Permit (175) CITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit#: MST2015-00239
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/23/2015
Parcel: 2S103BB07901
Jurisdiction: Tigard
Site address: 12350 SW 124TH AVE
Subdivision: LAKE TERRACE Lot: PT 8&PT TRACT
Project: Hinds
Project Description: Phase 2 of master bedroom/bath remodel to include a 27 sq ft addition.
BUILDING
Floor Areas Required Setbacks Required
Stories: Bedrooms 0 First: 27 sf Basement: 0 sf Left: 5 Parking Spaces 0
Height: 0 Bathrooms: 0 Second 0 sf Garage: 0 sf Front: 20 Smoke
Dwelling Units: 1 Third: 0 sf Right. 5
Detectors: Yes
Total: 27 sf Value: $27,500.00 Rear: 15
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories. 3 Dishwashers 0 Floor Drains: 0 Sewer Lines: 50 SF Rain Storm Sewer: 0
Tubs/Showers: 1 Garbage Disp: 0 Water Heaters Drains: 0 1 Water Lines: 0 Catch Basins 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 1 Backwater Value: 0
Other Fixtures: 0
Drywell-Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning N Vent Fans: 2 Clothes Dryers: 1
Heat Pump: N Hoods: 0 Other Units: 1
Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets 1
Furn>=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: 11
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp 0
601-1000 amp: 0 601+amp-1000v: 0
1000+a mp/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:
ADD SF VB R-3 27
Owner: Contractor:
HINDS,TOM M&JUDY G ALLAWAY CONSTRUCTION LLC Required Items and Reports(Conditions)
12350 SW 124TH AVE 901 BRUTSHER ST,STE D#101 1 Bolls in Concrete
TIGARD,OR 97223 NEWBERG,OR 97132
PHONE: PHONE: 503-217-4243
FAX:
Total Fees: $1,597.73
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
CNT'O ac rice 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
EN: gon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
0 through OA 5 1 09 You may obtain a copy of the rules or direct questions to OUNC by calling 503. 1987 or 1.800.3 . 344.�� Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspecit on 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.
t
_Electrical Permit Application
l
��gq ,
5 ���® Received Permit#:
City of Tigard. DateB
+ 13125 SW Hall Blvd..Tigard,OR 97223 Plan Review Related Permit#: '
Phone: 503.718.2439 Fax: 503.i�10 T�96 Date/By: r
Inspection Line: 503.639.4175 3 2015 ReadyDateBy: 1uri:: ® 5,a Page Zfor:
',
Notified/Method: Supp emental in )rmati d
Internet: www-tigard-or.gov1TV OP It , 4
t ,IJ
Please check all that apply(submit!sets of plins iiteths checked):: ;
New construction t®---tt Addition/alteration%replacement ❑Service or feeder 400 amps or more [I Build g'gyerdhree stories
Q Demolition u Other: where the available fault current Q 1&0 .@ s i d boatysrds. j
exceeds 10,000 amps at 150 volts or Float ig bpildings: .
less to ground,or exceeds 14,000 ❑CQ ercal-t}te agicultu E
I-and 2-famil dwelling ❑Commercial/industrial ❑Accessory building i
y g amps for an other installations.
❑Multi-family LI Master builder E]Other: ❑Fire pump. ❑Tnsta atiott of,150.k, of
❑Emergency system. large separately derived990-0- {r
" {]Addition of new motor load of syste 1
deb#: lob site address:11.2350 SW 124TH AVE, I00RP or more. D"A ;E"
❑Six or morb residential units. ;,
City/State/ZIP:TIGARD,OR 97223 [1Health-carePeeilities. ❑Rec 'atiprial vdritltpark$-
❑Hazardous locations. Q Sup y voltage for mbre th�n
Suite/bldg./apt.1u; Project name:HINDS MASTER STE REMODEL El Service or feeder 4500 amps or more. 600 olqs nonlinal i,
Cross street/directions to job site:HEAD WEST ON SCHOLLS FERRY FROM 217 , ;i ; ''s`, =t: a.i''`�'<,•:
Uescr! tion t ach To 1
LEFT ON SW 1215T AVE,RIGHT ON SW(CATHERINE ST LEFT ON SW 124TH New residential single-or malt!-family d elling.unit.
Subdivision:LAKE TERRACE Lot#;PTS Includes attached garage. i
1.000 sq,ft,or less 68;54 :4 .
Tax map/parcel#:2SI03DR07901 Ea.add']500 sq.ft.or portion 33,92 1
' .. . ...L`''�:;:` t: L"' Limited energy,residential 75,00
REMODEL;A13DITION TO MASTER BED AND BATH Limited wed above s .il-
energy,multi-family 75:04
residential, with above .ftJ
uAb Renewable ErwXy ❑ See a e 2'
M Services or feeders installation,alteratiol a d/or relkatio ;
Name:HINDS 200 amps or less 1 o0:7U 2'
201 amps to 400 amps 133,Sb i2
Address: 401 amps to 600 amps 0034
City/State/ZIP: 601 amps to 1Vomvoltl���
301:04 12
Phone:( ) Fax:( ) Ovor 1,000 am
Temporary services or feeders ln5talhitic n,diteratlon;and/or
Email: relocation
Owner installation: This installation is being made on property that l own which is not 200 amps or less Sgi36' i 1
intended for sale,lease,rent:or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08. i2.,
Owner signature:
Date, 401 arrips to 599 amps
l..
MUM
Branch circuit s-new,alteration,or ext gitjn ir srfel ;
'*"` A.Fee for branch circuits with
Business name:SCOTT/EDWARDS ARCHITECTURE above service or feeder fee, 7.42 1:z
each branch circuit 1: t
Contact name:JOE BRODERS 8,Fee for branch circuits without :
service or feeder fee,fimt / 56.18 t2
Address:2525 E BURNSIDE branch eitcuit
City/State/ZIP:PORTLAND OR,97214 Each add'!branch circuit Q 7,42 ??
Miscellaneous service or feeder not incl dcd _
Phone:(503)226-3617 Fax: :( ) Each manufactured or modular 67:84 2
dwelling,service and/or feeder i
Email:JOROX)EAS(3aSEALLF.COM Reconnect only .67.84,' i2
-: 'kx 7, 97,W'+y.' ``psi e ::i•' .r Pump of irrigation circle 67,84 2 j
Business name:SQUIRES ELECTRIC INC Sign or outline lighting 67.84 2
- Signal circuit(s)or limited-energy ❑ S;C Pag.1 ; :2,
Address:657 SE YAMHiLL ST. panel,alteration or extension.
Each additional inspection over allowable lo'in -of the abu c
City/State./ZIP:PORTLAND,OR 97nF
Additional inspection(I lit min) 66.25I
hr
Phone:(.503)252-1609 (503)253,5831 investigation(I hr min) 90.00thr
Email:ANDREWQSQUIRESELE TRIC.0 Inspecrionsfal ot(1 hr min) 7-6 It---__.
Inspections for which no fee is 90,OOi hr i
CCB Lie.: 135085 Electri 1 Lic.: 1101C Suprv,Lie.: 48825 svecificall. listed /,hr min
Suprv-Electrician signature,required: Su otal:
Print Hanle: JOE S RES Date: (2/21/15 ❑Plan Review Required(25%of permi fee):
State surcharge(12%ofpenni fee): .
TOTAL PERMIT EE: .
ut oozed signa l-e
This permit appticarlon expires if a permit A not ogmi red wlthirt 1 0.j
Print Date, days after It has been nccepted se.ompfe
• Number of iespections allowed per permit."
440-aGIST tt/OS/CO�f/WGG
taau:kdinglPermitstECC,,,Pe,mitADU_,Et.F_M,dpc f}ev 06!1712015 t ''
i
F lumbinf! Permit Applicatic ECEI V ED
Building Fixtures DEC 7 2015 FOR OFFWE USE ONLV
City Of Tigard Received n�
�JTY OF Date/By: 1'0 /5 Pennrt No.: N r/���.0 '�3 9
v 13125 SW Hall Blvd.,Tigard,OR 9 r TIGARl!DA�,1
Phone: 503.718.2439 Fax: 503BUIt-D NG DIVISION Plan Review
Date/By: Other Permit No.:
Inspection Line: 503.639.4175 Date Ready/By Juris H See Page 2 for
Internet: www.tigard-or.gov Notified/Method Supplemental Information
�m`�:,;•,y:;}`.:::-.-:;. .:S','".se�as .(.-- z:� :: ,a,�' »�.s:=^:-•-i: . --..-; .- _
, TYP-.E:OE.-�1 ORK,. :;_--__,, k...,- :5 FEE: SCHEDULE _ ':.:
-....,�¢--.,, =�a�%t'3.:.:�,,;�::::;, :�S�;M.i.�:.:.. 3.:�ws��,'�:�.� ,.sus:: »'�t*•.�a. .u:� :��`..,
❑New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. Total
'Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
v
,. ;.E•r, '`'"` T CATEGORY OEc CONSTRUCTION":x' ` SFR(1)bath 312.70
J�f1-and 2-f4mily dwelling _ ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory building ❑ Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑ Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
r _ ilOB bSar INFORMATION AND_LOCATION-: ;, - T k 3�, Site utilities:
Job site address: a 3sd j Lt/ r Catch basin or area drain 18.76
- O Drywell,leach line,or trench drain 18.76
TjCity/State/ZIP: 1�� G V
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name: l°vld5 t T�to 2 1 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.line ft.: ) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: ✓ Lot no.: Fixture or item:
Tax map/parcel no.: S D 3413 D qo I Backflow preventer 31.27
� , .: ,,, a Backwater valve 12.51
'.` ' DESCRIPTI0"OF` WURK
If
' ` '' s 111, ,h,,•,'; Clothes washer 25.02
✓ine1�'I Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
�,F>;.;,; `= p' Ex ansion tank 12.51
�x PROPERT.Y OWNER
❑i TEN�1NTn
Name: I��?a - S Fixture/sewer cap 25.02
0 Floor drain/floor sink/hub 25.02
Address: Garbage disposal 25.02
City/State/ZIP: 1 f^ pI y Q l Hose bib 25.02
Phone:(q')3 ) a� - Fax:( ) Ice maker 12.51
Interceptor/grease trap 25.02
APP
LICANT CONTACTPERSON,
s
Business name: .S'f0+f wa'-AS Medical gas(value:$ ) Page 2
Contact name: r
� oe►� Primer 12.51�
Roof drain(commercial) 12.51
Address: U✓V!j/d.� Sink/basin/lavatory 25.02
City/State/ZIP: r--V-C vt �aZ�W Solar units(potable water) 62.54
(rQ3) aa� 3 Tub/shower/shower pan 12.51
Phone: Fax: :( )
E-mail: ___
D evsLey, L a�'V1 Urinal 25.02
, „ .,, ;; - :_
IS`
.' Water closet 25.02
;�..
' CONTRACTOR'=:. ;Fa;
" e " `�-� ��°"" ����" Water heater 37.52
Business name: d �S utM t Water piping/DWV 56.29
Address: Q Other: 25.02
City/State/ZIP:
G'l� e 'vee Subtotal
��
Phone:,*-5 )<p a� �.7 Fax:( ) Minimum permit fee: $72.50
CCB Lic.: (99P S �o? /7 Plumbing Lic.no.: 49 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
its✓ Gi / after it has been accepted as complete.
"Fee methodology set by Tri-County Building Industry Service Board.
1.\13uilding\Permits\PLMU-PermnAppdoc 10/01/09 440-4616T(10/02/CONIAWEB)
Mechanical Permit Application Re ve
®� FOR OFFICE USE ONL'V4
City of Tigard RE ��`P�� Date/B}a ��is cei Pit No.:HlT�olS W.;?,3
° 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1 tt r 7 2015 Date/By: Other Permit:
Inspection Line: 503.639.4175 l• Date Ready/By: Juris FE, See Page 2 for
Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information
16
'COMMERCIAL FEE SCHEDULE = CHECKLIST,
;Er :,:.._• ';> *,...:.•' TYPE;; ORK :r`i: '.• . ir^
- USE •
� 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
I-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist.
❑Multi-family ❑ Master builder ❑Other: Description Qty. I Ea. Total
4 OB -:INFORMATIOAND_LOCATION',',., 'tet , Heating/cooling.
�,5.�,ITE.a- N:
Air conditioning 46.75
Job site address: ''Lt � 12tk'�k �i Furnace 100,000 BTU ducts/vents) 46.75
City/State/ZIP: �?, Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.: Project name:Nwr*}JV Duct work 23.32
Cross street/directions to job site: H dronic hot waters stem 23.32
`,/ Residential boiler(radiator or
M t'Lt ST AYT404 -my-&_ A h dronic) 23.32
Unit heaters(fuel-type,not electric),
d l in-wall,in-duct,suspended,etc. 46.75
k TI} Flue/vent for any of above 23.32
Subdivision: LAkL- t Lot no.:� Other: 23.32
Other fuel appliances:
Tax map/parcel no.: 1 Water heater 23.32
" yy',• Gas fireplace/insert 33.39
`? T DESCRIPTION.,;OFW.•,ORIC „ t•
Flue vent for water heater or gas
fireplace 23.32
E(SK(4- � U L'( a W li 23.32
Wood/pellet
er sttoo ve 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
_�.....a; - :- Other: 23.32
PROPERTY 6:'"__rNER` "" '" ( _TENANT Environmental exhaust and ventilation:
Name/ JV Range hood/other kitchen
b `` e ui ment 33.39
Address: irv"41 s Clothes dryer exhaust 33.39
City/State/ZIP: Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 23.32
Phone:(Sp'N Vkl — Lkq Fax:( AN Attic/crawls ace fans 23.32
r -,APPLICANT. CONTACT.PERSONµ Other: 23.32
Business name: T Fuel piping:
$14.15 for first four;$4.03 for each additional
Contact name: ' Furnace,etc.
Address: f6isGas heat um
' '�� Wall/suspended/unit heater
City/State/ZIP: IZL, Water heater
Phone:Q506) W g�IC�� tt Fax: Fireplace
Range
E-mail: Barbecue
CONTRACTOR _, Clothes dryer as
Business name: G h C Other:
�'Ircw .7 MECHANICAUPERMIT FEES* s
Address: � Subtotal
City/State/ZIP:77-t 6 1 J Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:( ) Fax:( ) State surcharge(12%of permit fee)
CCB lic.: Ja-�`q TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: * Fee methodology set by Tri-County Building Industry Service Board
Print name: Date:
1'\Building\Permits\MEC_PermitApp_040113.doe 440-4617T(11/02/COM/wEB)
City of Tigard
u COMMUNITY DEV]:,'LOPMENT DEPARTMENT
C
Building Permit Review — Residential
4'+
Building Permit #: �J 1 c�01 s' oZ-57
Site Address:
Project Name: Ay l?L�yyLot #:
(New dwelling=subdivision name; Addition or Alteration= last name of owner)
Planning Review
Proposal:
Verify site address/suite# gists and active in permit system.
%Akver Terrace Neighborhood: ❑ Yes ❑ No
Sitz Plan Elements:
�
nree(3) copies of site plan isting structures on site
e plan must be on 8-1/2"x 11"or 11 x 17"paper ootpri nt of nevv structure (including decks) ,vIth finished
raven to scale(standard architect or engineer scale) oor elevations
I' rth arrow SCJ Utili-'locations(required for nev>>,ma\7 apple for additions)
V
e address,project or subdivision name and lot number ocation of wells/septic systems
Zplicant information (name and phone number) 1-'rosion control (including drainage-xv,a} protection,silt fence
Lot dimensions and buildilig setback dimensions esign,location of catch basin,etc.) Sfe �� S
100t area,building coverage area,percentage of coverage and XS11reet
eet naives
impervious area (applicable if R-7,R-12,IZ-23& IZ-40) tree size,type and location
fo*lperty corner elevations(2 foot contour lines if more than lxisting trees to be retained with drip line,and tree
foot differential) protection measures
Clean Water rvices —Service Provider Letter(lot platted prior to 9/10/1993):
Required: Yes,applicant was notified ❑ No Received: Yes ❑ No
Public Facilities Improvement (PFI) Permit:
Required: ❑ Yes,applicant was notified No Applied For: ❑ Yes ❑ No,stop intake
Ind Use Case #:
Zoning:
Setbacks: Front Rear IS Side Street Side Garage0
Landscape Requirement: 0/0
of Coverage Maximum:
Building)-Leight: IVlaximum 1-1eight �� Actual Height A.?
visual Clearance
rsensitive
asements
.//� Lands: Yes ❑ No Type V4&p 06r
O'Krban Forestry Plan / -
0-onditions "Niet" prior to issuance of building permit
Notes:
Approved By Planning: — ,� Date: o�
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
I:\Building\Fornns\BldgPermitRvw_RES_070915.docx
Al
Building Permit Submittal /
Original Submittal Date: /R 1-7
Site Plans: # 3
Building Plans: # 13
Building Permit#: 2'Enter building permit# above.
Workflow Routing: Com]' Planning engineering �ermlt Coordinator ET-Budding
Workflow Sign-off: 0 Sign-off for Planning(include notes from planning review)
Route Application Documents: ff Engineering: (1) copy of permit application, (1) site plan, (1) building plan and
original plan review routing form.
wilding: original permit application, site plans,building plans, engineer and
beam calculations and trust details,if applicable, etc.
Notes:
By Permit Technician: Date: 9 /
,Engineering Review
L7 Slope at building pad:
conditions "Met"prior to issuance of building permit
Easements (encroachments) per engineering conditions of approval and plat
❑
Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: ❑ Yes 2-'No
Assess Water Quantity Fee in-lieu: ❑ Yes 2r--No
I_IDA Facility on lot: ❑ Yes 2--No
❑ NOT Approved by Engineering: Date:
Notes:
Approved by Engineering: Date:
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: ❑ Approved ❑ Not Approved
Permit Coordinator Review
❑ Conditions "Met"prior to issuance of building permit
❑ Approved, NOT Released: Date:
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant:
Revision Notice 2: Date Sent to Applicant:
Revision Notice 3: Date Sent to Applicant:
❑ SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes ❑ N/A
Tigard Trans SDC: ❑ Yes ❑ N/A
Parks SDC: ❑ Yes ❑ N/A
,�K`K to Issue Permit _
Approved by Permit Coordinator: ch4==:�
iv—L'.J Date:
I:\Building\Fonns\BldgPetmitRN,w_RES_070915.docx
\jClean Water Services File Number
CleanVVater Services 1 15-003804
Sensitive Area Pre-Screening Site Assessment
1. Jurisdiction: TIGARD
2. Property Information (example lS234A801400) 3. Owner Information
Tax lot ID(s): Name: Tom and Judy Hinds
2S103131307901 Company:
Address: 12350 SW 124th ave
Site Address: 12350 SW 124TH AVE City, State,Zip: Tigard,OR,97223
City, State,Zip: TIGARD,OREGON 97223 Phone/Fax: 503-297-8649
Nearest Cross Street: BROOK CT E-Mail: judyghinds@hotmail.com
4. Development Activity (check all that apply) 5. Applicant Information
W Addition to Single Family Residence(rooms,deck,garage) Name: Joe Broders
❑ Lot Line Adjustment ❑ Minor Land Partition Company: Scott I Edwards Architecture,LLP
❑ Residential Condominium ❑ Commercial Condominium Address: 2525 E Burnside St
❑ Residential Subdivision ❑ Commercial Subdivision
City, State, Zip: Portland,OR 97214
❑ Single Lot Commercial ❑ Multi Lot Commercial
Other Phone/Fax: 5032263617
E-Mail: JBroders@SEAllp.com
6. Will the project involve any off-site work? ❑Yes El No ❑ Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
27 s.f.addition to an existing house. Thanks much,Joe Broders
This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits,DEQ
1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands and/or Department of the Army
COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law.
By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority
to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify
that I am familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
PrintlType Name Joe Broders Print/Type Title Designer
ONLINE SUBMITTAL Date 11/24/2015
FOR DISTRICT USE ONLY
❑ Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
may also be required.
❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This
Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently
discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1. All required permits and
approvals must be obtained and completed under applicable local,State,and federal law.
Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially
sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water
quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order
07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law.
❑ This Service Provider Letter is not valid unless CWS approved site plan(s)are attached.
❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed by ( 4:e,_Z '"" Date 11/24/15
2550 SW Hillsboro Highway - Hillsboro, • -•• • - 1 11 1 -
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
12350 SW 124TH AVE, TIGARD, OR, 97223 April 20, 2017 at 10:04:14 AM
Record Type: Record ID:
Residential - Master Permit MST2015-00239
Inspection Type: Inspector:
199 Electrical final David Young
Result:
PASS
Comments:
Violation Summary:
Inspector Contractor
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
12350 SW 124TH AVE, TIGARD, OR, 97223 April 20, 2017 at 10:13:50 AM
Record Type: Record ID:
Residential - Master Permit MST2015-00239
Inspection Type: Inspector:
299 Final inspection David Young
Result:
FA I L
Comments:
Provide deck rail to code at new deck addition. R312.1
Provide missing smoke detector at existing bedroom. R315
Violation Summary:
Inspector Contractor
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
12350 SW 124TH AVE, TIGARD, OR, 97223 April 20, 2017 at 10:05:14 AM
Record Type: Record ID:
Residential - Master Permit MST2015-00239
Inspection Type: Inspector:
699 Mechanical final David Young
Result:
PASS
Comments:
Violation Summary:
Inspector Contractor
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
12350 SW 124TH AVE, TIGARD, OR, 97223 April 25, 2017 at 9:32:13 AM
Record Type: Record ID:
Residential - Master Permit MST2015-00239
Inspection Type: Inspector:
299 Final inspection David Young
Result:
PASS - NoCofO
Comments:
Corrections complete.
Violation Summary:
Inspector Contractor