Permit CITY OF TIGARD PLUMBING PERMIT
t� ' COMMUNITY DEVELOPMENT Permit#: PLM2020-00318
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 8/14/2020
T f Ca'1 F"O 9 Parcel: 2S103DD00850
Jurisdiction: Tigard
Site address: 13815 SW PACIFIC HWY 10
Project: Domino's Pizza Subdivision: None Lot: None
Project Description: ADD(1)clothes washer,(1)2"floor drain,(1)3-compartment sink,(1)mop sink,(3)hand sinks,(1)lay,(1)water
closet and(1)water heater; REPLACE existing(1)lay and(1)water closet.
Contractor: MY PLUMBER Owner: D W SIVERS CO
PO BOX 87460 4730 SW MACADAM AVE#101
VANCOUVER, WA 98687 PORTLAND, OR 97239
PHONE: 360-991-9991 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Clothes Washer 08/13/2020 $25.02
Specifics: 1 ea Floor Drain/Floor Sink/Hub 08/13/2020 $25.02
5 ea Sink 08/13/2020 $125.10
Type of Use: COM 2 ea Lavatories 08/13/2020 $50.04
Class of Work: ALT 2 ea Water Closet 08/13/2020 $50.04
Type of Const: 1 ea Water Heater 08/13/2020 $37.52
Occupancy Grp: 1 12%State Surcharge- 08/13/2020 $37.53
Stories: Plumbing
Total $350.27
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: if / (�f Permittee Signature: J
(� 20 �f'c.t fig-�'70�/
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit ADDlicatio ?ECElVED
Building Fixtures JUL 31 2020
City of Tigard R p l� M '^ 'n /tom b
.� Date/By: Q /Z/Z 0 40 Permit Nop i t Gil Zo.ix 31
13125 SW Hall Blvd.,Tigard,OR 9726JITY OF TIGARD V I
Phone: 503.718.2439 Fax: 503S 1 Plan 9
�llDING DIVISION Davey: DthePermit g�ZO �1(513
T 1 G A h D Inspection Line: 503.639.4175 Dale Ready/By: lure: ® See Page 2 for
Internet: www.tigard-or.gov Notiied/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
For special inforrrtoiian use checklist
❑New construction 0 Demolition
Description I Qty. I Ea. I Total
IJ Addition/alteration/replacement 0 Other. New I-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
❑ 1-and 2-family dwelling CaCommercial/industrialSFR(2)bath 437.78
❑Accessory building ❑Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: . /3 I Sr."' 5 Zl/ (pi( 0./1 (O Catch basin or area drain 18.76
City/Statc/Z1P:1`A-4 ) ( D� Drywall,leach line,or trench drain 18.76
Footing drain(no.linear ft.:, ) Page 2
Suite/bldg./apt.no.: , 0 I Project name:DJrA,i , O.� pl Z z_pr Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwaterval
s 12.51
�^ Clothes washer 1 ../ 25.02 5j ). {
I elv '-'r (//`P LiOv�, fKr'1vf t 0 NO- &VT' /C-1(Olt-.N Dishwasher 25.02
jlI, Jet S Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name: 1.::) �,,J 51 -il-S Fixture/sewer cap 25.02
Address: - Floor drain/floor sink/hub 25.02
�I'?3- 3w M� n.,e. ej6)
City/State/ZIP: (2 Garbage disposal 25.02
C" a Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT pa CONTACT PERSON Interceptor/grease nap 25.02
Business name: Medical gas(value:$_) Page 2
Contact name: 4 f 5 t)A/ ail) Primer 12.51
` +_ Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory S6e--IV a 7 / 25.02 1 )5-. )Y
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 2,, ,/ 25.02 5 0.c
Water heater 1 ✓ 37.52 31
Business name:M9 I .c ik.btA Y. (ALL-- Waterpiping/DWV 56.29 1y
�
Address: 15 VIf ue= f-0vr>;7 j/ PCi-1ry 1)(v O If l p Other 25.02
City/State/ZIP:VAS(-coVe!°, (4,4 9Fj 6 SF'Z Subtotal 3j Z..t
Phone:(3(p) 99(... 9 99/ Fax:( ) Minimum permit fee: $72.50
CCB Lic.: 4a 1 1.II Plumbing Lic.no.: p(3(7, Plan review (25%of permit fee)
� State surcharge(12%of permit fee) 3 7, 5,3 Authorized signattrreL � _ `^] ,/�4 fJ fO r�7
/�- TOTAL PERMIT FEE
Print name:/Ll.n .3 ti NIi1 /..L�5 Date y3 ci/C0j` This permit application expires if a permit Is not obtained within ISO days
'r T after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:lauitdir5WermihlpLMU-fumitApp.doe 10/0009 440.4616T(10/01JCOM/WEu)
Plumbing Permit Application - City of Tigard
Page 2-Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty• Fee(ea) Total Square Footage: Permit Fee:
Footing drain- I"100' 50.03 0 to 2,000 S 121.90
Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $23320
Sewer-1st lOD' 62.54
7,201 and greater $327.54
Sewer-each additional 100' 37.52
Water Service-1st 100' 62.54 Medical Gas Systems:
Water Service-each additional 100' 37.52
Storm&Rain Drain-1st 100' 62.54 Valuation: Permit Fee:
$1.00 to$5,000.00 Minimum fee$72.50
Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other Inspections or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
and including$10,000.00.
Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the fust$10,000.00 and$1.54 for
which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to
(minimum charge-1/2 hour) and including$25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to
Reinspection Fees 90.00/hr 1 and including$50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
(minimum charge-1/2 hour) each additional$100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
Baptistry/Font 0 Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
engineer.
-Jacurzi/Whidpool
Car Wash: Each Stall 0 New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuumsystems for health care facilities.
Dishwasher: -Commercial 0 Any multipurpose fire sprinkler system.
-Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2" i ✓
-3" Isometric or Riser Diagram
4' ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related I
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station) ( ) 3-CQ H Pfi2;h'iE]JT S'tn1K-D .tisoc tArrO t/
Rec.VehicleDumpStation 7 rr FL97p(ZSil$1K.---j74NcT ca tt.rd'r 01J SW/L
Shower. -Gang
-Stall �t Mt7f SfIJle, �NcrJ -F6�b) Tu'Y
Sink: -Lav/Bar non-food related .i ] t/ 1 ✓ a 3 n S iNr f4s as P(1-EP)
-Bradley i 1 &iki Lit/ t l r' L411 i C r'
-Com/Serv/Util food related ✓
-Service ✓ P^oP *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes i Closet-Toilet fees assessed for the sewer increase must be paid before the
Water Closet
Water Extractor 1 . I ,, plumbing permit can be issued.
Urinal
Other Fixtures:
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