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Plumbing Permit Application �Gf 1 �t i�M
BuildingFixtures NOISIAIG ONIG1If19 4 r , - 0 a vOil dO A.110 FOR OFFICE USE ONLY
Cityof Tigard nn77((�� d3S Received �////
:� ■ 131 SW Hall Blvd.,Tigard,OR 9722Y" 0 Date/By: VI// 2CJ A(0 Permit Lil 70 70.-00 3�r,0
Plan Review
Phone: 503.718.2439 Fax: 503.598.19Cy0'^^�� Other Permit No.:
,,/tco JJ J Date/By:
TIGARD Inspection Line: 503.639.4175 Date Ready/By. Juris ® See Paget for
Internet: www.tigard-or.gov a� Notified/Method:/IF)2-0 46 114 Supplemental Information
TYPE OF WORK Peen-- d 245 FEE* SCHEDULE
❑New construction ❑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 minerciai/industrial
SFR(2)bath 437.78
❑ Accessory building [1] Multi-family SFR(3)bath 500.32
Each additional bathlkitchen 25.02
❑ Master builder ❑Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: Coo 3 r1 cLA � a ef, I�f �d)oe3c /
i L atovh basin or area drain 18.76
Dry ell,leach line,or trench drain 18.76
City/State/ZIP: � pry ,
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: /S Q Project name: 0 „To - E.f-e_.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: Lot no.: Fixture or item:
Tax map/parcel no.: Back low preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
ileAk,11:73
.1.- �^ few K 4d�/�l_ Dishwasher 25.02
Sri l /Iliad 3 '`}- / Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER 0 TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: 1��-riE , ,, /�4� a Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory / 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
F.-mail: / Urinal 25.02
C�07t to j!-, .5,,, B G�F,J, oM •
Water closet 25.02
CONTRACTOR
! ,1�OLU� ��/ „/CC fi 4v Water heater 56.29
/
Business name: 6'U �/ Water 1 in WV 56.29
// /� /J� P�P PF�
Address: /S-Be id tr-etyc/[ /�4� vyr� Other: 25.02
City/State/ZIP: DfQ U,•,/ 4/ 6"2- I) d c,ts''• Subtotal
Phone:(g(J3)513-q1 / Fax:(63) 5)3 -077 l, Minimum permit fee: $72.50 7 2,50
CCB Lie.:)32 1/4(.2- I mbing Lic.no.: As 6.a 3 Plan review (25%of permit fee)
State surcharge(12%of permit fee) P. 70
Authorized sign J / TOTAL PERMIT FEE pj t ZZ
•
Print name: I?S ., /! Date:•3 ( 20 20 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.
I:\Building\PermitsWLMU-PermitApp.doc 10/01/09 440-4616T(I0/02/COMIWEB)
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-1'100' 50.03 0 to 2,000 $121.90
Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69
Sewer-1st 100' 62.54 3,601 to 7,200 $233.20
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' Valuation: Permit Fee:
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
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 chaz•e 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-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 ❑ Any new commercial building with water service 2"and
Bath: Tub/Shower greater,except systems designed and stamped by licensed
-Jacuzzi/Whirlpool engineer.
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 vacuum systems for health care facilities.
Dishwasher: -Commercial 0 Any multipurpose fire sprinkler system.
Domestic 0 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
4 ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage Domestic non-food that meet the qualifications above.
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
-Service *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
Water Extractor fees assessed for the sewer increase must be paid before the
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:1Building\Permits\PLMF_PermitApp.doe 08/04/2011 2