Permit CITY OF TIGARD • R . MASTER PERMIT
1 I COMMUNITY DEVELOPMENT 6 7 3 • Permit #: MST2013 -00122
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503 718.2439 : %.^ Date Issued: 06/13/2013
Parcel: 1 S 135 DA00400
Jurisdiction: Tigard
Site address: 11180 SW HALL BLVD
Subdivision: METZGER ACRE TRACTS Lot: 13
Project: Bergmann
Project Description: Add bathroom to existing shop. 6/27/2013: REPRINT permit to add 100' additional to water line,
(5) hose bibs and (1) backflow preventer.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms. 0 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 No
Total 0 sf Value $10,000 00 Rear 0
PLUMBING
Sinks' 0 Water Closets 1 Washing Mach 0 Laundry Trays 0 Rain Drain 0 Unnals 0
Lavatories 1 Dishwashers 0 Floor Drains: 0 Sewer Lines 30 SF Rain Storm Sewer 0
Tubs /Showers 0 Garbage Disp 0 Water Heaters: 1 Water Lines 130 Drains 0 Catch Basins. 0
Bckflw Prevntr 1
Footing Drain 0 Ice Maker: 0 Hose Bib. 5 Backwater Value 1
Drywell- Trench Drain 0 Other Fixtures 0
Other Fixture Units
MECHANICAL
Fuel Types 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
Fum > =100K 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits
1000 sf or less 0 0 -200 amp: 0 0 -200 amp 0 W/ Svc or Fdr 0
Ea add! 500 sf. 0 201 -400 amp. 0 201 -400 amp 0 W/O Svc/Fdr 0
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 Descnption 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:
BERGMANN FAMILY TRUST BERGMANN, KEN Required Items and Reports (Conditions)
BY BERGMANN, KENNETH L & 10726 SW 63RD PL
DONNA J TR TIGARD, OR 97223
10726 SW 63RD PL
PORTLAND, OR 97219
PHONE' PHONE. 503 - 781 -2193
FAX
Total Fees: $855 48
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
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 -0010 through OA 2 -0 0 You may obtain a copy of the rules or direct questions to OUNC by calling 50 232 1987 or 1 800 332 2344
Issued By: Permittee Signature: i
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each Inspection.
CITY OF TIGARD MASTER PERMIT
• COMMUNITY DEVELOPMENT • Permit #: MST2013 -00122
T l GARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/13/2013
Parcel: 1S135DA00400
Jurisdiction: Tigard
Site address: 11180 SW HALL BLVD
Subdivision: METZGER ACRE TRACTS Lot: 13
Project: Bergmann
Project Description: Add bathroom to existing shop
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 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: No
Total: 0 sf Value: $10,000.00 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: 30 SF Rain Storm Sewer: 0
Drains: 0
Tubs /Showers: 0 Garbage Disp: 0 Water Heaters: 1 Water Lines: 30 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Other Fixtures: 0
Drywell- Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types 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
Fum > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp 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: 0
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:
BERGMANN FAMILY TRUST BERGMANN, KEN Required Items and Reports (Conditions)
BY BERGMANN, KENNETH L 8 10726 SW 63RD PL
DONNA J TR TIGARD, OR 97223
10726 SW 63RD PL
PORTLAND, OR 97219
PHONE: PHONE: 503 - 781 -2193
FAX:
Total Fees: $638.33
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
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 -0010 through OAR 9 - 01 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: <0 Permittee Signature: J
Call 503.639.4175 by 7:00 a.m. for the next available Inspection date.
This permit card shall be kept in a conspicuous place on the Job site until completion of the project
Approved plans are required on the job site at the time of each Inspection.
Building Permit Application
Residential FOR OFFICE USE ONLY
R ECEIVED Received f ,
City of Tigard Date/B . , : / Permit No.: � �/ _IA 1...M 13125 SW Hall Blvd. Tigard, OR 97223
li g 1:1 2 8 2 013 � '�` (3
° Blvd., MAY Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/B : P • Other Permit:
Inspection Line: 503.639 Date Ready/By: ® y: loch See Page 2 for
I' I C. A It D
Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: p � 3 )75 Supplemental Information
BUILDING DIVISION, fPo /
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.
a.
Valuation: $ /0
❑ 1- and 2- family dwelling ❑ Commercial /industrial / c7J —
❑ 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: 1 I I cc e ) S UL/ /-4c.„ /l /3 ( v ti New dwelling area: square feet
City /State /ZIP: " Cr v C ] U « a 3 Garage /carport area: square feet
Suite/bldg./apt. no.: I Project name: 5 . C l e � / � ; 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.
j ; /1 (� L o 'y � j ... �� y Valuation: $
L•Q//1L� N •X j — Existing building area square feet
New building area: square feet
❑ PROPERTY OWNER I ❑ TENANT Number of stories:
Name: I Type of construction:
Address: ) cal .--) . ( j SW rY-/ /7/ Occupancy groups:
City /State /ZIP: P , -± (,, „ c .1 U C i > a /5' Existing:
Phone: (50j) l -. d / 93 Fax: (Su3) R t( ) Yo 9 New:
❑ APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
(Please refer to fee schedule)
Business name:
Structural plan review fee (or deposit):
Contact name:
FLS plan review fee (if applicable):
Address:
City /State /ZIP: Total fees due upon application:
Phone: ( ) Fax:: ( ) Amount received: / • 7 7
E -mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR roof -top mounted PhotoVoltaic Solar Panel System.
Business name: () (10 E. /'�- 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: ( ) State surcharge (12% of permit fee): $21.60
CCB lic.: / Total fee due upon application: $201.60
Authorized signature: �/ This permit application expires if a permit is not obtained
,�, ^1 p�� within 180 days after it has been accepted as complete.
• Fee methodology set by Tri -County Building Industry
Print name: 1<c r. Q �, S M a Date: s_ a 5 ...._... , 3 Service Board
I:\ Buildin \BUP- RESPermitApp.doc 02/24/2011 440 -4613T( 1 /02 /COM/WEB)
Building Permit Application Checklist -
One- and Two - Family Dwelling FOR OFFICE USE ONLY
•
City of Tigard Received Permit No.:
Date/By:
q 13125 SW Hall Blvd., Tigard, OR 97223 Associated permits:
Phone: 503.718.2439 Fax: 503.598.1960
I' I G A K D 24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
Internet: www.tigard -or.gov ❑ Other:
TI -IE 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 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- ❑ ❑ ❑
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 ❑ ❑ ❑
architect licensed in Ore:on 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 ". ❑ ❑ ❑
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 trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
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, ❑ ❑ ❑
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 Applicat
Building Fixtures
MAY 2 8 2013 Received
City of Tigard Date/By: 1 a8 / 3 C Permit No.: lY yraD / - �
14
V 13125 SW Hall Blvd., Tigard, OR �7 }, ® Plan Review
o Phone: 503.718.2439 Fax: 503. 6 F TIGARD Date/By: Other Permit No.:
Inspection Line: 503.639.4175 BUILDING DIVISION Date Read /B Ju ris: la See Page 2 for
TI G A K D Internet: www.ti ardor. ov Ready /By: g
g g Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction El Demolition For special information use check list
Description I Qty. I Ea. I Total
14 Addition/alteration/replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
1:1 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
TKI Accessory building CI Multi-family SFR (3) bath 500.32
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: / 1 1 k , C7 Sh/ / ? 6 /Vc-1 Catch basin or area drain J 18.76
City /State /ZIP: - G Drywell, leach line, or trench drain 18.76
U� S� aa3
d;,-,c,._ Footing drain (no. linear ft.: ) Page 2
Suite/bldg./apt. no.: Project name: 5 •+- u �� 5 / Manufactured home utilities Page 2
Cross street/directions to job site: J V Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: . 0 Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.:30) 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
ti.„ P r' t� v t o ` 4 r / Sc) . S `t �' C ) Dishwasher 25.02
o J Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
/ Fixture /sewer cap 25.02
Name: I< a r1 62 f M^ r ..
Floor drain/floor sink/hub 25.02
Address: / •7 -6 ) _s,.... G "_ /7/
Garbage disposal 25.02
City /State /ZIP: 6) c, ,- ± /e,., cJ O/ S a l5 Hose bib 25.02
Phone: ( S o3) 5-1 a 1 Fax: (5 )j a y6 _ / 4/0 9 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 (co rr.• ial) 12.51
Address: Sink/basi avatory ) 25.02
City /State /ZIP: Solar units (po • water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
CONTRACTOR Water closet
) 25.02
Water heater ) 37.52
Business name: J L,L) her Water piping/DWV 56.29
Address: 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: TOTAL PERMIT FEE
Print name: Date: This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building industry Service Board.
I:\ Building 'Permits\PLMU- PermitApp.doc 10/01/09 440- 4616T(I0 /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 - I" 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 Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
p 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
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 engineer.
- Jacuzzi/Whirlpool
-Each Stall ❑ New exterior plumbing site utilities for any complex structure
Car Wash: -
Each Stall 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
- 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/ServlUtil 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
RECEIVED
Property Owner Statement JUN 1 3 2013
Regarding Construction Responsibilities CITYOFTIGARD
Oregon Law requires residential construction permit applicants who are not Iicense•' i Q!G DIVISION
Construction Contractors Board to sign the following statement before a building permit 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:
ki I own, reside in, or will reside in the completed structure and my general contractor is:
K C' ,-, ,13 e• v1 `1 / 0 ti 3 % - q - iv
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
il' I will be performing work on property I own, a residence that I reside in, or a residence that I w ill
reside in. If I hire subcontractors, I will 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.
e il ez -. 6,, h ,,
Print Name of Permit Appl nt
Signature of Permit Appli nt Date
Permit #: / - O /ate,
/ / /PO Ski ' 9 c_ gLv, s = =
Address: �! ; zrl {` A
c i •
Issued by: "QV -- Date: 6/&33 t'li
This Copy for Permit Offices
)R ItJ) - -- R ECEIVED
MAY 2 8 2013
CITY OF TIGARD
BUILDING DIVISION
(.c- c S c d
o � 1 a
r —
s / 1
CITY OF TIGARD
Approved ... .�{ .,.. ... [ L�—
Conditionally Approved 1 [ j
See Letter to: Follow i [ I
ttache P
Permit Numbe A : ��v (� iE: -i I L
y f / Addr - `.' ∎
By: Date: r e/AIM
u J
Approved plans
shall be on job site.
OFFICE COPY
1 i - 'o6 1,c1