10665 SW COOK LANE rn
(n
0
n
O
O
r
a
10665 SW Cook Lane
MASTER PERMIT
CITY OF TIGARD
PERMIT#: MST2000-00487
DEVELOPMENT SERVICES DATE ISSUED: 11/1/00
13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171
SITE ADDRESS: 10665 SW COOK LN PARCEL: 2S103DA-05200
SUBDIVISION: FANTASY HILL ZONING: R-3.5
BLOCK: LOT: 007 .JURISDICTION: TIG
REMARKS: BATH ROOM RENOVATION
_ BUILDING
REISSUE: STORIES: FLOOR AREAS _ REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ALT HEIGHT: FIRST: at BASEMENT: rt LEFT: SMOKE DETECTORS:
TYPE OF USE: SF FLOOR LOAD: SECOND: at GARAGE: at FRONT: PARKING SPACES:
TYPE OF CONST: 5N DWELLING UNITS: FINBSMENT: of RIGHT:
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL. OAO of VALUE: S 1,50000 REAR;
PLUMBING _
SINKS: WATER CLOSETS: I WASHING MACH: LAUNDRY*TRAYS:: RAIN DRAIN: TRAPS:
LAVATORIES: I DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: CATCH BASINS:
TUBISHOWERS: 2 GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
MECHANICAL
OTHER FIXTURES:
FUEL TYPES FURN<100K: BOIUCMP c 3HP: VE 4T FANS: CLOTHES DRIER:
FURN>000K: UNIT HEATERS: HOODS: OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVCIFEEDERS- BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 200 amp: 1 0 200 amp: WP;VC OR FDR: PUMPIIRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 400 amp: 201 400 amp: tet WIO SVCIFDR: SIGNIOUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 000 amp: 401 600 amp: F.A ADDL BR CIR: SIGNAUPANEL: IN PLANT:
MANU HM/SVC/FDR! 601 Iono amp: 601+8mpa•1000v: MINOR LABEL:
1000•anplvolt:
Reconnect only:
PLAN REVIEW SECTION
._
>-4 RES UNITS: SVC/FJR> 226 A.: >600 V NOMINAL: CLS AREAISPC OCC:
ELECTRICAL•...:-41CTED ENERG
A.SF RESIDENTIAL B,COMMERCIAL
AUDIO&STEREO: VACUUM SYSTEM: AUDIO&STEREO: FIRE ALARM: INTERCOM/PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM•. OTH: BOILER: HVAC: LANDSCAPEIIRRIG PROTECTIVE SIONL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL OTHR:
HVAC: DATArrFLE COMM: NURSE CALLS TOTAL p SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 387.17
P')NIATOWSKI-D'ERMENGARD, HOEVE--RENOVATION INC This permit is subject to the regulations contained in the
MARIE LORRAINE 6215 SW MCEWAN ROAD Tigard Municipal Code,State of OR Specialty Codes and
10665 SW COOK LN LAKE OSWEGO,OR 97035 all other applicable laws. All work will be done In
TIGARD,OR 97223 accordance with r:pproved plans. This permit will expire H
work is not started within 180 days of issuance,or if the
work Is suspended for more than 180 days ATTENTION:
Phone Phone: Oregon law requires you to follow rules adoptee':1 t 1e
Oregon Utility Nv'I"cation Center. The:3 rules are set
Rapti: UC 1419% forth in OAR 9E 1-0010 through 95e 001-0080. You
may obtain copiL of these rules or direct questions to
OUNC by calling(503)246-1987.
REQUIRED INSPECTIONS
PLM/Underfloor Electrical Final
Plumb Top Out Plumb Final
Electrical Service Building Final )
EInctrical Rough In /
Framing Insp
Issued 1� _-
y Perrnittee Signature
Call (503) 639-4175 by 7:00 p.m. for an inspection needed the tSext business day
Building Permit Application
Datereceived: Permit no.:
\
a
City of Tigard
Address: 13125 SW Hull B10,Tilo 722.1 ProjecUappl.no.: Expire date:
ird.OR 9
City of Tigard Phone: (503) 639-4171 Date issued: By: Receipt no.:
Fax: (503)598-1960 Case file no.: Payment type.
Land use approval: _ I&2 family:Simple Complex:
3
a
U 1 &2 family dwelling or accessory U Commercial/industrial U Multi-family U New construction U Demolition (�
'5d Addition/aiteratiott/replacement U'tenant iniprovement U Fire sprinkler/alarm U Other:
Job address: /0A65— t_Q�—��a'�3 Bldg.no.: Suite no.:
Lot: I Block: Subdivision: Tax map/tax lot/account no.:
Project name: '
Description and location of work on premises/special conditions: _ EfIQitA' QF�lOK19-�O __
011 NHL FOR INFIORNIk)'110N, t!SE
Name: '
Mailing address: I &2 family dwelling:
-- vo-
City: Statc: 711': Valuation of work........................................ $
Phone: - Fux E mt►il: No.of bedrooms/baths...................... ......... _
Owner's representative: Total number of floors.................................
Phone: New dwelling area(sq.ft.)
Garage/carport area(sq.ft.)
Covered porch area(sq.ft.)
Name: ---- —
Mailing address: Zj -!_ Deck area(sq.ft.) ........................................
City:yQkf Other structure area(sq.ft.). .......................
Phone: Fax: E-mail: CommerelaUiudutrlal/multi-family-
Valuation of work........................................
Business name: - r Existing bldg.area(sq.
Address: ft.) ............. ..........
_ = New bldg.area(sq.ft.)
Cil State 7_.IP: — Number of stories..................... .................
Phone: ' _ Fn - E-mail: Type of construction.................... ...........
CCB no.: i Occupancy group(s): Ex g•.
_
New:
City/metro lic.no.: Notice:All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board under
Name provisions of URS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
City: Sta 71P: exempt from licensing.the following reason applies:
Contact person: Plan no.:
Phone: t,,� ► n,.i 1 -- ---
Name: Ch ni.,ct person: Fees due upon application ........................... $
Address: �— �- — Date received:
City: _ State: Amount received ........................................ $
Phone: Fax: Email: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all Jurindctions wow n>a,cards.Mew call jurisdiction for more information.
attached checklist.All provi ns of laws and ordinances governing this U visa t:]MasterCard
work will he compiled wit . he ec
d he n or not. Crttlit card number__ _ �— �_
a><rire.
Authorized signature:_ Date: Name of cardholder asah Wn on credit card —
f
Print name: umna. atpuiure Amoum
Notice:This permit application expires if a permit is not obtained within 190 days after it has been accepted as complete. 4104613(6AOROMI
One-and Two-Family Dwelling
Building Permit Application Checklist Reference no.:
Ciry ofTign,d rl`•r of Tigard Associated permits:
g
Address: 13125 SW Nat, U Electrical U Plumbing U Mechanical Blvd,Tigard,OR 97223 U ether:
Phone: (503) 639-4171
I�ax: (503) 598-1960
101to 111
I Land use actions completed.Sec jurisdiction criteria for concurrent reviews. _
2 Zoning.Flood plain.solar balance points,seismic soils designation,historic district,etc.
3 Verification of approved plat/lot.
4 Fire district__`_approval required.
5 Septic systeiv permit or authorization for remodel.Existing system capacity
6 Sewer permit.
7 Water district approval
8 Soils report.Must carry original applicable stamp and signature on file or with application.
'r Frosion control U plan U permit required.Include drainage•way protection,silt fence design and location of
catch-basin protection,e'c.
10 _ Complete vete of legible plans.Must be drawn to scale,showing conformance to applicable local and state
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size
sheet attached to the glans with cro.s references between plan location and details.Plan review cannot be completed
if copyright violation.exist.
I I Site/plot plan drawn to scale.The Man must show lot and building setback dimensions;property corner elevations(if
there is more than a 4-fi.elevation differential,plan must show contour lines at 24t.intery-1s);location of easements and
driveway;footprint of structure(including decks);locati.,a of wells/septic systems;utility locations;direction indicator,lot
arra;building coverage area;percentage of coverage;impervious area;existing structures on site;and surface drainage. _
12 Foundation plan.Show dimensions,anchor bolts,any hold-downs and teinfor+cing pads,connection details,vent
size and fixation.
13 Floor plans.Show all dimensions,room identification,window size,location of smoke detectors,water heater,
furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc.
14 Cross section(s)and details.Show all framing-member sizes and spacing such as Nor beams,headers,joists,sub-floor,
wall construction,roof construction.More than one cross section may be roquired to clearly portray construction.Show
details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings and foundation,stairs,
fireplace construction, thermal insulation,etc.
15 Elevation views.Provide elevations for new construction;minimum of two elevations for additions and remodels.
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full-size sheet addendums showing foundation elevations with cross t. ;erences are acceptable.
16 Wall bracing(prescriptive path)and/or lateral analysis plans.Must indicate details and locations;for
non-prescriptive pathavalysis provide specifications and calculations to engineering standards.
17 Floor/roof framing. Provide plans for all floom/roof assemblies,indicating member sizing,spacing,and bearing
locations.Show attic ventilation.
18 Basement and retaining walls.Provide cross sections and details showing placement of rebar. For engineered
systems,see item 22,"Engineer's calculations."
19 Ream calculations.Provide two sets of calculations using current code design values for ail beams and multiple joists
over 10 feet long and/or any beam/jofst carrying a non-uniform load.
'n Manufactured floor/roof truss design details.
21 Energy Code compliance.Identify the prescriptive path or provide calculations.A gas-piping schematic is required
for four or more appliances.
22 Engineer's calculations.When requirrd or provided,(i.e.,shear wall,r,- truss)shall be stamped by an !ngineer or
architect licensed in Oregon and shall he shown to be applicable•,me project under review.
23 Five(5)site plans are required for Item I I above.
24
25 -7_
26
27
28 i
Checklist must be completed before plan review scan date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 440-4614 OMDO'or.n
Plumbing Perntit Application
Date received: Permit no.:
City of Tigard Sewnrermit no.: Building permit no.:
Address: 13125 SW Hall Blv•i,Tigard,OR 97223
p _
Cuyr�fTigard Phone: (503) 639-4171 ProjecVappl.no.: EKpiredatc:
Fax: (503) 598-1960 Date issw!d: _ By: Receipt no.:
Land use approval: _ Case file no.:
Payment type:
U I &2 family dwelling or accessoryD::ontile rcial/industrial U Multi-family U Tenant improvurnent
6"��,.;&RMATIION
�+Oddition/alteration replacement U Food service U Other:
Job address: n Description Y. hee(ea.) Total
�L_--�_ _-- ew I-and 2-family dwellings only:
---- --
Bldg.no.: Suile no.: -- ___ (Incluies 100 it.for each utility connection)
Tax map/tax lot/account no.: SFR(1)bath
Lot: Block: Subdivision: _ SFR(2)bath - -__ - --- - -
Project name: ' - Ar-C) SFR 3 bath
City/county: _ 7!P: � „�� Each aoGitijual bath/kil.hen -
t DescriptiotiMd location of wor,�G,un,,remises,
�-{ SheuNlltieA.
Catch basin/aret.d-ain
_
_----- - D wells/leach linc/trench drain
Est.date of cornplelion/iuspcelion: rY _
Footing drain(no, in.ft.) _
0 Manufactured(tome utilities ---
Business_name: /�',t>D� {���yJ(�-- Manholes
Address:- 2� Rain drain connector
City: q - State: ZIP: �"� Sanrtaty sewer(ro.
Phone: Fax: I E-mail: Storm sewer(no.lin.ft.)
CCB no_4e . r Plumb.bus.reg.no: - Water service(no.lit:.ft.)
City/metro lic.no.: a/ Fixture or Item:
Contractor's repmse atur•* Absorption valve -
Print name: ate: Back floe preventer --
Backwater valve
t Basins/lavatory
Name: � 1�( i�• Clothes washer _
Address; _ Dishwasher
Drinking fountain(s)
_Cily: State: Z.IP: Ejectors/sump --
Phinu Fax: E-mai!: Expansion tank —
Fixture/sewer cap
Name(print): A flk ,E — C��10, Floor drains/floor sinks!hub
Mailing address: L/ --- Garbage disposal
Hose bibb
City: State:04.1 ZIP: e� Ice maker _
Phone: - Fax: E-mail: Interceptor/grease trap _
Owner instal lation/residential maintenance only: The actual installation Primer(s)
will he made by me or the maintenance and repa r made by my regular Roof drain(commercial) _
employee on the property I own as per ORS Chapter 447. Sink(s),basin(s),la_vs(s) _
Owner's signature:_ Datc: Sum
Tubs/shower/shower pan
Name: Urinal _^
Water closet
Address: Water heater
City: -�_ �— - State: ZIP: Other: --
Phone: Fax: E-mail: Total
Not all Jurl•d)caona acceptcredit cards,please call jurisdiction for rode edam•t Notice-This permit application Minimum fee................$
U Viso U MasterCard expires if a permit is not obtained Plan review(at _ %) $
Credit card number: — / LwiUtin !8(►days atter it has been State.ircharge(8%)....$
Expires tete. TOTAL •••••••••••••••••••••••
accepted as complete.Name of crdhol r u shown on credit card P P
t
Crdlwl�nature — Amount 440-46i51NOO/COM1
PLUMBING PERMiT FEES:
W
PRICE TOTAL New 1 and 2-family dweilings only: F_ —
FIXTURES�ndividua! _JY—_ QTY ea AMOUNT (includes all plumbing fixtures Ir. PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
/ for each utility!nnnection—
Lavatory _ __ � 16.60 /6.(9�- -One(1)bath _ ____ $249.20
Tub or Tub/Shower Comb — 16.60 Two 2 bath _ $350.00
Shower Only 16.60 Three(3�bath — $399.00
Water�,losal — — 16.60 ----- SUBTOTAL
Urinal— 16.60 _ 8%STATE SURCHARGE
Dishwasher 16,60 PLAN REVIEW 25%OF SUBTOTAL
Garbage Disposal - - - --16.60 ___ ___ _— _TOTAL -
Laundry 1-ray 16.60
Washing Machine 16.60 —
Floor Dialn'Floor Sink 2" 16.60
3" --- 16.60 PLEASE COMPLETE:
4--`— 16.60 _
Water Healer O conversion O like kind 16.60 —� Quantity bo Work Performed -
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. _ — Capped
MFG Home New Water Service 46.40 Sink _ _
MFG Home New San/Storm Sewer 4G 40 - Lavatory
---- Tub or Tub/Shower
Ho fibs 16.60 Combination
Ro Drains J 16.60 _Shower Only
Drinking Fountain 16 60 Water Closet
Other Fixtures(Specify) 16.60 - Urinal — —
_— Dishwasher
- —� -- Garbage Disposal— — ----
Laundry Room Tri _-
- -- -- Washing Machine _ —
Sewer-1st 100' 55.00 -Floor Drain/Sink: 2" —
—3„
Sewer-each additional 100 46.40 4"
Water Service- 1st 100' — 5500 Water Healer —
Wa:er Service-each additional 200' 46.40 Other Fixtures
Storm 8 Rain Drain-1st 100' 55,00
Storm 8 Rain Drain-each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40 -
Residential Backflow Prevention Device' 27.55 —- --
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 72.50
Requested Inspections en9v COMMENTS REGARDING ABOVE:
Rain Drain,single family dwelling 5525
—
Grease Traps 16.60
---- QUANTITY TOTAL - --- -------- — __--
Isometric or riser diagram is required it
Quantity Total Is;9 �'�J --- ----- ---
'SUBTOTAL
7,22 su
81/6 S-.ATE SURCHARGE
"PLAN P.EVIEW 25%OF SUBTOTAL
Required only it fixture qty lr tal is>9
----� � TOTAL ---- E w•
"Minim-im permit fee is$72 50•8%state surcharge,except Residential Back9ow
Provention Device,which is$36 25«8%state surcharge
**All New Commerclyd Buildings require plans with isometric or riser diagram and
plan review
I:\dsts\forms\plm-fees.doc 10/10/00
OC1-13-00 C9.15AM FROM.-MP PLUMBING 503655172E 7-771 p 01/01 F-52E
CITY OF TIGARD Plumbing Permit Application Plan Check s_
13125 SW MALL SLVD. "ommercial and Re3idential Recd By
TIGARD, OP 97223 pate Recd
(503)639-4171 Date to P1 _.
Print or Tvpe CA(etn DsT
Incomplete or illegible applications will not be accepted Perii1ta-
Related IR• __—
CaWe f
--- - Nana of Us-lop ent/Projecl
.lob �Re1E' Sk*
Address5} I/ State Lavatory 11.su
��iI 'rub or uh/Shower Comb. 11.50
ale
21p f Sri
Nam star IUrktal (Specify) 11.50
Dishwasher 11.50
OwnerMilli `?'' oe Dlspaol 11.50
Cify/Slate Zip _ phrxte Washing Metyib,rlLaundryTray (SpeciN;
Floor prakt/Floor Ski 2' 11
NAMG
_ _ 4' 11.ou
Occupant A1aMt ,a SuHe � Water Heater C oonversion O Ill&kind
•'t _- �'a OutI Ing r ekes e e arate neehanieaiap6(mi _
Cry to lip trona MFG Home Now Water Semice 2800
Name- - --- - MFi3 Home New San/Stoftn Sewer -- a 00
Hoo Biba
Contractor ifny ddress sett Rain Drama
brirwrig Fountain A 11.60
PIW ti:pwrmlt !State Zip P I Other t*xtures( peGb) 15.00
I issuance,s copy y s _
of all Iloenabs are C4ewfisqnst.Cort Board Lic,A its ------- ----,_m
required if -- - _1_ / - --—----- I
expired In COT Plunlblrl m e i E to
database
i
Name Sewer-1st 100'
Architect Sewer•each additional
exF32.00
Cr Mailing Add esa
En buite� Water Servioe- 1st 100' 38.00 dhisneer cityr a -� Zip °hone T Water servioe•escn sdvna.OF _^- a2 en �
9 term 6 Pain Drain-i;it 100' 3800 1
ee.ibe work to be duv { orm i In Drain-samh addititxial 100' W 32.00 l
New 0 Repair 0 Replace with like kitxt; Yes 0 No O I Comrneraial Becti#low Prevention aev.ue —
Residential • comnorcial O -
A —al deailriptic of wom - — -�— Residential Backflow Prevention DeviG•- _— 19.00
Catch Basin 1150
/'K�p-mac
Into of 9xisting Plumbimu 83 DO
Arc you capping,moving or replacing—any fixtures? - _ _ rmr_
Yes 0 No O Spiirplally Requested Inspections 50.00
If yes,see back cf form to indicate work performed by nhr
fixture. FAILURE TO ACCURATELY REPORT FIXTURE gain bren single family dwelling 45.00
`WORK COULD RESULT IN INCREASED SkWER FEES. Grease 7raps F 11.50
ihereby acknowledge that I have road thisapt lioation,that the informsoen QUANTITY TOTAL N
—
giver. a ok.rracl.that I am the owner or authortt,n agent of the owner,err
nd ;somnrk a er_�AT is reviaed I oventay Toa is f) _
that r sena auhrutled Ate in eoTpiiarxx with Ore on State!ewe. _ —'— --_v 'gUP_Tt)TAL
Sig ~tum of Uwne ant - t -— ,
TOA 1FURCHARGE
Contacl Person ame ono _nt1J
~PLAN REVIEW 25%OF-6iUeTorAL
1 R 1,09 any a Ponurs gtytall rs-0
� � ----- -- TOTAL,
(
•Minimum permit fee n$50•)q aurrharge,e.cep Recidamral aac„ww. pra.w
Oavwa wnicr!e its• X lurtl+xv
-MI Now CoTmemlai 1111010inprl req ikv plans rtln re."metic of rjW dislitam are
Clan fever.
. .,f�,a�arapc Doc tU�R+9
Electrical Permit Application
Date received: Permit na:
City of Tigard Project/ap,Ano.: Expire date:
City ofTigard Address: 13125 SW Hall Blvd,Tigard,OR 97223 Date issued: By: Receiptno.:
Phone: (503) 639-4171
Fax: (503) 598-1960 Case file no.: Payment type:
Land use approval:
U 1 &2 family dwelling or accessory U Commercial/industrial U Multi-family U Tenant improvement
U New construction > Addition/alteration/replacement U Other: U Partial
Job address: Q Bldg. no.: Suite no.: ITax map/tax lot/account no.:
Lot: _ Block: _Subdivision:
Project name: Description and location of work on premises:
Estimated date of completion/insix•Cliorn:
tis
Job no: Fee
Uescrl Ilon Uh. (ea.) Ilrlal no Imp
BUSIneSS name: —rm __ I
t New rcsldenlfal-single or multi-famih;x�r
Address: G _ dwelling nidi.Inchnies attached garage.
City: Slaw M ZIP: 5crvinlncluded:
Phcne: B Fax: 1,: trail: IWK)sq,It or less _Each additional 500 s .ft.or ortion their of
CCB n0.: EICC_bus.tic.n0: � ILimitedeacrgy,rcaidential 2
City/metro IIC.n .: Limited energy,non-residential 2
Fach manufactured home or modular dwelling
Signature of supervising elechician(required) bate Service and/or feeder 2
Slip,elect.name( rin0: License nu: Services or feeders—installation,
■Iteration or relocation:
200 amps or less ai 2
Name(print): 01 amps to 400 amps _ 2
Mailing address: 7j401 amps to 6011 amps 2
01 amps to 1000 ams 2
City: State ZIP: ver 1000 amps or volts _ 2
Phone: Fax: I E taail: Reconnect only I
Owner installation:The installation is being made on property I own Temporary services orfeeders-
which is not intended for sale,lease,rent,or exchange according to Installation,alteration,or relocation!
ORS 447,455,479,670,701. 2tx1 amps or less 2
201 amps tr aux)snips 2
OWner'S Si nature: Date- 401 to 600 anil: 2 —
Branch circuits-new,alteration,
or extension per panel:
Name: _ _ A Fee for branch circuits with pu chase of
Address: _ service or feeder fes,each bmich circuit �` �l 2
City: Slate: ZIP: h Fee for branch circuits without purchase
of service or feeder fee,first branch circuit _ 2
Phone: Pnx f nutil 1 at h additional branch circuit:
' Mlse.(Service or feeder not Included):
7i(qa:enZv
225 amps-commercial J Health-care facility 1 ach pump or irrigation circle 2
320 amps-rating of 1&2 U Hazardous lex ation Each sign or outline lighting _ 2
ngs U Building ovet 10,000 square feet four or Signal cncuius1 or a limited energy pan.fi00voltsnominal more residcntial units in one structure alteration,or extension" 2
U Building over three stories U Feeders.400 amps or more •tkscri rtion:
U Occupant load ove:99 persons U Manufactured structures or kV park Fach additional Inspection over the allowable Ir any of the above:
U fgmss/lightingplan U Ocher: -___—__ Perins tion
submit_,ttet,of pian with env of the above. Investigation fee
'rile above are not applicable to temporary construction service. Other
Not all)udsdedi
knons accept crt cards,please call iarisdicuon for snare itdotrnatlon. Notice:This permit application Permit fee.....................$ ' --
U Visa U MasterCard expires if a permit is not ootained Plan review(al " %) $ _
t•redii card number: _ _i / within ISO days after it has been State surcharge(8%)....$
Name of coir as —-
_— sownoncit card Expires accepted as complete. TOTAL .......................$
Ca dholder signature Amount 4104615 0OW/170M)
I
Electrical Permit Fees: Limited Energy Fees:
TYPE OF WORK INVOLVED - RESIDEN-IAL ONLY
Restricted Energy Fee -
Complete Fee Schedule Below: - -- - .. - -
P ...................................................... $-x-.,.-00—
4_ Number of Inspections pur permit allowed (FOR ALL SYSTEMS)
Service incluried:� Items Cost Total Check Type of Work Involved:
Residential-per. .
1000 sq ft or len:. _ $145.15 — 4 ❑ Audio and Stereo Systems
Lach additional 500 sq.ft.or
portion thereof _ $3340 1 ❑ Burg,3r Alarm
Limited Energy _ $75.00 _
Each Manufd Home or Modular — ❑
Dwel;ing Service or Feeder $90.90 Gamne Door Opener'
Services or Feeders ❑ Heati 1g,ventilation and Air Conditioninn System'
Installation,alteration,or relocation
200 amps or less $80.30 6—b.30 2
k„1 amps to 400 amps $106,85 _ El Vacuum Systems'
401 amps to 600 amps _ $160,60 _ 2 ❑
601 amps to 1000 amps T $24060_ 2 Other
Over 1000 amps or volts $454.65 2 —
Reconnect only $6685 2
Temporary Services or FeedersTYPE OF WORD INVOLVED -C.OMMERCIAL ONLY
Installation,alteration,or relocationion
200 em,re or less $66.85 _ 2 Fee for each system........... .... ..... .................................. $75.00
201 arnps to 4C0 a,;is S100.30 _ 2 (SEE OAR 918-260-260)
401 amps to 600 amps $13375 2
Over 600 amps to 1000 volts, Ct.•,ck Type of Work Involved:
see"b"above.
Branch Gircults ❑ Audio and Stereo Systems
New,alleral.on or extension per panel
a)The;ee for branch circuits ❑ Boller Controls
with purchase of serilce or
feeder lee. ❑ Clock Systems
Each branch circuit _ $6 65 ! �J.y_ 2
b)the fee for branch cin uits E] Data Telecommun cation Installation
wlth,ut purchase of service
or feeder fee. Fire Alarm Installallon
First branch circuit $46.85
Each additional branch circuit $6.65 ❑ HVA"
Miscellaneous
(Service or feeder not Included) Instrumentation
Each hump or Irrigatt�)n circle $5340
Each sign or odtllnn lighting $53.40
Signal circult(s)or a limited energy ❑ Intercom and Pagt�g Sysioms
panel,alteration or extension $15.00_
Minor labels(10) __— $125.00 Landscape irrigation Control'
Each additional Inspection over ❑
the allowable in any of the above Medical
Per inspection $62.50
Per hour $62.50 ❑ Nurse Calls
In Plant p $73,75_
❑ Outdoor Lanc;scape Lighting'
Fees:
Enter total of above fees $ rr❑---1t Protective Signaling
fti State Surcharge $ L_1 Other
25°o Plan Review Fee _-----_Number of Systems
See"Plan Review"section on $
front of application ' No licenses are required Licenses are required for at:other Installations
Total Balance Due $ Fees:
❑ Trust Account d Enter total of above fees S
i
I
8%State Surcharge $
Total Balati--e Due $
i\fists\forrr.;\elc-fees.doc 10/09/00
I
I
CITY OF TIGARDElectric I Prmit�Kpplication Plan C"ch 0 I
12126 SW HALL BLVD.
Rec d Uy
TIGARD OR 07223 � i Dote Recd
Phone IOW)"0-4171 x304 Dats to P.E.� I
f Dale to DST
Intq-„;,tKdn (50)(339A 175 Print of Type Parmlt r
Fox 503)598-1980 Incomplete or Illegible will not be accepted Called_-
1. Job Adplress: 14. Complete Ftee Schedule Below:Nana 6.r CNwalopment Numtaer of IrapEtilom per permit altotsed
Nornc(or nomq of bdoin000) Ce tAA ��r'e Service Included: Items Cost cum
Adore$$ 43ar1_g4o� l06it, 1_14 _ 4a, Resrderm -PHunn
+000 sq.R.a less $ 111,10 4
City/SfaleJZiptr�� I1�. QS.dN�i�a,�� 11-7f 4 Esoh additonal too sq f+ a — -
a 2825
Corrmardal 13 Residenti,� Limited�EEnthereof
gyor s 80 00 t
�t
Each Monufd Home or r
Modula
2a, COn9mcifor Insttallation only: E.Ivve'l'^o h4prvhoa qr f etroer 5 72.70 2
(Pio►to permit lestdnros,eppr”,1110 meet provltle Contractor'....w 4b.Services or Ferldsrta
Information for CAT da lle base), InstArethon,Alteration.or relocal,on
EI"r,Mc al Contractor /j7_J" _ l(z�r /C' l�j L I too 4,n„a u,IQ%b _ o a+.ro i o :
rrT--�'--r i" 201 amps to 400 smpa t 5550 2
Addr@35 �Y t f = tint amps In RM amps S 12111 so 2
Citj !`rU/ r. '-i1 eY fateta_te ziP 0D' amps to 1000 arrRa f 112.50 _ _ 1
Pho to No Over 1000 amps a Vohs --- -- ! 363.70 ---- 2
Job NoPaeoitneet only 6760 2
Elec.Cont l led No hip.D 11 ate r ,'L" 4a.TerporarY t;arvk:es or readers
OR State CCB Reg.No.1 C Exp Date 1 G' installation.alvellon,c•icocalion
93.0( 2
77 , c f
COT Business Tax or Metro N0 Y. Exp Cate l 2UU amps Of lel tot Amps to 400 dmlov
Signature of Supr E ec n — — 401 amps to$00 smog s 107.00 z
Over 603 amas to 1000 VONA
License No. �-s- -Exp Dula see"b"above
Phone No.
1C_)!'� i 4d Branch Ctneult>t
.'40*.alteration or ex ens or per panel
M The fee for branch or;jls
Zb, II`or owner Installations: with purrlleae of soresce of
hada.raa.
Pr,nt Owners Nall-le Each branch circuit _ s A 3r. I b.7 D a
Address b)The lee for branch circu+It
-- without purchase of a4wke
City „Stets t p _-_ or feeder dee.
Phollte No. -,w- firs;branch areuil 1 37,00 _
Ferh ade,Uonpl brennh dreua s a�0
The inotollot7on o5 being modo on property I own which s not w,Mtswliaiwvw
Intended for 0elie.Iso"or rent (Soni'^a or beds,not+ndudnd)
Each pump or irrigation olro4 I 42.10
Owner's Signature_ -- ----_�— Each tion or cul0rie fighting -� S 42,)9
Smprsl Nroull(s)or s Nhatied e'nrgy
9. Plan Rdvlew soetlon (K requlreeg.* penlleratlon or extension : an f
M�norLssale(tU) 107 0)
Please check appropriate Item and enter fee In 0ectlon 50, 411'.Etch addltlonal inspection over
4 or moire residsnbM writs to one structure the a0otpabla In Any of the above
--Sevin and feeder 22.5 srrmra a more rat ,tpgcncr+ � s eo a•.
Per,our - 1111;.00
System off 60C Vohs no!`:4nal h P ant f 5900
-C'951Od 0.00 or ski sure conlani Q special occupancy so
w descntie,to N E C,Chapter S 5, F@e4:
64 Eraat toil of above fast
subrnit I sets of planal vir th application where any of the above apply. $'4 ourcharge(.CS A l,)W legal t
Not r,pulr/d for temporary cotMtn+otlon 0ervl4a0• subtotal $
SIL Into,28%of hne so rw -
I"TI .E Paan ROWea L rwouinwt"0er �1 x .��
PERMITS 81COM!VW if WORK OR OONOTRUOTION AUTHORIZCO Subfohl
16 NOT COMMIN ICID WITHIN lie DAYS,CPR IF CONSTRUCTION OA
WORK IS SUSPENrl tnR ARANOOWE)FOR A PERIOD OF'180 3AYS ❑ Trust Account to
Al ANY TIME AFTER MRK IS COMMENCED reGlf balance Due w
t hr'shiri rn10,4 ririr(Inc
ze 'd L.;_9e 924 11385 1INI3313 3QIS 1S3M Wd 20: ZO nO-60-100
I
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
M P PLUMBING CO (MILWAUKIE)
P O LOX 393
CLACKAMAS, OR 37015
Plumbing Signature Form
Ftrmit #: MST2000-00487
male issue(j: I if1luu
Parcel: 2S103DA-05200
Site Address: 10665 SW COOK LN
Subdivision: FANTASY HILL
Block: Lot 007
Jurisdiction.. TIG
Zoning: R-3.5
Remarks: BATH ROOM RENOVATION
Your company has been indicated as the plumbing contractor for the permit indicated above. In order for the
plumbing permit to be valid, r)lease have the appropriate individual from your company sign below and return
this Plumbing Signature Form prior to the start of the work to the address above, ATTN: Building Dept.
No plumbinq inspections will be authorized lrntil this completed form is received
OWNER: PLUMBING CONTRACTOR:
PONIATOWSKI-D'ERMENGARD, M P PLUMBING CO (MILWAUKIE)
MARIE LORRAINE P O BOX 393
;0^C5 S`A' Ct:0.1l LN CLACK.^-MAS no o7n4ti
TIGARD, OR 97223
Phone tt- Phone #: 655-9161
Reg #: I Ir 5002
PI M 3-17PB
AN INK SIGNATURE 15 REQUIRED ON THIS FORM
.�-=-
Signature of Authorized Plumber
If you have any questions, please c-,ll (503) 639-4171, ext. # 310
CITY OFTIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
VVEST SIDE ELECTRIC CO ;NC
1834 SE 8TH AVE
PORTLAND, OR 97214
Electrical Signature Form
Permit ##: MST2000-00487
Date Issued: 1111/00
Parcel: 2S10',vA-05200
Site Address: 10665 SW GOOK LN
Subdivi:;ion: FANTASY HILI_
Black: Lot: 007
Jurisdiction: TIG
Zoning: R-3.5
Remarks: BATH ROOM RENOVATION
Your company has been indicated as the electrical contractor for the permit indicated above. In order for the
electr,Gal permit to be valid, the signature of the supervising electrician is required. Please have the
appropriate individ.ial from your company sign ualow and return Eloctrical Signatur:' Fo,m prior to th
start of the work to the address above, ATTN: Building Dept.
No electrical inspections will be autnorized until this con„pleted form is received
OWNER ELECTRICAL CONTRACTOR:
PCNIATOWSKI-D'ERMENGARD, WEST SIDE ELECTRIC CO INC
MARIE LORRAINE 1834 SE 8TH AVE
-10665 5YV COOK LN i`.^.^T LAND, ON R 9-7214
TIGARP., OR 97223
P lone Phone #. 231-1548
Req #: LIC 13306
SUP 15563
ELE 26-135c
AN INK SIGNATURE IS REQUIRED Gig THIS FORM
5)--”
x _
Signature of Supervising Electrician
If you have any questions, please call (50"\ 539.4171, ext. # 310
CITY OFTIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175
INSPECTION DIVISION 3usine:ss Line: (503) 639-4171 SMT _ �
BLIP
Received %2�— b�te�Requestedd 2 d AM PM P
su
Location &G r!, &- `- t6yk' '.41(_ ,it, _ MEG
Contact Person __'22j ,vj 6L ,L u {_ >) &3 9— S 2 PLM -
Contractor —_— Ph( ) _ _ SWR
Tenant/Ownor ELC -_-_-
Footing
Foundation ELC
Access:
Ftg Drain L-' ELR _ -_-
Crawl Drain
Slab Inspection otes: SIT
Post&Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing -- --- -
Insulation
Drywall Nailing
Firewall �� a 1 -I i
Fire Sprinkler
Fire Alarm
Susp'd Ceiling ,1
Roof ��,�� p4"2y\ -J`�1 C���� W hy"sw
0th r:
PA PART FAIL -
MBING
Pos eam /
Under Slab --- {
Rough-In `( V/
Water Service - I --
Sanitary Sewer
Rain Drains - -
Catch Bain/Manhole
Storm Drain - --
Shower Pan
C Thor . -- --- --- -
SS RT FAIL - ------.—. - ---- ------- --
MECHANICAL - -- - -- ----- -- -- —
Post& Beam ---
Rough-In -- ----- - - ---- ---- - -- -
Gas Line
Smoke Dampers -- -- ----- --- -- —
Final
PASS PART FAIL - ----- --- --- --------
EC
Service ---- -- ----- - ----
Rough•In - -------- -- -
UG/Slab
Low Voltage
Fire Alarm
1 inal ART FAIL Reinspection fee of$_ -required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
L�
SITE n Please call for reinspection RE: unable to inspect-no access
Fire Supply Lin@ r
ADA
Approach/Sidewalk Dste�-- _� _---_---- Inspeeter- 9lr
Other
Final DO NOT REMOVE this Inspection)record frim the job site.
PASS PAST FAIL