Permit /5.../2-41
C O TIGARD BUILDING PERMIT
PERMIT #: BUP2004 -00060
41 DEVELOPMENT SERVICES DATE ISSUED: 2/19/2004
- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 12458 SW WINTERLAKE DR PARCEL: 1S134CC -03600
SUBDIVISION: CAPSTONE ZONING: R -4.5
BLOCK: LOT: 003 JURISDICTION: TIG
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: OTR FIRST: sf N: S: E: W:
TYPE OF USE: SF SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: 5N sf N: S: E: W:
OCCUPANCY GRP: R3 TOTAL AREA: 0 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED:
STOR: 1 HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED
FLOOR LOAD: 40 psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET:
DWELLING UNITS: 1 FRNT: ft REAR: ft FIR ALRM : HNDICP ACC:
BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING:
VALUE: $ 25,000.00
Remarks: Repair tree damage to roof.
Owner: Contractor:
LULKIEWICZ, JACEK AND URSZULA OWNER
12458 SW WINTERLAKE DR
TIGARD, OR 97223
Phone:
Phone:
Reg #:
FEES REQUIRED INSPECTIONS
Description Date Amount Framing Insp
[BUILD] Permit Fee 2/19/2004 $283.30 Final Inspection
[TAX] 8% State Surcharl 2/19/2004 $22.66
[BUPPLN] Pln Rv 2/19/2004 $184.15
Total $490.11
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 -01 : • • ' OAR 952 - 001 -0100. You may obtain a copy of these rules or direct questions to OUNC by
calling .13) 246 -6699 o 1- 800 - 332 -2344.
Issue • = y:
Permittee f 1
Signature:
C. 639 -4175 by 7 p.m. for an inspection the next business day
Building Permit A v ' w elvED FOR OFFICE USE ONLY
City and �� of Ti Received i m: � .. t��. •
Tigard _ AI D .A I
13125 SW Hall Blvd., Tigard, OR 97223 [C B 1 9 2004 , rot `, „ Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 � � l ' � DateB : Other Permit:
Inspection Line: 503.639.4175 TlC}p►R ' !i f I.. Date R /Met o RI See Attached Checklist for
Internet: www.ci.tigard.or.us Ga./ DIVISIO Notified/Met �� Su lemental Information
BUILD
TYPE OF WORK 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
dition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
Valuation: $
1- and 2- family dwelling ❑ Commercial /industrial ‘75/05r) - Oo
❑ Accessory building Number of bedrooms:
❑ Multi -famil y
❑ Master builder El Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 12ls9, I A) I Di,_.t f, L �1 New dwelling area: square feet
City/State/ZIP: -- * A 4 n 91-22 1 Garage/carport area: square feet
Suite/bldg. /apt. no.: Project name: ‘ . _, u1.... . 1€ . I C " . Covered porch area: square feet
Cross street/directions to job site: -1 1. &A e f - ?c--.5. . 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.
Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Valuation: $
—1-1124E-7---- Existing building area: square feet
i9A CT New building area: square feet
ROPERTY OWNER ❑ TENANT Number of stories:
Name: L L Kl J %L_.. Type of construction:
Address: s ?�� ` tg S f■iifO Occupancy groups:
City/State/ZIP: Ti (moo / e-)4_,.. Existing:
Phone: ( ) sr, s .431 . -z i ( Fax: ( ) New:
PPLICANT ❑ CONTACT PERSON NOTICE
Business name: - -i-- ( 1.)..Ac 3c'Z All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name: '
` �x.3 .4 A-6— `V � K under ORS 701 and may be required to be licensed in the
Address: 3 . ki , �-
) L Tt ... k A.- c I ,- ` ( - l jurisdiction in which work is being performed. If the
applicant is exempt from licensing, the following reasons
City/ State/ZIP: - 1 1 '6,�� t , 5 nl�_ C17-2.4D9 apply:
Phone: (-�JI3) .-11;2 0 Li (9 Fax:: ( ) -1-1-4 . 04-12-1 E -mail: JJ'
CONTRACTOR
Business name: r 1 9„ I ? J V 'V.) } (4 --. v` BUILDING PERMIT FEES*
Address: '71 $-- SE .4-4-1.- Please refer to fee schedule.
City/State/ZIP:
—t'6 R -`Y0 Q ( / l Fees due upon application
Phone: (,b3) 23`4 „ O / Fax: (g(j'1) 2:q Amount received
CCB Iic.: 3 4 b Z
Date received:
Authorized signature: / This permit application expires if a permit is not obtained ahi within 180 days after it has been accepted as complete.
•
Print name: b A _ 1. Fee methodology set by Tn - County Building Industry
tt Date: , I 0 Service Board.
\
i\ Bui ldingPermits\BIJP- P 12/03 440- 613T(I1 /02/COM/WEB)
One- and Two - Family Dwelling
Building Permit Application Checklist FOR OFFICE USE ONLY
City of Tigard Received Permit No.:
g
13125 SW Hall Blvd., Tigard, OR 97223 Y
Associ permits
Phone: 503.639.4171 Fax: 503.598.1960 - - " ^�'I'y'' ,, ❑Electrical ❑Plumbing ❑Mechanical
24- Hour Inspection Line: 503.639.4175 ilk 'I
Internet: www.ci.tigard.or.us .... '. ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No N/A
1 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. Name of district: ❑ ❑ ❑
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 ❑ 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 addendum 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 ❑ ❑ El
architect licensed in Ore:on and shall be shown to be applicable to the .ro'ect 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 and 22 above. ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be 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 and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑
Street Tree List.
29 Site plan to include tree protection measures as required by conditions of approval. ❑ ❑ ❑
30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
i:\Building\Permits \One - Two- FamilyChecklist.doc 12/03
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Permit #: Paul I ;Doti - nO
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"' °' Issued D ate: 7/ lo
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exempt from registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
1. I own, reside in, or will reside in the completed structure.
..„Vi...._
,W__2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
❑ 3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
____a_ 3B. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above infor , tion is co , e t . d that I have read and do understand the Information
Notice to Property Owners abo - nstructi : n lie .. ■onsibilities on the reverse side of this form.
x - dt.P `4 . 7 /' 4 4/
: ignatur of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
. I
• l[n ?or ma'Uoi Mo ce ppopc ny Ow eve
Aboua constuoUon MesponsuAMes
Note: This Information Notice to Property Owners about Construction Responsibilities
was developed by'the Construction Contractors Board in accordance with ORS 701.055(5).
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent many problems by being aware of the following responsibilities and areas of concern.
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction o: improvemeni of a residential structure, you will, in most instances, be ruled to be an employer and the people
you hire will be employees. As the employer, you must comply with the following:
O .Te an's whYnolie ling ttzz) As an employer, you must withhold income taxes from employee wages at the time employees
are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more
information, call the Oregon Dept. of Revenue at 945 -8091.
U nemnpCmyrnnent irnsLara_,ce As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees For more information, call the Oregon Employment Division at the Department of Human Resources
at 378 -3524.
WarAen compensa em As an employer, you are subject to the Oregon Workers' Compensation Law, and Must
obtain walkers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject to penalties and a, ; t' liable for all claim costs if one of your employees is injured on the job. For more information,
call the Workers' Compens:i ;ion Division at the Department of Consumer and Business Services at 945 -7888.
U.S. I:nten 2171 i ee'enr :e Sa t-,se: As an employer, you must withhold federal income tax from employees' wages. You will be
liable fcr the tax payment even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1 -800- 829 -104C
c� [ RESPOMSBB LMES QNL] AREAS OF COMC ERR:
Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections.
ILiziaTly and prro ,:ri ty dam.agc >msu ra'inee: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools, paint overspray. water damage from pipe punctures, fire, or work that must be
re -done.
'IITb'nc to sanprcirvise ennpIloyees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough -in and finish
trades, and to notify building officials at the appropriate times so they can perform the required inspections.
If you have additional questions, write or call the' Construction Contractors Board (PO Box 14140, Salem, OR 97309 -5052,
503/378- 4621). The Board is located at 700 Summer St. NE Suite 300, in Salem.
prop- own.pm4
1 /94
CITY OF TIGARD
BUILDING DIVISION '' PERMIT #: BUP2004 -00060
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 2119/2004
Phone: (503) 639 -4171 Gtl1 i l
Inspection Requests (24 Hrs.): (503) 639 -4175 `'I ..
INSPECTION WORKSHEET FOR DATE: 6/14/2005 TIME: 7:10AM PAGE: 49
SITE ADDRESS: 12458 SW WNTERLAKE DR CLASS OF WORK:
SUBDIVISION: CAPSTONE LOT #: 003 TYPE OF USE:
PROJECT NAME: LULKIEWI
DESCRIPTION: Repair tree damage to roof.
OWNER: LULKIEWICZ, JACEK AND URSZULA, PHONE #:
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 6/14/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
299 Final inspection 009202 -01 503 - 685 -5342 Y
Corrections /Comments /Instructions:
1 .
(-97:-. .
f atASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ALL ." - 1 .ACTION ❑ ADDITIONAL FEES ASSESSED
Inspector: S Date:/ / ? vv Phone #: (503) 718.R