Permit .� '4 CITY OF TIGARD MASTER PERMIT
-° l: COMMUNITY DEVELOPMENT Permit #: MST2012 -00259
T]GARD, 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 10/17/2012
Parcel: 2S 110BA08900
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Jurisdiction: Tigard
' Site address: 14207 SW 116TH TER
Subdivision: EVERGREEN SPRINGS Lot: 14
Project: Roffelsen
Project Description: 727 sq ft interior addition to add bedroom, bathroom and media room.
BUILDING .,
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 1 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
• Height: 0 Bathrooms: 1 Second: 727 sf Garage: 0 sf Front: 0 Smoke '
Dwelling Units: 1 Third: 0 sf Right: 0
Detectors: Yes
Total: 727 sf Value: $75,549.84 Rear: 0
PLUMBING
Sinks: 1 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0
Tubs /Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 0 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Drywell- Trench Drain: 0 Other Fixtures: 0
Other Fixture Units:
' MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
Natural Gas Heat Pump: N Hoods: 0 Other Units: 0
Fum <100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Fum > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc /Feeders i Branch Circuits
1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0
Ea add9 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc/Fdr: 5
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
Ecom asin N
Other: N Other Description: p g
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
,: ADD SF VB R -3 727
Owner: Contractor:
ROFFELSEN, RYAN L & ADINA L OWNER Required Items and Reports (Conditions)
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14207 SW 116TH TER
PORTLAND, OR 97224
PHONE: 503- 430 -1814 PHONE: -
.
FAX:
Total Fees: $2,760.67
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 ION: • _.on law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -00 -0010 through OAR s . -00 , 4. - 0. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
J
Issu d By: /, Permittee Signature: -
d�
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. •
Building Permit Application RECEIVED
Residential FOR OFFICE USE ONLY
City of Tigard OCT 0 9 2012 Date/By: /d Q /04 / Permit No. / a20�rZ�e 7 9
• g
° 13I25 S W HaII Blvd., Ti ard, OR 972 y
_ Phone: 503.718.2439 Fax: 503.598. tin 1 OF lIUt11W PlanRevie•• , Date/By: OI I i�3 (
,' Other Permit:
TIGAKD Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready / ay I fur Ed See Page 2 for
Internet: www.tigard- or.gov - plotified/Method: IOI7/ /� / e Supplemental Information
TYPE OF WORK RQUIRED 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 Valuatio $ 6tl0 BS .824
❑ Accessory building ❑ Multi- family Number of bedrooms: 1
❑ Master builder ❑ Other: Number of bathrooms: 1
JOB SITE INFORMATION AND LOCATION Total number of floors: 1
Job site address: 14207 SW 116 Ter. New dwelling area: 727 square feet
City /State /ZIP: Tigard, OR 97224 Garage /carport area: square feet
Suite /bldg. /apt. no.: Project name: Roffelsen Addition Covered porch area: square feet
Cross street/directions to job site: SW 116 Ter. and Cole Lane 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.: 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.
Add bedroom with bath and mediaroom. Valuation: $
H
Existing building area: square feet 1
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name: Ryan and Adina Roffelsen Type of construction:
Address: 14207 SW 116 Terr. Occupancy groups:
City /State /ZIP: Tigard, OR 97224 Existing:
Phone: (503)430 -1814 Fax: (503)430 -1814 New:
❑ APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
Business name: N/A (Please refer to fee schedule)
Structural plan review fee (or deposit): 330 , o
Contact name:
FLS plan review fee (if applicable):
Address:
City /State /ZIP: Total fees due upon application:
Phone: ( ) Fax:: ( ) Amount received: 33 e, 0 S
E -mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
CONTRACTOR Commercial and residential prescriptive installation of
roof -top mounted PhotoVoltaic Solar Panel System.
Business name: Owner Submit two (2) sets of roof plan with connection details
and fire department access, along with the 2010 Oregon
Address: Solar Installation Specialty Code checklist.
City /State /ZIP: Permit Fee (includes plan review $180.00
and administrative fees):
Phone: ( ) Fax: ( ) State surcharge (12% of permit fee): $21.60
CCB lic.:
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: Ryan Roffelsen Date: 10/8/12 * Fee methodology set by Tri- County Building Industry
Service Board.
l:\Building\Permits\BUP- RESPermitApp.doc 02/24/2011 440- 4613T(11/02/COM /WEB)
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Plumbing Permit Applicati
Building Fixtures EIVED
Received / p
City of Tigard [� r T 09 2012 !s t!4 /J' Permit No. S /� evo2 /
II
v 13125 SW Hall Blvd., Tigard OR 97223 - Date/By: Review
Plan Review
• .
Phone: 503.718.2439 Fax: 503.59 (*TIGARD Date /By: Other Permit No.:
T 1 G A R D Inspection Line: 503.639.4175 x/� "" S10N Date Ready /By: Juns: 10 See Page 2 for
Internet: www.tigard- or.gov BUILDINGDN Notified /Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
1=1 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
® I - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
Accessory building SFR (3) bath 50032
❑ y g ❑ Multi- family
Each additional bath /kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 14207 SW 116th Ter. Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City /State /ZIP: Tigard, OR 97224
Footing drain (no. linear ft.: ) Page 2
Suite /bldgJapt. no.: I Project name: Roffelsen Addition Manufactured home utilities 50.03
Cross street/directions to job site: SW 116th Ter. and Cole Lane Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _ ) Page 2
Storm sewer (no. linear ft.: _ ) Page 2
Water service (no. linear ft.: _ ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
Backwater valve 12.51
DESCRIPTION OF WORK
Clothes washer 25.02
Add bedroom with bath and mediaroom.
Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
® PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name: Ryan and Adina Roffelsen Fixture /sewer cap 25.02
Floor drain /floor sink/hub 25.02
Address: 14207 SW 116th Terr.
Garbage disposal 25.02
City /State /ZIP: Tigard, OR 97224 Hose bib 25.02
Phone: (503)430 -1814 Fax: (503)430 -1814 Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap . 25.02
Business name: N/A
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address:
Sink/basin/lavatory 2. 25.02
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E - mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: Owner
Water piping/DWV 56.29
Address: Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: Ryan Roffelsen Date: 10/8/12 This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
I :\ Budding \Pcrmits\PLMU- PcrmuApp.doc 10/01/09 440- 4616T(10/02/COM/WEB)
Mechanical Permit Application , ,
RECEIVE , Received FOR OFFICE USE ONLY
City of Tigard DPlan at By: Rev D Permit No
q 1 3 125 SW Hall Blvd Tigard OR 97223 y g ��� / � rDO
IN .
view O Phone: 503.718.2439 Fax: 503.598.1960 CI C T 0.9 :2,0 1 Z Date/By:
Other Permit:
TI G A R D Inspection Line: 503.639.4175 Date Ready /By: Juris: 0 See Page 2 for
Internet: www.tigard CITYOFTIGARD Notified/Method: Supplemental Information
BUILIMDNISIO •
TYPE OF WORK COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
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: $
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
® I - and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: 14207 SW 116 Ter. (requires site plan showing placement) 46.75
City/State/ZIP: Tigard, OR 97224 Furnace 100,000 BTU (ducts /vents) ` 46.75
Furnace 100,000+ BTU (ducts/vents) 5491
Suite /bldgJapt. no.: Project name: Roffelsen Addition Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: SW 116th Ter. and Cole Lane Duct work 2332
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
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 2332
Add bedroom with bath and mediaroom. Gas fireplace/insert 33.39
Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 3339
Wood fireplace /insert 2332
® PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 2332
Other: 2332
Name: Ryan and Adina Roffelsen Environmental exhaust and ventilation:
Address: 14207 SW 116th Ter. Range hood /other kitchen equipment 33.39
City /State /ZIP: Tigard, OR 97224 Clothes dryer exhaust 33.39
Fax: 503 430 1814 Single - duct exhaust (bathrooms,
Phone:
(503)430-1814 ( ) toilet compartments, utility rooms) 1 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 2332
Business name: N/A
Other: 2332
Fuel piping:
Contact name:
$14.15 for first four; $4.03 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP:
Wall/suspended/unit heater
Phone: ( ) Fax: : ( ) Water heater
E -mail: Fireplace
Range
CONTRACTOR Barbecue
Business name: Owner Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00)
Plan review (25% of permit fee)
CCB tic.: State surcharge (12% of permit fee)
I
TOTAL PERMIT FEE
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Ryan Roffelsen Date: 10/08/12 * Fee methodology set by Tri- County Building Industry Service Board
1 : \Building \Permits \MEC- PermitApp.doc 03/07/12 440 -4617r I11 /02/COM/WEB)
Plumbing Permit Application
Building Fixtures City of Tigard Vi#-N.-‘1
R eceived Permit No. �, r,010 /-Q0� n 13125 SW Hall Blvd. T, 23 ^ 1� Date/By: i�0 / a //
Tig " �' oo LO Plan Review
C Phone: 503.718.2439 Fax: 503g0l90WV Date/By: Other Permit No.:
Inspection Line: 503.639.4175 \`1 -(� Date Ready/By: Juris: ® See Page 2 for
I' I G A K D Internet: www.tigard - or.gov `1 OVA Notified/ Method: Supplemental Information
g
�{ " _
TYPE OF 16 \ - ' FEE* SCHEDULE
❑ New construction Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
j- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
° `
building SFR (3) bath 500.32
❑ Accessory g ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
/ T •� 0 7 S I / / Catch basin or area drain 18.76
TG-
Job site address: . " `) ( 1 t -r
Drywell, leach line, or trench drain 18.76
City/State /ZIP:
t Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
G ce (� , Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
/�� Clothes washer 25.02
a 7 � - /� 44 A9 1 1-71 " - ' Dishwasher 25.02
-��/ ' ^`!�\ , 4 ,_. Drinking fountain 25.02
a 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 25.02
City /State /ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51 ,/
Address: Sink/basin/lavatory L 25.02 /50.0 7
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan , 12.51 /A..51
E -mail: Urinal 25.02
CONTRACTOR Water closet / 25.02 A5,02.
I Water heater 37.52
Business name: k y)e r( C tyl ( 0 ( /�� Water piping/DWV 56.29
Address: 1 "c P , (30--pc, 23°,8 S- Other: 25.02
City /State /ZIP: - a .,,,t / U & 9 7 L (- 3 .S.--- Subtotal 67.6 7
Minimum permit fee: $72.50 -----
Phone: 6o)) 6 - (K (- Fax: (575 3) (,zy- 2( 7 -
Plan review (25% of permit fee)
CCB Lic.: �i1 ' S 7 2 Plumbing Lic. no.: 2‘ --rig( S' P� State surcharge (12% of permit fee) f 51
Authorized signature: TOTAL PERMIT FEE enr,pg
I Print name: Wes( e el e Date: /(72...G7; 2 This permit application expires if a permit is not obtained within 180 days
! //! after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
1:\ Building \Permits\PLMU- PermitApp.doc 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 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 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
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 62.54
$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
111 Any new commercial building with water service 2" and
greater, except systems designed and stamped by licensed
Bath: - Tub /Shower
engineer.
- Jacuzzi/Whirlpool
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive 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
4 " ❑ Isometric or riser diagram is required for new buildings
- Car Wash Drain
Garbage Domestic non - food that meet the qualifications above.
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 Filler 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:�BuiIding\Permits\PLMF- PermitApp.doc 08/04/2011 2
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Electrical Permit Applicat G �y
Date/By: FOR OFFICE USE ONLY
City of Tigard f0 _I (o Permit NV A 2 _6Q a s9
Ill - ° 13125 SW Hall Blvd., Tigard, OR 97 i T 0 . 9 Z012 Plan Review
Phone: 503.718.2439 Fax: 503.598.`] 6 Date/By: Other Permit:
TIGARD Inspection Line: 503.639.4175 Clel'Y01 ^ Date Ready/By: Juris: See Page 2 for
Internet: www.tigard- or.gov 11�I Notified/Method: Supplemental Information
TYPE gli erDIVISION PLAN REVIEW
Phase check all that apply (submit 2 sets of plans w /items checked below):
❑ New construction ® Addition /alteration /replacement
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
® I- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", ' 1 -2 ", "I -3 ",
Job no.: Job site address: 14207 SW 116th Terr. IOOHPor more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /Zl P: Tigard, OR 97224 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: Roffelsen Addition ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: SW 116th Ter. and Cole Lane Description I Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.:
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 75.00 2
Add bedroom with bath and mediaroom. residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: Ryan and Adina Roffelsen 401 amps to 600 amps 20034 2
601 amps to 1,000 amps 301.04 2
Address: 14207 SW 116 Ter. Over 1,000 amps or volts 552.26 2
City /State /ZIP: Tigard, OR 97224 Temporary services or feeders installation, alteration, and/or
relocation
Phone: (503)430 - 1814 Fax: (503)430 - 1814 200 amps or less 5936 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, le• rent, or exchan :e . ording to ORS 447 449, 670, and 701.
d Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: lO /f ?�2 ..... A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee 7.42 2
each branch circuit
Business name: N/A B. Fee for branch circuits without
service or feeder fee, first , 56.18 2
Contact name: branch circuit
Each add'I branch circuit wt 7.42 2
Address: Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) 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: Owner panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (I hr min) 66.25/ hr
Industrial plant (I hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed (1 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Subtotal:
Suprv. Electrician signature, required: Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
Authorized signature: TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Ryan Roffelsen Date: 10/8/12 * Number of inspections allowed per permit.
1: \ Budding \ Permits \ELC- PcrmitApp.doc 07 /01 /10 440- 4615T(I I /05 /COM/WEB
• • .
Building Division
Development Code Provision Review
TIGARD Residential Projects
Building Permit No.: i /a- - DO .2s9
Site Address: / 0 7 SA_.9 // /o — 7 — 2-
Project Name & Lot No.: A-OG L c E:"/
CWS Service Provider Letter
Required: Yes ❑ No [r /A'7 CJo2. 1¢.6Di77 0A/
Received: Yes ❑ No ❑
Routed Plans:
Original Plan Submittal Date: ✓0 /Q /�-
1st Revision Submittal Date: ❑ Site Plan Only
2nd 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. 1/,/
Planning Review (contact , � at 503-718-; r 1' or @tigard- or.gov)
L Use Case No. R ' '7 ' S
a
Zoning
Iii Setbacks: iith
Front Rear i Side Street Side Garage
❑ Maximum Building Height Aip Actual Building Height
❑ Visual Clearance
❑ Easements /1//4"
❑ Sensitive Lands Type: Ni i ,
Notes: c _ I
Original Plan: Approved E:( Not Approved ❑ Date: I U — i 0 —/ Z-
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)
❑ Actual Slope:
Notes: � /
iiv
Original Plan: Approved ❑ Not Approved ❑ Date:
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
(Review Continues on Page 2)
Page 1 of 2
City Arborist Review (contact Todd Prager at 503 -718 -2700 or todd@tigard-or.gov)
tigard- or.gov)
❑ Street Trees /
❑ Protected Trees J f'�
Notes: 0 1 `
Original Plan: Approved ❑ Not Approved ❑ Date: •
Revision 1: Approved ❑ Not Approved ❑ Date:
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 ssuance of Building Permit
Notes :
1\i
Original Plan: Date Sent to Applicant:
Revision 1: Date Sent to Applicant
Revision 2: Date Sent to Applicant
Okay to Issue Permit: Yes ❑ No ❑
Date Routed to Building:
is
•
Page 2 of 2
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that a II subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I w ill
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this horn eowner statement is true and accurate.
1 Pc74,1
Printilame of Permit Applicant
ign; re of Permit Applicant Date
Permit #: MeT a90 /o'.- oZ 59
/ // 0 = 7
Address: ao7 c & l ��o lea K �,. . • - A2�,02 97a3- :� „��
• • ;
Issued b % t '\ Date: ID / y f1-
This Copy for Permit Offices