Permit CITY OFTIGARD MASTER PERMIT
� i ., DEVELOPMENT SERVICES LEP,Hi ; ��:„ .. • o {�IST7'7 -� ��7 ;
-M I '� 13125 SW Ha!! Blvd., Tigard, OR 97223 503 639.4171 DATE ISSUED: 0 3 i 6 / 3
PARCEL: 281 i.0CC -'Z 8B00
SITE ADDRESS... :15770 SW QUEEN. VICTORI1==. PL
SUBDTVI SION. . . . : ZONING
BLOCK........... LOT.............; JURISDICTION: KIN
Reoarks: Alteration SUN ROOM
-- --- - - ---- -- BUILDING -
REISSUE: STORIES • 1 FLOOR RREPS BASEMENT...: 0 sf REQUIRED SETBACKS - - -- REQUIRED -
CLASS OF WOR;. :ALT HEIGHT........: 0 FIRST 0 sf GARAGE • 0 sf LEFT . 0 SMOKE DETECTRE:
TYPE OF USE, ..:SF FLOOR LOAD....: 0 SECOND...: 0 sf FRONT : 0 PARKING SPACES: 0
TYPE OF CONST, :SN DWELLING UNITS: 0 FINBSMENT: 0 sf RIGHT : 0
OCCUPANCY GRP.:R33 FARM: 0 BATH: 0 TOTAL . 0 sf VALUE-$: 1000 REAR : 0
-- - -- PLUNGING - ---
SINKS • 0 WATER CLOSETS.: 0 WASHING MACH..: 0 LAUNDRY TRAYS.: 0 RAIN DRAIN ft: 0 TRAPS - • 0
LAVATORIES..,.: 0 DIEHWAEHERS...: 0 FLOOR DRAINS,.: 0 SEWER LINE ft: 0 SF RAIN DRAINS: 0 CATCH BASINS..: 0
TUB/SHOWERS...: 0 GARBAGE OISP..: 0 WATER HEATERS.: 0 WATER LINE ft: 0 BCKFLW PREVNTR: 0 GREASE TRAPS..: 0
. OTHER FIXTURES; 0
' MEC?ANICAL -- - - --
FUEL TYPES FURN ( 100K ..: 0 BOIL /CMPL t 3HP: 0 VENT FANS...,.: 0 CLOTHES DRYERS: 0
FURN ) =i00K ..: 0 UNIT HEATERS..: 0 HOODS....,....: 0 OTHER UNITS...: 0
MAX INP,: 0 BTU FLOOR FURNACES: 0 VENTS....,,...: 0 WiOODSTOVES.,..: 0 GAS OUTLETS.,.: 0
-- ELECTRICAL - -
--RESIDENTIAL u BR - CIR_. --MISCELLANEOUS-- -._
-- ;�;_;siur.N`rJ3T -- ---SERVICE/FEEDER---- - -TEMP S?i�C!FEEDcr[5 - - ---BRANCH �irc�rrsi5 - -- -- 'Renti�tLLAni�u�� - - -- - -AUD'L INSPECTIONS--
1000 SF OR LESS: 0 0 - 200 asp..: 0 0 - 200 aop..: 00 W /SVC OR FOR..: 0 PUMP /IRRIGATION: 3 PER INSPECTION: 0
EA ADD'L 500SF.: 0 201 - 400 aop..: 0 , 201 - 400 app..: 0 1st W/O SVC /FDR: 0 SIGN /OUT LIN LT: 0 • PER HOUR.,....: 0
LIMITED ENERGY.: 0 401 - GOO app..: 0 401 - 600 anp..: 0 EA ADDL BR -CIR: 0 5IGNAL!PANEL...: 0 IN PLANT....:.: 0
MA NF HN /SVC /FDR: 0 601 - 1000 app.: 0 601 +aoos -1000 v: 0 MINOR LABEL -10: 0
1000+ asp /volt.: 0 PLAN REVIEW SECTION -- -
Reconnect only,: 0 ) =4 RES UNITS,.: SVC /FDR) =225 A_: ) 600 V NOMINAL: CLS AREA /SPC OCC:
ELECTRICAL - RESTRICTED ENERGY
A. SF RESIDENTIAL - - - - -- B. COMMERCIAL - - ---
AUDIO & STEREO.: VACUUM SYSTEM..: AUDIO & STEREO.: FIRE ALARM • INTERCOM /PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM..: OTH: :: BOILER • HVAC ..... ....... LANDSCAPE /IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER..: CLOCK..........: INSTRUMENTATION: MEDICAL . OTHR: ..
HVAC DATA /TELE COMM.: NURSE CALLS....: TOTAL 1 SYSTEMS: 0
Owner: Contractor: TOTAL FEES:$ 42,50
RALEIGH MEYER OWNER
15770 SW QUEEN VICTORIA PL
KING CITY OR 97224 .
Phone 5: Phone 5;
Reg S..:
This oeroit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Specialty Codes and all other
applicable laws. All work will be done it accordance with approved plans. This peroit will expire if work is not started within 180
days of issuance, or if work is suspended for Dore than 183 days.
REQUIRED INSPECTIONS - --
Franing Insp
Insulation insp - - -
Oya Board lnsp -
Building Final — _ '
r e r ., is i. r .r a e Signature: ,(r s �.l - ci _- ! _- __ _____._...._..
H "1 for inspection - 639• -4175
Plan Check '51
.. OF TIGARD Residential Building Permit Application Recd By
25.SW HALL BLVD. New Construction Additions or Alterations. Date Recd 5'17 i7
.ARD, OR 97223 Single Family Detached or Attached (Duplex) Date to P E.
33-634 -4171 Oate to DST - /
503 -684 -7297 Permit 4 MST qi -07073
Print or Type Called 032 c'22y1 k—
Incomplete or illegible applications will not be accepted V ,� �
Name of Protect Name •
Job f1).- / R 1 R bL6-t-" Architect Mailing Address
Address Site Address
15nnv 5ui.. A ite's ") I) - cT'2'i& p C,
_ , fS' •• I e 1 10A G L r'-/ � D /l ct') t- t -!f
1 S7 70 �' Name City /State Zip Phone
2 u.Le -i 6/'( °t• Vc_1? AZ N) '1 - ') Name
Owner Mailing Address
/5 S c3 0uE_ U-� _TS i i PI.
City/State Zip Pho ne Engineer Mailing Address
lr' I N& C / `� O � Cf r 2. Z 6 21> --7 City /State Zip Phone
Name
General 5P L F Describe work New 0 Addition 0 Alteration 0 Repair 0
Contractor Mailing Address to be done:
Additional Descnption of Work:
City/State Zip Phone '
Oregon Const. Cont. Board Lrcri Exp. Date
4ttach Copy of
- Current -COT Business- Tax -or Metro A - Exp. - Date -- -- - PROJECT - - -- - - - - -- — — - - - -- _
Licenses - VALUATION
"' n Name NEW CONST U O
Mechanical
Sub- Marlin 3,e
ress Sq. Ft. House: Sq. Ft. Garage
•:ontractor Corner Lot YES NO Flag Lot YES NO
City/State Zip Phone
(check one) (check one) ,
Oregon Const. Cont. Boara Lic.0 Exp. Date Restricted Audio/Stereo Burglar
• teach Copy of Energy System Alarm
Current COT Business Tax or Metro 4 Exp. Date Installation Garage Door HVAC
Licenses Opener Systems
• Name (check all that
Other:
Plumbingr apply) -
Sub- Mailing Address Will the electrical subcontractor wire for all YES I NO
Contractor restricted energy installations?
CiryiS ;ate zip 1 Phone Has the Subdivision Plat recorded? N/A YES I NO
Oregon Const. Cont. Board Lic.4 I I Exp. Date Reissue of MST*: Solar Ccmpliance
Attach Copy of (Calculation Attached)
Current Plumbing L:c. 4 1 Exp. Date I hearby acknowledge that I have read this application, that the
Licenses I information given is correct. that I am the owner or authorized
COT Business Tax or Metro 4 I Exp. Date agent of the owner. and that plans submitted are in compliance
Name with Oregon State laws.
a re of wn gent Date
Electrical ,�.1� 1
Sub - Mailing A ddress Contact P son Name � � P #
• :ontractor
CityrSta:e Zio Phone FOR OFFICE USE ONLY:
Plat #: Map/TLtt:
Oregon Const. Cont. Board Lic.$ Exp. Date
teach Copy of Setbacks: I Zone: Solar. / / /
Current Eiecncal L:c. 4 Exp. Date
Licenses Engineering Approval: I Planning Approval: TIE
COT Business Tax or Metro 4 Exp. Date
i:\sfapp.doc (dst) 1/97
P rmi # Account Description Amount Amt. Pd. Bal. Due
ni51fl -00731 1ST. Permit (BUILD) 23: " .
' 915 ^O° •
Plumb: Permit (PLUMB)
Mech. Permit (MECH)
ELC /ELR Permit (ELPRMT)
State Tax (TAX) /,ZJ 1.
Bldg: /, 2
Plumb:
Mech:
ELC /ELR:
Plan Check -
MST: (BUPPLN) 16 • a5
Plumb: (PLMPLN)
Mech: • (MECPLN)
CDC Review (LANDUS)
Sewer Connection (SWUSA)
Sewer Inspection (SWINSP)
Parks Dev Charge (PKSDC)
Residential TIF (TIF -R)
Mass Transit TIF (TIF -MT)
Water Quality (WQUAL)
Water Quantity (WQUANT)
Erosion Control Permit (ERPRMT)
Erosion Planck/USA (ERPLAN)
Erosion Planck/COT (EROSN)
Fire Life Safety (FLS)
1�
TOTALS: i/c2 , 9%. 51)
Osfapp.doc (dst) 1197
Permit #: , 5T 9 - 7 "s
• OF O
Address: I c7 7 a`^' � V�ZTar> f f
`�. Issued by: Date: 03
� 5 9
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:
at 1. I own, reside in, or will reside in the completed structure.
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
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 information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this for .
.J .. X 06 9
(Signature of permit .' plicant) (D. e)
(White copy to issuing agency permit file,
pink copy to applicant)
En1To m era n Pl ��I y 0' � En'o [�
nn j��v \r�S� C) \ V� c�J
lArnou'( �`A\J1111 ��J���J.��l�!l�L� lacco_y_'oi:.[KL' o
/Vote: 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.
rl;l 11, I Ll. r!, l7 I - i l,. 1. 1
L _ . ' f,
J- 1:,�4������•. :J lam' /J �_ _� _. .5a
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the
construction or improvement 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:
Oregon's vv:t1!1:�_ "d?mg pax law: 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 yo emp :oyees. For mo-:;
information, call the Oregon Dept. of Revenue at 945 -8091.
'J-^emvp o u gent insurance "...ax: .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.
WorZ ers' cTSU:VEET._2: As an employer, you are subject to the Oregon Workers' Compensation Law, and roust
obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject to penalties and will be ;_able for all claim costs if one of your employees is injured on t!'c job. For ono information,
call the Workers' Compensation Division at the Department of Consumer anc Business Services at 945 -7888.
U. . nmteraai Revenue Se v ce: As an employer, you must withhold federal income tax from employees' wages. You d1ill be
liable for the tax payment even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1- 800 -829 -1040.
Code comps5ance: 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.
Liability and property damage ^nsuramee: Contact your insurance agent to see if you have adequate insurance coverage for
accident. 3 and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must he
re -done.
Time to supervise e^mplloyees: 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
KC—
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CITY OF TIGARD BUILDING INSPECTION DIVISION
24 -Hour Inspection Line: 639 -4175 Business Phone: 639 -4171 el,,
Da equested: fiR I C i 1 A.M. P.M. MST: 7 0 0 7 3
Location: _ I I _I5 _1!1, u BUP:
Tenant: Suite: Bldg: MEC:
Contractor: Phone: `` PLM: � — - , 2 ",E /
Owner: fp
Phone: - Z�) ZZ ELC: WA ' i
ELR:
SIT:
BUILDING : LD con't) PL MECHANICAL ELECTRICAL SITE
Site •ost/Beam s e am Post/Beam Cover /Service Sewer /Storm
Footing Roof UndFl/Slab Rough -In Ceiling Water Line
Slab Framing n Top Out ..tt Gas Line Rough -In UG Sprinkler
Foundation Insulation J 1( I U / W " Sewer Hood/Duct Reconnect Vault
Bsmt Damp Drywall Storm Furnace Temp Service MISC.
Masonry Ceiling Rain Drain A/C UG Slab
Shear /Sheath Fire Spklr /Alm Crawl/Found Dr Heat Pump Low Volt
oved ) Approved Approved Approved
Appr /Sdwlk - "lsI roved Not A. 'roved Not Approved Not Approved Not Approved
IN • FINAL FINAL FINAL
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Inspector: At_ _ ._ Date: /1 Page of
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