Permit CITY OF TIGARD MECHANICAL PERMIT
11 COMMUNITY Permit#: MEC2014-00138
DEVELOPMENT
Date Issued: 05/07/2014
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1 S136CD00102
Jurisdiction: Tigard
Site address: 11681 SW PACIFIC HWY
Project: Jimmy John's Subdivision: 2006-016 PARTITION PLAT Lot: 3
Project Description: HVAC modifications for TI
Contractor: PROTEMP ASSOCIATES INC Owner: WILSAL LLC
9788 SE 17TH AVE 834 SW ST CLAIR ST
PORTLAND, OR 97222 PORTLAND, OR 97205
PHONE: 503-233-6911 PHONE:
FAX: 503-238-9767
FEES
Specifics: Description Date Amount
Type of Use: COM Permit Fee 05/07/2014 $855.71
Class of Work: ALT Type of Const: VB Plan Review 05/07/2014 $213.93
Occupancy Grp: B Occupancy Load: 12%State Surcharge-Mechanical 05/07/2014 $102.69
Stories: 1
Project Valuation: $30,000.00
Fuel Air Handlers
Fuel Types: Natural Gas Units<10000 cfm:
Gas Pressure: Units> 10000 cfm:
Furnaces Boilers&Compressors
Furnaces< 100K BTU: 0-3 HP:
Furnaces>= 100K BTU: 3-15 HP:
Floor Furnaces: 15-30 HP:
Unit Heaters: 30-50 HP:
Vents w/o Appliances: 50 or Greater HP:
Air Conditioning:
Heat Pump:
Appliances
Vent Fans: 2 Vent Systems: Total $1,172.33
Hoods: Comm Incinerators:
Required Items and Reports(Conditions)
Woodstoves: Gas Fireplaces:
Clothes Dryers: Other Mech Units:
Gas Outlets: Other Desc: Grills,
Duct Work: 1 Diffusers
Fire/Smoke Dampers:
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 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC • calling 503.232.1987 or 1.800.332.2344.
Issued By: ! l.LC / Permittee Signatur=•
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.
11.:rtr!F11.1'
Mechanical Permit Application I ,)R OFFICE USE ONLY
City of Tigard 252n"
Received ,�j(�� �� -er6/15�f
DateBy: �1
It
13125 SW Hall Blvd.,Tigard,OR 97223 Plan• vie
3 Phone: 503.718 2439 Fax: 503.598.1960 3i fry� `j� - . L Other Permit n``
Vi- 111Ul�t il, Date/By: /6uP�a/ :4
TI GAR D Inspection Line: 503.639.4175 Date Rea.• Juris to See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Alcliji Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE-USE CHECKLIST
9i i.i " Mechanical permit fees'are based on the value of the work
❑New construction C7 Addition/alteration,/replacement performed Indicate the value(rounded to the nearest dollar)of all
El Demolition
El Other: ti *14/r N mechanical materials,equipment,labor,overhead,and profit.
Value:5 30,000
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT/SYSTEMS FEES* "�
E] I-and 2-family dwelling [3/Commercial/industrial Commercial/industrial [71 Accessory building For special information use checklist. r�
❑Multi-family ❑ Master builder ❑Other: Description Qty. I Ea. I 'Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning 46.75
Job site address: //(0 8/ 5 ) P4C 1 F fC Ft IC�a-I t r9 y _ _ Furnace 100,000 BTU(duets/vents) 46.75 , (\
City/State/Z1P: 7-I0 Ida O,Q 97223 Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06 _
Suite/bldg./apt.no.: Project name: J/M h-t Y clog N 5 / Duct work 23.32
Cross street/directions to job site: 5w Pr�C1 F 1G KWY 3 Ste, 7c7r�E Hydronic hot water system 23.32
Residential boiler(radiator or Iry
hydronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for any of above 23.32
Other: 23.32 R----)
Subdivision: Lot no.: -
Other fuel appliances:
Tax map/parcel no.: /5/36 C7)06/0 2 Water heater _ 23.32
DESCRIPTION OF WORK Gas fireplace/insert 33.39
Flue vent for water heater or gas
TEN/4-NT /AA Pao v6 MENT 14..0 re t4 New teEST/4'IiR/4 N-- , fireplace 23.32
NEW NOA/ rrt,�.4€.4� P*a7.1770N Log g stove 23.32
5r� s/ FIN l$hltsr Wood/pellet stove 33.39
csgN ri JG I TGFN E4teJPMt'NTr, RESfROO M _-- — Wood fireplace/insert 23.32
.1-I 6-7 1.47 I NL7 Chimney/liner/flue/vent 23.32 3/15'
❑ PROPERTY OWNER I (3TENANr Other: - 23.32
Environmental exhaust and ventilation:
Name: //4./0/2 V ENTU.00;-/Ae - 5COTF PItJOr2 Range hood/other kitchen S
Address: equipment 33.39
>'5O 33 EVER6-T7,2_6-E-N Pik Imy 5 cAc_r TE . Clothes dryer exhaust 33.39 -
City/Slate/ZIP: r Single-duct exhaust(bathrooms,
� }y l �N- D2 97� ) toilet compartments,utility rooms) 23.32
-r--
Phone:( ) Fax:( ) Attic/crawlspace fans 23.32
❑ APPLICANT E'ONTACT PERSON Other: _ 23.32J
Fuel piping:
Business name: H
5T�r 4! CG 1(e[rL4 $14.15 for first four;$4.03 for each additional
Contact name: XUBEQT ,.1.4DN/SK`/ Furnace,etc.
Address: /??�.2 /�r e 5�/ 7 Gas heat pump
Ode
! � � Wall/suspended/unit heater
City/State/ZIP: 56-A. pi 9 i3 10 1 Water heater
Phone:(,204) 71 D.- 3 h Fax::( ) Fireplace
Range
E-mail: Re 8E2-r, 2t-( N i SK/ STr¢• T&-C. Cd tit Barbecue
CONTRACTOR '� Clothes dryer(gas)
Business name: ,2 A C f s . .-c s Other:
Tt3 p��rvL hhG����J �( T` MECHANICAL PERMIT FEES*
Address: 47 7n4 ! Sc f- '.( - Subtotal
'/�� 0 2 9101-1 Minimum permit fee($90.00)
Cily/State/LIP: /'�2 �- Plan review(25%of permit fee)
Phone:6,3) X33 —0,/ Fax:( ) State surcharge(12%of permit fee)
CCB lie.: '.3,16, TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within ISO
days after it has been accepted as complete.
Authorized signature: 7"°..e>,,,,d'
* Fee methodology set by'Fri-County Building Industry Service Board
Print name: `a/&F A J Date: 3/?j/ y
f\nuilding\Permits l.M1C_Permit App 040113 doc 440-4617T(11/02/COM/WEB)
riftCOMcheck Software Version 3.9.2
Mechanical Compliance Certificate
2010 Oregon Energy Efficiency Specialty Code
Section 1 : Project Information
Project Type: New Construction
Project Title : Jimmy Johns Tigard, OR
Construction Site Owner/Agent: Designer/Contractor:
11681 SW Pacific HWY Mark Robison
Tigard,OR 97223 Robison Engineering
20300 19th Ave NE
Shoreline,WA 98155
206-364-3343
Section 2: General Information
Building Location(for weather data): Adair Village,Oregon
Climate Zone: 4c
Section 3: Mechanical Systems List
Quantity System Type&Description
1 HVAC System 1 (Single Zone):
Heating: 1 each-Central Furnace,Gas,Capacity= 120 kBtu/h
Proposed Efficiency=81.00%Et,Required Efficiency=80.00%Et
Cooling: 1 each-Rooftop Package Unit,Capacity=72 kBtu/h,Air-Cooled Condenser,Air Economizer
Proposed Efficiency= 11.50 EER,Required Efficiency=11.00 EER
Fan System: None
Section 4: Requirements Checklist
In the following requirements, blank checkboxes identify requirements that the applicant has not acknowledged as being met. Checkmarks
identify requirements that the applicant acknowledges are met or excepted from compliance. 'Plans reference page/section'identifies where in
the plans/specs the requirement can be verified as being satisfied.
Requirements Specific To: HVAC System 1 :
a 1. Equipment meets minimum efficiency: Central Furnace(Gas): 80.00%Et(or 78%AFUE)
u 2. Equipment meets minimum efficiency: Rooftop Package Unit: 11.00 EER(11.2 IEER)
❑ 3. Energy recovery ventilation systems. Individual fan systems that have both a design supply air capacity of 5,000 cfm or greater and a
minimum outside air supply of 70 percent or greater of the design supply air quantity have an energy recovery system.
Exception(s):
O Where energy recovery systems are prohibited by the International Mechanical Code.
D Systems serving spaces that are not cooled and are heated to less than 60°F.
❑ Where more than 60 percent of the outdoor heating energy is provided from site-recovered or site solar energy.
j Type 1 kitchen exhaust hoods.
J Cooling systems in climates with a 1-percent cooling design wet-bulb temperature less than 64°F(18°C).
U Systems requiring dehumidification that employ series-style energy recovery coils wrapped around the cooling coil when the
evaporative coil is located upstream of the exhaust air stream.
J Systems exhausting toxic,flammable,paint exhaust,corrosive fumes,or dust.
j Laboratory fume hood systems that include qualifying features.
Plans reference page/section:
Project Title: Jimmy Johns Tigard, OR Report date: 01/30/14
Data filename: Untitled.cck Page 1 of 5
] 4. Supply air economizers shall be provided on each cooling system and are capable of providing 100-percent outdoor air,even if
additional mechanical cooling is required to meet the cooling load of the building.Systems provide a means to relieve excess outdoor
air during economizer operation to prevent overpressurizing the building.
Exception(s):
] Cooling equipment less than 54,000 Btu/hr total cooling capacity.
Plans reference page/section:
Generic Requirements: Must be met by all systems to which the requirement is applicable:
] 1. Calculation of heating and cooling loads. Design loads are determined in accordance with the procedures described in the
ASHRAE/ACCA Standard 183.Alternatively,design loads have been determined by an approved equivalent computation procedure.
0 2. Packaged Electric Equipment.Specified packaged electrical equipment has a heat pump as the primary heating source.
Exception(s):
] Unstaffed equipment shelters or cabinets used solely for personal wireless service facilities.
❑ Requirement is not applicable.
Plans reference page/section:
] 3. Equipment and system sizing.Heating and cooling equipment and systems capacity do not exceed the loads calculated in accordance
with Section 503.2.1.
Exception(s):
] Required standby equipment and systems provided with controls and devices that allow such systems or equipment to operate
automatically only when the primary equipment is not operating.
U Multiple units of the same equipment type with combined capacities exceeding the design load and provided with controls that
have the capability to sequence the operation of each unit based on load.
Plans reference page/section:
U 4. HVAC Equipment Performance Requirements.Reported efficiencies have been tested and rated in accordance with the applicable test
procedure.The efficiency has been verified through certification under an approved certification program or,if no certification program
exists,the equipment efficiency ratings are supported by data furnished by the manufacturer.
] 5. Thermostatic Controls.The supply of heating and cooling energy to each zone is controlled by individual thermostatic controls that
respond to temperature within the zone.
Plans reference page/section:
] 6. Heat pump supplementary heat.Heat pumps having supplementary electric resistance heat have controls that,except during defrost,
prevent supplementary heat operation when the heat pump can meet the heating load.
Plans reference page/section:
] 7. Set point overlap restriction.Where used to control both heating and cooling,zone thermostatic controls provide a temperature range
or deadband of at least 5°F(2.8°C)within which the supply of heating and cooling energy to the zone is capable of being shut off or
reduced to a minimum.
Exception(s):
j Thermostats requiring manual change over between heating and cooling modes.
Plans reference page/section:
] 8. Optimum Start Controls.Each HVAC system has controls that vary the start-up time of the system to just meet the temperature set
point at time of occupancy.
Plans reference page/section:
] 9. Off-hour controls. Each zone is provided with thermostatic setback controls that are controlled by either an automatic time clock or
programmable control system.
Exception(s):
] Zones that will be operated continuously.
D Zones with a full HVAC load demand not exceeding 6,800 Btu/h(2 kW)and having a readily accessible manual shutoff switch.
Plans reference page/section:
] 10.Shutoff damper controls.Both outdoor air supply and exhaust are equipped with not less than Class I motorized dampers.
Exception(s):
] Gravity dampers shall be permitted for outside air intake or exhaust airflows of 300 cfm or less.
Plans reference page/section:
Project Title: Jimmy Johns Tigard,OR Report date: 01/30/14
Data filename: Untitled.cck Page 2 of 5
❑ 11.Freeze Protection and Snow melt system controls.Freeze protection systems,such as heat tracing of outdoor piping and heat
exchangers,including self-regulating heat tracing,include automatic controls capable of shutting off the systems when outdoor air
temperatures meet code criteria.
Plans reference page/section:
] 12.Separate air distribution systems.Zones with special process temperature requirements and/or humidity requirements are served by
separate air distribution systems from those serving zones requiring only comfort conditions,or shall include supplementary control
provisions so that the primary systems may be specifically controlled for comfort purposes only.
Exception(s):
] [503.2.4.8+]Zones requiring only comfort heating or comfort cooling that are served by a system primarily used for process
temperature and humidity control.
Plans reference page/section:
u 13.Humidity control.If a system is equipped with a means to add or remove moisture to maintain specific humidity levels in a zone or
zones,a humidity control device is provided.
Plans reference page/section:
u 14.Humidity control.Where a humidity control device exists it is set to prevent the use of fossil fuel or electricity to produce relative
humidity in excess of 30 percent.Where a humidity control device is used for dehumidification,it is set to prevent the use of fossil fuel
or electricity to reduce relative humidity below 60 percent.
Exception(s):
] Hospitals,process needs,archives,museums,critical equipment,and other non-comfort situations with specific humidity
requirements outside this range.
Plans reference page/section:
u 15.Humidity control.Where a humidity control device exists it is set to maintain a deadband of at least 10%relative humidity where no
active humidification or dehumidification takes place.
Exception(s):
L.1 Heating for dehumidification is provided with heat recovery or heat pumping and the mechanical cooling system efficiency is 10
percent higher than required in section 503.2.3,HVAC equipment performance requirements.
Plans reference page/section:
u 16.Ventilation.Ventilation,either natural or mechanical,is provided in accordance with Chapter 4 of the International Mechanical Code.
Where mechanical ventilation is provided,the system has the capability to reduce the outdoor air supply to the minimum required by
Chapter 4 of the International Mechanical Code.
Plans reference page/section:
] 17.Demand controlled ventilation(DCV). DCV is required for spaces larger than 500 ft2 for simple systems and spaces larger than 150 ft2
for multiple zone systems.
Exception(s):
] Systems with energy recovery complying with Section 503.2.6
] Spaces less than 750 ft2(69.7 m2)where an occupancy sensor turns the fan off,closes the ventilation damper,or closes the
zone damper when the space is unoccupied.
Plans reference page/section:
❑ 18.Kitchen hoods. Kitchen makeup is provided as required by the Oregon Mechanical Specialty Code.
Exception(s):
j Where hoods are used to exhaust ventilation air that would otherwise be exhausted by other fan systems.
] Kitchen exhaust systems that include exhaust air energy recovery complying with section 503.2.6.
Plans reference page/section:
u 19.Enclosed parking garage ventilation controls. In Group S-2,enclosed parking garages used for storing or handling automobiles employs
automatic carbon monoxide sensing devices.
Plans reference page/section:
] 20.Duct and plenum insulation and sealing.All supply and return air ducts and plenums are insulated with the specified insulation.When
located within a building envelope assembly,the duct or plenum is separated from the building exterior or unconditioned or exempt
spaces by a minimum of R-8 insulation.All ducts,air handlers and filter boxes are sealed.Joints and seams comply with Section 603.9
of the International Mechanical Code.
Exception(s):
Li When located within equipment.
] When the design temperature difference between the interior and exterior of the duct or plenum does not exceed 15°F(8°C).
Project Title: Jimmy Johns Tigard. OR Report date: 01/30/14
Data filename: Untitled.cck Page 3 of 5
] 21.Low-pressure duct systems.All longitudinal and transverse joints,seams and connections of low-pressure supply and return ducts are
securely fastened and sealed with welds,gaskets,mastics(adhesives),mastic-plus-embedded-fabric systems or tapes installed in
accordance with the manufacturer's installation instructions.
Exception(s):
] Continuously welded and locking-type longitudinal joints and seams on ducts operating at static pressures less than 2 inches w.g.
pressure classification.
Plans reference page/section:
] 22.Medium-pressure duct systems.All ducts and plenums designed to operate medium-pressure are insulated and sealed in accordance
with Section 503.2.7.Pressure classifications specific to the duct system are clearly indicated on the construction documents.
Plans reference page/section:
] 23.High-pressure duct systems.Ducts designed to operate at high-pressure are insulated and sealed in accordance with Section 503.2.7.
In addition,ducts and plenums are leak-tested in accordance with the SMACNA HVAC Air Duct Leakage Test Manual.
Plans reference page/section:
] 24.Air system balancing. Each supply air outlet and zone terminal device is equipped with means for air balancing in accordance with the
requirements of IMC 603.17. Discharge dampers intended to modulate airflow are prohibited on constant volume fans and variable
volume fans with motors 10 horsepower.
Plans reference page/section:
0 25.Manuals.The construction documents require that an operating and maintenance manual be provided to the building owner by the
mechanical contractor.See long description for specifications.
Plans reference page/section:
] 26.Air System Design and Control.Each HVAC system having a total fan system motor nameplate hp exceeding 5 hp meets the provisions
of Sections 503.2.10.1 through 503.2.10.2.
Plans reference page/section:
] 27.Allowable fan floor horsepower.Each HVAC system at fan system design conditions does not exceed the allowable fan system motor
nameplate hp(Option 1)or fan system bhp(Option 2)as shown and calulated in requirement details.
Exception(s):
] Hospital and laboratory systems that utilize flow control devices on exhaust and/or return to maintain space pressure relationships
necessary for occupant health and safety or environmental control shall be permitted to use variable volume fan power limitation.
D Individual exhaust fans with motor nameplate horsepower of 1 hp or less.
Plans reference page/section:
U 28.Motor nameplate horsepower. For each fan,the selected fan motor is no larger than the first available motor size greater than the brake
horsepower(bhp).
Exception(s):
• For fans less than 6 bhp,where the first available motor larger than the brake horsepower has a nameplate rating within 50
percent of the bhp,selection of the next larger nameplate motor size is allowed.
] For fans 6 bhp and larger,where the first available motor larger than the bhp has a nameplate rating within 30 percent of the bhp,
selection of the next larger nameplate motor size is allowed.
Plans reference page/section:
] 29.Large Volume Fan Systems. Fan systems over 8,000(7 m3/s)cfm without direct expansion cooling coils that serve single zones reduce
airflow based on space thermostat heating and cooling demand.A two-speed motor or variable frequency drive reduces airflow to a
maximum 60 percent of peak airflow or minimum ventilation air requirement as required by Chapter 4 of the International Mechanical
Code,whichever is greater.
Exception(s):
I] Systems where the function of the supply air is for purposes other than temperature control,such as maintaining specific humidity
levels or supplying an exhaust system.
Plans reference page/section:
] 30.All air-conditioning equipment and air-handling units with direct expansion cooling and a cooling capacity at ARI conditions greater than
or equal to 110,000 Btu/h that serve single zones have their supply fan operation controlled according to code specific requirements.
Exception(s):
D Systems where the function of the supply air is for purposes other than temperature control,such as maintaining specific humidity
levels or supplying an exhaust system.
Plans reference page/section:
Project Title: Jimmy Johns Tigard, OR Report date: 01/30/14
Data filename: Untitled.cck Page 4 of 5
1 l
• 31.Series fan-powered terminal unit fan motors.Fan motors for series fan-powered terminal units are electronically-commutated motors
and have a minimum motor efficiency of 70 percent when rated in accordance with NEMA Standard MG 1-2006 at full load rating
conditions.
Plans reference page/section:
• 32.Hot Gas Bypass Limitation.For cooling systems<=240 kBtu/h,maximum hot gas bypass capacity is no more than 50%total cooling
capacity.
Plans reference page/section:
Section 5: Compliance Statement
Compliance Statement: The proposed mechanical design represented in this document is consistent with the building plans,specifications
and other calculations submitted with this permit application.The proposed mechanical systems have been designed to meet the 2010
Oregon Energy Efficiency Specialty Code requirements in COMcheck Version 3.9.2 and to comply with the mandatory requirements in the
Requirements Checklist.
•
1\II b. g ov,t oh, r't• _311•11. II(
Name-Title Signature Date
Section 6: Post Construction Compliance Statement
• HVAC record drawings of the actual installation,system capacities,calibration information,and performance data for each equipment
provided to the owner.
• HVAC O&M documents for all mechanical equipment and system provided to the owner by the mechanical contractor.
0 Written HVAC balancing and operations report provided to the owner.
The above post construction requirements have been completed.
Principal Mechanical Designer-Name Signature Date
Project Title: Jimmy Johns Tigard, OR Report date: 01/30/14
Data filename: Untitled.cck Page 5 of 5
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL HEALTH PROGRAM
155 North First Avenue, MS 5, Suite 160
Hillsboro,OR 97124
Telephone:(503)846-8722 ♦ Fax: (503)846-3705 Public Health
www.co.washington.or.us/foodsafety Prevent Promote. Protect.
RESTAURANT PLAN REVIEW INSTRUCTIONS
This packet includes information and instructions for restaurant plan review. Floor plan, menu, and food
preparation activities will be reviewed to assure your proposed new or remodeled facility will meet health
code requirements. Please follow the instructions included in this packet and be sure all information is
complete. Incomplete information may result in delays.
General Restaurant Requirements are included in this packet; however, for complete information
regarding restaurant sanitation requirements please review the Oregon Food Sanitation Rules. Copies of
the rules are available online at www.healthoregon.org/foodsafety or in our office.
1. Submit the Plan Review Application, Floor Plan, Menu, Food Service Preparation Activities Form,
Food Cooling & Reheating Form (forms included in this packet) and appropriate fee to Washington
County either in our office or by mail:
Washington County Environmental Health Program
155 North First Avenue, MS 5, Suite 160
Hillsboro, OR 97124
2. You will receive a written response within 10 working days. If changes are required to your plans,
you will be notified. Construction may not begin until your plans receive approval from this office.
Required Inspections:
New Facilities: Prior to opening the facility, you must pass a pre-opening inspection. This
inspection is conducted when construction is complete and all equipment is installed and
operational. Submit a license application and license fee to this office prior to scheduling the pre-
opening inspection. Call (503) 846-8722 to schedule a pre-opening inspection at least one week
prior to the anticipated opening date. Staff will then contact you by telephone and conduct an
operational review of your facility prior to the pre-opening inspection. Your business may not open
until you receive approval from this office and other required agencies.
Remodeled Facilities: During remodel construction, the facility may not operate if there is an
interruption in power, gas, sewage disposal, or water supply. Complete all construction activities
that create dust or other possible contamination during closed hours or under methods of
contamination containment. If the facility is closed for business during the remodel, an inspection is
required prior to re-opening. If the facility is open during the remodel, the remodeled area must be
inspected prior to use. Call (503) 846-8722 to schedule an inspection.
Note: New construction and remodels may require the approval of other agencies. Please contact other
appropriate authorities including zoning, planning, building, plumbing, and fire departments to determine
requirements.
12/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES
"""s4 ENVIRONMENTAL HEALTH PROGRAM
155 North First Avenue, MS 5, Suite 160
Hillsboro,OR 97124
Telephone: (503) 846-8722 • Fax: (503)846-3705 Public Health
°Ric:0s Prevent. Promote. Protect.
www.co.wash i ngton.or.us/foodsafety
RESTAURANT FLOOR PLAN REQUIREMENTS
Floor plans must be accurate and drawn to scale; a minimum scale of% inch=1 foot is required. Floor plans
must include all food preparation areas, outdoor barbecues, storage areas, mop/maintenance areas, wait
staff areas, restrooms, outdoor garbage areas, self-service areas, seating layout, etc. Submit the following
specific requirements with your floor plans:
1. Information on equipment including the location and common name.
2. Information on plumbing, including location of floor sinks and drains, hub drains, overhead
wastewater lines, water heater BTU or KW and recovery capacity, and grease removal devices
(grease traps and/or grease interceptors).
3. Location of food preparation sink(s) and provision for indirect waste.
4. Location of all handwashing sinks (e.g., in the restrooms,food preparation areas, beverage
service areas, and dishwashing areas).
5. Location of the mop/maintenance area (e.g., utility sink or curbed cleaning facility) including
facilities for hanging wet mops.
6. Location of bussing areas for temporary dirty dish storage.
7. Location of area where chemicals will be stored.
8. Location of the area for storage of employee personal items such as dressing rooms, locker
areas and/or employee rest areas.
9. Location of dishwasher(s) and/or 3-compartment sink(s) and dishwashing equipment drains. If
dishwasher(s) are on the plans, indicate if dishwasher machine(s) sanitizes with a chemical or
high temperature rinse.
10. A wall, floor, and ceiling finish schedule. (If a finish schedule is not included with the plans,
submit an Interior Finishes/Surfaces Form, which is included with this packet.)
11. Location of waste receptacles such as dumpsters, compactors, garbage cans, and waste oil and
recycling containers, and the surface materials underneath the waste container in areas
immediately adjacent to the restaurant. If the restaurant's waste disposal area will be located
in a common shared area (e.g., in a mall) provide written information describing the waste
area location and design.
12/2013
ONcoG DEPARTMENT OF HEALTH AND HUMAN SERVICES
co ENVIRONMENTAL HEALTH PROGRAM
S7?
155 North First Avenue, MS 5, Suite 160
Hillsboro,OR 97124
Telephone:(503)846-8722 ♦ Fax: (503)846-3705 PublicHealth
OREGON www.co.washington.or.us/foodsafety Prevent Promote.Protect.
RESTAURANT PLAN REVIEW APPLICATION
This Box for Office Use Only � /
Facility#: Facility Name: . /MM Y Jd/-!P.( '5
Facility Address:(include city,state,zip) //(p g/ ,5 et) l?/9C/pi. /'{/&rH .'f1Y 7-/4•14-R Lb, 2.2.3
Mailing Address:(include city,state,zip)
Phone: I Fax:
E-mail:
New restaurant facility and location? lEl<fes ❑ No
Facility licensed previously? IT es ❑ No
If yes, previous business name: TG a y Date of last operation for previous owner:
Owner Name: Pf4✓OR VEJJT 42I 5/ I NC• — Sea TT- P4Jbee
EttrzYJ
Owner Address:(include city,state,zip) /g0 3 3 /UW z VER -02.6EN P421Gr t ' STEM er� 4, '
Telephone: Cell:
E-mail: Business start date:
/ CONSTRUCTION INFORMATION
Construction: ❑ New i> Major Remodel ❑ Minor Remodel Completion Date:
Water: public ❑ Private I Sewage: (Public ❑Private Number of Seats:
Plan review should be sent to(check all that apply): ❑Owner construction Contact
Construction Contact: 57A-PTCC H 1T GTu../LE - /20 0Ei2T 2.0 D N/5/4y
Contact Address:(include city,state,zip) /r?3 Z 1 Sr A-vE TE. 3D7 SE,4T LE, (,e7 14 90 10)
Telephone: (2a0)770- 3811 9 I Cell:
E-mail: gage-gr.. /2[.IDN/sKy 571 . COM
Oregon Administrative Rules require that plans for new,remodeled or converted food service establishments be submitted to the local public
health authority for review and approval prior to construction. The local public health authority must conduct an inspection of the food service
establishment to assure food safety standards are met prior to the start of the establishment's operation or the use of a remodeled area.
Note: Fee must accompany this application.
Mail application and check or money order payable to: Washington County Environmental Health
Applicant Signature:
Print Name: Date:
DO NOT WRITE IN THE SPACE BELOW
Fee Received: Ck/MO#: Receipt#:
Received By: Date: Approved? ❑Yes ❑No
Remarks:
12/2013
•
I DEPARTMENT OF HEALTH AND HUMAN SERVICES
'1 ENVIRONMENTAL HEALTH PROGRAM
EFJ
155 North First Avenue, MS 5, Suite 160
Hillsboro,OR 97124
Telephone: (503)846-8722 ♦ Fax:(503)846-3705 public Health
OREco Prevent Promote Protect.
www.co.washington.or.us/foodsafety
INTERIOR FINISHES/SURFACES
Facility Name: c//A/1/4 V cki--1A '5
Facility Address: //(2 / SLJ //-G/F/C h'/C!-//XI4)' 7-7 thei) 97223
(Street Address) (City) (Zip)
Fill out the chart below if your plans do not specify wall, floor, and ceiling surface finishes.
FINISH SCHEDULE
AREA Food Contact
Floors Cove Base Walls Ceilings Shelving
Surfaces
Example:
Example:Stainless
Example: Example: Steel Work Tables,
Example: Example: Vinyl Example:
Kitchen Quarry Tile Quarry Tile FRP Acoustical Hardood Cutting Stainless Steel
Cove Enamel Paint Tile Boards
Kitchen
Bar
Storage
Rooms
Service Areas
Bathrooms
Garbage&
Refuse
Storage
Mop/
Maintenance
Area
Dishwashing
Areas
Walk-in
Refrigerators
& Freezers
12 2013
TONCO DEPARTMENT OF HEALTH AND HUMAN SERVICES
GZa ENVIRONMENTAL HEALTH PROGRAM
155 North First Avenue, MS 5, Suite 160
Hillsboro,OR 97124
Telephone: (503)846-8722 ♦ Fax: (503)846-3705 Public Health
OREGON www.co.washington.or.us/foodsafety
RESTAURANT, CATERING, and BED & BREAKFAST LICENSE APPLICATION
This Box for Office Use Only
Facility#: Facility Name: OMIA(y %HA/ 15
Facility Address:(include city,state,zip) //443/ S(„JJ PAu FkC /1/61 w,4y Y( -121), 012 9 7 22 3
Facility Phone#: Facility Fax#:
Seating Capacity: .2 Facility E-mail Address:
Is this a new restaurant facility and location? CJ'Yes ❑No Your business start date:
Was this facility licensed previously? lE Yes ❑No Date of last operation for previous owner:
If yes,previous business name: --rc Y I FAC # REL# (Office Use Only)
Construction: ❑ New remodel Completion Date:
Water: I2Publicly Operated ❑Privately Operated Sewage Disposal: El Publicly Operated ❑ Privately Operated
Owner Name: Corporation Name:
Home Phone#: Chief Corporate Officer:
Office Phone#: Office Phone:
Cell Phone#: Cell Phone#:
Fax#: Fax#:
E-mail Address: E-mail Address:
Owner Home Address:
Corporation Address:
Billing Name:
Billing Address:
Note:All licenses expire every year on December 31. Licenses are not transferable. Please call the Washington County Environmental
Health Office if you have questions regarding your license,fees,facility inspections or how to obtain a Food Handler Card.
The license fee of$ is hereby made for application to operate the above establishment in compliance with all applicable food service
regulations. I understand that failure to mcct the requirements of the provisions of Oregon Revised Statues, Chapter 624, and the Administrative Rules,
Chapter 333 of the Department of Human Services may require denial or revocation of the license.Furthermore,I attest that the information provided on this
form is accurate. It is a Class B Misdemeanor to knowingly make any false written statement in connection with an application (ORS
162.085). All information provided is a matter of public record. License fees are based on the type of business operation. Please see the fee
schedule to determine the amount and submit the proper fee with completed application prior to opening or change of ownership.
Mail application and check or money order payable to: Washington County Environmental Health
Applicant Signature:
Print Name: Date:
DO NOT WRITE IN THE SPACE BELOW
Fee Received: Ck/MO#: Receipt#:
Received By: Date: Approved? ❑Yes ❑No
Remarks:
12/2013
000NCO DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL HEALTH PROGRAM
1411411.5i
155 North First Avenue, MS 5, Suite 160
Hillsboro,OR 97124
Telephone: (503)846-8722 ♦ Fax: (503)846-3705 Public Health
OREGON www.co.washington.or.us/HHS/EnvironmentalHealth P "' "'"° °rni ct
Change of Ownership Application Addendum
Facility Name ('/,UAI V (hf'N�S
Facility Address //A6/ SCc) PAC/F IG H/CwSy 776,1/2-4 02 97223
1. Is the seating of this restaurant changing? dyes No
If yes, how many seats are you planning to have?
2. Is the menu changing from the previous facility's menu? EYes No
If yes, please provide details: s5A ft c,JIC H SNnP—
3. Are you adding any new equipment or removing any old equipment9
Yes No
If yes, please provide details:
4. Are you adding or removing any sinks? ❑Yes No
If yes, please provide details:
5. Prior to change of ownership, was this facility closed? ❑Yes ❑No
If yes, how long was the business closed?
By signing below, I understand that the information provided on this report is being used to determine the status
of my facility. Should any information be discovered that invalidates the above information, I may be required
to go through plan review or other administrative processes as deemed necessary.
Signature Date
Printed Name
Office Use Only
Any "Yes"answer above will require Plan Reviewer sign-off before license approval.
Plan Review Required? Yes No If yes, Minor Major
Plan Review Approval by: Date
12/2013