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©2006 NKBA BMF9 of 19

Copyright 2006 by NKBA. All rights reserved. No part of this document may be reproduced in any form by photostat, microfilm, xerography, or any other means, or incorporated into any informational retrieval system, electronic or mechanical, or transmitted, in any form or by any means, without the prior consent of the copyright owner. 37944-1

Add Your Logo Here Add your Company Name And Address Here Designer: Bath Design Survey Form Date:

Name: Peakes

Residence: 680 Ferndale Drive

New Britain, Oregon

Jobsite Address:

Client 1: Jacques Peakes Client 2: Simone Peakes

Home Phone: Home Phone:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

Email: Email:

Appointment Allied Professional

Schedule: Name:

Call When Ready: Firm:

Times Available: Address:

Directions: Office Phone:

Cell Phone:

Email:

Notes:



General Client Information 1. What type of project is this? xRenovation New Construction 2. Have you ever purchased a bathroom before? Yes xNo 3. When would you like to start the project 3t? 6 months Complete the Project? By Christmas 4. How much time do you / will you spend at the jobsite residence? Permanent residence 5. How did you learn about our firm? Referral 6. Has anyone else assisted you in preparing a design for the bath? no 7. Do you plan on retaining an interior designer or architect to assist in the bath planning? If so, Name: No Phone: 8. Do you have a specific builder / contractor or other subcontractor / specialist with whom you would like to work? If so, Name: Phone: 9. What portion of the project, if any, will be your responsibility? Painting, permits 10. What budget range have you established for your bath project? $5,000–$10,000 $10,000–$20,000 x$20,000–$30,000 $30,000–$50,000 $50,000–$60,000 $60,000–$75,000

$75,000+ 11. How long do you intend to own the jobsite residence? To retirement ____________________________________________________________

a. Is return on investment a primary concern? No ____________________________________________________________________________ b. Do you plan on renting the jobsite residence? No __________________________________________________________________________

12. What family members will share in the final decision-making process? Husband, wife _____________________________________________ 13. Would you like our firm to assist you in securing project financing? Yes xNo

14. What do you dislike most about your present bath? Old, dated, not water efficient fixtures, poor lighting, no direct entry from master bedroom. _____________________________________________________________________________________________________________

15. What do you like most about your present bath? The big window, over all size __________________________________________________

_____________________________________________________________________________________________________________________ 16. Sustainable design ideas important to your family:

Use of “Green” Products General products made from recycled materials: Cabinets Counters Floors Walls Building

Materials

Wood products supplied by environmentally responsible manufacturers

xWater usage: Sustainable design details incorporated into the plan

xWater efficient fixtures: xToilet xBathtub xShower

Energy efficient lighting systems:

17. If you are remodeling: Is there a room addition planned? Yes xNo

a. When was the house built? 1973 How old is the present bath? Original bath __________________________

b. Are you considering relocating windows xdoors xwalls in your new plan? 18. If you are building a new home:

a. Are you able to relocate windows doors walls at this stage of construction? Yes No b. Are you able to relocate walls at this stages of construction Yes No

19. Is there a view from the bathroom to be considered: Yes xNo a. Sun exposure ________________________________________________________________________________________________ b. From where in the bathroom should the view be visible? Bathtub Vanity Shower Other ___________________________ c. What about privacy? ___________________________________________________________________________________________



Specific Bath Questions

1. Is this a xMaster Children Other Family Member Guest Special Area: bathroom?

2. How many bathrooms are in the home? two

3. Who will use the bathroom? Jacques & Simone ______________________________________________________________________________ 4. Characteristics of family members who use the bathroom: Are you planning on enlarging your family while living here? xYes rNo

Name Age Handed Height Physical Limitations/Mobility Aids 1. Jacques 34 xR L 5’ 10” none 2. Simone 33 xR L 5 ’4” none 3. R L 4. R L 5. R L

5. Personal Information about the bathroom:

a. Will more than one person be using the bathroom at the same time? Yes How often? Daily __________________

b. What types of bathroom activities can be done in a shared bathroom space? Showering grooming _________________________________

c. What types of bathroom activities need to be done in private? none ___________________________________________________________

d. How important is auditory privacy? n/a Are bathroom noises a problem? no _____________________ 6. Visitability: a. Will this bathroom be used by visitors to the home? Yes xNo How often? ___________________________________________________ b. Will the visitors be children or adults? ______________________________________________________________________________________

c. Do any regular or frequent visitors have any physical limitation? no ________________________________________________________________ 7. Do you prefer separate showering and bathing areas? yes ___________________________________________________________________ 8. Would you like to consider a tub that will accommodate more than one person? yes _____________________________________________

9. Would you like to consider a shower that will accommodate more than one person? yes __________________________________________

10. Do you prefer the water closet and/or bidet be separate from the other fixtures, and placed in its own compartment? no _______________

11. Checklist for Bathroom activities:

Grooming Activities Location Person Vanity /

Lavatory Dressing

Table Bathtub Shower Other

Room Person #1 Person #2 Person #3

Body: Washing x x x x x Shave - Face x x x Shave - Body x x x Apply Lotion x x x Hair washing x x

Teeth: Brush x x x Floss x x x

Nails: Finger x x Toe x x

Cosmetics: Apply x x Remove x x

Face: Skin Care x x x Hair: Blow Dry x x x

Brush / Style x x x Color x Cut / Trim x x x

First Aid: Treating cuts and burns

x x x x

Hands: Apply Lotion x x x Wash x x x

Medicines / Vitamins: x x x



Bathing / Showering Activities Location Person Bathtub Shower Other Room Person #1 Person #2 Person #3 Bathing: With Someone x x x x

Assisting an Adult Bathing Pets Soaking / Relaxing x

Showering: With Someone x x x Assisting an Adult Steam Showering

Sauna: Relaxing Other:

Toileting Activities Person Person #1 Person #2 Person #3 Assisting an Adult: Toileting: x x Personal Cleansing: x x Diaper Changing: Reading:

Other Bathroom Activities Location Person Vanity /

Lavatory Dressing

Table Bathtub Shower Other

Room Person #1 Person #2 Person #3

Display Collections Undressing / Hamper Dressing: Underwear / Sleep clothes Dressing: “Street” Clothes: Drink Beverages Eat Snacks Exercise w/o equipment Exercise using equipment Grow Plants Laundry: Air Dry Laundry: Hand-wash Laundry: Machine Wash Laundry: Sort / Fold Listen to Music x x x Massage Meditation Personal Pampering Exercise Equipment Polish Shoes Read: Books / Newspapers Supervise Children Talk on Telephone Talking with People Tanning / Sunning Watch Television x x x Other:

12. What appliances do you plan on using in the bathroom:

x Blowdryer xHandheld Wall Mounted

x Electrical Toothbrush Radio/DVD/VCR Valet x Electrical Razor x Television Washer & Dryer Fireplace

Wood Burning Gas

Towel Warmer Hydronic (hot water) Electric

Other:

x Curling Iron Hot Rollers Scale Other:



Storage Checklist

Item User Type of Equipment Shelf / Drawer Space Required Make-up Storage (person #1) Yes xNo (person #2) xYes No Shaving Storage (person #1) xYes No (person #2) xYes No Hair Grooming Equipment (person #1) xYes No (person #2) xYes No Hand and Foot Grooming Equip (person #1) xYes No (person #2) xYes No Personal Hygiene Equipment (person #1) xYes No (person #2) xYes No Medicine / First Aid xYes No Bathroom Paper Product Storage xYes No Bath Towel Storage xYes No Household Bedroom Linen Yes xNo Personal Pampering Equip (person #1) Yes xNo (person #2) Yes xNo (person #3) Yes No (person #4) Yes No Exercise Equipment (person #1) Yes xNo (person #2) Yes xNo (person #3) Yes No (person #4) Yes No Pet Grooming / Bathing Area Yes xNo Cleaning Supply Storage Yes xNo Shoe Polishing Paraphernalia Yes xNo Other

Hanging Yes No Shelf Length: Double Pole: Single Pole: Shoes # of Pairs Boxed: Yes No Shelf Length: Folded Clothing # of Drawers / Pull- outs

Accessories Yes No Types: Wall Space for Racks: Hats Rack: Yes No Boxes: Yes No Shelf Space: Full Length Mirror Yes No

Other

Hanging Yes No Shelf Length: Double Pole: Single Pole:

Shoes # of Pairs Boxed: Yes No Shelf Length: Folded Clothing # of Drawers: Accessories Yes No Types: Hats Rack: Yes No Boxes: Yes No Full Length Mirror Yes No



Storage Checklist (Continued)

Laundry Facilities Yes xNo Equipment Size: Mini Kitchen Yes xNo What Type of Equipment? Bar Sink Coffeemaker Cooktop Microwave

Refrigerator Other: Other:

Other:

Design Information

1. What type of feeling would you like your new bathroom space to have? Have you created a scrapbook of notes, photos and ideas of

bathrooms that you like?

Bamboo cabinetry, tile flooring, quartz surfaces __________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

2. What colors do you like? Beige, nature colors, neutral ______________________________________________________________________

And dislike? Primary colors_______________________________________________________________________________________________

What colors are you considering for you new bathroom? Muted sage green ____________________________________________________

What are the color preferences of other family members? ___________________________________________________________________ 3. Are there specific materials, fixtures, cabinetry or other features that you have pre-selected and want included in the project? No _______

_____________________________________________________________________________________________________________________

4. Design Notes: Semi private toilet, two lavatories at different heights, rainhead and handheld showers, whirlpool tub. Existing closets to be removed. Must have 60” x 24” clothes closet in new design. Window A cannot be changed in size or relocated. _______

_____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

Special Details: add skylight Radiant heat in floor Vessel sinks, 15” round by 6” high. Oil rubbed bronze finish Minimum 15 sq. ft. shower Need direct access to bathroom from master bed room Eliminate door from hall to bathroom. Lavatory heights @ 30” + 36” (two different heights)

American Country xAsian / Warm Contemporary Old World European Sleek Contemporary American Formal Craftsman / Arts and Crafts Personal Design Statement (Eclectic) Traditional



Soffit / Fascia

Use Existing Yes xNo

Furnished by Installed by BS O/OA BS O/OA

Fascia / Soffit Construction Fascia / Soffit Materials xOpen Extended Flush Recessed Remove

Other: Wallpaper Wood Display Rail Paint Lighted

Cornice Other: Surfaces Source Key: BS= Bath Specialist O= Owner OA= Owners Agent


Furnished by Installed by BS x O/OA BS x O/OA

Material Vanity Shower Walls

Tub Platform

Other Edge Treatment

Vanity Shower Walls

Tub Platform Other

Concrete Thickness 3 cm 3 cm Cultured Marble Shape: Decorative Laminate Bevel Engineered Stone (Quartz)

x x Ogee

Granite Bull Nose Full

Marble ½ Full Solid Surface Square x x Tile x floor Other: Size 12x24 24x24 Backsplash Grout matching matching Height 4” & 2cm

thick

Wood End Splash Sides Other Stone: Countertop ext.

over Water Closet

Special Notes Special Notes

In shower, use ½” cement board for walls and water proof membrane under shower pan.

Cabinetry Source Key: BS= Bath Specialist O= Owner OA= Owners Agent



Style Base Wall Tall Face Material Base Wall Tall Furniture (Unfitted) Wood-Species (Bamboo) x x x Built-In (Fitted) Laminate

Construction Paint Framed Acrylic Frameless x x x Metal

Door Type Other: Full Overlay x x x Door Style Partial Overlay Slab x x x Lip Inset

Hardware Color and Finish Knob Natural x x x Pull x x x Finger Pull Material



Bath Fixtures & Fittings - Water Closet Use Existing

Yes xNo Furnished by Installed by

BS x O/OA BS x O/OA

x 1 Piece Low Profile 2 Piece Standard Height Color: Linen Wall Hung x Elongated Seat Seat: Soft close Round Seat Other Trip Lever Finish: ORB Comfort Height Other Stop & Supply Finish: ORB

Bath Fixtures & Fittings - Bidet / Bidet Seat

Use Existing Yes No

Furnished by Installed by BS O/OA BS O/OA

Vertical Spray Vacuum Breaker Color: Other: Horizontal Spray Faucet Finish: Other:

Bath Fixtures & Fittings - Bathtub



Material Placement Cast Iron Fiberglass Ceramic Tile Cult Marble Left Drain Right Drain

Steel xAcrylic xColor:Linen x36x72 Fitting #1

Configuration Type: Wide Spread

Finish: ORB Location: Deck

xPlatform Skirted Platform w/ Steps Free Standing Fitting #2 Type: Hand held ______________________________________________________________________________________________________________________ Finish: ORB Location: Deck

Bath Fixtures & Fittings - Shower



Fabricated Fittings

1 Piece Multiple Piece Shower #1 Valve Type: Pressure Balance

Head Type: Rain head

Finish: ORB

Custom Shower #2 Valve Type:

Head Type:

Finish:

Shower Wall Material: Tile 12x24 Height: 96”

Shower Floor/ Pan Material: Poured with 2x2 tiles

Curbless threshold

Shower #3 Valve Type:

Head Type:

Finish:

Shower #4- Body Sprays Finish:

Shower #5- Hand-Held Finish: ORB Diverter Finish: ORB

Configuration: Drain Finish: ORB Grooming Recess: Size:

Bench Size: minimum 24”W Other



Bath Fixtures & Fittings - Lavatory Use Existing


BS x O/OA BS x O/OA

Material Fittings xPorcelain Glass Cast Iron xColor: Linen 4” Centers 8” Centers

Stainless Steel Decorative

Metal Composition xSingle Hole Wall Mounted

Configuration Finish Pedestal/Trap Cover Rimmed Under-Counter Wall Hung x ORB

xVessel Self-Rimmed Integral Other:

Ventilation


Furnished by Installed by

BS x O/OA BS x O/OA

Fan Fan, Light (Combo) xFan, Light, Heat (Combo) Switch xTimer

CFM Capacity: 150 CFM Duct Work Space:

Heating



Auxiliary xTimer: Thermostat Placement: :

xSupplement Heat: Radiant Floor Heat

Enclosures (Steam Door/s, Shower, Doors, Drapes, Etc.)



BS x O/OA BS x O/OA

Tub Finish: Size: Type: Material:

Shower Finish: ORB Size: ½” Type: Tempered Material: Clear glass

Steam Finish: Size: Type: Material:

Sauna Finish: Size: Type: Material:

Curtain Rod Finish: Size: Curtains (Color) Size:

Light Fixtures



BS x O/OA BS x O/OA

General Ambient Incandescent xHalogen Fluorescent Xenon Cove Recessed Pendant Surface Mounted

Decorative Track Incandescent Halogen Fluorescent

Incandescent Halogen Fluorescent Xenon Special Details

Task Lighting Side lights at each vanity sink for grooming/makeup.

Incandescent xHalogen Fluorescent Xenon Recessed ceiling lights WP fixture in shower and tub.



Accessories Use Existing


BS x O/OA BS x O/OA

Glass Shelves Qty: Support: Size:

Finish: Edge Treatment:

Medicine Cabinet Qty: 1 Surface Mount xRecessed Size: x 24 x 30

Finish: Mirror Size:

Mirror Qty: 2 xSurface Mount Frame

Towel Bars Qty: 2 Finish: ORB Size: No:

Towel Rings Qty: 1 Finish: ORB Size: No:

Robe Hooks Qty: 1 Finish: ORB Size: No:

Tub Soap Dish Qty: Surface Mount Recessed Finish: Placement:

Shower Soap Dish Qty: 1 Surface Mount xRecessed Finish: Placement:

Bidet Soap Dish Qty: Surface Mount Recessed Finish: Placement:

Lavatory Soap Dish Qty: Surface Mount Recessed Finish: Placement:

Tub Grab Bars Qty: 1 Finish: ORB Placement:

Toilet Grab Bars Qty: Finish: Placement:

Paper Holder Qty: 1 Surface Mount Recessed Finish: ORB Placement:

Magazine Rack Qty: Surface Mount Recessed Finish: Placement:

Soap/Lotion Dispenser

Qty: Finish: Placement:

Tumbler Holder Qty: Finish: Placement:

Toothbrush Holder Qty: Finish: Placement:

TV Qty: 1 Finish: Placement:

Sauna



BS O/OA BS O/OA

Capacity: Interior: Style: Heater:

Timer Location: Wall Material: Floor Material: Other:

Steam Bath



BS O/OA BS O/OA

Tub Shower Steam Generator Location: Timer Location: Wall Material: Floor Material:



Exercise Equipment Treadmill Size: Clearance Required: 30 sq. ft

Free Weights Size: Clearance Required: 20-30 sq. ft.

Bikes, Recumbent & Upright Size: Clearance Required: 10 sq. ft.

Rowing Machines Size: Clearance Required: 20 sq. ft.

Stair Climbers Size: Clearance Required: 10 to 20 sq. ft.

Ski Machines Size: Clearance Required: 25 sq. ft.

Single-Station Gym Size: Clearance Required: 35 sq. ft.

Multi-Station Gym Size: Clearance Required: 50 to 200 sq. ft.

Yoga Matte Size: Clearance Required:

Flooring Use Existing


BS x O/OA BS x O/OA

Floor Preparation Floor Covering xRemoval: existing vinyl/ luan plywood Material

Leveling: Bamboo Carpet x Ceramic Tile Cork Shim: Laminate Linoleum Vinyl-Sheet Vinyl-Tile

xSubfloor Material: use existing Wood Wood-Engineered Stone Other xUnderlayment: ½” cement board Color or Pattern:

Baseboard: Describe: straight bond 24” x 24” Transition Treatment

Windows Check all that apply. Slider = S Casement = C Double-Hung = DH Skylight = SL Bow = BO Bay = BA

Vinyl = V Aluminum = A Aluminum Clad = AC Wood = W Glass Block = GB Use Existing xYes No


Interior Wall Patch: Exterior Wall Patch: Sink Vent Relocation: Window # Configuration New Windows Sizes A Use existing Screen: Yes No B New SL 24”x48” – between existing joists. Screen: Yes No Screen: Yes No Screen: Yes No Screen: Yes No Screen: Yes No



Doors Check all that apply. Bi-Fold = BF Slider = S Pocket = P French = F Swing = SW

Solid Core = SC Steel = ST Hollow Core = HC Use Existing


BS x O/OA BS x O/OA Door # Configuration Hinge Size Screen

Yes No Screen: Yes No

Yes No Screen: Yes No Yes No Screen: Yes No Yes No Screen: Yes No Yes No Screen: Yes No Yes No Screen: Yes No Yes No Screen: Yes No Yes No Screen: Yes No Hardware Finish: ORB Passage xPrivacy Knob Lever

Decorative Surfaces


Furnished by Installed by BS x O/OA x BS x O/OA x

Wall Preparation x New Plaster/Drywall Clean Patch Exist Remove Exist. Covering: Wall Finish x Paint O/OA x Wallpaper Other_______ Ceiling Finish x Paint O/OA x Wallpaper Suspended Vaulted Other: Ceiling Preparation x New Plaster / Drywall Clean Patch Exist Remove Existing Covering

Other: Repairs: Window Treatment

Blinds Fabric Shutters Other:



Construction Source Category

Use Existing

Responsibility BS O / OA

HVAC Details: Forced warm air

x x Air Conditioning System Age: N/A Planned Improvements: N/A Heating System Age: Original Planned Improvements: Bathroom Exhaust Fan Age: N/A Planned Improvements: New

Electrical Work:

x New Service Panel: Yes, 200 AMPs Code Updates: Yes Modifications to Exist. Service: Yes Heated Floor: x Yes No Heated Towel Bar: Yes x No

Plumbing: Vent stack may be relocated.

x New Rough-In Requirements: Yes New Drainage Requirements: Yes New Vent Stack Requirements: Modifications to Exist. Lines: Yes

General Carpentry:

x Demolition Work Exist. Fixture and Equip. Removal: Yes Trash Removal: Yes - daily Reconstruction Work (Except as previously noted.) Windows: No Doors: Yes Interior Walls: Yes Exterior Walls: Yes Insulated: Yes Cabinet Install. / Trim-Out: Yes

Miscellaneous Work:

x x Jobsite / Room Clean-up: B/S Building Permits: O/OA Structural Engineering / Architectural Fees: O/OA Inspection Fees: B/S Jobsite Delivery: B/S Other: Trash removal daily



Existing Construction Details

1. Age of Home: 50 years Access Roads to Home: Good Delivery Truck Clearances: Good Elevator Size Limitations: N/A Access to Bath: x Through House Exterior Access 2. Type of Neighborhood:

Rural x Suburban Urban Historic Mixed Use Multi-Family Gated Community Planned Development

3. Type of Home: x Single Family Duplex Townhouse Condominium Apartment / Flat Other: 4. Structure of Home:

One Story Two-Story Three-Story x Ranch Split-Level Split-Foyer/Raised Ranch Other:

5. Approximate Size of Home: 2400 Sq. Ft. 6. Style of Home (Exterior): Wood siding

7. Is the home historic? Yes x No What time period? Are there historic covenants or restrictions affecting the home?

8. Is the home part of a Homeowner’s Association? Yes x No

Are there Homeowner’s Association covenants or restrictions affecting the home? Yes x No

9. Style of Home (Interior)

Colors: Light green/terra cota

Materials: Paint

Furniture: Traditional

Accessories: Other:

10. Room Below Bathroom Open basement Room Above Bathroom Attic



11. Condition of –

Surface Walls drywall cracked Floors: Sheet vinyl worn Ceilings: drywall cracked Soffit/Fascia: Squareness of Corners: good Parallel Wall to Within ¾) yes Is there any hazardous material to be removed? no

12. Construction of Floor: Slab x Frame 13. Direction of Floor Joists: x Parallel to Longest Bathroom Wall Perpendicular to Bathroom Longest Wall Joist Height: 10” 14. Exterior: Brick Aluminum Stucco x Wood Other:

15. Interior: xDrywall Lath & Plaster Wood Other:

16. Windows Can Be Changed: Yes x No Doors Can Be Relocated: x Yes No Walls Can Be Relocated: x Yes No

17. Windows: Sliders Double-Hung Skylights x Casement Greenhouse Bow/Bay Other:

18. Sewage System: x City Service Septic System Other:

19. Type of Roof Material: Shingle Age of Roof 10 year

Access:

Can Equipment Fit Into The Room? Yes Basement: stairs (limited) Attic: yes Crawl Space: N/A Material Storage: Garage Trash Collection Area: Driveway dumpster HVAC: Describe Existing System: Heating: forced air Ventilation: N/A Air Conditioning: N/A

Plumbing: Location of Existing Vent Stack: behind toilet Type of Trap: “P” Add Additional Line: Yes

Electrical GFCI Existing: Yes x No New Wiring Access: Hard x Average Easy Number of Open Circuits for Expansion: 2 Existing Electrical Service Capacity: 100 AMP Number of 120V Circuits: 24 Number of 240V Circuits: 0

Existing Construction Details- continued



Water Closet Bidet Lavatory Width: Water Supply: Floor Wall Height: Drain out of: Floor Wall Depth: Bottom of Trap to Floor: Type of W.C.: Wall Hung 2 Piece 1 Piece Type of Lavatory: Wall Hung In Vanity Pedestal

Wall Hung: Width: Height: Wall Mount: Width: Height: Distance Tank for Walls: Vanity: Width: Height: Depth: Soil Stack Location: Vent Pipe Location: Water Supply Height: Off floor:

Tub Shower Width: Height: Depth: Tub/Shower Material: Cast Iron Steel Fiberglass Other Tub/Shower Surround: Yes No Surround Material: Tub Shower Surround With: Height: Width: Shower Stub Out Height: Plumbing Access Below: Yes No Type of Drain: Cast Iron Copper Plastic

Existing Plumbing Center Lines



Existing Construction Details

Doo

rs

G 39”

0

26 ½

”

F

37 ½

”

29 ½

”

29 ½

”

E

25 ½

”

18 ½

” 0

D

2 ¾”

2 ¾”

2 ¾”

C

32”

24”

24”

B

80”

80”

80”

A

96”

96”

96”

No. 1 2 3



Existing Construction Details (continued)

Win

dow

s

I 11

H 76

G 15

F

50 3/

4

E

45 ¼

”

D

2 ¾”

C

70 ½

”

B

36”

A

96”

No. A



T5cExisting Mechanical Details

Floo

r Reg

iste

r or F

an

G 40”

F

18”

E

44”

D

3”

C

6”

B

99”

A

108”

No.

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