Permit Building Permit Application RECEIVED — EX P ( RED --
Fire Protection System FOR OFFICE USE ONLY
City of Tigard MAY 2 9 2009 Received
- -J g DateB : Permit No.:�S2�C�,�0 2
11111
" 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Revie
Phone: 503.639.4171 Fax: 503.598.16cry OF TIGARD DateB •: i,�7�/ �� Other Permit. F 9(5 dr r , r
Inspection Line: 503.639.4175 Date Ready/By BU ILDING DIVISION See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
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 CONSTRU'CTIO'N 1 ai ii work indicated on this application.
❑ 1-and 2-family dwelling ❑Commercial/industrial Valuation: $200
❑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:9304 SW Mandamus Ct g 3l(o) 932o, Gl X32, 9,3', A1 New dwelling area: square feet
City/State/ZIP:Tigard,OR 97223 9 4 Garage/carport area: square feet
Suite/bldg./apt.no.:Bld 5 Project name:Longstaff Condos 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.
Monitored Fire Alarm System Valuation: $ 214 Le
Existing building area: square feet
New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name:Brownstone at Lincoln Park Type of construction:
Address:7050 SW Clinton Street Occupancy groups:
City/State/ZIP:Portland,OR 97223 Existing:
Phone:( ) Fax:( ) New:
❑ APPLICANT ® CONTACT PERSON NOTICE
Business name:RCM Homes,Inc All contractors and subcontractors are required to be
Contact name:Ron Lightner licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address:7050 SW Clinton Street jurisdiction in which work is being performed.If the
City/State/ZIP:Portland,OR 97223 applicant is exempt from licensing,the following reasons
apply:
Phone:(503)598-7565 x 101 Fax::( )
E-mail:rightner@brownstonehomes.net
CONTRACTOR BUILDING PERMIT FEES*
Business name:Dms Electric,Inc. (Please refer to fee schedule)
Permit fee:
Address:8504 SE Stark ST
State surcharge(12%of permit fee):
City/State/ZIP:Portland,OR 97216 0
FLS plan review(40%of permit fee):
Phone:(503)209-9298 1 .x: i 3 252-6611 (Due upon application.)
CCB lic.:118073 i Total permit fees:
Authorized signature: ' Amount received:
This permit application expires if a permit is not obtained
Print name:Paul Grushevskiy Date:5/26/2009 within 180 days after it has been accepted as complete.
* Fee methodology set by Tri-County Building Industry
Service Board.
1:\Building\Permits\FPS-PermitApp.doc 03/23/06 440-46131(11/02/COM/WEB)
CITY OF TIGARD FEE AND PAYMENT HISTORY
IIi II
II � 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
FPS2009-00042 - 9304 SW MANDAMUS CT
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due
Permit Fee-COM 245-0000-432000 $69.65 $69.65 $69.65
12%State Surcharge-Building 100-0000-207020 $8.36 $8.36 $8.36
Plan Review-Fire Life Safety-COM 245-0000-433020 $27.86 $27.86 $27.86
Totals for Fees $105.87 $105.87 $0.00 $105.87
Receipt# Payment Method Check# Pavor: Receipt Date Receipt Amount
Total Payments: $0.00
Balance Due: $105.87
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