Permit ...., ....,,,
CITY OF TIGARD BUILDING PERMIT
PERMIT #: BUP2003 -00172
� y DEVELOPMENT SERVICES DATE ISSUED: 5/30/03
�.,� Ii 13125 SW Hall Blvd.. Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 43960 PACIFIC HWY PARCEL: 2S103DD -01201
SUBDIVISION: `3 se go ZONING: C -G
BLOCK: / D LOT: JURISDICTION: TIG
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: ALT FIRST: 4,454 sf N: NR S: NR E: W:
TYPE OF USE: COM SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 5N : sf N: N S: N E: N W: N
OCCUPANCY GRP: S3 TOTAL AREA: 4,454 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED:
STOR: 1 HT: ft GARAGE: sf OCCU SEP. RATED: 1HR
BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED
FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET:
DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC:Y
BEDRMS: BATHS: 2 IMP SURFACE: PRO CORR: PARKING:
VALUE: $ 12,550.00
Remarks: TI
Owner: Contractor:
MILLER, PRUDENCE M DICKERHOOF CONST LLC
4220 SW GREENLEAF DRIVE PO BOX 1583
PORTLAND, OR 97221 CORVALLIS, OR 97339
Phone:
Phone: 541 - 760 -8360
Reg #: LIC 151634
FEES REQUIRED INSPECTIONS
Description Date Amount Mechanical Permit Require
[BUILD] Permit Fee 5/30/03 $168.10 Electrical Permit Required
[TAX] 8% State Tax 5/30/03 $13.45 Framing Insp
Gyp Board Insp
[BUPPLN] Pln Rv 5/30/03 $109.27 Appr /sdwlk Insp
[FLS] FLS Pin Rv 5/30/03 $67.24 Final Inspection
Total $358.06
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 than 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 -0100. You may obtain a copy of these rules or direct questions to OUNC by
calling (503) 246 -6699 or 1- 800 - 332 -2344.
Issued By: }: 3/.//l ■ ' //-) _
Permittee ♦ 0 /
Signature: Ak p , j / . �L / ' ` /I _ rlr/
Call 639 -4175 by 7 p.m. for an inspection t • next business day
0 ee $ -• - .!' . , , A : Vi t d r
-- •- - J S I3
J �
Building Permit Application
Datereceived• - , ,v?_, Permit no..OF 3 -00 /
A �� lI'' City of Tigard
Project/appl. no.: Expire date: C.i
City ojTigard Address: 13125 SW Hall Blvd, Tigard OR 97223 �
Phone: (503) 639 Date issued: :e yA Receipt no.: ;S
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: l &2 family: Simple Complex:
• TYPE OF PERMIT
-- f
❑ 1 & 2 family dwelling or accessory NI CommerciaUindustrial ❑ Multi- family ❑ New construction ❑ Demolition
It Addition/alteration /replacement ❑ Tenant improvement ❑ Fire sprinkler /alarm ❑ Other:
JOB SITE INFORMATION
Job address] , ') /3 9,/.2 5°, ev Pa" c / /'G //ply Bldg. no.: Suite no.:
Lot: (i) I Block: /, 7 (Subdivision: I Tax map /tax lot/account no.: E
Project name: I ' /SEE
7
Description and location of work on premises/special condition l: i? /� GA e / 4 e�%' /o p- p 0.71 /D fJ 5 .
hi Sfa 1/ g ,rA.�P. door of 14I �
/M AI work /h sfa l/ - Q e �
'.:, i , :_ -,'' .' OWNER• ;' FOR SPECIAL INFORMATION, USE CHECKLIST -
Name: pi V Q 0 jPrp '&r /P S (Floodplain, septic capacity, solar, etc.)
Mailing address: P Q R ,,, 4 3 1 1& 2 family dwelling:
City: c 4/1//' S S tate: O/ ZIP: 9'733 9 Valuation of work $
Phone;fyl.- 4' / / 94 IFax:75 - 03731E -mail: No. of bedrooms/baths _
Owner's representative: P u, ! �A , ' Di% - e.r.hp Total number of floors
Phone: - 6 Fax: / E - mail: New dwelling area (sq. ft.)
' '-` ?. APPLICANT Garage/carport area (sq. ft.)
Name: �� Covered porch area (sq. ft.)
f . / 4,-5 r
Mailing address: Deck area (sq. ft.)
City: I State: I ZIP: Other structure area (sq. ft.)
Phone: Fax: E -mail: Commerciallindustriallmulti- family:
CONTRACTOR Valuation of work $ /a, 5 OD • / Cenci:, G Existing bldg. area (sq. ft.)
Business name:
� G /\ r oQ New bldg. area (sq. ft.)
Address: f0 8 /,j
Number of stories
City: r a f// S' I State: 0 R ZIP: 77 3 3 p
l Type of construction
Phone:y 760 ,9 Fax: I E -mail:
Occupancy group(s): Existing:
CCB no.: j 5 4 ' Ai New:
City /metro lic. no.: Notice: All contractors and subcontractors are required to be
ARCHITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: ,Ca/ 9 2/9 e 27/ &r 4 ' provisions of ORS 701 and may be required to be licensed in the
Address: Pl 3o X ,5� j jurisdiction where work is being performed. If the applicant is
City: 1 S' State: v21 ZIP: 173 3 f exempt from licensing, the following reason applies:
Contact person: ,C fr •, e Plan no.:
Phone:, / -7 ,-. - Fax: E -mail:
. ENGINEER r -
Name: /Y ,i Contact person: Fees due upon application $
Address: ,i/ ff ar(>h1v/-?J /,(/Q 6"k Date received:
City: (State: (ZIP: Amount received $
Phone: I Fax: I E -mail: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached checklist. All provisions of laws and ordinances governing this 0 Visa 0 MasterCard
work will be complied w' . , whether sp ified . ere' or n . Credit card number: / /
Expires
Authorized signature: _,/ _'., / _ 7 � A v % ' I' :' " 3 Name of cardholder as shown on credit card $
Print name: B it a. P D ili t & p.,4 Cardholder signature Amount
Notice: This permit ap lication expires if a permit is not obtained' ithin 180 days after it has been accepted as mplete. 44o-4613 (6/00/COM)
�, 1 0 C 1 t ai' y i" I(og)��� -zsk,o�o
f%I 61 • 11( p t45 •l
SITE WORK PERMIT CHECK LIST •
Commercial, Multi - Family (R -1 occupancy) and Residential:
Please complete all items below, unless otherwise noted.
Excavation Volume: ,9- cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) � cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to 90% of
maximum density) cu. yds.
Retaining structure? (Check one) ❑ Rock
„ ` ❑ CMU
/4/ ❑ Concrete
❑ Other
*Total new impervious area including all buildings, �/
sidewalks, and paving: ND 12 ,f e sq. ft.
Site Utilities Plumbing Work:
Complete the "TAN" 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 *Parking (including ADA) and
ADA compliance Lighting Plan
# Grading Plan and details if/4 , *Landscaping Plan
// _ g Erosion Control Plan and details i/,t'Soils Report (if required)
Retaining Structures
�
*Does not apply to 1 and 2- family dwellings.
# of Plans
TYPE OF SUBMITTAL Required at
(Includes New, Additions or Alterations) Submittal
Commercial 4
Multi- Family R -1 Occupancy 4
One- & Two - Family Dwelling 4
NOTE: Plan review is dependent upon submittal of a completed application and plans.
After plan review approval, the Plans Examiner will contact the applicant to request
additional sets of plans for distribution purposes (for Contractor, City of Tigard,
Washington County, and Tualatin Valley Fire & Rescue).
is \dsts\forms\sitecheckiist.doc 09/24/01
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST
INSPECTION DIVISION Business Line: (503) 639 -4171 " BUP
•
3 --.10/
-
Received Date Requested ' - AM PM BUP
Location P Suite MEC
Contact Person `3 ? � � Ph ( ) 6 3 — '+i °° PLM
Contractor Ph ( ) 7S'f '"3CQ 3 d SWR
BUILDING Tenant/Owner ELC
Footing
ELC
Foundation
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Ot - ••
PART FAIL
1NG
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole —
Storm Drain
Shower Pan 1'
Other:
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
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
Approach/Sidewalk Date �� Inspector — Ext
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL