Permit CITY OF TIGARD SITE WORK PERMIT
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COMMUNITY DEVELOPMENT Permit #: SIT2011 -00014
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/04/2012
Parcel: 1S136DB00201
Jurisdiction: Tigard
Site address: 11565 SW PACIFIC HWY
Project: Fred Meyer Subdivision: 2000 -025 PARTITION PLAT Lot: 2
Project Description: Site work for expansion and remodel
Contractor: SD DEACON CORPORATION Owner: FRED MEYER INC
901 NE GLISAN ST #100 3800 SE 22ND AVE
PORTLAND, OR 97232 PORTLAND, OR 97202
PHONE: 503 - 297 -8791 PHONE: 503- 232 -8844
FAX: 503 - 297 -8997
FEES
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Description Date Amount
Specifics: Permit Fee - Site Work 04/04/2012 $1,370.67
Plan Review 04/04/2012 $890.94
Type of Use: COM 12% State Surcharge - Building 04 /04/2012 $164.48
Class of Work: ADD Plan Review - Fire Life Safety 04 /04/2012 $548.27
Erosion Control 04 /04/2012 $80.00
Project Valuation: $225;000.00 Erosion Plan Review CWS 04/04/2012 $26.00
Erosion Plan Review COT 04/04/2012 $26.00
Site Specifics:
Excavation Volume: 100 cu. yd.
Fill Volume: 50 cu. yd.
Impervious Surface: sq. ft.
Engineered Fill: Soil Report Required:
Paving: Yes Grading: Yes
Landscaping: Yes Site Prep: Yes
Storn Drains: Yes Retaining Wall:
Fire Underground: No Accessible Parking: Yes
Fence: Yes
Total $3,106.36
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 -001 090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800. 344.
Issued By - ermittee Signature:
Call , 5 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
Site Work op FOR OFFICE I'sl: ONLY
C
City of Tigard ) \ Received
`J g �J O�
Date/B : D i w7�� �a•.�__
II • 13125 SW Hall Blvd., Tigard, OR Plan Review . «F II�II�
Phone: 503.718.2439 Fax: 503.59 960 <S.+ Y'' Date/B . . . i� p..- Other Permit:
Inspection Line: 503.639 O v C Date ReadyReady/By: luris: SI See Page 2 for
TIC e1 K D
Internet: www.tigard O G � � �" Notified/Method: ME= Supplemental Information
TYPE OF WO RIf' � REQUIRED DATA: 1 -AND 2- FAMILY DWELLING
❑ New construction ❑ 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.
❑ 1- and 2- family dwelling ® Commercial /industrial Valuation: 5
❑ 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: 11565 SW Pacific Highway New dwelling area: square feet
City / State/ZIP: Tigard, OR 97223 Garage /carport area: square feet
Suite/bldg. /apt. no.: I Project name: FM#375 Tigard Covered porch area: square feet
Cross street /directions to job site: SW 71" Ave Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL - USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: 1S136DB, Tax Lot 201 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.
Installation of new Storm Water - Quality vault, sewer Grease Interceptor vault, Valuation. $225,000.00
and side sewer connection as condition of Land -Use Decision MMD2011 -00013: Existing building area: 138,806 square feet
New building area: 142,934 square feet
® PROPERTY OWNER I ❑ TENANT Number of stories: I
Name: Fred Meyer Stores Type of construction: V -B
Address: 3800 SE 22 Ave Occupancy groups:
�7'F� s: P
City /State/ZIP: Portland, OR 97202 Existing: M
Phone: (503)232 -8844 Fax: (503)797 -3509 New: M
❑ APPLICANT ® CONTACT PERSON NOTICE
Business name: MulvannyG2 Architecture All contractors and subcontractors are required to be • Contact name: Amy Scheckla -Cox licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 601 SW Second Ave Suite 1200 jurisdiction in which work is being performed. If the
City / State/ZIP: Portland, OR 97202 applicant is exempt from licensing, the following reasons
apply:
Phone: (971) 998 -1443 Fax: : (503) 223 -8381
E -mail: amy.scheckla- cox @mulvannyg2.com
CONTRACTOR • .
Business name: T3 S 0 V^ o a �N BUILDING PERMIT FEES*
,a (Please refer to fee schedule)
Address: ( ( Na 6(1:.ret (151-, 4t-( Ut.)
Structural plan review fee (or deposit):
City /State/ZIP: Po ( e Cr plan review fee (if applicable):
Phone: (go) ) ?..61 — 8 Fax. (S ,,Lq) .- 3 7
CCB lie.: Total fees due upon application:
Amount received:
Authorized signature: � This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: 4(•t.r.•o.rn M. Mr — Q� I Date: 1 Z - / I I • Fee methodology set by Tri -County Building Industry
Service Board.
1:\Building \Permits \SIT - PermitApp.doc 10/01/09 440- 4613T(1I /02 /COM/WEB)
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City of Tigard: . Site Work Permit Checklist
Page 2 - Supplemental Information
• Commercial, Multi- Family and One- and Two - Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way, or wetland, the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below, unless otherwise noted. •
Excavation Volume: 100 cu. yds.
Grading Volume: • .
• (Soils report required for >5,000 cu. yds.) 100 cu. yds.
Fill Volume:
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(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) • 50 cu. yds.
Retaining structure? (Check one) ❑ Rock
❑CMU
❑ Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks, and paving: 0 sq. ft.
Site Utilities Plumbing Work: •
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See "Site Work Permit Application - Plan Submittal Requirements" attached. •
The following must accompany this application: • •
• ® Site Plan with Vicinity Map showing ADA ❑ *Parking (including ADA) and Lighting
compliance Plan •
® Grading Plan and details ❑ *Landscaping Plan
® Erosion Control Plan and details: ❑ Soils Resort (if re •wired)
• Retaining Structures •
*Does not apply to One - and Two - family dwellings.
Plan Submittal: Permit Fee:
TYPE OF SUBMITTAL # of Plans Valuation: Permit Fee: •
(New, Additions or Required at $.00 to $500.00 • $51.09 minimum permit fee
. Alterations) Submittal $500.01 to $2,000.00 $51.09 for the first $500.00 and
$2.69 for each additional $100 or fraction
Commercial 3 • thereof, to and including $2,000.00.
$2,000.01 to $25,000.00 $91.44 for the first $2,000.00 and
Multi - Family R -1 Occupancy 3 $10.76 for each additional $1,000 or
fraction thereof, to and including
$25,000.00.
One- & Two = Family Dwelling 2 $25,000.01 to $50,000.00 $338.92 for the first $25,000.00 and
$8.06 for each additional $1,000.00 or
fraction thereof, to and including
$50,000.00. ,
$50,001.00 to $100,000.00 $540.42 for the first $50,000.00 and
$5.38 for each additional $1,000.00 or
fraction thereof, to and including
• . • $100,000.00. •
$100,000.01 and over $809.42 for the first $100,000.00 and
• $4.49 for each additional $1,000.00 or
• fraction thereof.
L\BuildingWPermits\SIT- PermitApp.doc 03/03/2011 • 2 •
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Site Work Permit Application
Plan Submittal Requirements
T I G A R D Commercial, Multi - Family and One- & Two - Family Dwellings
A site work permit is required for all commercial projects including new buildings, additions,
accessory buildings larger than 120 square feet, modular structures and multi - family R -1
occupancies. A site work permit is required for excavation, fill, grading, paving, retaining walls,
fire hydrants and fire department access on private property for work on individual lots not
covered under the subdivision development.
Note: A separate "plumbing" permit for site utility plumbing work is required for sanitary
sewer, storm sewer and potable water systems on private property. Please see the Site
Utilities - Plumbing Permit Application for plan submittal requirements.
1. SITE PLAN and vicinity map (fully dimensional, drawn to scale) showing the geographic
location labeled with:
A. ® map & tax lot # ® project name ® site address ® suite number
❑ zoning ® applicant name ® applicant phone number
B. North arrow.
C. Scale (architectural or engineering only).
D. Street names.
E. Building pads (drawn to scale) with project location.
. 2. BUILDING PLAN submittal requirement: Two (2) complete sets, Civil only.
All details listed below shall be incorporated into the plans_
A. Site plan showing.
1) Required parking spaces and driveways.
2) A route, accessible to persons with disability, leading from the public way to an
accessible building entrance.
3) Accessible parking spaces and adjacent access aisle connecting with the accessible
route. •
4) Curb ramps along the accessible route, curb, sidewalk and gutter.
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5) Finish grade elevations along the accessible route.
B. Topographic survey plan showing grade elevations crossing the entire site.
C. Overall grading plan.
D. Utilities plan showing.
1) Fire hydrant location and pipe size if on private property.
2) If the building is to be protected with an automatic fire sprinkler system, show
location of the water service vault and the fire department connection (FDC)
within 70 feet of a fire hydrant.
3) Size of underground water service for the sprinkler system.
E. Erosion control plan complying with the requirements of the Clean Water Services
(CWS) agency showing:
1) Silt fence locations.
2) Bio- filter bags /other approved barrier material surrounding catch basins.
I:\Building\Permits \SIT - PermitApp.doc 03/032011 3
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3) Illustrations detailing the correct installation of the silt fencing and catch basin
protection.
4) • Any other measures to ensure compliance with CWS standards.
F. Landscaping plan.
3. ADDITIONAL REQUIREMENTS:
A. Soils (geotechnical) report. A soils report is required for new buildings and additions
to contain the following.
1) The report shall address the potential of soil liquefaction and instability (OSSC
Sec. 1804.2). •
2) Fills to be used to support foundation of buildings (OSSC Sec. 3301.1).
3) Foundation and lateral pressures exceeding 1,500 lb. /sq. ft. (OSSC Sec. 1805).
B. Fire flow and hydrant worksheet.
C. Plan review deposit based upon project valuation. •
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1: \Building\Permits\S1T- PermitApp.doc 03/03/2011 4 •
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Location:
Record Type:
Inspection Type:
Comments:
Inspection Date:
Record ID:
Result:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
11565 SW PACIFIC HWY, TIGARD, OR, 97223
Commercial - Site Work
499 Final inspection
04/11/2013 00:00
SIT2011-00014
PASS - No C of O
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Comments:
Inspection Date:
Record ID:
Result:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
11565 SW PACIFIC HWY, TIGARD, OR, 97223
Commercial - Site Work
499 Final inspection
04/11/2013 00:00
SIT2011-00014
PASS - No C of O
Violation Summary:
Inspector Contractor