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MASTE
ERMIT
CITY OF TIGARD PERMIT
: MST2
V/ PERMIT#: MST2003-00031
DEVELC;FAIENT SERVICES DATE ISSUED: 2/20/03
1312.5 SW Hull Blvd., Tigard,OR 97223 (503) 6394171
SITE ADDRESS: 12800 SW BLUE HERON PL PARCEL: 2S103BC-08700
SUBDIVISION: BLUE HERON PARK ZONING: It-4.5
BLOCK: LOT: 304 JURISDICTION: TIG
REMARKS: C
BLILDING
REISSUE: STORIES: 2 FLOOR AREAS -__ REQUIRED SETBACKS REQUIRED -
CLASS OF WORK. NEW HEIGHT: 25 FIRST: 1,157 of BASEMENT: of LEFT: SMOKE DETECTORS: Y
TYrE OF USE: SFA FLOOR LOAD: 40 SECOND: 944 at GARAGE: 400 of FRONT: 20 PARKIVG SPACES: 2
TYPE OF CONST: 5N DWELLING UNITS: 1 THId1 sf R'GHT: 5
VALUE: 203,852 40
OCCUPANCY GRP: R3 BDRM: 7 BATH: 3 TOTAL: 2.101 of REAR: 28
PLUMBING —
SINKS: 1 WATER.G,OSETS: 3 WASHING MACH: 1 LAL NDRY TRAYS: RAIN DRAIN: 100 TRAPS•
0VATORIES: 4 DISHWASHERS: i FLOOR DRAINS: :EWER LINES: 100 SF RAIN DRAINS: 1 CATCH BASINS•
T111312.HOWERS: 2 GARBAGE DISP: 1 WATER HEATERS: 1 WATER LINES: 100 BCKFLW PREVNTR: 1 GREASE TRAPS:
OTHER FIXTUkLE'
MECHANICAL
FUEL TYPES FURN<100K: BOIL/CMP<3HP: VENT FANS: 3 CLOTHES DRYER: 1
GAS FURN"100K: 1 UNIT HSATERS: HOODS: OTHER UNITS: 1
MAX INP: btu FLOOR FURNANCES: VENTS: 1 WOODSTOVES: GAS OUTLETS: I
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEED ! _ TEMP SRVCIFEEDERS BRANCH CIRCUIT S MISCELLANEOUS _ ADD'L INSPECTIONS
1000 SF OR LESS: 1 0 -200 amp. 0 -200 amp: W/SVC OR FDR: PUMP/IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 3 201 - 400 amp: 201 - 400 amp: tat W/O 8VCfFDR: SIGN/OUT 1.I1 T: PER HOUR:
LIMITED ENERGY: 401 600 am!): 401 600 amp: EAADDL BR,:IR: SIGNALIP' .EL: IN PLANT:
'AANU HMISVCIFDR: 601 1000 amo: 601+amps-1000v: MINOR LABEL:
1000+a+nplvolt: PL44 REV*WSECTION
Reconnect only: >„4 RES UNITS: SVCIFDR>-225 A_ >600 V NO',AINAL: CLS AREA/SPC OCC:
ELECTRICAL•RESTRICTED ENERGY _
A.SF RESIDENTIAL B.COMMERCIAL
AUDIO&STEREO: VACUUM SYSTEM: x AUDIO 6 STEREO: FIRE ALAP,0: INTERCOMIPAGING: OUTDOOR LNDSC LT:
BURGLAR ALARN OTH:hLL �'ty(pIM BOILER: HVAr' LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
I 1
IIS CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
GARAGE OPENER:
HVAC: DATArELE COMM: NURSE CALLS: TOT 41_a RYSTEMS:
TOTAL FEES: :; 6,443.83
Owner: Contractor: This permit is subject to the regulations contained in the
WINDWOOD CONSTRUCTICIJ WINDWOOD HOMES INC Tigard Municipal Code,State of OR. Specialty Codes and
12655 SW NORTH DAKOTA 12655 SW NORTH DAKOTA all other applicable laws. All work will be done in
TIGARD,OR 97223 TIGARD,OR 97223 accordance wiGl ,p proved plans. This permit will expired
work is not started within 180 days of Issuance,or if the
work is suspended for more than 180 days. ATTENTION:
Oregon law requires you to follow rules adopted by the
Phone: Phone: 625-b�L6 Oregon Utility Notification Center. Those rules are set
501-625-6526 forth in OAR 952-2-01-0010 through 952.001-0080. You
Rao 0: LIC 50190 may obtain copies of these rules or direct questions to
OUNC by calling(503)246-1987.
REQUIRED INSPECTIONS
Erosion Control Insp& Post/Beam Mechanica Mechanical Insp Shear Wali Insp Insulation Insp Appr/Sdwik Insp
Sewer Inspection Underfloor insulation Plumb Top Out Exterior Sheathing Inst Gyp Board Insp Electrical Final
Footing Insp Crawl Drain/Backwater Electrical Service Low Voltage Firewall Insp Mechanical Firal
Foundation Insp Footing/Foundation Dr, Electrical Rough In Gas Line Insp Rain drain Insp Plumb Final
Post/Beam Structural PLM/Underfloor Framing Insp Gas Fireplace Water Line Insp Final inspection
Issued By : Perml'.tee Signature-
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
i
CITYOF TIGARD _ SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT#: SWR2003-00028
13125 SW Hall Blvd., Tigard, OR ^,223 (503) 639-4171 DATE ISSUED: 2/20/03
SITt'. ADDRESS; 12800 SW BLUE HERON PL
PARCEL: 2S 103BC-08700
SUBDIVISION: BLUE HERON PARK ZONING: R-4.5
BLOCK: LOT: 004 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SFA NO OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: S
Owner: FEES
WINDWOOD CONSTRUCTION
12655 SW NORTH DAKOTA Description Date Amount
TIGARD, OR 97223 1SWUSA]Swr Connect 2/20/03 $2,300.00
ISWUSAJ Swr Connect 2/20/03 $0.00
Phone: 503-625-6526 ISWINSP] Swr Inspect /20/03 $35.00
tSWINSPI Swr Inspect 2/20/03 $0.00
Contractr),: — -
Total $2,335.00
Phone:
Reg#:
Required Inspections
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is riot located at the measurement given, the installer shall prospect
3 feet in al! directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Perm
J /
Issued by: _�`kz� & Z —_ permittee Signa tlytJ� ..' _
Call (503)639.4175 by 7:00 P.M. for an inspection needed the next business day
Ov' v
Building Permit Application
City of Tigii .` E 11/ E D Datsteceived: _ Permit no.::
k Address: 13125 SW Hall Blvd,Tigard.OR 97223 Projecl/appl.no.: _ Expire date:
CiryofTigard Phone: (503) 6394171Date issued: Byr— Receiptno.:
Far+: (503) 598-1960 r' t!,;
.11 1Case file no.: Payment typc:
1.;I11' OF rIGNFiI.) I&2family:Simple Complex.
Land use approvtdD lar DING i,,.;T�l�,j,, _
�,IM i family dwelling car accessory U Commercial/industrial U Multi-family J New construction L=1 Demolition
U Addition/alteration/replaceinent J Tenant improvement U Fire sprinkler/alirn: J Other:
k 'VA el-fee Bldg.no.: Suite no.:
Job address: /a'"t;8'00 � ' _
Lot: ntocx: Subdivision: ,6uC llemn Q;,;:l I Tax map/tax lot/account no: '
Project name:
Description and location of work on premises/special conditions: _
M1 N4 It If
FOR SPECIAL t
Name: .i 611b4 WWWA
Mailing address: c,v IVO,-A4t 1 &2 family dwelling: .2 U3 z `I
City: r� stat ZIP: P'�?a3 Valuation of work........................................ $
Phone: ��'_ G. Fa tL E-mail: No.of bedrooms/baths.. .........3. ................. -j
Owner's representative /C t � Total number of floors........•.c4,...................
P.one t��ls'I Fttx f? mail: New dwelling area(sq.ft.) ...�0MW /
Garage/carport area(sq.ft.).....���G..........
Nat:c__ Q pR[' Covered porch area(sq.ft.)...... �t4............ -_
Mail.ng address: D•:ck area(sq. ft... ........................................
-_-- Orher structure area(s ft.
City: _ State:_ ZIP: q. ).........................
iiklm
, ! mail Commercial/industrialimulti-family:
t Valuation of work.........,L.............................. $
Business name: Existing bldg.area(sq.
`~ - New bldg.area(sq.ftz7t
)
Address: - -- .......City: state: ZIP: - Number of stories... .......
Type of constructiut�Phone: Fax: E-mail:CCB no.: ��% Occupancy group(s): New: - --
City/metro lic.no.: Notice:,JI contracU.rs and subcontractors are required to be
In IN a ILI licensed with the Oregua Construction Contractors Board under
_Name: _^ provisions of ORS 701 and may be requited to be licensed in the
Address: _ w t jurisdiction where work is being performed.if the applicant is
Cit / Statetyr Zlr': Q ).w>✓ exempt from licensing,the following reason applies:
Y
Contact p:rsort- a A _ Plan no.: -
Phone- E-mail: --- — ---
Name , Contact person: Fees due upon application ...........................$
Add3ate received:
City: Stat• . ZIP: of 6 Amount received ....................... ............. $
Phone: :2 Sy4J� Fax:'1 Gj E-mail: Please refer to fee schedule.
I hereby certify 1 have read and examined this application and the NM di iunadicham strep credit eardde,pieme cAlt jurtdktion for more infunlmdw.
attached checklist. All provisions of laws and ordinances governing this U Visa U MasterCard
work will be complied with,whether specified herein or not. CfM1 cud nt''nb
• plree
Authorized signature --''Date: _ -- Nunn at cudhoider u blown on credit cud
$
Print name:_T_ - `C f — CudWdu siputwe -- AUWWI
Notice:n s permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 4404613(6AOM)
One-and Two-Family Dwelling r
Building Permit Application Checklist Referenccno.:
-- A Qsociated permits:
CitY of Tigard City of Tigard ❑Electrical 13 Plumbing U Mechanical
Address: 13125 SW Hall Blvd,Tigard,OR 97223 O Other:
Phone: (503) 639-4171
Fax: (503) 598-1960
'
1 Land use actions completed.See jurisdiction criteria for concurrent reviews. _
2 Zoning.Flood plain,solar balance points,seismic soils designation,historic district,etc.
3 Veri_Ocation of approved platflot.___ 7
— —-
4 Fire district approval required.
5 Septic system 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. _
9 Erosion control 0 plan U permit required.Include drainage-way protection,silt fence design and location of
catch-basin protection,etc, —
10 : Complete sets of legible plans.Must be drawn to stele,showing conformance to applicable local and state
building codes.Lateral design details and-onnections must he incorporated into the plans or on a sepora!e full-size
sheet attached to the plans with cross references between ph a location and details. Plan review cannot be completed
if copyright violations exist. - -__F1 Site/plot plan drawn to scale.The plan must show lot sad building setback dimensions;property corner elevations(if
there is more than a 4-11.elevation differential,plan must show contour lines at 24 intervx:�);location of easements and
driveway;footprint of structure(including decks);location of wells/sep!ic systems;utility locations;direction indicator,lot
area;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 reinforcing pads,connection details,vent
size and location.
I i Floor plans.Show all dimensions,room identification,window size,location of smoke detectors,water heater,
furnace,ventilation dans,plumbing F Atures,balconies and decks 30 inches above grade,etc.
14 Cross section(s)and detalls.Show all framing-member sizes and spacing such as floor beams,headers,joists,sub-floor,
wall construction,roof construction.More than one cross section may be required to clearly portray construction.Show
details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings and foundation,stairs,
fireplace constriction, 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 cnvelope.
Full-size sheet addenudms showing foundation elevations with cross references are acceptable.
16 Wall bracing(prescriptive path)and/or lateral analysis plans.Must in0icate details and locations;for
non-prescriptive path analysis providt specifications and calculations to engineering standards.
17 Floor/roof framing.Provide plans for Y1 floors/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 rebw�.For engineered
systems,see item 22,"Engineer's calculations."
19 Beam calculations.Provide two sets of calculations using current cede design values for all beams and multiple joists
over 10 feet long and/or any beanyjoist carrying a non-uniform!oad.
20 Manufactured floorlroof truss design details. _
21 Earergy Code compliance.Identify the prescriptive path or provide calculations.A gat-piping schematic is required
for four or more app;,antes. _
22 Engineer's calculations.When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or
architect licen-ed in Oregon and shall be shown to be applicable to the project under review.
23 k'ive(5)site plans arr requited for Item 11 above. Site plans must be 8-1/2"x 11"or 1 I"it 17".
24 Two(2)sets each are tegnired for Items 16 19 20&22 above.
25 Building plans shall not contain red lines nr tape-ons. "Mirrored"building plans will be not accepted.
26 "Reversed"building plans must meet criteria outlined in the Pc-nit&System Development Fees document.
27 "Drawn to scale"indicates standard architect or engineer scale.
28 Site plan to include tree size,type&location per approved project street tree plan(if applicable),and COT Streei Tree List.
Checklist must he completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 410-4614(NW.oM)
a
'�M=*."ing Permit Application
Date re.rived• Permit no.:
City of Tigard Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd Tigard,OR 9722
Ciryo�Tigurd Phone: (503) 639-4171 ProjecUappl.no.: Expire date:
Fax: (503) 598-1960 Date issued: By: Receipt no.:
Land use approval: _ Case file no.: Payment type:
)dl & 2 family dwelling or accessory U Commercial/industrial U Multi-family U Tenant improvement
U New construction U Addition/alteration/replacement U Food service U Other
t . t ,
Job address: 1,2gt 2 6 4e 6!k'-o"'t /Da. I)escri tion Qty. Fee(ea-) 'Total
Bldg.no.: I Suite no.: -- New I-and 2-family dwellings only.
Tax map/tax lot/accountno.: Y-s/ OtYbLt,1 3 O (includes lft
0a ,for each utility connection)
SFR(1)bath
Lot: Block: Subdivision: �< /IE'w�l SFR(2)bath -- - _ -
Project name: ,t Al SFR(3)bath
City/county: JIJA I ZIP: Q Each additional hath/kitchen '
Description and I( . tion of work on premises:_ Site utilities:
Catch basin/area drain
Est.date of completion/inspect ion: Drywells/leach Iineltrench drain
Footing drain(no.lin.ft.)
Manufactured home utilities
Business name: �Lo _ _ Manholes M _
Address: C) / v Rain drain connector
City: 1,,�(y_ State 2 ZIP: -24: 7 Sanit •,ewer(no. lin.ft.)
Phone: y 410 Faxx32 E-mail: Storm sewer(no.lin. ft.)
CCB no.: '71 &6o I Plumb,bus.reg.no: [� b(,- Water service(no.lin.ft.)
City/metro tic.no.: (0
Fixture or Item:
Contractor's representative signature: Aasotion valve
— Back flow preventer
Print name: t Date: Backwater valve
t Basins/lavatory
Name: //1< Clothes washer
Address: Dishwas er
Drinking fountains)
City: _ _State: ZIP: Ejectors/sump
Phone: - I aY E-mail: Expansion tank _
Fixture/sewer cap
Name(print): CUd-lS 1` L Floor drains/floor sinks/hub
Mailing address: 5 ,J N,,.,'-� /cc//cc/r-aGarbe a disposal
Hose Bibb
City: art I Statr6K I ZIP: 2-:1 Ice maker
Phone: Fax:G,5--6SXTE-mail: _ Inter-e tor/ rease trap
Owner installanun/residential maintenance only: The retual installation Primer(s) _
will be made by me or the maintenance and repair made by my regular Roof drain(commercial)
employee on the property 1 own as per ORS Chapter 447. Sink(s),basinks),IRvs(S)
Owner's signatu • _ ate: Sum
Tubs/shower/shower pan _
Name: Urinal
--- --7 -- - — — Water closet—
Addmss: _ Water heater
City: tate: ZIP: Other.
__ _
Phone: Fax: m oW
Not d1 furikkdom ametu credit card: 1lesse au jurisdiction for mare infamrioa Notice:This permit application Knimum fee................S
U Ya U MasterCard expirer if a permit is not obte:ned Plan review(at , %) S
Credit card number within 180 days after it has been State surcharge(8%)....$
Name or cardboltler as ddtoten an creciii e accepted as complete. TOTAL .......................$
S
cw side AmoaM 1164616(60YMM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2-family dwellings only.,
FD(TURES Individual QTY ea AMOUNT (includes all plumbing fixtures In PRICE TOTAL
Sink 16.60 the dwelling and the flrst100 fit. QTY Ion) AMOIINT
Lavatory 1J.0%. for each utilityG3nnection
One 1 bath $249.20
Tub or Tub/Shower Comb. 16.60 Two 2 bath _ $350.00
Shower Only 16.60 Three 3 b) ath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8%STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25%OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Flour Sink 2" 16.60
PLEASE_ COMPLETE:
3" 16.60
q•' 16.60 _
Water Heater O conversion O like k'nd 16.60 Quantl b Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit Capped
MFG Home New Water Service 46.40 Sink
Lav
MFG Home NsTub or
w San/Storm Sewer 46.40 _
Tub or Tub/Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Other Fixtures(Specify) 16.60 Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain/Sink: 2"
Sewer-1s1100' 55.00 3"
Sewer•each additional 100' 46.40 4"
Water Service-1st 100' 55.00 Water Heater
Water Service-each additional 200' 46.40 Other Fixtures
_ Specify)
Storm&Rain Drain-1st 100' 55.00
Storm&Rain Drain-each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin 6.t.i,
Inspection o1 Existing Plumbing or Specially 62.50
Requested inspectionsper/hr COMMENTS REGARDING ABOVE:
Rain Drain,single Inmily dwelling 65.25 _
Grease Traps 16.60 -
QUANTITY TOTAL
Isometric or riser diagram Is required M
Quantity Total Is >9 -
"SUBTOTAL _-
8%STATE SURCHARGE -
"PLAN REVIEW 25%OF SUBTOTAL "
Required only If nature qty total is>g _
TOTAL s
*Minimum permit foe Is$72.50•P%state s irc isrge,except Residential Backflow
Preverdlon Device,which it$J6.25•s%st As surcharge.
"All liar Ca.,namlol aulldlrge require 2 sats of plans with lsomatrk or d"r
diagnuar for plan review.
I:WstsVon.•ts\plm-fees.doc 12/28/01
n Mechanical Permit Application ~
-� Datercceived: Permit no.:
City Of. Tigard Project/appl.no.: Expire date:
City ofTigard Addreft: 13125 S0 Hall Blvd,Tigard,OR 97223 —
Phone: (503) 639-4171 Date issued: By: Receipt no.:
Fax: (503) 598 1050 Case f le no.: Payment type:
Land use approval: Building permitno.:
IBM=,
U 1 &2 family dwelling or accessory `J Commercialt„odustri.al J Multi-fanuly ❑Tenap.t improvement
U New construction U Addiuon/alteration/replacenictit U Other:
1 ORMATION
Job address: Z a1,C.i MC /rry /a 1e Indicate equipment quantities in boxes below. Indicate the dollar
Bldg.no.: Suite no.: value of all mechanical materials,equipment,labor,overhead,
Tax map/tax Iot/accr junt no.: j/ 0LJ,6C tL_ 39'00 profit. Value$
Lot: block: Subdivision: *See checklist for important application information and
Project name: k-2 u jurisdiction's fee schedule for residcntinl prrmh fee
City/county: U
Description and location&Work on premises:
Fee(ea.) Total
Est.date of completion/inspection: Dxi Resod Rea.00l
Tenant improvement or change of use: IC:
Air handling unit CFM
Is existing space heated or conditioned?U Yes U No Air conditioning(site plan required)
Is existing space insulated?U Yes U No Alteration of existing HVAC system
of er compressors
p State boiler permit no.:
Business name: ___-_ HP Tons. BTU/H _
Address: d 3/2(, Fire/smoke dampers/duct smoke etc.:tors
City: -r A C4 State: IP: 4?-,)930 Heat pump(site p an require )
Phone: - Fax: E-mail: nstn replacer.furnacc1buraer_H
— Including ductwork/vent liner U Yes O No
CCB no.: Install/replac reocateheaters-suspended,
City/meiro lie.no.: $'eJ ___ wall,or floor mounted
Nam s(please print): p r/t S� ,1nt for appliance or than furnace
tCo
gerat on:
sorption units BTU/H
Name: -5c(ZIA <1 illers _ HP
Address: mrressors __ HP
•ronmenta epinuq a vent tWie
City: State: ZIP: pliance vent
Phone: Fax: I E-mail: ryerex gust
pe 17117res. itc a azmat
hood fire suppression system
Name: -►v 0 waoij-4 cow s r 4-1 Exhaust fan with single duct(bath fans)
Mailing address• r,c%J rr/' !t1016-A&M Exhaust s stem a art Com eatin or
AC
State: /� ZIP: u-e rlp ng andistribution(up to outlets)
City: A/L/0 -1 j i33 T LPG NO Oil
Phone:ti►a'-6,S�G Fax: (,. / E-mail: Fuel tin each additional over 4 outlets
Process piping(sc ematic required)
Number of outlets
Name: _. ter 1WR opplis ce or M pment:
Address: _ Decorative fireplace
City: State: Z r: Insert-type
Phone: Fax: E-mail: Woodstov pe et stove
er:
Applicant's signature: D_de: t
Name (print):
Not art jartdkUau Carp cornu conk,please caa jwis&ctien for mwe ff_&r4 ion. Permit fC:......................$
L3 Visa ❑MssterCrid Notice:'(tris permit application Minimum fee................$
Credit cod rwm� J_ expires if a permit;snot obtained At Plan review(at _ %) $
Expires within 180 days aRur it has been State sumharg,:(8%)....S
Num of cardiolder as dwwn on ,,;,,d accepted as complete.
S TOTAL .......................$
CadbaWK 1(patute Amount 440-1617(6WCOM)
MECHANICAL PERMIT FEES
COMMERCIAL FEE SCHEDULE: 1 & 2 FAMILY DWELLING FEE SCHEDULE:
TOTAL VALUATION: PERMIT FEE: Description: - Price Total
$1.00 to$5,000.00 Minimum fee$72.50 Table 1A Mechanical Code Ory (Ea) Amt
$5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and 1) Furnace to 100,000 BTU
$1.52 for each additional$100.00 or including ducts R vents 14.00
fraction thereof,to and including 2) Furnace 100,000 BTU+
$10,000.00 including ducts 6 vents 1740
$10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and 3) Floor Furnace
$1.54 for each additional$100.00 or including vent 14.00
fraction thereof,to and including 4) Suspended heater,wall heater
$25,000.00. or floor mounted heater 14.00
$25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and 5) Vent not included in appliance permit
$1.45 for each additional$100.00 or 6.80
fraction thereof,to and including 6) Repair units
$50,000.00. _ 12.15
$50,001.00 and up $742.00 for the first$50,000.00 and Check all that apply: Boiler Heat Air
$1.20 for each additional$100.00 or Fer items 7.11,seeC m Pump gond
fraction thereof. footnotes below. p
Minimum Permit Fee$72.50 SUBTOTAL: 7)<3HP;absorb unit
$ to 100K BTU 14.00
'/.State Surcharge 8)3-15 HP;absorb
8
g $ unit 100k to 500k BTU 25.60
25%Plan Review Fee(of subtotal) $ 9)15-30 HP;absorb
_Required for ALL commercial only unit.5-1 mil BTU 35.00
TOTAL COMMERCIAL PERMIT FEE: $ 10)30.50 HP;absorb
unit 1-1.75 mi;BTU 52.20
11)>50HP;absorb
unit>1.75 mil BTU 67.20
ASSUMED VALUATIONS eER APPLIANCE: 12)Air handling unit to 10,000 CFM
_ 10.00
Description_ O (Ea) Amount 13)Air handling unit 10,000 CFM+
17.20
Furnace to 100,000 BTU,including 955
14)Non-portable evaporate cooler
duds&vents
10.00
Furnace> 100,000 BTU Including 1,170 �-
duds 8 vents 15)Vent fan cend
nected to a single du
6.60
Floor furnace Including vent 955
Suspended heater,wall heater or 955 16)Ventilation system not Included in
floor mounted heater appliance permit 10.00 _
Vent not included In applicance 445 17)Hood served by mechanical exhaust
10.00
_pe
rtnil 18)Domestic Incinerators
Repair units 805 17.40
<3 hp;absorb. unit, 955
tu 100k BTU 19)Commercial or Industrial type incinerator
69.95
3.15 hp;absorb.unit, 1,700
10'lk to 500k BTU 20)Other units,including wood stoves
10.00
11,30 hp;absorb.unit,501k to 1 2,310
mil.BTU 21)Gas piping one to four outlets
5.40
30-50 hp;absorb unit, 3,400 2
1-1.75 mil.BTU 2)More than 4-per outlet(each)
1.00
>50 hp;absorb.unit, 5,72.5 Minimum Permit Fee$72.50 SUBTOTAL: $
>1.75 mil.BTU _
Air handling unit to 10,000 cfm 656 _ ---- - -- -
AJr handling unit>10,000 cfm 1,170 606 St.:-Rurcnarga $
Non por'able evaporate cooler 656 TOTAL RESIDENTIAL PERMIT FEE: $
Vent fan connected to a single dud 446
Ve, t system not Included In 656
appliance permit
Hood served by mechanical exhaust 656 _ Q1her InaosctI ns rnd Fees:
Domestic incinerator 1 170 1 Inspedions outside of normal business hours(minimum charge-two hours)
$eper hour.
Commercial or Industrial Incinerator 4,590 =
_ pec:c Uons for which no lee is specifically indicated (minimum charge-half hour)
Other unit,Including wood stoves, 856 $92.50 per hour
Inserts,etc. 3 Additional plan review required by changes,additions or revisions lu plans(minimum
Gas piping 1-4 outlets 360 charge-ane-half haw) 12 50 per hour
Each addlbonal outlet 63
- "CJIc Convacto•9olisr Certification required for units>200k BTU.
TOTAL COMMERCIAL $ "Residential a',,requires site plan showing placement of unit
VALUATION: _--a All New commercial Buildings require 2 sets of plans.
1ldstsUorms%mech-fees.doc 12/26/01
I
Electrical Permit Application_ Received Electrical
Date/By: Pero-nit No.:
City of Tigard Date/ate/Planning Approval Sign
Date/ 7Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard,Oregon 97223 Date/B . Permit No.:
Phone: 503-639-4171 Fix: 503-598-1960 Post-Review Land Use
Date/By; Case No.:
Internet: www.ci.tigard.or.us Contact lu-is.: IN See Page 2 for
24-hour Inspection Request: 503-639-4175 Name/Method: __— Supplemental Information.
TYPE OF WORK PLAN REVIEW Please creek all th'it ipply)
Uf4ew construction LJ Demolition Service over 225 amps- Healtt care facility
y
commercial ❑Hazardous location
TTA d;'.iion/alteration_/re lacement ❑ Uther: ❑Se,vice over 320 amps-rating of I ❑Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION I i 2 family dwellings fount more residential units in
I &2-Family dwelling _ CommerciaUIndustrial` ❑S)stem over 600 volts nominal one structure
❑Building over three stories ❑Feeders,400 amps or more
Accessory Building_ ]Multi-Family ❑Occupant load over 99 persons ❑Manufactured structures or..V park
Master 13uilder Other: ❑Egresslighting plan ❑Other:
JOB SITE''INFORMATIO ;a d LOCATION Submit__sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: GAJ L Q�n � -� —y FEE*SGHEpULE
Suite#: _ _ Bid ./A t.#: Number of Ins ections per pcrmit allowed
Project Name: Description Qtr Fee(ea.) --Total
New resldentlel-single or multi-family per
Cross street/Directions to job site: dwelling unit.includes attached garage.
Service Included:
1000 sq.ft.or less 145.15 — 4
Each additional 500 sq.ft.or portion thereof 33.40 1
lk Limited energy,residential 75.00 2
Subdivision: Lot#: Limited energy,non residential 75.00 Y
Tax map/parcel #: _ Each manufactured home or modular dwelling
DLSCRIPTION OF WORK. service and/or feeder 90.90 ?
Services or feeders-Installation,
alteration or relociition:
200 amps or less _ 90.30
—_ — -- 291 amps to 400 amps ---- 106.85 2
4)1 amps to 600 amps 160.60 2
�ROPFR1N,0WNER TENANT. --�— FA1 ams to 101A ams — 240.60 2
——--- Over 1000 amps or volts 454.63 2
Naine: W 4'�uD OLCki.O c6, f _, _ Reconnect oniy 66.85 2
Address: (d SCJ ✓t�N ai+. Temporary services or feeders• installation,
alteration or relocation:
City/State/Zip: !X �/���_; 2f 0 amps cr less 66.85 1
Phone: 6,2 63'�a6 I Fax: )Sb Zi I amps to 401 to 600 ami amps — 133.75.30 2
7( "'.« U,; 1 1043ONTACT=PERSON Branch circuits-new,alteration,or
Name: — _ _ extension per panel:
A.Fee for branch circuits with purchase of
Address: __ service or feeder fee,each branch cr curt 6.65 2
city/state/zip: _ — _ _— B.Fee for branch circuits without purchase of
1 �.� service or feeder fee,first branch circuit 46.85 2
Phone: _ l ax: _ _ _ Fach additional brunch circuit 6.65 2
E-mail: Fach
or feeder not included):
CC14'I RA R _ Fach um or irrigation circle 53.40 2
_ Each sign or outline lighting 53.40 2
Job NO: Signal circuit(s)or a limited energy panel,
alteration or extension Pae 2 2
Basiness Name: /,Ac �`>� �1rc: Description:
Address:
City/State/Zip: — Fach additional Inspection over the allowable in any of the above:_
_ Per inspection r hour min. I hour 62.50
Phone: i aX: Investi ation fee: __
Other:
CCB Lic.#:
Lic.#: elect ,b � ..f�
Supervising electrician Subtotal S —
signature required: ' Plan Review 25%of Permit Feel S _
Print Name: Lic.#: State Surchar a 8%of Permit Fee S
TOTAL PERMIT FEE S
Authorized Notice: This permit application expires If a permit Is not obtained within
Signature: _ Date:___ 180 days after it has been accepted as complete.
'Fee methodology set by Tri-County Building Industry service Board.
;Please print name)
i:U%ts\Permit Fornu)ElcPemtitApp.doc 01103
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I
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
METZGER ELECTRIC INC;
8780 SW LEHMAN ST
TIGARD, OR 97223
Electrical Signature Form
Permi: #: MST2003-00031
Date Issued:
Parcel: 25103BC-08700
Site Address: 12800 SW BLUE HERON PL
Subdivision: BLUE HERON PARK
Block: Lot: 004
Jurisdiction: TIG
Zoning: R-f.5
Remarks: C
Your comrany has been indicated as the electrical contractor for the permit indicated above. in order for the
electrical hermit to be valid, the signature of the supervising electrician is required. Please have the
appropriate individual from your company sign below and return this Electrical Signature Form prior to the
start of the work to the address above, ATTN: Building Division.
No electrical inspections will be authorized until th. completed form is received
OWNER: ELECTRICAL CONTRACTOR:
WINDWOOD CONSTRU(.TION METZGER ELECTRIC INC
12655 SW NORTH DAKOTA 8780 SW LEHMAN ST
TIGARD, OR 97223 TIGARD, OR 97223
Phone #: 503-625-6526 Phone #: 244-9025
Reg #: MEI' 103.E
LIC 96805
SLIP 31305
FI r 34-1670
AN INK SIGNATURE IS REQUIRED ON THIS FORM
Signature of Supervising Electrician
If you have any questions, please call (503) 639-4171, ext. # 310
06 09.200;1 11:18 FAX 503179865e lei 002
CITE' OI- TIGAhD
131, 5 5 W. HALL BLVD.
TIGAR'1 OR 97223
IMPORTANT MUTICE
GRE`-i VWAY TCTRIZ COROPANY
1510 Si DR
:P o CS N. OR 97007
4ik-,4trical Signature F-arm
Permit#- MST20i U31
Date Issued: 2/20/03
Parcel. 2S103BC-08700
Site Address: 12800 SW BLUE HERON PL
Subdivision: BLUE HERON PARK
Block. Lot; 004
.Jurisdiction TIG
toning- R-4.5
Remarks- Construction of now SFA dwelling
Your company has been indicated ;i7 s the electrical c,nntractorfor the permit indicated above. In ordes for the
electrical permit to be vatic:, the signature of the supervising electrician is niquired. Please have the
appropriatB individual from your company sign below and return this Electrical Signature Form prior to the
start of the worfc to the address above, ATTN: Building Divk-ion
No electrical inspections will be authorized until this comple'vci torm is received
OWNER: ELF_CTRICAL CONTRACTOR:
WINDWOOO CONSTRUCTION, INC_ GR.EE.NWAY ELECTRIC COMPANY
12655 SW NORTH DAKOTA 15145 SW GULL DR
TIGARD, OR 97223 BF..AVERTON, OR 97007
Phone #. 503-625-6526 hone#- 503-519.8054
Reg : L c 153121
U. 3d,617C
SUP 50255
AN INK SIGNAT-URE IS REQUIRED ON THIS FORM
x L,/ y
sir"Wre o -upervising Winctriciar
If you have any questions, please call 501718.2433.
a00� ,Ld2l(I !)Cnq 4W"I.L 30 7LLIj 169Ct79C0� XVJ CU T r NOK CO. 60 90
�f.
;,ITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
GREENWAY ELECTRIC COMPANY
15145 SW GULL OR
BEAVERTON, OR 97007
Electrical Signature Form
Permit #: MST2003-00553
Date Issued- 1/26104
Parcel: 2S103BC-08700
Site Address: 12800 SW BLUE HERON Pl.
Subdivision: BLUE HERON PARK
Block: Lot: 004
Jurisdiction: 1IG
Zoning: R-4.5
Remarks: Convert 550 square feet of crawl space to habitabie space.
Your company has been indicate.' as the electrical contractor for the permit indicated above. In order for the
electrical permit to be valid, the signature of the supervising electrician is required. Please have the
appropriate individual from your company sign below and return this Electrical Signature Form prior to the
start of the work to the address above, ATTN: Building Division.
No electrical inspections will be authorized until this completed form is received
OWNER: ELECTRICAL CONTRACTOR:
ROBERT HANSEN GREENWAY ELECTRIC COMPANY
12800 SW BLUE HERON 15145 SW GULL DR
T?GARD, OR 97223 BEAVERTON, OR 97007
Phony #: 503-579-3252 Phone #: 503-579-8054
Req #: LIC 151421
ELF' 34-617C
SIT 50255
AN INK SIGNATURE IS REQUIRED ON THIS FORM
S'g ature of Supery Ing E actrician
If fou have any questions, please call 503.718.2433.
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 3 ^ O 0c 3 I
INSPECTION DIVISION Business Line: (503)639-4171 MS
BUP _--
Peceived `t _• 7 Date Re uested____ _L 7 AM -.-- PM — BUP
Location __ _���(� PL-Suite MEC
Contact Person _ (��_ V� _�. Ph -'3
Contractor -------_..-_ _�------ ---- - -- Rh (---) — -- SWR _-- —__—
BUILDING Tenant/Owner — _ _-- — —_ _ ELC
Footingv-�
Foundation ELC
Access. /
Ftg Drain ( ELR
Crawl Drain _
slab Inspection Notes: SIT
IPost& Beam __.._----
Shaar Anchors
Ext Sheath/Shear _
Int Sheath/Shear —— —
Framing - -- -_--- --- --
Insulation
Drywall Nailing --
Firewall
Fire Sprinkler ('�
Fire Alarm IJV -��, rN ` zG
Susp'd Ceiling —��-`� '�
Roof
-
Fin
S PART FAIL
PLUMBING
Post& Beam
Under Slab -- ----
Water Service —
Sanitary Sewer
Rain Drains - -
Catch Basin/Manhole
Storrs Drain ---
Shower Pan
r SS PART FAIL - ---- -
MECHANICAL
Post& Beam
Rough-art _
---
Gas Line
S Dampers -�-�=--r
- ---- ���..� I -
Fi
PAS PART FAIL _ -
ELECTRICAL _
Service \X
i
Rough-In 4�4410UG/
Lov, ab 000944
94 4C1L
j: m
` f El Reinspection fee of$ �—required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
S PART FAIL
----------
i SITE Please call for reinspection RE _ _ —_ [� Unable to inspect--no access
Fire Supply Line ^
ADA
Approach/Sidewalk Date �rJ 11 _ Inspectort�� Kxt
Other:
Final DO NOT REMOVE this Inspection record ont the Jo site.
PASS PART FAIL
6TYOF •TIGARD - MASTER PERMIT
DEVELOPMENT SERVICES DATEERVIT ISSUED: 1/26/04003-00553
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171
SITE ADDRESS: 12800 SW BLUE HERON PL PARCEL: 2S103BC-08700
SUBDIVISIOI': BLUE HERON PARK ZONING: R-4.s
BLOCK: LOT: 004 JURISDICTION: I I(1'
REMARKS: Convert 550 square feet of crawl space to hat itable space. 3/9/04, adding gas fireplace, gas piping,
relocate ducts &grilles.
BUILDING
REISSUE: CUSTOM .STORII_S _ FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT. FIRST: 5511 sf BASEMENT. st LEFT: SMOKE DETECTORS: v
TYPE OF USE: SF FLOOR LOAD: 111 SECOND: sf GARAGE: sf FRONT: PARKING SPACES
TYPE OF CONST: 5N DWELLING UNITS: 1 TIOND sf RIGHT
OCCUPANCY GRP: R3 BDRM. BATH: TOTAL: sf VALUE: 11 381 00 REAR:
_ PLUMBING _
SINKS. WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS.
LAVATORIES: DISHWASHERS: FLOOR D'tAINS: SEWER.LINES. SF RAIN DRAINS: CATCH BASINS:
TUBISHOWERS. GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR. GREASE TRAPS.
MECHANICAL
OTHER FIXTURES
FUEL TYPES F1JRN c 100K: BOILICMP c 3HP: VENT FANS. CLOTHES DRYER
' FUIlN a0001(: UNIT HEATERS: HOODS: OTHER UNITS: 1
MAX INP btu FLOOR FI/RNANCES: VENTS: WOODSTOVES GAS OUTLETS: 1
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC/FEEDERS BRANT H CIRCUITS MISCELLANEOUS ADVL INSPECTIONS
1000 SF OR LESS. 0 200 amp, 0 •200 amp: WISV3 OR FDR: PUMPIIRRIOATION: PER INSPFCTION:
EA ADD'L 500SF. 201 - 400 amp: 201 400 amp: lot W/O AVC/FDR; 00 SIGNIOUT LIN LT: PER HOUR:
LIMITED ENERGY- 401 • 600 amp: 401 000 amp, EAADDL BR CIR: z isi SIONAUPANEL: IN PLANT:
MANU HMISVCIFDR 601 - 1000 amp 601-amps-1000V. MINOR LABEL:
1000.amplv011
Reconnect only PLAN REVIEW SECTION
=4 RES UNITS SVCIFDR>=225 A.: >$00 V NOMINAL: CLS AREASP(,OCC:
ELECTRICAL-RESTRICTED ENERGY
A.SF RESIDENTIAL B.COMMERCIAL _
AUDIO 8 STEREO: VACUUM SYSTEM: AUDIO&STEREO: FIRE ALARM: INTERCOWPAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER. HVAC: LANDSCAPEARR1G: PROTECTIVE SIGNL:
(;ARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: O1HR:
HVAC: DATAITELE COMM: NURSE CALLS: TOTAL 0 SYSTEMS:
Owner: Contractor TOTAL FEES: $ 417.47
ROBERT HANSEN OWNER This permit is subject to the regulations contained in the
12800 SW BLUE HERON Tigard Municipal Code,State of OR. Specialty Codes and
TIGARD,OR P7223 all other applicable laws. All work will be done In
accordance with approved plans. This permit will expire If
work is not started within 180 days of Issuance,or if the
work Is suspended for more than 180 days. ATTENTION:
Oregon law requires you to Iollow rules adopted by the
Phone: 503-579-3252 P11011e Oregon Utility Notification Center. Those rules are set
forth In OAR 952-001-0010 through 952-001-0080. YOU
Rep a may obtain copies of these rules or direct questions to
OUNC by calling(503)248-11)87.
REQUIRED INSPECTIONS
Footing Insp Fireplace Insp Final Inspection
Post/Beam Structural Gas Line Insp
Underfloor Insulation Insulation Insp
Electrical R In Electrical Final
Fram 'Insp Mechan!r,al Final
Issue By Permittee Signature : —
Call (503) 6394175 by 7:00 p.m.for an inspection needed the next business day
I
Medwifib"A Permit A licatio �jFOR OFFICE USe ON LV
L-
City of Tcrnu777
Tigard �f �� DataB d / O P7); . 11If�J
125 SW Hall Blvd.,Tigard,OR Plan Review Other Permit
v -W
Phare: 503.639.4171 Fax: 503. B. 960 O�
Inspection Line: 503.639.4175 a /Bv:n� 9 ZO Date Ready/By: n if J-0-See Page 2fur
Internet: www.Ci.tigafd.or.Us MH r I(,• Notified/Method: Supplemental Information
.i::r � 4—�E _ [ COM1 tXdAI, FEE* SCHEDULE - USECHECKLIST
❑New construction Mechanical permit fees"'are based on the value of the work
❑Addition/alterationireplacemcnt
performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other mechanical materials,equipment,labor,overhead,and profit.
CATEGORY OF CONSTRUCTION Value:S
❑
I-and 2-familydwelling R "g ❑ Commercial/industrial ❑ Accessory building ASIDENTIAL EQUIPMENT/SYSTEMS FEES
❑ Multi-family ❑ Master builder For special information use checklist
--_ ❑Other
Descn tion
- --. P Qty-1 Ea. Total
_JOB SITE INFORMATION AND LOCATION Heating/co linil _
Job site address: Air conditioning or heat pump
/.�80 O S G., /S� «p�( (requires site plan showing placement 14.00
City/State/ZIP: T r A, re __—�� Z�� Furnace 100,000 BTU ducts/vents) 14.00
Furnace 100,000+BTU ducts,,veou 17.90
Suite/bldg./apt.no.: _ Project name: Gas heat pump 14.00
Cross street/directions to job site: Duct work 14.00
H dronic hot waters stem 14.00
Resident:al boiler(radiator or
h dronic) 14.00
- - Unit heaters(fuel-type,not electric),
in-wall,in-duct suspended,etc 1000
Subdivision: Lot no.: Flue/venr for any of above 10.00
- --------- —.___ Other: lallo _
Tax map/parcel no.: _ Other fuel appliances
DESCRIPTION
llances
DESCRIPTION 0I' WORK Water heater 10.00
Gas fireplace 10.00
Flue vent for water heater or gas
Fireplace 10.00
------ - ---
Log lighter as 10.00
Wood/pellet stove 10.00
Wood fireplace/insert 10.00
Chimney/liner/nue/vent 10.00
TVNANT
-— -------.----- Other: 10.00
Name: tQp�r L7-�X� r'Vy�'�iy/__— _ - Environmental exhaust and ventilation
Address: p Range hood/other kitchen
00 $Gtr /7 y tL 04141"I_/4"'4— - equipment 10 00
City/State/ZIP: !� & 7�7,Z Clothes d er exhaust 10.00
Single-duct exhaust(bathrooms,
Phone:(s»S) a'7' 3 Fax:( ) toilet compartments,utility rooms) 6.80
_ C] iil"PLICANT ❑ CONTACT PERSON _ Attic/crawls ace fans 10.00
Business name: — -- - Other: moo
--- -.- --- — -_- Fuel piping
Contact name: $5.40 for Ilrst four;$1.00 for each additional
Address: Furnace,etc.
- -- -------- --- Gas heat u _
City/State/zlp: Wall/suspended/unit heater
Phone:( ) Fax: :l ) Water heater
E-mail: -- Fireplace --
--r- ---- �_
Range -- -- —
4 r Barbecue _
clothes dryer as)
Business cl
name: � �� �_--------- ___— (B — --- ---
-- ----- Other_ _
Address: ' MECHANICAL PE1 NIft FEES
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee($72 50)
Plan review(25%of permit fee)
CCB lic._ _ _ State surcharge(Belo of permit fee)
TOTAL PERMIT FEE
Authorized signature: ���� all;e
_--- This permit application expires If a permit to not obtained within 180
days after It has been accepted-it complete.
r Print name: s`on �-- ,� ,���1N1 t Dale _s� Fee methodology set by Tri-County Building Industry Serviv Board
itBuildina`PerlmtsN.EC-PrmutAppJuc 12,01 440.4617T(IIr02R'OWWEa)
Mechanical Permit Application - City of Tigard
(Page 2 - Supplemental Information
Commercial Fee Schedule:
I'otil Valuation: Pair t `e'er,' ' I .
$1.00 to$2,000.00 Minimum fee$72.50
$2,001.00 to$5,000.00 $72.50 for the first$2,000.00 and$2.30
for each additional$100.00 or traction
thereof,to and including$5,000.00.
$5,001.00 to$10,000.00 $141.50 for the fust$5,000.00 and
$1.80 for each additional$100.00 or
fraction thereof',to and including
$10,000.00. _
$10,001.00 to$50,000.00 $231.50 for the first$10,000.00 and
$1.35 for each additional$100.00 or
fraction thereof,to and including
_ $50,000.00.
$50,001.00 to$100,000.00 $771.50 for the first$50,000.00 and
$1.25 for each additional$100.00 or
fraction thereof,to and including
_ $100,000.00.
$100,000.01 and up $1,396.50 for the first$100,000.00 and
$1.10 for each additional$100.00 or
fraction thereof'.
Note: All new commercial buildings require 2 sets of plans.
r`[buildingTermits\MLC•PennitApp.dec 12103 2
CITY O F T I GA R D MASTER PERMIT
PERMIT#: MST2003-00553
DEVELOPMENT SERVICES DATE ISSUED: 1/26/04
13125 SW Hall Blvd.,Tigard, OR 97223 (503)639.4171
SITE ADDRESS: 12800 SW BLUE HERON PL PARCEL: 2S10313C-08700
SUBDIVISION: BLUE HERON PARK ZONING: R-4.5
BLOCK: LOT: 004 JURISDICTION: TIG
REMARKS: Convert 550 square feet of crawl space to habitable;space. 3/9/04, adding gas fireplace, gas piping,
relocate ducts& grilles.
BUILDING
REISSUE: CUSTOM STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: ADD HEIGHT- FIRST. 550 at BASEMENT: 31 LEFT: SMOKE DETECTORS: Y
TYPE OF USE: SF FLOOR LOAD: 40 SECOND: at GARAGE: at FRONT: PARKING SPACES:
TYPE OF CONST: 5N DWELLING UNITS: THRD It RIGHT:
OCCUPANCY GRP: RJ BORM: BATH: TOTAL: 550 at VALUE: 1138100 REAR:
PLUMBING;
SINKS: WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS: RA 4 DRAIN: TRAPS
LAVATORIES: DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN,'-AINS: CATCH BASINS:
TUB/SHOWERS: GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GRE/SE TRAPS.
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN<100K: SOIL/CMP c OHP: VENT FANS: CLOTHES DRYER:
FURN>=100K: I]NIT HEATERS: HOODS: OTHER UNITS: I
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS: I
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVCIFEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 200 amp: 0 200 amp: W/SVC OR FDR: PUMPIIRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 400 amp: Ini 400 amp tat WIO SVCIFDR: oo SIGN/OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 600 amp: 401 - 000 amp: EAADDL BR CIR: 2 nu SIGNAL/PANEL: IN PLANT:
MANU HWSVCIFDR: 601 1000 amp: 001+amps-1000v: MINOR LABEL:
1000+amolvolt
PLAN REVIEW SECTION
Reconnect only'
—4 RES UNITS: SVCIFDR>*228 A.: >800 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL•RESTRICTED ENERGY
A.SF RESIDENTIAL B.COMMERCIAL
AUDIO 6 STEREO: VACUUM SYSTEM: AUDIO&STEREO: FIRE ALARM: INTERCOMIPAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: ALL ENCOMP BOILER: HVAC: LANDSCAPEIIRRIG: PRnTECTIVE SIGNL:
GARAGE OPENER. CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATAITELE COMM: NURSE CALLS: TOTAL N SYSTEMS.
Owner: Contractor: TOTAL FEES: $ 417.47
This permit is subject to the regulations contained in the
ROBERT HANSEN OWNER Tigard Municipal Code,State of OR. Specialty Codes and
12800 SW BLUE HERON all other applicable laws. All work will be done in
TIGARD,OR 97223
accordance with approved plans. This permit will expire if
work is not started within 180 days of issuance,or if the
wcrk is suspended for more than 180 days. ATTENTION:
Oregon law requires you to follow rules adopted by the
Phone: 503-579-3252 Phone: Oregon Utility Notification Center. Those rules are set
forth in OAR 952-001-0010 through 952-001-0080. You
Reg e: may obtain copies of these rules or direct questions to
CLINIC by calling(503)246-1987.
REQUIRED INSPECTIONS
Footinp Insp Electrical Rough In Insulation Insp Final inspection
Post/Bearn Structural Framing Insp Firewall Insp
Post/Bearn Structural Low Voltage Firewall Insp
PosLDeam Mechanica Fireplace Insp Electrical Final
Underfloor insulation Gas Line Insp Mechanical Final
r 14
Issued By : ;Permittee Signature :
all (503) 6394175 by 7:00 p.m. for an inspection needed the next business day
I
d
CITYOF TIGARD MASTER PERMIT
DEVELOPMENT SERVICES
PERMIT#: M6/04 00553
DATE ISSUED: 1/226/04
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639.4171
SITE ADDRESS: '2800 SW BLUE HERON PL PARCEL: 2SiO3BC-08700
SUBDIVISION: BLUE HERON PARK ZONING: R-4
BLOCK: LOT: 004 JURISDICTION: TIG
REMARKS: Convert 550 square feet of crawl space to habitable space.
BUILDING
REISSUE- CUSTOM 3TORIES: FLOOR AREAS _ REQUIRED SETBACKS REQUIRED
CLASS OF WORK. ADD HEIGHT: FIRST 55(" of BASEMENT: sf� LEFT: SMOKE DETECTORS: y
TYPE OF USE: Sr FLOOR LOAD: 40 SECOND, sf GARAGE sf FRONT: PARKING SPACES
TYPE OF CONST 5N ')WELLING UNITS: THRID st RIGHT.
OCCUPANCY GRP R7 pDRM BATH: TOTAL: ,Su VALUE: 1 3y,,nu sf REAR:
PLUMBING
SINKS. WATER CLOSETS: WASHING MACH: LAUNDRY TRAYS, RAIN DRAIN: TRAPS.
LAVATORIES: DISHWASHERS, FLOOR DRAINS SEWER LINES: SF RAIN DRAINS CATCH BASINS:
TUBISHOWE.RS: GARBAGE DISP. WATER HEATERS WATER LINES. BCKFLW PREVNTR: GREASE TRAPS:
MECHANICAL
OTHER FIXTURES:
FUEL TYPES FURN<10OK: BOIL/CMP<OHP; VENT FANS: CLOTHES DRYER.
FURN y*100K: UNIT HEATERS. HOODS OTHER UNITS.
MAXINP. btu FLOOR FURNANCES: VENTS: WOODSTOVES GAS OUTLETS:
_ ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC/FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 -200 amp 0 200 amp: W/SVC On FDR: PUMPIIRRIGATION: PER INSPECTION
EA ADD'L 500SF: 201 - 400 amp 201 - 400 amp: 1st W/0 SVCIFOR. no SIGNIOUT LIN LT PER HOUR
'I LIMITED ENERGY 401 600 amp 401 - 600 amp: EAADDL BR CIR. 21W SIGNAI./PANEL: IN PLANT
MANU HMISVCIFDR: 601 - 1000 amp 601+amps-1000v* MINOR LABEL:
1000-amp/volt
Reconnect only:
ALAN REVIEW Sr CI ION
-
—4 RES UNITS SVC'FDR-225 A. >600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL•RESTRICTED ENERGY
A.SF RESIDENTIAL B.COMMERCIAL
AUDIO d STEREO VACUUM SY'1-EM. AUDIO 6 STEREO, FIRE ALARM: INTERCOMIPAGING: OUTDOOR I-NDSC LT:
BUFBLAP ALARM OTH BOILER: HVAC LANDSCAPEORRIG, PROTECTIVE SIGNL.
GARAGE OPENER CLOCK: INSTRUMENTATION. MEDICAL OTHR:
HVAC, DATAlTELE COMM: NURSE CALLS TOTAL 0 SYSTEMS:
Owner: Contractor: TOTAL FEES: $ 339.17
ROBERT HANSEN OWNER This permit is subject to the regulations contained in the
12800 SW BLUE HERON Tigard Municipal Code,State of OR. Specialty Codes and
TIGARD,OR 97223 all other applicable laws. All work will be done In
accordance with approved plans. This permit will expire if
work is not started within 190 days of issuance,or if the
work is suspended for more than 180 day's. ATTENTION.
Oregon law requires you to follow rules adopted by the
Phone: 503-579-3252 Pb�,na- Oregon Utility Notification Center. Those rules are set
forth in OAR 952.001-0010 through 952-001-0080. You
Reg a may Obtain copies of these rules or direct questions to
OUNC by calling(503)246-1987
REQUIRED INSPECTIONS
Footing Insp Insulation Insp
Post/Beam StructW_ Electrical Final
Underfloor insulation Final inspection
Electrical Rough In
Framing Insp
Issued By : , Q��-� Permittee Signature ;'A �� /
Call (503r 639.4175 by 7:00 p.m. for an inspection needed the next business day
- J
Building Permit Application FOR OVFWE (ISE ONLV
Received building
Date/By: ) Iq 0_3Permit No.:
City of Tigard Planning Approval other u
Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other o
Tigard,Oregon 97223 Date/By: Permit No.:
Phone: 503-639-4171 Fax: 503-598-1960 Post-Review Land Use
Internet: www.ci.tigard.or.us Date/By: Case No.
Contact Ju' .: See Page 2 for
24-hour Inspection Request: 503-639-4175 Name/Method: Supplemental Information
r TYP.L OF+WORK ::+.. c,j ...t x+,
New constructionI Ll
Demolition
LJ Addition/alteration/replacement Other:
e 'C GO F
TRUCTIMNote: Permit fees*are based on the total value of the work performed. Indicate
1 &2-Family dwelling Commercial/Industri 1 the value(rounded to the nearest dollar)of all equipment,materials,labor.
overhead and profit for the work indicated on this application.
Accessory Building Multi-Family ,/ sel +
Master Builder Other: Valuation......................................................... _
A". ';IO `'IT1E"IN QR TIt)$201 10 I ' No.of bedrooms: - No.of baths:
Job site address: > p,pp !'L Total number of floors.........................
t'ew dwelling area(sq.ft.)............
Suite#: — Bld . A t.#: — G trage/carport area(sq.ft.)............................ _
Project Name: ,o - -iY =S Cuvered porch area(sq.ft.)................—........ .
Cross street/Directions to job site: Deck area(sq.ft.)................................ ........,
Other structure area(s ft.) J.Qo r.7 mwrl,�Wr7 Al
i� -
�rR
x
Sltbdivision:
ax map/parcel #: Note: Permit fees*are based on the total value of ti.a work performed. Indicate
the value(rounded to the nearest dollar)of all equipment,materials,labor,
�,ee_ 74,
overhead aid profit for the work indicated on this application.
Valuation.......................•................................. S
Existing building area(sq.ft.)......................... _
- - New building area(sq. ft.)...............................
_ _ Number of stories............................................
_PI�pPFI TE1A_ NT Type of construction...............................•.......
Existing:
Occupancy group(s):
Name: .—�`�,�iE'� � � �,4�YSe-/f New:
Address: 7 on Sw rR'c� L
City/State/Zip: -
Phone: 5 `7 Z,;Z- Fax: NOTICE: All contractors and subcontractors are required to be
• r�P1l : LIC` .. CT p licensed with the Oregon Construction Contractors Board under
- provisions of ORS 701 and may be required to be licensed in the
Business Name: _a r• 't ifi jurisdiction where work is being performed. If the applicant is exempt
Contact Name: from licensing,the following reason applies:
Address: -----
Cit /State/Zip: - _ -- ---- ---- - -- —.
Phone: -
-- --- Fax: _ ----- — - - iis*
E-mail:
—T Please rg t e schedule.W taw=
Business Name' r. t ✓�r l/�. Fees due upon application........................ $ SL'
Address:
City/State/Zip: Amount received............................................. S
Phone: — Fax:'
Date received:
CCB Lic. #:
Authorized Notice: This permit application expires If a permit Is not obtained within
Signature: %/� �_ bate: /� ��� ___ INtl dad%after It has been accepted as complete.
*Fee methodology set by rrl-County Building Industry Service Board.
(Please print name)
i:'\Dsts\Permit Fomu',BldgPermitApp.doc 01/03
One- and Two-Family Dwelling
.Building Permit Application Checklist Reference no,:
Associated permits:
Citynf Tigard Cit of Tigard City g ❑Electrical O Plumbing O Mechanical
Address: 13125 SW Hall Blvd,Tigard,OR 97223 O Other:
Phone: (503) 639-4171
Fax: (503) 598-1960
FOLLOWING1 1 FOR PLAN REVIEW Ves No NJA
I Land use actions completed.See jurisdiction criteria for concurrent reviews.
2 Zoning.Flood plain,solar balance points,seismic soils designation,historic district,etc.
--
3 Verification of approved platllot. _
4 Fire district approval required.
5 Septic system 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,
9 Erosion control 0 plan ❑permit required,Include drainage-way protection,silt fence design and location of
catch-basin protection,etc.
10 _L Complete sets 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 plans with cross references between plan location and details.Plan review cannot be completed
if copyright violations exist.
I I Site/plot plan drawn to scale.The plan must show lot and building setback dimensions;property corner elevations(if
there is more than a 4-11.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements and
driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction indicator;lot
area;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 reinforcing pads,connection details,vent
size and location.
13 Floor plans.Show all dimensions,room identification,window size,location of smoke detectors,water heater,
furnace,ventilation fans,plumbing fixtures,balconies ar.i decks 30 inches above grade,etc.
14 Cross section(O and details.Show all framing-membe• sizes and spacing such as floor beams,headers,joists,sub-floor,
wall construct ion,roil construction.More than one cross section may be required 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 references are acr_eptable. _
16 Wall bracing(prescriptive path)and/or lateral analysis plans.Must indicate details and locations-,for
non-prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor/roof framing.Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing
locations.Show attic ventilation.
18 Basement and retalWng 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 all beams and multiple joists
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 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 required or provided.(i.e.,shear wall,roof truss)shall be stamped by an engineer or
architect licensed in Oregon and shall be sho\%n I- i1,111(cable to the project under review.
23 Five(5)site plans are required for Item I l above. Site plans must be 8-1/2"x 1 I"or t I" x 17".
24 Two(2)sets each are required for Items 16, 19,20&22 above.
25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will be not accepted.
26 "Reversed"building plans must meet critena outlined in the Permit&System Development Fees document.
27 "Drawn to scale" indicates standard architect or engineer scale.
28 Site plan to include tree size,type&location per approved project street tree plan(if applicable),and COT Street Tree List
Checklist must be completed before plan review start 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(6=/COM)
Electrical Permit Application Rec/Bd Electrical
Da
Permit No.: M�)I�L'�,?te'U j53
Cit of Ti and Planning Approval Sign
y g DateB : Permit No.:
13125 SIN Hall Blvd. Plan Review Other
Tigard,Oregon 97223 Date/By: Permit No.:
Phone: 503-639-4171 Fax: 503-598.1960 Post-Review Land Use
Internet: ww DateBy: Case No.:~N.ci.tigard.or.us ContactSee Page 2 for
24-hour Inspection Request: 503-639-4175 Name/Method: 1 i Supplemental Information.
New construction Demolition Service over 225 amps- Health care facility
Addition/alteration/re lacement Other: commercial ❑Hazardous location
❑Service over 320 amps-rating of ❑Building over 10,000 square feet,
r till 1&2 family dwellings four or more residential units in
1 & 2-Family dwelling Commercial/Industrial ❑System over 600 volts nominal one structure
Accesso Buildin, Multi-Famil [I Building over three stories ❑Feeders,400 amps or mote
rY � Y ❑Occupant load over 99 persons ❑Manufactured structures or RV park
Master Builder Other: ❑Egress/lighting plan ❑Other:
Submit_sets of plans with ar,of the above.
The above are nota Ilcnble to tem orar construction service.
Job site aridress: 12 zinc �G� /3C���C_FCo�e Z7L
Suite#: Bldg./Apt.#: Number of ins ectiona per permit allowed
Project Name: Description Qtr Fee(on.) Total
New residential-slogle or multi-family per
Cross street/Directions to job site: dwelling unit.Includes attached garage.
Service included:
1000 sq.ft.or less 145.15 4
Each additional 500 sq.ft.or portion thereof 33.40 1
Limited energy,residential 75.00 2
Subdivision: _ Lot#: Limited energy,non residential 1 75.00 2
Tax ma / arcel #: Each manufactured home or modular dwelling
a ' service andrbr feeder 90.90 2
t.�
Services or feeders-Installation,
alteration or relocation:
200 amps or less 80.30 2
201 amps to 400 Lm s 106.85 2
401 ams to 600 ams 160.60 2
601 wtgm to 1000 amps 240.60 2
Over 1000 6m s or volts 454.65 2
Name: <tN E Reconne,:t only 66.85 2
Address: Z ti�cc. p
s�J r-5�.•e Pau„
' Tem orary services or feeders-installation
fL.
alteration,or relocation:
City/State/Zip: 200 amps or less 1 66.85 1 1
Phone: Fax: 201 ams to 400 ams _ 100.30 2
401 to 600 ams 133.75 2
Branch circuits-new,alteration,or
Name: e,<• extension per panel:
Address: A.Fee for branch circuits with purchase of
_ service or feeder fee each branch circuit 6.65 2
City/State/Zip: B.Fee for branch circuits without purchase of
service or feeder feeHrst branch circuit 46.85 2
Phone: Fax: Each additional branch circuit 6.65 2
E.-mail: Misc.(Service or feeder not included):
Each pump or irrigation circle 53.40 2
Each sign or outline li htin 53.40 2
Job No: } Signal circuit(s)or a limited energy panel.
Business Name: Cl alteration,or extension Pae 2 2
L Description:
Address: /ti %�/z
/State/Zi - \ Each additional Inspection over the allowable In an of the above:
C1
�r9 IJf�'TL Per inspection pet hour min. 1 hour 62.50
Phone: / VF- ,3 Fax: Investigation fee
CCB Lic. #: /5 3 y Lic.#: b y- i other:
Supervising electrician Subtotal S
signature required: _ Plan Review(25%of Permit Fee) S
Print Name: Lic.#: 1_10�5 S State Surcharge(8%of Permit Fee) S
_ TOTAI.PERMIT FEE I S
Authorized Notice: This permit application expires If a permit Is not obtained within
Signature _ Date: 190 days after It has been accepted as complete.
*Fee methodology.ttl by Tri-County Building Industry Service Board.
(Please print name)
i:\Dsts\Permit Forum\ElcPettrdtApp.doc 01103
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Feefor all systems............................................................ $75.00
Check Type:f Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating,Ventilation and Air Conditiuning System*
Vacuum Systems*
❑ Other
COMMERCIAL WORK ONLY:
Feefor each system.......................................................... $75.00
(SEE OAR 418-260-260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication In-tallation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
Pr-)tective Signaling
❑ Other _ --�-
,_. _Number of Systems
* No licenses are required. Licensee are required for all
other installations
i;\Dsts\Permit Fomu\ElcPermitAppPg2.doc 01/03
I'crmit #:
w Q \
of
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered 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 registration 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.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
❑ IA. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
3B. 1 will be m general contractor.
-� Y own
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
1 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 orin.
4. - 09 :L ` — 1021
-
(Signatu e of permit applicant) (Date)
(White copy to fssuing agency permit file,
pink copy to applicant)
informatiotl Notice to Property Owners
About Construlc'.on Responsibilities
!dote; Tf1ic !n/� rmu(iwal\+lr,,,.t' to Proliertl' OilviP, '11)wit('omstmction J'tesponsibilitics
+rtty der' 111;11 1 ht'the Bmird in accor-dam-ir ik:Wi ORS 70;1`155,5).
I)'you ;_lrc: acting as sour own c(mtracll,r w cowok tact ;l new h(1111C I I L 1 a 'It IhaaIt.idI iIlIprovCIII nt to an existing at•uctul ,
s011 c;111 pIt'Vent nlsuly P)rahlCtII."I)y Lit:IjI JW.IrC UI IIIc IolI(omnr!. w,plmmUi1iIu.•artd are;i, Irl con,.ctrl.
EMPLOYER RESPON 31B1UTWS:
11 ytill hire' pt'l-soll`, Iltlt „IISI;IIItw. :n the
construclleltl ,.ilk Imi')hlt'cmetlt Irf a rt,itletltlal tlU 'lllrc, ;IHS vs'III, In rtii)til ill,t,f it;r•,, i)C rtllt't1 ',I 1)'' .'I! 17 plt)ter and the t)c',llllt:
ynu hire will he ofilplOyre . 1, the employer. v"u rmr,( c omply with the rllllo,`.vim'.
C Irel;otl'S ssItilltOldill�t>)X ltltti" As arl ei t!i(,4l'1,V{Ill mo,0 wilhhol,I IYII'(,nif,Inti ,froill PI1)1)I1)trr't'+,V?t"'r:;It tll( I:ilc t'ICt ,l,
,lrr p,Iiti )',,11 will by liable for the t(w Pavm"'n!;evr!1 if volt durl't actually withhold the m%q twill s onr rittpl,) ::e5. I Pu nr
mforrn:llim), t:;lll diL i icgon I kpl. ilf R-nrnur at(W-),1191.
UnemploYmet►tinsurance tav A, ;ill 'IIrok,1111,1t,V11it'll! 111"111,11K ' illlrli, ;Ilh
wages ofall t_rllPlt`VC('S. Flit milli, info rmiluoll,e-all Vic i;)renon Do i`,ionw the Oop:ul,gtcni of lltullan Rv,�mn•co',
at :179... 15214
Workers' compensation huilraticv: A', ,it'; rig,k,�rt. 4Oil ;IiI' I,,Shr I)IC';' ,I1 Wk iihtillllsl
C)tltillllt\Ul'tl'r9'C111T1PC11�OtllJn ,1111Jr,i,n_:. ItH yI'dl! CIT�I,I, JC It 11,111;111 Ill :11)iJItI Ib,IC):'(� UU11,PCII'1;1!I(Ill !I1;,;1'aiK1',�llil nGt1
hi7�1llhi(t l 1,,pe'itlltic. im'd will l)t`liahlh I,;,I ,'III.:I Iim c;"I`,if m of N olio,,nllllo\lec�k iiljtlrt-t)ell tilt, job f'cir tin ;r infl vI!latirm.
�'ta,ll Ill, W,itKer;'(' Impt_11'.o itnl Do,)-sine if tht 0c'pallint•nl inti 1)4` 798y
t f,S.lntcrnul C�c.vcnuc Strv'icc: As an ulupluyc r.}(�u 11111"1 „ithhold(t:d,:t.t1 incnrlle VOL f-011) tt
ltaht�;fnt't'hetlt�(1:1s'rrlcnt r�, II I' vcnJdi,lrl'I;r.!!I;Illr ,�. Ilh!trlltl the LI�, Ivrc Irl+,rc illlurnl.ttit�n :ail tllt� li!t;�null It_ ;rl',tlt'�t•rt'ir;
ut i 8lxl�x2y-l(WU.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
('otlt compliance: Asthe Prt'nlilhul,.lrrfor thi"0rt)jt'c!. tL",I)t 411 lhlrl,,rrt' I,I4ii :'.Jn% 1'tilmc0,nicet ;,,1;'n'yuilc'ticnt-
taat nmN lit, brought to your allrntio ll thrrnlgh insPeCtltms.
Liabilit;I and property damaigeir>G`mkin(:r: Cmilact your 111;41WiLO agent to skw it you 1wvc.aldequate ul:+ur,ulc (:w k !.wr fur
t1A ldcnt, inti oillissiurls such as falling tt,til". paint uvcrspra), water damage 1voill Pipe punt ture4, fire,ur Wol;k ''I.it nulst I)t'
re-dome.
Tlnte .0 cupert'lse employees: Make sure you hasp nl'I'icicm time to sulk rvlse your employees.
17, I'I'1!tie! W10,otilit,Vnii hnvr'tile-v%Ivrivzv if,','_(alk,V(ltlrrlWyl gonem!CQn*,riC'Tt)r,to coordirlatetho work of rimPh ltl and t"mi4h
trade. imil Irvh0tlfy hllil(hnr itfficink at th@ aPpmpfiate limvc F(,thcv c:n peKrntl the regtired inepectionr.
If you have additiunal quimnon., s+'rite ur call the Construction Contracture Hoard(Po Box 141 40,Salelrtr,'OR 97300-5052,
503/:478-4621), The Board IG located at M)Summer St. NE Suite AX), rn Salem.
prop-owti iP
I,'9d
CITY OF TIGARD 24-Hour
BUILDING Inspection (503)639-4175 MST
INSPECTION DIVISION Busine Ine: (503)639-4171
BUP - _ .-
Received ____ _--_.___ Date Requested__- '. AM_- _ PM _ BLIP -----_--_--
Location - /,P-- J ��,(� jZ MEC ------ ---
Contact Person �- - Ph PLM -- -----------
Contractor Ph ( ) _ SWR
BUILDING Tenant/Owner - _.. .- _ ELC - - __-
Footing ELC
Foundatior, Access: .f-A i
Ftg Drain ELR _..-
Ci awl Drain -- - _ SIT
Slab Inspection Notes: -----
1'-ust&Beam -- --- - - ___
Shear Anchors -
Ext Sheath/Shear - -
Int Sheath/Shear
Framing ---
Insulation
Drywall Nailing - -�--—
Firewall
Fire Sprinkler -�
Fire Alarm
Susp'd Ceiling �-
Roof _ ----- ----
Other:
nVASPART FAIL
PLUMBING --- - -- ----- _
Post& Beam
Under Slab ----- - -- ----- f� --—
Rough-In
Water Service --- ------
Sanitary Sewer _
Rain Drains --- -"- --� -
Catch Basin/Manhole
Storm Drain — -
Shower Pan _
Other:-------- —_ -
Final -
PASS PART FAIL -
M_FCHANICAL -
Post&Beam
Rough-In - ----- -
Gas Line
ampers - - -
FPASPAS PART FAILTRICAL _
ServiceRough-1nSmalwD
UG/Slab
Low Voltage
Fire Alarm
Final E-1 Reinspection fee of$_ _required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS_PART FAIL
Please call for reinspection RE: - - _ Unable to inspect-no access
Fire Supply Line I „ �-
C- --�
Approach/Sidewalk e -- --
ADA
Dat ____�_ Inspector � iJlt
Other:
Final — DO NOT REMOVE this Inspection reco f from the jr;b site.
I PASS PART FAI
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 MST
INSPECTION DIVISION Business Line: (503)639-4171 —
_ BLIP _
Received Date Requested-_...� � AM- _ PM BLIP —_
Location -_AUC� ILa
—_ Suite --_ MEC — —
Contact Person T_��-0--�' — _ Ph ( _—)-2 e"2 PLM
Contractor _.__. --- -- - --___-- _ Ph ( ) _ _ — SWR
BUILDING Tenant/Owner ELC
Footing ELG _
Foundation Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT _
Post& Beam
Shear Anchors - -------
Ext Sheath/Shear
i
Int Sheath/Shear _ - ILI
-�Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler -- -- --— --- — — - __
Fire Alarm
Susp'd Ceiling -- - --
Roof ---- ----- ---
Other
Final —
PASS PART__ FAIL --- ------ - �_- ---- -
PLUMBING —
IIost 8 Beam _...—
Under Slab —- - - --- -- ---. -------- - -- ---
Rough-In
Water Ecry -.e -- -_.,.--- ----
Sanitary Sower -- -_-Rain Drains
Drains ------ ----- -_— -- -------- —
Catch Basin/Manhole
Storm Drain - - - - -. ---- --
Shower Pan
Other: ---- -- - ---- _- —
Final
PASS PART FAIL --- - - --
MECHANICAL _ _
Post&Beam
Rough-In -----
Gas Line
Smoke Dampers -- - --- --- ----- -----
Final
PASS PART FAIL - -- — --
ELECTRICAL
Service - �- -- ------ --
Rough-In
UG/Slab -- --- ---Low Voltage
Voltage
Fire AlaLm - - `- - --
n Reinspection fee of$ required before next inspection. Pay at City Hall. 13125 SW Hall Blvd.
ASS PART FAIL
_] Please call for reinspection RE:_ Unable to inspect-no access
fire Supply Line
l)A
App 0 I'd - -
Approach/Sidewalk Date - -__- Inspsctorr _ �.L�' Ext _-
Other:
Final DO OT REMOVE this Insipectlon recor from the Job site.
PASS PART FAIL.
I _
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175
INSPECTION DIVISION Business Line: (503)639-4171 MST
BLIP
Received _ _ Date Requested_/�_Qq- AM PM BUP
Location ,1` U!V -&� Q� 1✓`oyl ate' Q Suite MEC
Contact Person 10 � 1.�i_C: ---- Ph( �523 ) q30 L}3Q PLM _ —
Contractor �)Ll Ph SWR
BUILDING Tenant/Owner _ _— ELC
Footing r -f
Foundation Access' ELC
Ftg Drain ✓�,l L j ELR
Crawl Drain 6I
Slab Inspection Notes: SIT
Post&Beam - ---- ---- ---- ---------
Shear Anchurs l o l l �t'r • l aC Ar •
Ext Sheath/Shear l
Int Sheath/Shear
Framing - - _.. --- -- .--- ------- _------- ...---
Insulation
Drywall Nailing - -._ -- --,. - - --- --- ---. _.— - _
Firewall
Fire Sprinkler -- --
Fire Alarm _
Susp'd Ceiling -- -- - - -- __- ------ -- -- ---
Roof
Other: _ _ _ - ---- ----- -- -- �..- --
Final -
_PASS PART FAIL -- --- --- - --- - ---- - - - ----- - ------
PLUMBING
Post&Beam
Under Slab -------- -_--___-_ --
Rough-In ----------
Water Service
Sanitary Sewer
Rain Drains --- -- _
Catch Basin/Manhole
Storm Drain
Shower Pan
Other: ----- --
Final ----�-- ----
PASS PART FAIL - -- --- -- --
MECHANICAL
Post&Beam -- ------ - - --
Rough-In
Gas Line
Smoke Dampers ------ - -- —__
Final
PASS PART FAIL -- --- - --
ELECTRICAL
Service —
Rough-In
UG/Slab
Low Voltage
Fire Alarm _ _ -
F - Reinsoectlon fee of$. required before next Inspection. Pay at City Hall, 13125 SW Hall Blvd.
PAS PART FAIL
Please call for reinspection RE: F'j Unable to inspect-no access
Fire Supply Line
ADA -�
Approach/Sidewalk ��------- hnsq�ctor ._-
Other:
Final DO NOT REM 10) E this inspection coal from the Job site.
PASS PART FAIL
1