Permit 1 7 ,' F!--7 n s. n E D
o SEP 2011
IN : Com Development �,..�, .�a- _;,,,aD
TIGARD Request for Permit Action °j n:;r L3 \1;ri3 l Co/`�
W iVO r /S�Scc Z
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 1kt City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) I CID _ C HA LCa r rc . i2 s__it e/ 7D
Mailing Address: /A 33 3 t.tD I lou_pC,4)
City/State /Zip: - 4 2b OQ. 9 7.l g 3
Phone No.: O02 ,)- 2j ( 7 -C)36 9 J
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
g CANCEL PERMIT APPLICATION. /t/0 /n/140 / C
_ _
'-EFUND PERMIT FEES (attach receipt, if available). �
INVOICE FOR FEES DUE (attach case fee schedule and explain below). &)(P /2
P. ❑ ' MOVE CONTRACTOR FROM PERMIT (do not cancel permit). iy L /M /Tff
Permit #: �DD�f DO lop
SOT /�S G��g
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G � ST r /3/o y
Site Address or Parcel #: I a 1DQ d(.�) Y J
Project Name: � 1 !C 2I Ce. 97a2.3
Subdivision Name: 4si- Lot #: 4A-
EXPLANATION: - Q JE} n1T /V o I- .oA/lbe L e>J r' 1.4-5 r 13€ 55
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Signature: Date: Q � 0
Print Name: `T 61, / f 2. F1-1 fr J
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date ' ara_us1�7 Rte to Bid: Admin: Date . /J�' ul�J %%
Refund Processed: Date Al /9- By ,/ Invoice Processed: Date By
Permit Canceled: Date / /�//// By % ' eel Tag Added: Date By
Receipt # Date Method Amount $
1:\ Building \ Forms \Regl'emutActron doe Rev 07/26/07
1111.W. LI 1 ?�3 t2A (-C' ,e560 MA (
Building Permit Application EXPIRED /1/9�/
Commercial ; r ,- r t �� l� I 0 FOR OFFICE USE ONLY
r City of Tigard ill ?' 1 . r ,,, ,..) R eceived / 11 0 EMNI/009
13125 SW Hall Blvd , Tigard, 1910 OR 97223 I 3 Plan Revt
% C Phone. 503 639 4171 Fax. 503 598 19. N J 2��9 Date/B awj �� Vl Other Permit
T I G RID Inspection Line 503 4175 Date Re ¶'. Q � S ®S ee Page 2 for
Internet: www tigard- or.gov CITY Li' TIGARD Notrfiei iw od 7 / e � /, �/ 11 � ,, I � S , elemental Information
l t!1 t „ \Ir: tit
r/JcIf1M Air — it%(/ —/!L'7 r�iMI IP i
TYPE OF WORK ' ) REQUIRED I ATA: I- 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
- ddition/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: S
❑ 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: /2 yt G ' - � / 4 0 ; a ST New dwelling area: square feet
City /State /ZIP: 7' A/ , d, 9 202 3 / Garage /carport arca: square feet
Suite/bldg. /apt. no.: Project name: /1 73 Covered porch area. square feet
Cross street/directions to job site: g�r.;1I t,,, Rd ///”' Deck arca: square feet
&p '/ C 0 " 7 / 01 A/v 4-,M .'N Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: I 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.
2 CV/' 4•ir+ L( /ALAS / l,/A<r A.4.9 ...N Valuation: S 560 0
2 r / / Existing building area: 4.12,e,,,0 square feet
pn / A/ -1LS IV/ ZO /1, -'iv c,r,rr
New building area: s. square feet
❑ PROPERTY OWNER }TENANT Number of stories:
Name: 7. /2 3.1 5' u/fL, G•„ d l5,,,� Type of construction:
Address: (4.a„ A w,,,✓�� .-f JA JI Occupancy groups:
City /State /ZIP: rt 6, ` v O '99 7'L) Existing:
Phone: (s'-o3) ? / 0 74 it Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name: T C I) All contractors and subcontractors are required to be
t licensed with the Oregon Construction Contractors Board
Contact name:
c ' 1 _ 4 ' c ' G • under ORS 701 and may be required to be licensed in the
Address: /Z 3.2 St../ A L.,,.. jurisdiction in which work is being performed. If the
applicant is exempt from licensing, the following reasons
City/State/ZIP: 7
J /9/ Oki f? 2 ?) apply:
Phone: ( SO ) 3 / 7-. 6344 I Fax: . (.0 5 90 5/2 39
E -mail: Ch i C j ca 9, / ev--■
CONTRACTOR
Business n a m e : BUILDING PERMIT FEES*
Address: (Please refer lo fee schedule)
City /State /"ZIP: Structural plan review fee (or deposit):
Phone: ( ) Fax: ( ) FLS plan review fee (if applicable):
CCB lie.: /Sd gem Total fees due upon application:
Amount received:
Authorized signature: !✓� �� / 1
'S�' ' / This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Date: *
Fcc methodology set by Tn- County Building Industry
Service Board.
1. \Building\Permits \BUP -COM PermitApp doe 2 /23/07 440- 4613T(11 /02 /COM/WEB)
I e_
Building Division
. Accessibility: Barrier Removal Improvement Plan
TIGARD .
REQUIREMENT: OREGON REVISED STATUTE (ORS) 447.241.
(1) Every project for renovation, alteration or modification to affected buildings and related
facilities shall be made to insure that the path of travel to the altered area and the restroom,
telephones and drinking fountains are readily accessible to individuals with disabilities unless
such alterations are disproportionate to the overall alterations in terms of cost and scope.
(2) Alterations made to the path of travel to an altered area may be deemed disproportionate to
the overall alteration when the cost exceeds twenty-five per -cent (25 %).
VALUATION: Total of all renovation, alteration or modification being done, �1 tar excluding painting and wallpapering: [1] $ ✓K./,
MULTIPLIER (25% barrier removal requirement): x .25
TOTAL BUDGET FOR BARRIER REMOVAL: [2] $
ELEMENTS: In choosing which accessible elements to provide under this section, priority shall be given
to those elements that will provide the greatest access. Elements shall be provided in the
following order:
(a) Parking $
(b) An accessible entrance: $ e..---
(c) An accessible route to the altered area: $ '�
(d) At least one accessible restroom for each sex or a single unisex 1.----
restroom: $
(e) Accessible telephones: $
(f) Accessible drinking fountains: and, ft }4 C/A... $ /4—
(g) When possible, additional accessible elements such as storage and /
alarms: $ l �
TOTAL (shall equal line [2] of Valuation Computation): $
I: \Building \Permits \BUP -COM PcmutApp.doc 06/25/08
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CITY OF TIGARD
Approved bade. Limo} [
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See Letter to: Follow [ j
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Date: ��
OFFICE COPY
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