Permit Buifdink Permit Application EXPIRED a /mss /i.3 4
FOR OFFICE USE ONLY
RE CEI V E D R eceived
il . City of Tigard DateB : � m � Permit No.: NSjOrj /��Oboi?Z-
13125 SW Hall Blvd., Tigard, OR 97223
CIlYOFTM AI Plan Rev,
Phone: 503.718.2439 Fax: 503.598.1960 AY - 3 2012 Date/By. 1 ' '� )5 i7 1— Other Permit:
T I G i1 K D Inspection Line: 503.639.4175 Date Re. • ;: y: �� �� �>{/f Aids: See Page 2 for
Internet: www.tigard- or.gov IGq ;p Notified/Method: '�7�►tr ® Supplemental Information
BUILDING DIVISION /9�7 IA l'o►`lii calla( c
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 (rotnded 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. P
Valuation: $ 0 .
and 2- family dwelling ❑ Commercial/industrial t p
❑ Accessory building ❑ Multi - family
Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE ( ITEE INFORMATION AND LOCATION Total number of floors:
Job site address: 13 P/ ` Z -rfi g_k04 New dwelling area: Ze)6 square feet
City /State /ZIP: T t✓ C3t__ Garage /carport area: square feet 4
Suite/bldg. /apt. no.: Project name: Covered porch area square feet
Cross street/directions to job site: Deck area: I u e3, square feet
Other structure area: square feet k-
REQUIRED DATA: COMMERCIAL -USE CHECKLIST C\
Subdivision: Lot no.: Permit fees' are based on the value of the work performed.
Indicate the value (rotnded to the nearest dollar) of all —L
Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the
DESCRIPT ON OF WORK work indicated on this application.
6 .F .2601 11� L (01 i � • p V _ Valuation: $
fl cr6+r`i F - nti�.
CkSi K.Cg'e - s 'y j� Anoc�)� N€CJ DC--1� Existing building area square feet
New building area: square feet kr OWNER ❑ TENANT Number of stories:
111
Name: '-0...4 o y . f l In,. ` Q . [ , v t _ Type of construction:
Address: q2 ) ,3 9_0) Occupancy groups: 1•
City /State /ZIP: es Existing: \
Phone: (f, 3) ow / Ze. o c7 Fax: ( )
New:
APPLICANT ❑ CONTACT PERSON
NOTICE
Business name: 1/4„.\,.„....0._ teci �^ All contractors and subcontractors are required to be
par> Contact name: --' f�,`` licensed with the Oregon Construction Contractors Board N�
under ORS 701 and may be required to be !tensed in the
Address: I . 5-5 - /)4 g' — *ADC jurisdiction in which work is being performed. If the
City /State /ZIP: 46.,?, l ,\ b f 6 - T" I I Z4
applicant is exempt from licensing, the following reasons
Phone: ( ? 3 3 3 Fax: : ( )
E -mail: a Ul►t 1� (l7 r 9 Mira• 1 r ( \-
CONTRACTOR BUILDING PERMIT FEES*
(Please refer to fee schedule) A
Business name: Permit fee:
Address:
State surcharge (12% of permit fee):
City /State /ZIP: FLS plan review (40% ofpermit fee):
Phone: ( ) Fax: ( ) (Due upon application.)
CCB lit.: , Total permit fees:
Authorized signature: /�,' Amount received:
0 /_/ This permit application expires if a permit is not obtained
Print name: 1f r 1.- 1 ik Date: 1g_ within 180 days after it has been accepted as complete.
!� * Fee methodology set by Tri -County Building Industry
Service Board
I: Building Permits'FPS-PcrmitApp.doc 02/01/2011 440-4613T(l1 /02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2 - Supplemental Information
Describe work to be done:
1.) El New 2.) Modification to sprinkler heads only:
❑ Addition El 1 -10 heads: No plan review required.
El Alteration ❑ 11+ heads: Plan review required.
El Repair
Number of sprinkler heads:
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
❑ Wet ❑ Dry
Additional Standpipes
Information: Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
Submittal shall Battery Calculations ❑ Yes
include: Individual Component ❑ Yes
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $
FLS Plan Review (40% of permit fee): $
TOTAL: $
Plan review requires a completed application and three (3) sets of plans at submittal.
Plan review fees are required at submittal.
I: \Building \Permits \FPS - PermitApp.doc 02/01/2011 2
Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard , ' eceivev d
�n �1 permit No.: l �a
III
0 q
City R ECEIVE ate !� !/ v , � (//yt -v am / •
Q
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2439 Fax: 503.598.1960 Other Permit:
I I G A R D Inspection Line: 503.639 MAY — 3 �012 Date Ready/By: Juris: RI See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
CITY OF TIGA D
TYPE OF WO
IJILDINl7 fl COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
N 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*
gi- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist.
❑ Multi - family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heatinp/cooling:
Air conditioning
Job site address: V A 4Z t (2 i d c T � (requires site plan showing placement) 46.75
City /State /ZIP: �- t ,� n ^ ,� f Furnace 100,000 BTU (ducts/vents) 46.75
t 1 C.L it —v ` Furnace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: Project name: Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work Z 23.32 4/(,. t•
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 23.32
P �� J� Gas fireplace/insert 33.39
C Q t"sue s c L - °` c j.J Flue vent for water heater or gas
fireplace 23.32
�� Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
❑ PROPERTY OWNER ❑ TENANT Chimney/liner/flue/vent 23.32
, l Other: 23.32
Name: ` 1 M 044 ` M t•.PrtJ Environmental exhaust and ventilation:
Address: 1't- IS Li 'L 'Tt�ev R O '--v�L--(R -10- Range hood/other kitchen
equipment ment 33.39
City /State /ZIP: ••"\ aft id-C-- Clothes dryer exhaust 33.39
`� Single -duct exhaust (bathrooms,
Phone: \ b _-7 -tp Fax: ( ) toilet compartments, utility rooms) 23.32
❑ APPLICANT CONTACT PERSON Attic /crawlspace fans 23.32
Business name: Other: 23.32
�7r �t.S 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: 565) -260 -sip s3 Fax: : ( ) Water heater
E -mail: Fireplace
Range
CONTRACTOR Barbecue
Business name: Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES* -A
City/State /ZIP: Subtotal y( ., -�`f
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) 4.3 .c.,
Plan review (25% of permit fee)
CCB tic.: 49 State surcharge (12% of permit fee) ( 0. 00
TOTAL PERMIT FEE O. eC
Authorized Si r" This permit application expires if a permit is not obtained within 180
_■ days after it has been accepted as complete.
,r
I Print :/! -- D ate: — * Fee methodology set by Tri -County Building Industry Service Board
I:\Building\Pe it 1 C- PermitApp . • • • 07/12 440-4617T (1 I /02/COM/WEB)
' Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi - Family Fee Schedule:
Total Valuation: - Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
, $500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
$2:54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
1:\Building\PennitsVv1EC- PermitApp.doc 03/07/12 2
Elettricaf Permit Application FoR OFFICE USE ONLY
51 • City of Tigard , eied / Permit No.: 13125 SW Hall Blvd., Tigard, OR 97223 RE CE " 4 �
1 � :
; • .
C Phone: 503.718.2439 Fax: 503.598.1960 , Other Permit:
TI G A R D Inspection Line: 503.639.4175 MAY - 3 2012 Date Ready/By: Juris: El See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK p CI I f Tf y ! I � O �� FFTIGARD PLAN REVIEW
❑ New construction [ Addition /alteratiord� dCEtGt DIVISION 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
4E61- and 2- family dwelling ❑ CommerciaUindustrial ❑ 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 - ", "1 - ",
1 2 I OOHP or more. occupancy.
Job no.: Job site address: )��Z -I- eta. T€ A 6 ❑ Recreational vehicle arks.
❑ Six or more residential units. p
City/State /ZIP: "r I (1,43 era-- ❑ Health -care facilities. ❑ Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: ❑ 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'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
sq. 75.00 2
DESCRIPTION OF WORK ( with above q• ft. )
Limited energy, multi - family 75.00 2
tVOt n► —1 Z-•—%D e...o2 ila'S t residential (with above sq. ft.)
AD DL or feeders installation, alteration, and/or relocation
ADDLr; el ("Jag- ("Jag- 67C15 Cier 200 amps or less 100.70 2
PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 'Tr`,�&I ("\O 4t % IA(., 601 amps to 1,000 amps 301.04 2
Address: I?� 4 7 f ems,(1� Over 1,000 amps or volts 552.26 2
d 11 ``-- '''' Temporary services or feeders installation, alteration, and /or
City/State /ZIP7N c..,,A 0 0 relocation
Phone: (5t', 5) O i0 _ p� Fax: ( ) 200 amps or less 59.36 1
�� '' 201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with I I I t
❑ 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: --'•e . .., branch circuit
Each add'I branch circuit f 7.42 '7. 4r2 2
Address: l - ,Z €' --
Miscellaneous (service or feeder not included)
City/State/ZIP:f� / 'a7 Each manufactured or modular 67.84 2
77r /l �j� dwelling, service and/or feeder
Phone: (,r35) "'( 7 � g'''' Fax: : ( ) Reconnect only 67.84 2
.TT 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:
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
Clty/State /ZIP: Industrial plant (1 hr min) 78.18 / hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed (%2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Subtotal: 103 , (,C)
Suprv. Electrician signature, required:
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): 7 Ur'
TOTAL PERMIT FEE: 7 1 t Z �
Authorized signature:
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 07/01/10 440-46I5T(11/05 /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:
rCOMMERCIAL WOR : K. ONLY: •
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000) :;
Check Type of Work Involved: •
L
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ 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- PermitApp.doc 07/01/10
CITY OF TIGARD
Building Division
TIGARD 13125 SW Hall Blvd.,Tigard, OR 97223 503.718.2439
INVOICE
TO: Tony Moghimian Customer ID: C13 -0002
13842 SW Fernridge Ter Invoice No.: INV2013 -00002
Tigard, OR 97223 Invoice Date: 2/25/2013
Date Due: 3/25/2013
I Case No. SiteAddress Subdivision - Lot # or Project Name Amoun D ue
MST2012 -00092 13842 SW Fernridge Ter Moghimian $50.31
Note: This permit was submitted
• 5/3/2012, plan review was
completed the permit was made
ready to be issued and balance of
plan review fees due were never
paid and permit was never issued.
Invoice Total: $50.31
® Please see attached fee schedule for description of fees due.
(Detach and return this portion with payment.)
Case No.: MST2012 -00092 Customer ID: C13 -0002
Site Address: 13842 SW Fernridge Ter Invoice No.: INV2013 -00002
Project: Moghimian Invoice Date: 2/25/2013
Date Due: 3/25/2013
Invoice Total: $50.31
Amount Paid: $
Office Note: Route copy of receipt to Dianna Howse.
Please mail payment to:
City of Tigard, Building Division
Attn: Dianna Howse
13125 SW Hall Blvd.
Tigard, OR 97223
1:\ Building \ Accounting \lnvoice.doc 01 /14/2011
a CITY OF TIGARD FEE AND PAYMENT HISTORY
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
.111G`ARID
MST2012 -00092 - 13842 SW FERNRIDGE TER, TIGARD, OR 97223
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt # Due
Plan Review 230 - 0000 -43106 $316.56 $316.56 $316.56 5/4/12 Check 186590 $0.00
Plan Review 230 - 0000 -43106 $35.81 $35.81 $35.81
Info Process /Archiving - Sm $0.50 (up to 230 - 0000 -43135 $14.50 $14.50 $14.50
11x17)
Totals for Fees $366.87 $366.87 $316.56 $50.31
Receipt # Payment Method Check # Payor: Receipt Date Receipt Amount
186590 Check 407 Hamid Moghimian DDS 05/04/2012 $316.56
& Zahra Moghimian
Total Payments: $316.56
Balance Due: $50.31