Permit CITY OF TIGARD MASTER PERMIT
1111 • COMMUNITY DEVELOPMENT Permit#: MST2013-00002
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/23/2013
T I(:r A K C) 9 Parcel: 2S109DA05600
Jurisdiction: Tigard
Site address: 12785 SW SUMMIT RIDGE ST
Subdivision: SUMMIT RIDGE Lot: 33
Project: Cristurean
Project Description: Remodel master bedroom.
BUILDING
Floor Areas Reaulred Setbacks Reauired
Stories: 0 Bedrooms: 1 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0
Detectors: Yes
Total: 0 sf Value: $2,500.00 Rear: 0
PLUMBING
Sinks: 0 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: 0 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 TVDe} Air Conditioning. N Vent Fans. 0 Clothes Dryers. 0
Heat Pump. N Hoods. 0 Other Units. 0
Fum<100K: 0 Vents: 0 Woodstoves 0 Gas Outlets: 0
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Tema Srvc/Feeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add'I 500 sf. 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr 1
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
Other: N Other Description: Ecompasing. N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ALT SF VB R-3 0
Owner: Contractor:
CRISTUREAN,FLORIN&IOANA M OWNER Required Items and Reports(Conditions)
12785 SW SUMMIT RIDGE ST
TIGARD,OR 97224
PHONE: PHONE.
FAX:
Total Fees: $334.18
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
da ' • . •regon law requires you to follow the rules adopted by the Oregon Utility Notification Ce s- rules are set forth in •
2-001-0010 through O•• 952-a• !0. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232. 87 or 1.80. 32.2344. r
Issued By: / L.i , �:l Permittee Signature: 4 , , _ 1 /
■ Call 503.839.4175 by 7:00 a.m.for the next available inspect)•n date.
This permit card shall be kept in a conspicuous place on the Job site until completion of th• • •act.
Approved plans are required on the job site at the time of each inspection.
Building Permit Application
Residential RECEIVED FOR OFFICE USE ONL1
Cl /of Tigard Received , 1 Permit No.: r" //Date/B
13125 SW Hall Blvd.,Tigard,OR 974Vm 10 2013 Plan Review toy
Phone: 503.718.2439 Fax: 503.59g'{ �� Other Permit:
I I t i A It I) Inspection Line: 503.639.4175 CITY OF TIG a D n Date Ready' J�9 ® See Page 2 for
Internet: www.tigard-or.gov V 1 T tU/1flD Notified/Method: Supplemental Information
BUILDING DIVISION
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
❑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 Valuation: $ ,z900, 00
❑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: I`. -$5 SkJJ
, 1 t- New dwelling area: square feet
City/State/ZIP: 11 a F.D, O- ( l-ZZLI
Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: hS-Tk.7 I\f Covered porch area square feet
Cross street/directions to job site: 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.
'&cj ,- k�j t t i__ (IJ. ( Valuation: $
>�(/l 4 ��'�l Existing building area square feet
New building area: square feet
❑ PROPERTY OWNER I ❑ TENANT Number of stories:
Name: `Q R CV ;5T )ge Type of construction:
Address: I 5 ) t U,.mm` \ LL € c8c . Occupancy groups:
City/State/ZIP: C .A OR_, on—Z Zq
Existing:
Phone:( 03 0 . 4 3 0 Fax:( ) New:
❑ APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
Business name: (Please refer to fee schedule)
Structural plan review fee(or deposit):
Contact name:
FLS plan review fee(if applicable):
Address:
City/State/ZIP: Total fees due upon application:
Amount received:
Phone:( ) J Fax: :( )
E-mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Business name: d6 /A / F J 2 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:( ) o
State surcharge(12%of permit fee): $21.60
CCB lic.:
Total fee due upon application: $201.60
Authorized signat e: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: I f} C4?. JTu£ 7 -1'( Date: I J.0l 13 *Fee methodology set by Tri-County Building Industry
Service Board
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received
Permit No
Ilhi a 13125 SW Hall Blvd.,Tigard,OR 97223 DateBy.
17 Phone: 503 718.2439 Fax 503.598.1960 Associated permits.
24-Hour Inspection Line: 503.639.4175 0 Electrical 0 Plumbing 0 Mechanical
l'I G Alto
Internet: www tigard-or gov ❑ 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. El ❑ El
3 Verification of approved plat/lot. ❑ El ❑
4 Fire district approval required. Name of district: . El El ❑
5 Septic system permit or authorization for remodel. Existing system capacity El ❑ El
6 Sewer permit. El ❑ El
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. ,
I I Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if El ❑ ❑
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 ❑ El El
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, El El El
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- El El El
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. ❑ El ❑
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full-size sheet addendums 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- ❑ ❑ El
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 ❑ El ❑
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. ❑ El El
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required El ❑ El
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 Ion and shall be shown to be applicable to the .ro'ect under review.
JURISDICTIONAL SPECIFICS
23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". El El El
24 Two(2)sets each are required for Items 16, 19,20 and 22 above. El ❑ El
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. El El ❑
28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard El ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, ❑ El ❑
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, ❑ ❑ El
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\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Plumbing Permit ApplicatiriECEI QED
Building Fixtures V I ()ii t 1i I It i i �i ()NI
City of Tigard JAN 10 2013 Received
Date/By: /!. /3 ' Permit No.: r,*5_ -
lig • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Revie
• ' Phone: 503.718.2439 Fax: 503.59 Other Permit No.:
Cillf OF TIGARD Date/By:
1. 11\I Inspection Line: 503.639.4175 Date Ready/By:
RI See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: Supplemental Information _
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist
Description I Qty. [ Ea. 1 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
❑ 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑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: l o- fon)i.-1-- I`Ale Catch basin or area drain 18.76
City/State/ZIP: -("'1 '.b Op_ off-ZZ'1 Footing 1,leach line,or trench drain 18.76
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: CR-1 -rt.) ...---13(-$.1 Manufactured home utilities 50.03
Cross street/directions to job site: 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
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
� -16 Qht + ook , t Dishwasher 25.02
( ,yt,. ck . Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: I0 �l CJ'-jv -�CI� Fixture/sewer cap + 25.02
G Floor drain/floor sink/hub 25.02
Address: 1 t 5. StA) (T\T' 4 ` &k Garbage disposal 25.02
City/State/ZIP:
11 �X r1 1`� I� �
v � + T Z Z- 9 Hose bib 25.02
Phone:(503 g o( . 3 0 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 1 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
O t� \ E Water heater 37.52
Business name: N Water piping/DWV 56.29
Address: 1 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: /, �1 u ' TOTAL PERMIT FEE
a ` 1 This permit application expires if a permit is not obtained within 180 days
Print name: j(� / ( s� Date: ( (� �3
-` , after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\PermiMPLMU-PennitApp.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-10 100' 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 ec
Ins tions or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
Inspections 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 ,,ti,l
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 ❑ Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
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
❑ 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 I,
-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 Filter 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
WaterCloset-Toilet plumbing';permit can be issued. ?
Urinal -,
Other Fixtures:
I:\Building\Permits\PLMF-PermitApp.doc 08/04/2011 2
Electrical Permit A A. t li ', t EIVED
miReceived
City of Tigard Date/By: l4 /A PennitNo.: l 5rd,,,3�voc, y
INI 13125 SW Hall Blvd.,Tigar., '7223 Plan Review
Phone: 503.718.2439 Fax: 503., 9(�)0 2013 Date/By: Other Permit:
TIGARD
Inspection Line: 503.639.4175 Date Ready/By: Juris ® See Page 2 for
Internet: www.tigard-or.gov W OF TIGARD Notified/Method: Supplemental Information
TYPM191Bi3IVISION PLAN REVIEW
❑New construction ❑Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked below):
❑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
❑ 1-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","l-2","l-3",
Job no.: Job site address: ! } IOOHP or more. occupancy.
1��ta� �V V �u t'tt r t) ,_ I ❑Six or more residential units. ❑Recreational vehicle parks.
City/State/ZIP: Cent t�\ (/,•�► 4 ( ❑Healthcare facilities. ❑Supply voltage for more than
ty "v '" L O `���4 ❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: I Project name: C KI 5TU F I4 ❑Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: 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'l 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.)
i Limited energy,multi-family 75.00 2
I 0 Oi. •. i. i�l 1 IL e_.___&'
- t es/ t A . . ..Ji L... ! residential(with above sq.ft.)
Services or feeders installation,alteration,and/or relocation
i ' 200 amps or less 100.70 2
•Oil PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
I(i �,�`sT , 401 amps to 600 amps 200.34 2
Name: (Asp)V
601 amps to 1,000 amps 301.04 2
Address: [p S 5\,,,j mm ,e 51 , Over 1,000 amps or volts 552.26 2
City/State/ZIP: / 1\lT"f'C op_. 2 / Temporary services or feeders installation,alteration,and/or
1 relocation
Phone:( goo .31030 Fax:( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation:This instal . ion is being made on proterty that I own which is not t--
intended f o r sale,lease ent,o x h.••' • t Ing o 0 RS 447,449,670, d 7 1. 401 amps to 599 amps 168.54 2
/ Branch circuits—new,alteration,or extension,per panel
Owner signature: _ _ _ �� A._ Date: '{ 7 Q l� A.Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
-
Business name: B.Fee for branch circuits without
service or feeder fee,first 1 56.18 2
Contact name: branch circuit -
Each add'I branch circuit 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: OW/,J 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
Investigation(1 hr min) 66.25/hr
City/State/ZIP: Industrial plant(1 hr min) 78.18/hr
Phone:( ) Fax:( ) Inspections for which no fee is 9000/hr
specifically listed(%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):
TOTAL PERMIT FEE:
Authorized signatur
■ This permit application expires if a permit is not obtained within 180
Print name: /0 }� s�/ Date: /7/0/13 • Number of it has
oweddpperape�accepted as complete.
I:\Building\Permits\ELC-PermitApp.doc 07/01/10 440-4615T((Il/05/COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating,Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls 1
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1\Building\Permits\ELC-PermttApp doc 07/01/10
RECE ED
Property Owner Statement JAN 10 2013
Regarding Construction Responsibilities YOFTIGARD
•Oregon Law requires residential construction permit applicants who are not licensed;w 3\J SON
Construction Contractors Board to sign the following statement before a building pefmi can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical,and plumbing per mits.
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 be em wooerty I own, a residence that I reside in, or a residence that I w ill
reside will in.p If I rfor hire ing subcontractors rk on prp, Iwill 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 homeowner statement is true and accurate.
k OPc1.k ff C,F.(‘s-r U Pie-A N
Print Name of Permit Applicant
►.4 - ! - I 1 fel02013
Signature of '•- it ,F.?PIc A Date
Permit#: H --k-OiO( - 0000 9-
Address: 11)%1S5 .b W 1: 1-4-tN1-1 L R OL': 'Yr- '►�-,\ Vii.
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Issued • : ,_ 0 Date: �/ .! 1 , _ t l li
This Copy for Permit Offices
Location:
Record Type:
Inspection Type:
Comments:
Inspection Date:
Record ID:
Result:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
12785 SW SUMMIT RIDGE ST, TIGARD, OR,
97224
Residential - Master Permit
299 Final inspection
02/25/2013 00:00
MST2013-00002
PASS - C of O
Violation Summary:
Inspector Contractor
Location:
Record Type:
Inspection Type:
Comments:
Inspection Date:
Record ID:
Result:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
12785 SW SUMMIT RIDGE ST, TIGARD, OR,
97224
Residential - Master Permit
199 Electrical final
02/25/2013 00:00
MST2013-00002
PASS
Violation Summary:
Inspector Contractor