Permit t EXPIRED 3 ?-? iCe
Building Permit l� ,
` ° : .�„ FOR OFFICE l SE ONLI
11114
City of Tig R /�� ��� tf/,5
C q 13125 SW Hall BI d,'Tigard,OR 974.23;1 2 Date/B � ��� !/�_ Permit No.: S �r
Plan Review
Phone: 503.639.4171 Fax: S`Q3t 5�98.�96d i Date/B : Other Permit:
T I G A RD Inspection Line: 503.639.4175Jv -4__-,...,' Date Ready/By: ® See Attached Checklist for
Internet: www.ti and-or. ov k: ��- '
g g } �!. Notified/Method:
"-�( 1 . t- S Supplemental Information
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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
Ad dition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1-and 2-family dwelling 0 Commercial/industrial Valuation: $ �/„'{
/
El Accessory building ❑Multi-family Number of bedrooms: j iL J
0 Master builder 0 Other: Number of bathrooms: l
JOB SITE INFORMATION AND LOCATION Total number of floors: _?
Job site address: /S26 G 5.44 /0.7'` Ts.-r,we New dwelling area: L 05.0 square feet
City/State/ZIP: Tj�t.•.-,l ox f 7)-2-5 Garage/carport area: square feet
Suite/bldg./apt.no.: / / Project name: Covered porch area: square feet
Cross street/directions to job site: 1)44.
c. 0o,s '-'J z ~'-'9 Deck area: square feet
C� "14 L 01,•74" /07 " T+,,,, 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.
• c;:" 4. cv-o4v/ 6'/OA,(.4. Valuation: $
Existing building area: square feet
New building area: square feet
I -PROPERTY OWNER 0 TENANT Number of stories: r
Name: atey4r7� Type of construction:
Address: lS2 LG -5.3v. % p G�/o7 N 7-4"-460'4"
Occupancy groups:
City/State/ZIP: 0,w, , 0 g q 222N Existing:
Phone:(
sa 3) 7p/- D%Yq Fax:( ) New:
APPLICANT 0 CONTACT PERSON
//_ NOTICE
'J A
Business name: s' io„, O•_3 y 1;iirI, All contractors and subcontractors are required to be
Contact name: �""' licensed with the Oregon Construction Contractors Board
Mr.Stuart 1?vens`"t under ORS 701 and may be required to be licensed in the
Address: 10955 SW130th:we jurisdiction in which work is being performed. If the
Portland,OR 97223
City/State/ZIP: applicant is exempt from licensing,the following reasons
apply:
Phone:(503 ) 3/7- qyitl 2
/Fax::(503) 5 ! —/7/`
E-mail: 5-/--14 owl" G 1f- G 5Y €. rj^J. Ci i4.,
CONTRACTOR
Business name: S'Mr4t of At,dotre-- BUILDING PERMITFEES*
Address: (Please refer ro fee schedule) ` v
i�
City/State/ZIP:
Structural plan review fee(or deposit):
Phone:( ) Fax:( ) FLS plan review fee(if applicable):
CCB lic.: /73 23O Total fees due upon application:
Amount received:
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: S-1-� /2• e„,, s-,. Date: * Fee methodology set by Tri-County Building Industry
Service Board.
I.\Building\Permits\BUP-PermitApp.doc 03/21/06 440-4613T(11/02/COM/WEB)
Electrical Permit Application=- :_ - . .. FOR OFFICE USE()\l.1
' -Rat ve,'. n •SCJ/J7
City of Tigard _ --_ _ • ' _et 7 pR 67 Permit No. M�j/ O�t'7�
13125 SW Flail Blvd.,Tigard,OR 97223 Plan Review
l M Phone: 503.639.4171 Fax: 503.598.1960 .s ., r let/6-+e Other Permit:
T I G A R D Inspection Line: 503.639.4175 JUL L ; v 2007 Date Ready/By: L_.r'..i i 1^r I 1._D Juris: El See Page 2 for
Internet: www.tigard-or.gov Notified/Method: t " a Supplemental Information
a e r 1
TYPE OFAAi ' PLAN REVIEW
❑New constructionEr -Addition/.ltd, tt07t/replacement 1 Please check all that apply(submit 2 sets of plans w/items checked below):
0 Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
less to ground,or exceeds 14,000 ❑Commercial-use agricultural
El-and 2-family dwelling ❑Commercial/industrial ❑Accessory building amps for all other installations. buildings.
0 Multi-family 0 Master builder ❑Other: 0 Fire pump. 0 Installation of 75 KVA or
JOB SITE:INFORMATION AND LOCATION
,0 Emergency system. larger separately derived system.A
0 Addition of new motor load of ❑"A","E","1-2","I-3",
10OHP or more. occupancy.
Job no.: Job site address:
See, /..;,,,„ Dom- 6 .l..i' 0 Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIP: 0 Health-care facilities. 0 Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name: 0 Service or feeder 600 amps or more.
// FEE SCiEDULE
Cross street/directions to job site: �+`iArJ�r Description I Qty. I Fee. I Total I *
4,,-;--
New residential single-or multi-family dwelling unit.
qq — Of A#4,1•04° tQ, 0^/0 3 4 ® 107 ✓V' , Includes attached garage.
Subdivision: Lot no.: 1,000 sq.ft.or less 145.15 4_
Ea.add'I 500 sq.ft.or portion 33.40 1
Tax map/parcel no.: Limited energy,residential
DESCRIPTION OF WORK (with above sq.ft.) 75.00 2
ly
,��1�.�'w✓I �� Limitedienergy,(withmabove
sq.ft ' 75.00 75•� 2
LZ� 'i��'�."a,'.� Gyyt"�/ 4 yJ'�`''r1 residential above sq.ft.)
/ Services or feeders installation,alteration,and/or relocation
200 amps or less 80.30 2
12'"kROPERTY OWNER 0 TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name:
aY 4 w✓fi.✓ 601 amps to 1,000 amps 240.60 2
Address: /52, Lt: 5.tv, /0 70" '7 .,- Over 1,000 amps or volts 454.65 2
d Temporary services or feeders installation,alteration,and/or
City/State/ZIP:
Ti�fv
� ./i pie /7�2y relocation
Phone:( 5.o3) 70 i_ 6 f tel Fax:( ) 200 amps or less 66.85 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 133.75 2
Branch circuits-new,alteration,or extension,per panel
Owner signature: Date: A.Fee for branch circuits with
ErAPPLICANT ❑ CONTACT PERSON. above service or feeder fee, 6.65 2
each branch circuit
Business name: 52 E ,,(L,G7 r PG S1-s, B.Fee for branch circuits
' / without service or feeder fee, i 46.85 2
Contact name: Mr.Stuart Evensen first branch circuit
10955 SW 130th:'rve Each add'I branch circuity 6.65 2
Address: Portland,OR 97223 d
Miscellaneous(service or feeder n t included)
City/State/ZIP: Each manufactured or modular 90.90 2
dwelling,service and/or feeder
Phone:(503) 317- q y�I Fax: :(503 ) 524 - /7/C Reconnect only 66.85 2
E-mail: f/AA-ver e S✓t de-efi r'tS. 4.4l1-1 Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
/ Signal circuit(s)or limited-
Business name: ,41,e, energy panel,alteration,or
extension.Describe: Page 2 2
Address:
City/State/ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone:( ) Fax:( ) Investigation per hour(1 hr min) 62.50
CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES,,
Suprv.Electrician signature,required: Subtotal:
Date: Plan review(25%of permit fee):
Print name: State surcharge(8%of permit fee):
Authorized signature: /�1 TOTAL PERMIT FEE:
, f,,�iYl So- This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
' Number of inspections allowed per permit.
I.\Building\Permits\ELC-PermitAPP doe 05/23/06 440-4615T(I l/05/COM/WEB
I
f
PitAOISIFI• *I.
(40/14.11104
Plumbing Permit Appl atio_n . - '
7d FOR OFFICE ISE ONL1�
Cityof Tigard ;J 200 1 RDate/By. 7 0'�,� b7j`{5r'-' )0' -x/37
41 g 1 t' Permit No..
13125 SW Hall Blvd.,Tigard,OR 97 Plan Review
= Phone: 503.639.4171 Fax 503.598.1960 ^i Date/By: Other Permit No.:
DInspection Line: 503.639.413'.1Date Ready/BF
1 ® ee Page 2 for
Internet: www.tigard-or.gov - . trotified/Method: /7 �p SupplementalInformation
TYPI�WONK-T N • y a 1.•,..).... - FEE* SCHEDULE
El New construction El Demolition For special information use checklist
Description I Qty. Ea. I Total
lEr"Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 249.20
Eg'1'-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 350.00
ElAccessory building 0 Multi-family SFR(3)bath 399.00
Each additional bath/kitchen 45.00
0 Master builder ❑Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: ,. c iera�� Ofi✓h 4r 11.4.....,..-
Catch basin or area drain 16.60
City/State/ZIP: Drw lI
>
leach line,or trench
drain 16.60
Suite/bldg./apt.no.: Project name: Footing drain(no.linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
� s n Manholes 16.60
q/ J%"
L F.. �rr g,".. - .- - ld3 Rain drain connector 16.60
0 c 8. ot 14f„....,-,....., g o. /j7 /` / Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: ) Page 2
Subdivision: Lot no.:
Water service(no.linear ft.: ) Page 2
Fixture or item
Tax map/parcel no.: Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Ali
`u4s%div /fjyt- 'M474 j'a7 (q-ot w/ 1,A.�c Backwater valve 16.60
/t4 /0 !� Clothes washer 16.60
Dishwasher 16.60
LyPROFERTY OWNER 0 TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: �� r /y-f G�74,
Expansion tank 16.60
Address: /5 2 “ •f.t'.I iO7 4. /fav Fixture/sewer cap 16.60
City/State/ZIP: ;',"rot, O 172 1-1 Floor drain/floor sink/hub 16.60
Phone:(5o 3 ) 70 1- 0 1 y I Fax:( ) Garbage disposal 16.60
Hose bib 16.60
[rAPPLICANT 0 CONTACT PERSON
Ice maker 16.60
Business name: 5X1' it....t O&'d 1, - e1 sA-- Interceptor/grease trap 16.60
Contact name: 111r.Stuart F.vcn,cn Medical gas(value:$ ) Page 2
Address: 10955 SW 130thAs ve Primer 16.60
Portland,OR 97223
City/State/ZIP: Roof drain(commercial) 16.60
Sink/basin/lavatory 1 16.60
Phone:(spa )3/7' f qle Fax: :(503) j / 17/4
Tub/shower/shower pan 16.60
E-mail: 5/ f e snAe5 hs. Gds.* Urinal 16.60
CONTRACTOR Water closet [ 16.60
Business name: 71-6 r( Water heater 16.60
Address: Other:
City/State/ZIP: Subtotal
Minimum permit fee: $72.50
Phone:( ) Fax:( ) Residential backflow minimum permit fee: $36.25
CCB Lie.: Plumbing Lic.no.: Plan review (25%of permit fee)
State surcharge(8%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: ��K f Ss,t„ Date: This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I\Building\Permits\PLM-PermitApp.doc 06/26/06 440-46161(10/02/COM/WEB)
Mechanical Permit Atpiileatiee I V °L.:, FOR OFFICE l'SE O L
Received
City of Tigard 'lf! „'• Permit No.: 1tif5� , ,,7.. j/.{
14 111 13125 SW Hall Blvd.,Tigard,OR 91J�"33 J 2007 Date/By:anw`
Plan Review
Phone: 503.639.4171 Fad,,, 03 59$.1960 Date/By: Other Permit:
Inspection Line: 503.639. 17 I E ''
T 1 G A R D p 3 t -�'� Date Ready/By: /e I I i L. ® See Page 2 for
Internet: www.tigard-pzggpx..,.„ 7,.„. ..., s;T TjNotifed/Method: Supplemental
L4' l./rit _ V :_3.1.01\
TYPE OF WORK COMMERCIAL FEE* SCHEDULE -.USE CHECKLIST
(Addition/alteration/replacement Mechanical permit fees*are based on the value of the work
1:3 New construction performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,and profit.
CATEGORY OF CONSTRUCTION Value:$
RESIDENTIAL EQUIPMENT/SYSTEMS FEES*
1-and 2-family dwelling ❑Commercial/industrial 0 Accessory building
For special information use checklist.
❑Multi-family ❑Master builder ❑Other:
Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
,/J /- � � � Air conditioning or heat pump
Job site address:
St.G gam /s Ota 6.t, (requires site plan showing placement) 14.00
IP:
City/State/Z ✓✓ Furnace 100,000 BTU(ducts/vents) 14.00
Furnace 100,000+BTU(ducts/vents) 17.90
Suite/bldg./apt.no.: Project name: Gas heat pump 14.00
Cross street/directions to job site: Duct work 14.00 _
pHydronic hot water system 14.00
'". trw MG •� ---1oK /0.3."41 Residential boiler(radiator or
0 a^ hydropic) 14.00
mA. rrc.._ / 107 /�•-i-•� Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 10.00
Subdivision: Lot no.:
Flue/vent for any of above 10.00
Other: 10.00
Tax map/parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
Gas fireplace 10.00
int.GA rwfe-1 4-711 nhr 627-.4.41,(4 t-w. Flue vent for water heater or gas
r/ // fireplace 10.00
Log lighter(gas) 10.00
II
Wood/pellet stove 10.00
Wood fireplace/insert 10.00
Chimney/liner/flue/vent 10.00
OrPROPERTY OWNER 0 TENANT
Other: 10.00
Name: Y A4 - _ Environmental exhaust and ventilation
Range hood/other kitchen
Address: /t7:17 5 w. J0 7 r 1:,,-rr+..- equipment 10.00
City/State/ZIP: ?-r,.�,,/, a It 17,2-1 Clothes dryer exhaust 10.00
Single-duct exhaust(bathrooms,
Phone:(503 )71,i - Of y1 Fax:( ) toilet compartments,utility rooms) 1 6.80
(APPLICANT .; ❑ CONTACT PERSON Attic/crawlspace fans 10.00
Other: 10.00
Business name: . 'ie .
/N i y t'ea*j�jh. Fuel piping
Contact name: Mr.Stuart Evensen ✓✓ $5.40 for first four;$1.00 for each additional
10955 SW 130th Ave Furnace,etc.
Address: Portland,OR 97223
- Gas heat pump
City/State/ZIP: Wall/suspended/unit heater
Fax: :( spj) Water heater
Phone:(so3) 3/J- 914(1S?1../7/L Fireplace
E-mail: 57L;j a,-I G 5'ft it f 7)/4. Go N. Range
/ CONTRACTOR Barbecue
Clothes dryer(gas)
Business name:
71-1
Other:
Address: MECHANICAL PERMIT FEES*
City/State/ZIP: Subtotal
Minimum permit fee($72.50)
Phone:( ) Fax:( ) Plan review(25%of permit fee)
CCB lic.: State surcharge(8%of permit fee) _
TOTAL PERMIT FEE
N/ This permit application expires if a permit is not obtained within 180
Authorized signature: '(^testi/ days after it has been accepted as complete.
Print name: S K �veysG4, Date: * Fee methodology set by Tri-County Building Industry Service Board
I:\Building\Permits\MEC-PermitApp.doc 04/06/06 440-4617T(II/02/COM/WEB)
A-VP TO J u /5 Nq I-T q `Fil-c-K rr
Construction Contractors Board Permit#:t4 4 2L 7 -co X31
700 Summer St NE Suite 300 Address: -L(o SU) /01 Ill T -Ale- .
1/''air PO Box 14140
t Az Salem OR 97309-5052
LJ Phone: 503-378-4621 Issued by: Date:
I.j'y� Web Address:www.ccb.state.or.us
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not
licensed with the Construction Contractors Board to sign the following statement before a building
permit can be issued. This statement is required for residential building, electrical, mechanical and
plumbing permits. 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.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
-- 1. I own,reside in, or will reside in the completed structure.
� /l. I understand that I must become licensed as a construction contractor if the structure is sold or
offered for sale before or on completion.
❑ 3A. My general contractor is
(Name) (CCB #)
I will instruct my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
OR
,..tr3B. I will be my own general contractor.
fk,
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 contract with a contractor who is
licensed with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
,,,a _ r.A -
7/2,4
0 7
igna a of permit applicant (Da e)
(White copy to issuing agency permit file,pink copy to applicant.)
Property_owner.doc 06-01-04
Acting as Your Own General Contractor?
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTE: This Information Notice to Property Owners about Construction Responsibilities was developed by the
Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature.
ft you arc acting as your own contractor to construct a new home or make a substantial improvement to an existing
structure, you can prevent many problems by being aware of the following responsibilities and concerns.
Employer Responsibilities
You will, in most instances,be ruled to be an "employer" and the contractors you contract with will be "employees" if
you use contractors not licensed with the Construction Contractors Board to do labor in constructing or to assist in the
construction or improvement of a residential structure. As the employer,you must comply with the following:
Oregon's Withholding Tax Law: As an employer, you must withhold income taxes from employee wages at the time
employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your
employees. For more information, call the Department of Revenue at 503-378-4988.
Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance purposes
on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488.
The Oregon Business Identification Number (BIN) is a combined number for both Oregon Withholding and
Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or www.dor.state.or.us/formspay.htmll for the
appropriate forms.
Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law,
and must obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation
insurance, you could be subject to penalties and be liable for all claim costs if one of your employees is injured on the
job. For more information, call the Workers' Compensation Division at the Department of Consumer and Business
Services at 503-947-7815.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages.
You will be liable for the tax payment even if you didn't actually withhold the tax. For a Federal EIN number, call the
IRS at 1-800-829-4933 or visit their web site at wv‘rw.irs.g.ov.
Other Responsibilities and Areas of Concerns
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code
requirements that may he brought to your attention through inspections.
Liability and Property Damage Insurance: Contact your insurance agent to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe punctures, fire or
work that must be redone.
Time: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the skills to act as your own general contractor, to coordinate the work of rough-in
and finish trades, and to notify building officials as the appropriate times so they can perform the required inspections.
If you have additional questions call the Construction Contractors Board (503-378-4621) or write the agency at PO
Box 14140, Salem, OR 97309-5052.
Property owner.due 06-01-04
09/28/2007 12:33 5032224812 FEDEXKINKOS NWPORTLD PAGE 01/01
72-72
.5-2i/ -----Pk-P77777
4�
March 12, 2008
Avery and April Carter
15266 SW 107th Terrace
Tigard, OR 97223
Permit #: MST2007-00137
Site Address: 15266 SW 107th Terrace
Project Name: Carter
Dear Applicant:
This letter is to notify you that your plan review application for the above referenced permit
will expire in accordance with Section R105.3.2 of the Oregon Residential Specialty Code.
Applications are valid for a maximum of 180 days from the date of the application. Since
this permit has not been pursued in good faith,it will be expired on April 15th of 2008.
A new application,building plans, and the plan review fees are required to be submitted for a
new permit number to be assigned.
If you have any questions,please feel free to contact me.
Sincerely,
Loraine Sellers
Plans Examiner
loraine@tigard-or.gov
Phone: 503.718.2708
Fax: 503.624.3681
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