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Permit
rt CITY OF TIGARD PLUMBING PERMIT 1 Ilk COMMUNITY DEVELOPMENT Permit#: PLM2020-00374 -f lc,AR o 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 9/24/2020 Parcel: 2S103DA05401 Jurisdiction: Tigard Site address: 13405 SW 107TH AVE Project: CARDWELL Subdivision: None Lot: None Project Description: Connecting existing house to sewer: 125 ft.of sanitary sewer. Septic tank to be pumped and filled. Contractor: BELL CONSTRUCTION INC Owner: CARDWELL, SAMMIE LIVING TRUST 47333 SW CARPENTER CREEK RD CARDWELL, HELEN L LIVING TRUST FOREST GROVE, OR 97116 13405 SW 107TH AVE TIGARD, OR 97223 PHONE: 503-357-8892 PHONE: FAX: FEES Quantity Description Date Amount 125 If Sanitary Sewer 09/24/2020 $100.06 Specifics: 1 12%State Surcharge- 09/24/2020 $12.01 Plumbing Type of Use: SF Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $112.07 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: , Permlttee Signature: o 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 Application Building Fixtures RECEIVE B FOR OFFICE USE ONLY Received City of Tigard PennitNo.: w DateBy: 13125 SW Hall Blvd.,Tigard,OR 97223 SEP 10 2020 1 `T1 - Plan Review Phone: 503.718.2439 Fax: 503.598.19 Other Permit No s, doi S? Dale/By Inspection Line: 503 639 4175 (ATV OF TiGARD Date Read IB tuns 0 See Page 2 for TIGARD Y Y g Internet www.tigard-or.gov ��i�il [)jj�l(� �(1_/ICIf��., Norified/Method. '0-t Supplemental Information TYPE OF WORK FEE* SCHEDULE ❑New construction D Demolition For special information use checklist. Description I Qty. I Ea. I Total ®Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 ® 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 ❑Accessory building 0 Multi-family Each additional bath/kitchen 25.02 0 Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address:13405 SW 107th Ave Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76 City/State/ZIP:Tigard, OR 97223 Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.: Project name: ctt. .i( Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:MS) Page 2 fin), 04. - - - 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 Backwater valve 12.51 Clothes washer 25.02 Disconnect from onsight septic and reconnect to public sewer. Dishwasher 25.02 Approximatly 200ft in right of way and 125 feet in plumbing. Drinking fountain 25.02 Ejectors/sump 25.02 0 PROPERTY' OWNER 0 'TENANT Expansion tank 12.51 Name:Leta Cook, POA for the Helen Cardwell Living Trust Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address:13405 SW 107th Ave Garbage disposal 25.02 City/State/ZIP:Tigard, OR 97223 Hose bib 25.02 Phone:(503 )537-4421 Fax: I ) Ice maker 12.51 _ 0 APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02 Business name:Bell Construction, INC. Medical gas(value:$ ) Page 2 Primer 12.51 Contact name:Joe Bell Roof drain(commercial) 12.51 Address:47333 SW Carpenter Creek RD Sink/basin/lavatory 25.02 City/State/ZIP:Forest Grove, OR 97116 Solar units(potable water) 62.54 Phone:(503 )357-8892 Fax: :( ) Tub/shower/shower pan 12.51 E-mail:joebellconstruction@gmail.com Urinal 25.02 Water closet 25.02 CONTRACTOR Water heater 37.52 Business name:Bell Construction, INC. Water P rP �in WV 56.29 Address:47333 SW Carpenter Creek RD Other: 25.02 City/State/ZIP:Forest Grove, OR 97116 Subtotal /pd,p(, Phone:( 503)357-8892 Fax:( ) Minimum permit fee: $72.50 Plan review (25%of permit fee) CCB Lie.: 113011 IOW_ Plumbing Lie.no.: "I I F � �p State surcharge(12%of permit fee) f3.0/ Authorized signature: ge a TOTAL PERMIT FEE //?. e Print name:Joe Bell Date:9/10/2020 This permit application expires if a permit is not obtained within ISO days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. 1:1Building\Permits lPLMU-PermitApp.doc 10/01/09 440-4616T(10)02/COM/WEB) 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- 100' 50.03 0 to 2,000 $121.90 Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer-1st 100' 62.54 / 42,De 7,201 and greater $327.54 Sewer-each additional 100' ! 37.52 .37,Sy Water Service-I st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 Valuation: Permit Fee: Storm&Rain Drain-1st 100' 62.54 -- $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 P and including$10,000.00. Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$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 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-12 hour) each additional$100.00 or fraction thereof. Subtotal: 10.00 0.00 Commercial Fixture Work: Are you capping,adding or replacing fixtures? If"yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations Quantity by Fixture Type Plan review is required for any of the following. Fixture Type for Replace/ Please check all that apply. Work Performed: Capped Added Relocate Baptistry/Font ❑ Any new commercial building with water service 2"and greater,except systems designed and stamped by licensed Bath: -fub/Shower engineer. -Jacuzzi/Whirlpool ❑ Car Wash: Each Stall New exterior plumbing site utilities for any complex structure Drive as defined in OAR918-780-0040. ElCuspidor Water Aspirator Medical gas and vacuum systems for health care facilities. Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system. Domestic ❑ Any complex structure as defined in OAR918-780-0040. Drinking Fountain Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: -2" 3" Isometric or Riser Diagram ❑ Isometric or riser diagram is required for new buildings -Car Wash Drain that meet the qualifications above. Garbage -Domestic non-food Disposal: -Domestic food related -Commercial food related -Industrial food related Ice Mach./Refrig.Drains Comments regarding fixture work: Oil Separator(Gas Station) Rec.Vehicle Dump Station Shower: -Gang -Stall Sink: -Lay/Bar non-food related -Bradley -Com/Serv/Util food related -$ervice *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 fees assessed for the sewer increase must be paid before the Water Extractor Water Closet-Toilet plumbing permit can be issued. Urinal Other Fixtures: I:1Building\Permits\PI,MF_PermitApp.doc 08/04/2011 2 RECEIVEDRECEIVED SEP 10 2020 SEP 1 >0 CITY OF TIGARD CITY OF TIGARD 41-RI.N1C DIVISfON 13UIL--OINu VIvrs!oN S\- QN ot is ok�'6yr. i, 4 10-c L i044 tf 0,\64,;‘-, ^s ar ck:g . 8 " S IAA, I')".Oi n QD+a S\ q\5 SLOSYwkv 4-- a"o 13 c,'^) to'7 Ctv� yo• 1 fir,) DocuSign Envelope ID: 11A62224-C893-473A-9513-F53505ECD531 • Z, GtON c0G DEPARTMENT OF HEALTH AND HUMAN SERVICES y ENVIRONMENTAL HEALTH PROGRAM 1 �1 1 �{ 155 North First Avenue,MS 5,Suite 160 1 J E C E I V E D Hillsboro,OR 97124 SEP 10 2020 Telephone:(503)846-8722 ♦Fax:(503)846-3705 oaEGoN www.co.washington.or.us/hhs/environmentalhealth CITY OF TIGARD ilf t4 'fvr DIVISION AUTHORIZATION OF REPRESENTATIVE ,—DocuSgned by: �'" 'I r I, 1 G. 1 r/,06(C� pmrtv� (kt,lt,u. (, (,aretwati topulr toii BELL CONSTRUCTION, INC. \-557c93rint6Macne of Property Owner Print Name of Authorized Representative to act as my agent in performing the activities necessary to obtain site evaluations, permits and other onsite wastewater treatment program services provided by Washington County on the property described below in accordance with OAR chapter 340, division 071. I agree that any costs not satisfied by the Authorized Representative are my responsibility. PROPERTY IDENTIFICATION Property Address:13405 SW 107th Ave, Tigard OR 97223 Township: Section: Range: Tax Lot Number(s): PROPERTY OWNER INFORMATION Name: Leta Cook PofA Helen L. Cardwell Living Trust Mailing Address:(incILd §stggzgp7th Ave, Tigard OR 97223 Telephone: 503-537-4421 Fax: E-mail: sharky15@frontier.com DocuSigned by: Signature of Property Owne1lr�j (fn�, (��(1 f"� {hu. (k�lf1A (, (rL II (j,,wA �a9/10/2020 ��557C56E ,AiiORIZED REPRESENTATIVE Name: BELL CONSTRUCTION, INC. Mailing Address:(include city,slate,zip) 47333 SW CARPENTER CREEK RD FOREST GROVE, OR 97116 Telephone: 503-357-8892 Fax: E-mail: joebellconstruction©gmail.com Signature of Authorized Representative: 9 a, g Date: 11/11 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT IN "_ Reimbursement District Payment Worksheet T I c,A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov This worksheet must be completed by the Finance Department and provided to the applicant to submit together with a completed plumbing permit application and payment for sewer connection and reimbursement district fee, if applicable, by expiration date shown below to the Building Division. FINANCE DEPARTMENT TO COMPLETE: Site Address: 13405 SW 107th Avenue Reimbursement District #: none Parcel #:Amount Due: $0.00 Amount Due Expires On: Not in SRD Applicant: Daytime Phone. Email Address: Ei Sewer Loan Processed (journal entry to follow for payment of deferred sewer connection fee and reimbursement district fee,if applicable)* By: Ma&Quaff Date: 9/23/2020 Name Printed: Mai Quach BUILDING DIVISION TO COMPLETE: *If a sewer loan is processed, wait forjournal entry before creating plumbing and sewer permits. Reimbursement Amount Paid: $ Receipt #: SWR #: r� X o2 f j—()()L53 PLM #: PL/h 1 003 717 Enter parcel conditions in Accela (check all that apply): ❑ Ente ` ' on 'don. Enter "deferral" con ton,if applicable. By: Date: '''f/ / ,, Name Printed: 6r--tj /7 y,— Attach this worksheet to issued sewer permit for records scanning. I,\Building\Riembursement Districts\ReimDistPaymentWorksheet_NoDeferredAccounts_041918.docx