGNATURE IS REQUIRED ON THIS FORM
X
Signature of A 'horized Plumber
If you have any questions, please call 503.718.2433.
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
BOONES FERRY ELECTRIC INC
PO BOX 628
WILSONVILLE, OR 97070
Electrical Signature Form
Permit #: MST2003 -00375
Date Issued: 11110/03
Parcel: 2S103BA -00142
Site Address: 11875 SW LYNN ST
Subdivision: LERON HEIGHTS NO. 2
Block: Lot: 032
Jurisdiction: TIG
Zoning: R-4.5
Remarks: Addition of 1456sf. (2) story plus modification of existing space.
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:
ALAJMI, ABDULHADI M + MARCIA M BOONES FERRY ELECTRIC INC
11875 SW LYNN ST PO BOX 628
TIGARD, OR 97223 WILSONVILLE, OR 97070
•
Phone #: Phone #: 682 -4936
Reg #: SUP 3170S
LIC 88482
ELE 3 -223C
AN INK SIGNATURE IS REQUIRED ON THIS FORM
X , 2,1/10S
igna wire of Supervi ng Electrician
If you have any questions, please call 503.718.2433.
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST 2 ' VS
INSPECTION DIVISION Business Line: (503) 639 -4171
�f BUP
Received �j Date Requested . 9 4441 0 " � , AM PM BUP
Location l t 0 7 S Suite MEC
Contact Person Ph ( ) PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR (
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam /
Sr Anchors
AWN
Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
EC
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
PAS PART FAIL 111 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
SITE ❑ Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line
ADA ^ n� ,
Approach/Sidewalk Date ! b I N C )8 a Ext
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503 -4175 ?-66 3 - Od 3 75"
INSPECTION DIVISION Business Line: • (5 3) 171
BUP
Received Dat Requested / 2 ' AM PM BUP
Location I t 15 e" ? S � � Suite MEC
Contact Person Ph ( ) PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: 3( SIT
Post & Beam
Shear Anchors n
Ext Sheath/Shear � l ' e
Int Sheath/Shear
Framing
Insulation 1n S J / 'G�.� s� SkiL_G‘.4 s
Drywall Nailing
Firewall
Fire Sprinkler w� Y 1 `` •
Fire Alalarm
1,2 ✓, S
Susp'd Ceiling
Roof CO ° w \ •
Other:
Final
PL PRT FAIL 7 �I l ,DE
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
nal
PART FAIL
AN L
Pos eam
Rough -In
Gas Line
Sm • ke Dampers
0 PART FAIL
" CTRICAL
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: Unable to inspect — no access
Fire Supply Line
ADA / 2 (6
Approach/Sidewalk Date / Inspector ` � L.� Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (50 175 - 0 e03 . OO 3 7S
INSPECTION DIVISION Business Line: (5oci •-4171 lug
BUP
Received Date Requested 1 6 AM PM BUP
Location I I Cr C 1\ Suite MEC
Contact Person Ph ( ) PLM
Contractor Ph ( ) SWR
B D& Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: r , n &r S SIT
Post & Beam V\ 1�
Shear Anchors / j ) ' ■
Ext Sheath/Shear ( v
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Othe •
PART FAIL
• BING
Pbst & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART F
ELECTRICAL i/
Service W‘i
Rough -In T) (N1)
UG/Slab
Low Voltage AS 5
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: ❑ Unable to inspect — no access
Fire Supply Line ] \
ADA
Appro ach/Sidewalk Date (/� 6 y Inspector �/ l 1` Ext
PP
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL