Permit -R . /
CITY TIGARD BUILDING PERMIT
�L PERMIT #: BUP2003 -00704
DEVELOPMENT SERVICES DATE ISSUED: 12/31/03
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 PARCEL: 1S135BD -01200
SITE ADDRESS: 09802 SW SHADY LN
SUBDIVISION: ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: ALT FIRST: sf N: S: E: W:
TYPE OF USE: COM SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 5N : sf N: S: E: W:
OCCUPANCY GRP: B TOTAL AREA: 0 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: 29 BASEMENT: sf AREA SEP. RATED:
STOR: HT: ft GARAGE: sf OCCU SEP. RATED:
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:
BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING:
VALUE: $ 45,000.00
Remarks: TI: new restaurant in existing tenant space.
Owner: Contractor:
FORBES, DONALD CAROLYN SSB, INC.
BURDICK, DONALD LINDA 20492 SW CRESTMONT PL.
434 RIDGEWAY RD SHERWOOD, OR 97140
LAKE OSWEGO, OR 97034
Phone:
Phone: 503 - 625 -1355
Reg #: LIC 157844
FEES REQUIRED INSPECTIONS
Description Date Amount Mechanical Permit Require
[BUILD] Permit Fee 12/31/03 $433.30 Electrical Permit Required
[TAX] 8% State Surchart 12/31/03 $34.66 Fl Permit Required
Framing Insp
[BUPPLN] Pln Rv 12/31/03 $281.65 Gyp Board Insp
[FLS] FLS Pln RN/ 12/31/03 $173.32 Susp Ceilng Insp
Total Final Inspection
$922.93
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: ig�j
Pe rm ittee a Signature: X \`
Call 639 -4175 by 7 p.m. for an inspection the next business day
'ilding FOR OFFICE USE ONLY
Bu Permit Application Received Building /��, /
Date /By: Permit No.t*(po2� 3- 007 Di
/ � CIt of Tiaand Planning Approval Other VY fF
y Tigard
Dale /By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503-639-4171 Fax: 503-598-1960 / A
: Post - Review Land Use
�����r Ill
Date Case No.
Internet: www.ci.tigard.or.us s'-'i r ' ' y
Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name /Method: Supplemental Information
• TYPE OF WORK REQUIRED DATA:
El New construction ❑ Demolition I & 2 FAMILY DWELLING •
El Addition /alteration/replacement ❑ Other:
CATEGORY OF CONSTRUCTION Note: Permit fees* are based on the total value of the work performed. Indicate
El 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
El Master Builder ❑ Other: valuation $
JOB SITE INFORMATION and LOCATION No. of bedrooms: No. of baths:
Job site address: Te Z SW " Total number of floors
New dwelling area (sq. f
Suite #: I Bldg. /Apt. #: Garage /carport area (sq. ft. ft.)
Project Name: / h /. [D .. St/R- Covered porch area (sq. ft.)
Cross street/Directions to job site: Deck area (sq. ft.)
Other structure area (sq. ft.)
REQUIRED DATA: •
COMMERCIAL - USE CHECKLIST
Subdivision: I Lot #:
Tax map /parcel #: 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 a �nl �2i Ji ?no' Ly r -- overhead and profit for the work indicated on this application.
'` VG Valuation S S - D0 0
Existing building area (sq. ft.) / *Z1
New building area (sq. ft.)
Number of stories
❑ PROPERTY OWNER' • I X TENANT Type of construction
Name: ACV 1 �
D o) L� e - Q „ ^ / 61 , 5 O ccupanc y group(s): Existing: A55a(mtp I/Al
New:
Address: 7...-0 L S w u or/7 PC_
City /State /Zip: S oh 3//4u) a0 0 O rt- 17/la
Phone: 3 (p) - ,3 j S 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: jurisdiction where work is being performed. If the applicant is exempt
Contact Name: from licensing, the following reason applies:
Address:
City /State /Zip: •
Phone: Fax:
•
E -mail:
BUILDING PERMIT FEES* '
CONTRACTOR - .. Please refer to fee schedule. 2
Business Name: SS3 / ft : Fees due upon application S 9aa •' 3
Address: 2,0 iti 2.— Sc,.) 0. s77 J1,1 jam_
City /State /Zip: .S i2-G0 I) OE 9 tiv Amount received $
Phone: a 3 !o ZS -,1» / Fax: Date received:
CCB Lic. #: -
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: L / e `��� 180 days after it has been accepted as complete.
AV / v ` - A-74 ) lam_ *Fee methodology set by Tri -County Building industry Service Board.
(Please print name) �co
is \Dsts\Perrnit Forms\BldgPermitApp.doc 01/03 40 �� ✓ ` 1 �°L ' - `/ '" , e--t-e S 5
r
Plan Submittal Requirement Matrix
•� �l Commercial & Multi- Family
City of Tigard New, Additions or Alterations
TYPE OF SUBMITTAL # of Plans
(Includes New, Additions or Alterations) Required at .
Submittal
Site Work 4
(must include location of all accessible parking)
Plumbing - Site Utilities 2
Building 1*
Fire Protection System 3 **
Mechanical 2
Plumbing - Building Fixtures 2
•
•
Electrical 2
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).
*For over - the - counter commercial tenant improvements, submit 2 sets of plans.
** "New" fire protection systems require that plans bear the original seal of an.
Oregon licensed fire suppression engineer, or NICET level "3" technicians.
•
i:\ Building \Forms \PlanSubMatrix.doc 04/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line (503) 63 -4175
INSPECTION DIVISION Business Line: (503) 171 MST d0-00209°
Received Date Re e•ted _ I AM PM BUP
Location y — , vQ Suite MEC
Contact Person Ph ( ) PLM
Contr } Ph ( ) SWR
UILDI Tenant/Owner ELC
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
• 1
PART FAIL
:ING
Post & Beam
Under Slab
Rough -In l\ / -
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
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 E] Please call for reinspection R • El Unable to inspect - no access
Fire Supply Line
ADA
\
Approach/Sidewalk Date Inspector
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL
CITY OF TIGARD 24 -Hour
bUILI5NG Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 M T ,
gpt■ 3 ---oo 76 4/
Received Date Requested 3 �/ c-" AM PM BUP I "
Location AP • 0 2_ i � ' / - - ... Suite MEC 0 �� 7
Contact Person /g--e )-e__- Ph ( ) PLM
Contractor Ph ( SWR
BUILDING Tenant/Owner /v y ELC
Footing /
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing / /n�
Drywall Nailing 1 . / i �1„t i / 1 / ' ' .t , , % f I /# 4
Dryll Nailing p I /,, /r / -
Fire
PM/ I "1 ` 1 � T al,( (
(�/ jsfhW �1 ALe
Fire Sprinkler /' V //
Fire Alarm P ��� / t (∎ it� // (9 � til?
Susp'd Ceiling J' 1' %
Roof
Ot er: + l'ililrje/7'S j p', Ina %laa f / / fA /iG[ Wi
ASS PART
PLUMBING
Post & Beam �����/ , ��'� j�
Under Slab AWAY/ `7 2 L.f.i� 6 d , /
•
Rough -In _ r , _ /1 - _�I� - - , %,
Water Service �wr� I.UT�- "
Sanitary Sewer 1
Rain Drains
Catch Basin / Manhole "I /' / Ge) f j � �_/ � r
Storm Drain J j /' ` �� `� /
Shower Pan
Other:
Final Ma S S ui-)3 ` LU oi[G pb_ _ p S --
PASS PART FAIL /
MECHANICAL /
Post & Beam /
Rough -In ��k
Gas Line \ XV
t) S e Dampers
PART FAIL 6
TRICAL
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: Li Unable to inspect — no access
Fire Supply Line
ADA / ` r ,
Approach/Sidewalk Date D ' Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL
, Z7 4 r *
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1 A/ 4 ANEW
❑ EXISTING
BACKFLOW ASSEMBLY TEST REPORT 0 REMOVED
PROPERTY :7 RFPLACEMENT
OWNER: /lit i ti+' r- A 2::o,,,,, PHONE
MAILING , lAdt
ADDRESS: = - '' NA i / L '.
CITY t^'', •C +% STATE c ZIP 2i' 1 l
ASSEMBLY
ADDRESS:
STREET
7 R.P.B.A. [Ti D.C.V.A. ❑ R.P.D.A. D.C.D.A. ❑ P.V.B.A. ❑ S.V.B.A. C7 A.V.B. C] AIR GAP
SIZE: w = MAKE: " MODEL: 7-5 - i
WATER SERIAL
PURVEYOR: 7./ c A' arc IP NUMBER: ? ''J 1
ASSEMBLY
LOCATION: (J'' .0.tc r'i o' .) ,f" / 4C b
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST
#1 CHECK DOUBLE CHECK AIR CHECK PASSI:D,e 1 •
INITIAL PRESS DROP_., (A)1 CHECK 1 INLET FAILED 0 1 ,
RECITE VAL.VI (I3)1 TIGHT OPENED AT: PRESS DROP
TEST oPE.NED AT ` " Mry� D 1
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RESULTS I LEAKED 0 PRO llA / �,e
BUFFER ■ PS[D 1'SIO 3 / "
-- . / x
A - B = MIN 3 Psi i CHECK #2
DID NOT FAILED
RELIEF VAT. : :TIGHT SYSTEM
OPEN ❑ ❑ PSI
PASS . FAIL ❑ LEAKED ❑ . ID
-
COMMENTS
REPAIRS
AND /OR
PARTS
i
REMIT PRESSURE ASSEMBLY P.V.B.A. /S.V.B.A. AFTER REPAIRS
#1 CHECK P D.C.V.A
PRESS DROIg�. f A)i OPE EI) AT PRESS DROP DATE:
TEST RELIEF CHECK in
AFTER OPENED (B) TIGHT ❑ Psrn / /
BUM P(iN z Psis r CHECK #2
REPAIRS
A °E - MIN 3 PSI I non o —Air sin PsID PASSED ❑
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TIMER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAIN[!) IN ACCORDANCE WITH ALL APPLICABLE j
RULES AND RE ULIS AT OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRATION DATE Il 5 /s/ DETECTOR ME READING
"4,--i — 3' 2' fir'
TE.STIiH SIGNATURE CERT #
TES71B$ NAME PRINTED 16120 SW 72P D. PORTLAND. 97.24 (503) GAUGE it
603 -9988
:::: PHONE # '
WA CR METRICS CO. WEST wWW.WAT1:RMETRICS.COM
/ .�
. --.1 - --� SERVICE RESTORED 7
REPORT RECEIVED BY: (. i (REPRESENTATIVE OF OWNER)
WHITE - WATER SYSTEM COPY PINK - CUSTOMER COPY YELLOW - TESTER COPY
................... ....._...... _
WatorMetrIcsWest .
zfZ 00693 -B
,..ZNEW
Li EXISTING
BACKFLOW ASSEMBLY TEST REPORT 7 1 REMOVED
PROPERTY 1 , -- , 1 REPLACEMENT
OWNER: i'VZ' Jew' .14 0<X ...1,7 f.",::' _, PHONE
MAILING — r ,
ADDRESS: , - A r 5, 2. —; k " ) - 404 /
CITY re'4 ov 0 STATE ( -2 , ( ZIP
ASSEMBLY
ADDRESS:
STREET
7 R.P.B.A. Li D.C.V.A. 0 R.P.D.A. 0 D.C.D.A. n P.V.B.A. El S.V.B.A. ri A.V.B. Li AIR GAP
t--- 1 A r r 5
SIZE: — -.) MAKE: MODEL: '; ),
WATER SERIAL
PURVEYOR: i (,.,. NUMBER: 2 2 .- ` 1 / 1
ASSEMBLY
LOCATION: 0 r's.? "4" t /'4C Iii"oet
......gam.
REDUCED PRESSURE ASSEMBLY PN.B.A. / SN.B.A. INITIAL TEST
#1 [NECK 7 4 , 1 DOUBLE CHECK AIR CHECK PASSEDAfr
INITIAL PRESS DROP ' (A) CHECK , E551 INLET FAILED 0
TE OPINED 00 TIGHT ED RELIIT VALVE e OPEN AT: PRESS DROP
AT ..
M N 2 DATE:
RESULTS ,,, , LEAKED El — RED
BUFFER
A - B - -> - 4 psiu
MIN 3 PSI CHECK #2
DID NUT FAILED
RELIEF N;11 Tim Of SYSTEM
OPEN 0 0
PASS FAIL 0 , LEAKED El ----" PSI - -
COMMENTS
mi l
REPAIRS
AND/OR
PARTS
ROOM PRESSURE ASSEMBLY P.V.B,A./S.V.B.A. AFTER REPAIRS
#1 CHECK D.C.V.A
PRESS DROP (A)
CHECK #1 OPENED AT PRESS DROP DATE:
TEST Rau
AFTER OPENED _ on TIGHT 0 M ' / /
MIN 2 kW
REPAIRS BUFFER CHECK #2
A-13- MN 3 PSI TIGHT 0 MD PSIO psib PASSED 0
GAUGE IN COMPUTING AND SWIMMING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
KILLS AND RE9ULATIOJIS OF THE WATER vivo& AND STATE REGULATIONS.
GAUGE CALIBRATION DATE it 6 it'/ DETECTOR ME19 READING
7 -1- ",.,,4 7 44.....--te.,..-
TESTER SIGNATURE .7 CRT #
ltbaRS NAME PRINTED CADGE: #
16120 SW 72ND, ROR'ILAND. 97224 (503) 603-9988
TESTERS ADDRESS PHONE N
NAME / '
/, WrR METRICS CO. WEST WWW.WATERMEIRICS.COM
COMPANY
...,..00,......** yl SERVICE RESTORED
.r.o.. JVER BY: (REPRESENTATIVE OF OWNER)
ITE - WATER SYSTEM COPY PINICalli CO YELLOW - TESTER COPY