Permit ipl
VQ ! O
i •
. Community Development ,A,.3//..z_
Request for Permit Action /
TIGARD
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ;Rr City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) /J/4�1
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
In- CANCEL PERMIT APPLICATION.
El REFUND PERMIT FEES (attach copy of original receipt).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
rEl REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). ,/
Permit #: H -F-42.0//—�Ogt' �` �uvA,�0l(-4ev077
Site Address or Parcel#: /5340 c6w /1fyfe d/ tJ
Project Name: 421.1 dorz'4 46 T5 No 3 DoT(o
Subdivision Name: Lot #:
EXPLANATION: 512 411.4 TIT ED —Di k--�geg �ou£4._ A413.
)-11-Po i a--aco 4 .
Signature: Date: .25/12-
2
Print Name: egg/ f 4 A, }H j
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date B Rte to Bld.admin: Date a$® Bjj j
Refund Processed: Date n/ 19 :i Invoice Processed: Date By
Permit Canceled: Date.42//aS//mil By ' r Parcel Tag Added: Date By
Receipt# Date Method Amount$
l:\Building\Forms\RegPemutAction.doc Rev 04/26/2011
/4‘41-A/ Ie mil//Ect), S /49/.0
. .
Building Permit Application V ® 0`�4 ��
Residential \� FOR OFFICE USE ONLY
City of Tigard Received
Y g %\\ Date/B : f �1/ iME . .I �V
13125 SW Hall Blvd.,Tigard,OR 97
g 1� Plan Review �, �ram '
Phone: 503.639.4171 Fax: 503.598. 960 Mai �Q Date/B other Permit: SW_45
I it, \1,1) Inspection Line: 503.639.4175 lr` (�, Date Read �� ,±/n Juris: ® See P 2 or
Internet: www.tigard-or.gov �/' N • e od: 7(A S �I 1 Supplemental Information
TYPE OF WORICOr REQUIRED DATA:1-AND 2-FAM1LY 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.
Valuation: $
® I-and 2-family dwelling ❑Commercial/industrial �) '
El Accessory building ❑Multi-family Number of bedrooms:
❑Master builder ❑Other: Number of bathrooms: .3
JOB SITE INFORMATION AND LOCATION Total number of floors: ?-
Job site address:IC 3 40 SW SUM M FA2 J I ElvV yiL.. New dwelling area: 2'0 0 square feet
City/State/ZIP:Tigard,OR 97223 Garage/carport area: S 12— square feet
Suite/bldg./apt.no.: Project name:Arlington Heights Covered porch area: 14s square feet 1,57..,
Cross street/directions to job site: Deck area: 11 . square feet
tZt
Other structure area. ?J Z square feet 2--2-.5—REQUIRED DATA: RCIAL-USE CHECKLIST
Subdivision:Arlington Heights I Lot no.: bq 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.
New,Single Family Residential Valuation: $
Existing building area: square feet
New building area: square feet
® PROPERTY OWNER ❑ TENANT Number of stories:
Name:Stone Bridge Homes Type of construction:
Address: 16869 SW 65th Avenue#505 Occupancy groups:
City/State/ZIP:Lake Oswego,OR 97035 Existing:
Phone:(503)387-7577 Fax:(503)387-7616 New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name:SEE ABOVE All contractors and subcontractors are required to be
Contact name:Deirdre Britt licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed.If the
City/StatelZIP: applicant is exempt from licensing,the following reasons
apply:
Phone:( ) Fax::( )
E-mail:dbritt@stonebridgehomesnw.com
CONTRACTOR
Business name:SEE ABOVE BUILDING PERMIT FEES*
Address: (Please refer to fee schedule)
City/State/ZIP: Structural plan review fee(or deposit):
FLS plan review fee(if applicable):
Phone:( ) Fax:( )
CCB lie.:173318 Total fees due upon application:
Amount received:
Authorized signature:1\ . ..ASIck
This permit application expires if a permit is not obtained
���/// within 180 days after it has been accepted as complete.
Print name: DE1 RPP.E ' J .XT1 Date: D�, 1 0.11 * Fee methodology set by Tri-County Building Industry
Service Board.
I:1Building\Permits\BUP-RES PermitApp.doc 10/01/09 440-4613T(I 1/02/COM/WEB)
Electrical Permit Application a FOR OFFICE USE ONLY
City of Tigard `, Received ,) Q a
�, Date/By: i,.,,,,t No.: 7_c0)(—ock t
13125 SW Hall Blvd.,Tigard,OR 9 1, Plan Review
II Phone: 503.639.4171 Fax: 503.5 '�� c) Date/By: Other Permit:
I, Inspection Line: 503.639.4175 `�,Py r�i• "date Ready/By: luris: ® See Page 2 for
Internet: www.tigard-or.gov �`^ 4\V \Co 'Notified/Method: Supplemental Information
TYPE OF WO REVIEW
®New construction ❑Addition/alteration/reply' ` nt Please check all that apply(submit 1 sets of plans v.,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 Illir exceeds 10,000 amps at 150 volts or ❑Floating buildings.
less to ground,or exceeds 14,000 ❑Commercial-use agricultural
® 1-and 2-family dwelling ❑Commercial/industrial ❑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.
tp ❑Addition of new motor load of ❑"A","E","t-2","I-3",
Job no.: ` Job site address: 15340 Ste) S VM M E.V I-1N D12- I00HP or more. occupancy.
�� ❑Six or more residential units. ❑Recreational vehicle parks.
City/State/ZIP:Tigard,OR 97223 ❑Health-care facilities. ❑Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name:Arlington Heights ❑Service or feeder 600 amps or more.
Cross street/directions to job site: FEE SCHEDULE k
J Description I Qh. I Fee. 1 Total I
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision:Arlington Heights Lot no.: (01 1,000 sq.ft.or less I, 168.54 ((cal-- 4
Ea.add'I 500 sq.ft.or portion 15— 33.92 I1, 1
Tax map/parcel no.:
pir Limited energy,residential
RIPTION OF WOR (with above sq.ft.) ( 75-t
Limited energy,multi-family
67.84 2
residential(with above sq.ft.) -
Services or feeders installation,alteration,and/or relocation
200 amps or less 100.70 2
® PROPEWIN 201 amps to 400 amps 133.56 2
Name:Stone Bridge Homes 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: 16869 SW 65th Avenue 9505 Over 1,000 amps or volts 552.26 2
City/State/ZIP:Lake Oswego,OR 97035 Temporary services or feeders installation,alteration,and/or
relocation
Phone:(503)387-7577 Fax:(503)387-7615 200 amps or less 59.36 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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
0 APPLICANT 1 ❑ CONTACT PERSON above service or feeder fee,
- each branch circuit 7.42 2
Business name:SEE ABOVE B.Fee for branch circuits
without service or feeder fee,
Contact name: Deirdre Britt first branch circuit 56.18 ,
Address: Each add'I branch circuit 7.42 _ 2
Miscellaneous(service or feeder not included)
City/State/ZIP: Each manufactured or modular
67.84 2
Phone:( ) Fax: :( ) dwelling,service and/or feeder
Reconnect only 67.84 2
F.-mail: dbrittnstonebridgehomesnw.com Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
Business name:City Electric Signal circuit(s)or limited-
energy panel,alteration,or
Address:55568 SW Schaltenbrand Lane extension.Describe: Page 2 2
City/State/ZIP:Sherwood,OR 97140 Each additional inspection over allowable in any of the above
Per inspection 66.25
Phone:(971)404-1714 Fax:(503)625-3052 Investigation per hour(I hr min) 66.25
CCB Lie.: 42422 Electrical Lie.: 26-289C Suprv.Lie.: 35925 Industrial plant per hour 78.18
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: A 11?,/4
Print name: Chuck Friesen Date: Plan retie" (25%of permit fee):
D s I I` State surcharge(12%of permit fee):
Authorized signature: e.....2__, TOTAL PERMIT FEE: it L 2,
r
This permit application expires Ka permit is not obtained within ISO
Print name: Date: days after it has bees accepted as complete.
' Number of inspections allowed per permit.
I:\Building\Petmits'I..I.C-PemtitApp.doc 10'01/O4 4.01-41.151(1 I u“t1n1 S fn
Mechanical Permit Application V li R FOR OFFICE USE ONLY
City of Tigard ec,Date :y: Permit No.: sT,Vit— �trf
13125 SW Hall Blvd.,Tigard,OR 97223 fi O�� Plan Review in J/ l
g Phone: 503.639.4171 Fax: 503.598.1 �. Other Permit:
17ate1By_
t 1 c,A R D Inspection Line: 503.639.4175 y Date Ready/13y: June El See Page 2 for
Internet: www.tigard-or.gov ` `�P C�\( Nc titled Methcxi: Supplemental Information
TYPE OF WORK\`• COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Mechanical permit fees'are based on the value of the work
®New construction 0 Addition/alteration/replaces3ren{ performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,and profit.
CATEGORY OF CONSTRUCTIIII Value:$
"` t EQUIPMENT/SYSTEMS FEES*
® 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building
For special information use checklist.
❑Multi-family ❑Master builder ❑Other: Description I Qty. Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Job site address: 1 534 Q �W U M M ER )I F Air conditioning
S „/�/����. (requires site plan showing placement) 46.75
City/State/ZIP:Tigard,OR Furnace 100,000 BTU(ducts'vents) j 46.75 4`70',
Furnace 100,000+BTU(ductsivents) 54.91
Suite/bldg./apt.no.: Project name:Arlington Heights Heat pump 61.06
Cross street/directions to job site: Duct work 23.32
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
Flue/vent for any of above 23.32
Subdivision:Arlington Heights Lot no.: (g Other: 23.32 _
Tax map parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater ( 23.32
New,Single Famih Residential Gas fireplace I 33.39 337471
g 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 I Chimney/liner/flue/vent 23.32
❑ TENANT Other: 23.32
Name:Stone Bridge Homes NW,LLC Environmental exhaust and ventilation
Address:16869 SW 656 Avenue#SOS Range hood/other kitchen
equipment 1 33.39 :33
City/State/ZIP:Lake Oswego,OR 97035 Clothes dryer exhaust ( 33.39 "'v v.,
- Single-duct exhaust(bathrooms,
Phone:(503)387-7577 Fax:(503)387-7616 toilet compartments,utility rooms) 4..5 23.32 (( .
r
❑ APPLICANT ❑ CONTACT PERSON Attic/crawlspace fans 23.32
Other: 23.32
Business name:same as above
Fuel piping
Contact name: Deirdre Britt $14.15 for first four;$4.03 for each additional
Address:
Furnace,etc. ( (q,1%-7
Gas heat pump
City/State/ZIP: Wall/suspended/unit heater
Phone:( ) I Fax::( ) Water heater
Fireplace
E-mail: dbritt @stonebridgehomesnw.com Range
CONTRACTOR Barbecue
Business name:Comfort Zone Clothes dryer(gas)
Other:
Address:1032 NW Corporate Drive MECHANICAL PERMIT FEES*
City/State/ZIP:Troutdale,OR 97060 Subtotal `� p,`�
Phone:(503)667-5595 Fax:(503)491-8252 Minimum permit fee($90.00)
Plan review(25%of permit fee)
CCB lic.: 110091 State surcharge(12%of permit fee) '3 L,.12....
TOTAL PERMIT FEE .3...- 7 j7,
This permit application expires if a permit is not obtained within 180
Authorized signature: days after it has been accepted as complete.
Print name:David Heldstab I Date: ()S.It,1I " Fee methodology set by Tri-County Building Industry Service Board
I:/Building\PemtitsMEC-PennitApp.doc 10/01/09 440-4617'1(11/02/WM/WEB)
Plumbing Permit Application
Building Fixtures FOR OFFICE USE ONLY
City of Tigard Rec .'ed Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 Dace y: �{1s�// oopir i
1 11 1111 . Plan eview Phone: 503.639.4171 Fax: 503.598. G O� Other Permit No.:
Date y:
Inspection Line: 503.639.4175 Date Ready/By: low.
T I G A R D ,k ‘1% n'�j y: ® See Page 2 for
Internet: V,V,w'.tigard-oGQOv \ 'fied/Method: Supplemental Information
TYPE OF WORK t.',, FEE* SCHEDULE
®New construction ❑Demolition " For special information use checklist.
Description I Qty. I Ea. I Total
❑Addition/alteration,replacement ❑Other: New I-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
-® I-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath k 500.32 ?IJ
❑Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Othcr. Fire sprinkler(_sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: I&- 1 D SW U M cv ER V I EVV pa. Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,OR 97223
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: I Project name:Arlington Heights Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision:Arlington Heights Lot no.: 1 Fixture or item:
Tax map parcel no_: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
New,Single Family Residential
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name:Stone Bridge Homes Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 16869 SW 65th Avenue#505
Garbage disposal 25.02
City/State/ZIP:Lake Oswego,OR 97035 Hose bib 25.02
Phone:(503)387-7577 Fax:(503)387-7615 Ice maker 12.51
❑ APPUCANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
-
Business name:SEE ABOVE Medical gas(value:$ ) Page 2
Primer 12.51
Contact name: Deirdre Britt Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54 l
Phone:( ) Fax: :( ) Tub/shower/shower pan 12.51
E-mail: dbritt(iestonebridge homes nw.com Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name:Legacy Plumbing Water Pip g/1 m DWV 56.29
Address:8985 Hazelvern Way Other: 25.02
City/State/ZIP:Portland,OR 97223 Subtotal .'jam
Phone:(503)816-8887 Fax:(503)297-4587 Minimum permit fee: $72.50
Plan review (25%of permit fee)
CCB Lie.: 159281 Plumbing Lie.no.:26-5I7PB
,,g.�/) State surcharge(12%of permit fee) (,o4-
Authorized signature: rOX/// /,,4-___.-- TOTAL PERMIT FEE'
Print name:Matt Nelson Date: (S. 1 O,`y 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:\BuildingTemtitsTLMU-PertnitApp.doc 10/01;19 440-461611l0/02/COM/WEB)
I Building Division
Development Code Provision Review
1` G n R D Residential Projects
Building Permit No: f Y]S T 2 I i i 1.--006 (
CWS Service Provider Letter Received: Yes ❑ No ❑ N/A
Routed Plans:
Original Plan Submittal Date: .j i °
1st Revision Submittal Date: ❑ Site Plan Only
2^d Revision Submittal Date: ❑ Site Plan Only
To the Applicant:
Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies to the
Building Division. Only checked (V) items are approved. Items not approved and those listed in the notes must be
revised prior to re-submittal. For questions please contact the appropriate staff person(s) listed above each section.
Staff: please check items along left only if approved.
Planning Review(contact at 503-718- a�� or �"1-' @ tigard or.gov)
Lan Use Case No.'�,L� O2 c 01)02) Name itt 1. I , ■si.
O' Zoning -1
l3Setbacks,:7 T
Front j Rear /.<- Side Street Side /7) Garap'e ,�(J
1:KMaximum Building Height _16 Actual Building Height s
Er-Visual Clearance
�� sements n i J � c , �` 1 l '
L�l' Sensitive Lands Type: COOL it J �'( (Olt M(GI.�
Notes: U Q
Original Plan: Approved ? Not Approved ❑ Date: / f
Revision 1: Approved H' Not Approved ❑ Date: 57/ I f
Revision 2: Approved ❑ Not Approved ❑ Date:
Engineering Review(contact Mike White at 503-718-2464 or MikeW @tigard-or.gov)
f( Actual Slope: frG
`Notes:
Original Plan: Approved ,ld Not Approved ❑ Date: 5 1 8
Revision 1: Approved .0r Not Approved ❑ Date: S ('I l
Revision 2: Approved ❑ Not Approved ❑ Date:
(Review Continues on Page 2)
Page 1 of 2
City Arborist Review(contact Todd Prager at 503-718-2700 or todd @tigard-or.gov)
p/ Street Trees
[3 Protected Trees
Notes: /ha/ -i- .ii'4 ` sp etc,"4 Rrywrod A k re 8u 0 ,
Original Plan: Approved —❑ Not Approved l Date: S-/?r 11
Revision 1: Approved L Not Approved ❑ Date: 3-1 'I- s I
Revision 2: Approved ❑ Not Approved ❑ Date:
Permit Coordinator Review(contact Albert Shields at 503-718-2426 or albert@tigard-or.gov)
❑ Conditions of Approval Prior to Issuance of Building Permit
Notes :
Original Plan: Date Sent to Applicant: 6)/ "/I/ 01
Revision 1: Date Sent to Applicant
Revision 2: Date Sent to Applicant
-.
Okay to Issue Permit: Yes ',I No s
Date Routed to Building: / I4i I
Page 2 of 2
STONEBRIDGEAW- LOT:89 40
HOMES NAP T.7.0 LOT: 69
1.BOOS 8w ear AVE.. * 50e 4„4.4 DATE: 5/19/11
Less 0919190, OssaON 9 703 5 PROPERTY: ARLINGTON
(505)587-7677 HEIGHTS
1111.381' CITY: TIGARD
51.U.315' SCALE: 1"=20'
PLAN No.: 228
, --. \ °MC my
. ... ,
ri..3.0› , ..
/ �� MAY 1 9 2011
5'WIDE LIME�/ / \ •\
//.-'/ P CITY OF TIGARD
/ // bS1NING/ENGINEERING
/ ,
a, / , / 380 d�
see •j/ \`
#//•. - 'a. `.'1`'� EL■314'
//_,-// ..\ ,•. ,
,.
ti / , 60 ea . 2 - 1W / •.
/ / Pt • 3�' e P • 3AOb' ,/ • / ,Y!?.
3L• // // / //
/ • / / ;.,
t /
0.; ' /
O�LF1, 315 Ai 1 ,////...%/
,� l8 ' 11`� , / //
qa 380 Iti, •�j/ /.
/ /
/ /
315 / ,
316 , ` //
,4.;
314D
�V'
*(e,
LOT COVERAGE 01N STREET TREES
LOT AREA: 4,153 SQ. FT.
BUILDING AREA: 1,921 SQ. FT.
0
PERCENTAGE: 40% —RAYWOOD ASH
FRAXMUS OXYCARPA-
NOTES:
ALL GRADE AND PROPERTY LINES ARE ESTIMATES OF CURRENT LOCATIONS.
ALL DIMENSIONS AND SQUARE FOOTAGE ARE APPROXIMATE FIGURES.
ALL RETAINING WALL HEIGHTS AND LOCATIONS ARE ESTIMATES. LOT ViS
DRIVEWAY VARY D E TO LOCAL ON OF UTILITY BOXES, 4,153 sq. ft.
STREETLIGHTS, AND OCHER SITE CONDITIONS.