Permit CITY OF TIGARD PLUMBING PERMIT
''7 I. ' COMMUNITY DEVELOPMENT Permit#: PLM2020005174
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/18/2020
Parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY
Project: PacTrust Subdivision: WEST PORTLAND HEIGHTS Lot: 9-25, PT
Project Description: Interior improvements of common area restrooms. All existing fixtures to be removed and replaced. No new
fixtures added.
Contractor: RAYBORN'S PLUMBING INC Owner: PACIFIC REALTY ASSOCIATES
PO BOX 69 ATTN: N PIVEN
19990 SW CIPOLE RD 15350 SE SEQUOIA PKWY#300
TUALATIN, OR 97062 PORTLAND, OR 97224
PHONE: 503-692-4139 PHONE:
FAX: 503-691-2328
FEES
Quantity Description Date Amount
4 ea Drinking Fountain 12/18/2020 $100.08
Specifics: 16 ea Lavatories 12/18/2020 $400.32
8 ea Urinal 12/18/2020 $200.16
Type of Use: COM 24 ea Water Closet 12/18/2020 $600.48
Class of Work: ALT 1 12%State Surcharge- 12/18/2020 $156.12
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $1,457.16
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: E / Permittee Signature: it ,`_ / Li 0
_
i!
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
Site Utilities RECEIMM=MMOMM
City ofSW
te/B: )z�1�/ .. Pennit No.:PLr'1• riAN �ttn py
ceived
11 13125 SW Hall Blvd.,Tigard OR 97223 DEC 7 Z0 n Review W f
Phone: 503.639.4171 Fax: 503.598.1960 Other Perm it No.:
i i c n If n Inspection Line: 503.639.4175 CITY OF •�I �/Byc lure: ® See Page 2 for
Internet: www.tigand-or.gov BUD `) thed:I211?/� supplemental Information
TYPE OF WORK EMS L1 1r109.11/43 S FEE* SCHEDULE
❑New construction 0 Demolition For special information use checklist -
Description I Qty. Ea. I Total _
)(Addition/al teration/replacement 0 Other: Newt-2-family dwellings(includes 100 ft.for each utility connection)_
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
rJ 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
❑Master builder 0 Other Fire sprinkler( sq.R) Page 2
. « u;. xa,JOB SITle.1NFORM44TJON AND LOCATION Site utilities:
Job site address: (' oci S� 6O8�. ?i,,(,,y Catch basin or area drain 18.76
6 Drywell,leach line,or trench drain 18.76
City/State/ZIP:
-64,1( D� t--Z23 Footingdmin(no.linearft.: ) Page2
Suite/bldg./apt.no.: Project name: F -fi.J !�S / Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain corrector 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 Backwater valve 12.51
Clothes washer 25.02
12..t'."6J4,- + ke,et 4...l'. rote- Q1 sr}h10r. Dishwasher 25.02
k: c- ,fti S Drinking fountain y 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER I 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 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name: j�q`faeatAis PwrA3.4trPrimer Medical gas(value:$_) Page2
Contact name: �}u} 12.51
f�}WGfLt poi Roof (commercial) 12.51
Address: 1gg410 cs-J G
'POL.E SinWbasirvlavatory ag, 25.02
City/State/ZIP: rrobv_ Lod/ t g1-0(0Z. Solar units(potable water) 62.54
Phone:(913 )(092-Y IS9 Fax: :(RS )601 ( _ Z318 Tub/shower/shower pan 12.51
E-mail: riM&JFa M'f(3424f. c hrr.l Urinal 8 25.02
Water closet 2/ 25.02
CONTRACTOR
Water heater 37.52
Business name: RAYBORN'S PLUMBING INC Water piping/DWV 56.29
Address: P.O.Box 69 Other. 25.02
City/State/ZIP:Tualatin,OR 97062 Subtotal /30i3Ott
Phone:(503)692-4139 Fax:(503)691-2328 Minimum permit fee: $72.50 f
CCB Lic.:87852 Plumbing Lic.no.:34-166P6 Plan review (25%of permit fee)
State surcharge(12%of permit fee) (s(o,f z.
Authorized signature: TOTAL PERMIT FEE if ys7r 140
Print name: ,// Date: y� This permit application expires if a permit is not obtained within ISO days
F!/}(,(S �R.E,.,f 7 Z t,,y'�+O`I.f1 after it has been accepted as complete.
'Fee methodology set by Tri-County Building Industry Service Board.
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site.Utilities • - • Qtr• Fee(ea) Total Square Footage: ` Permit Fee: ;
Footing drain-1 e 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 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 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
pand 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 90.00fhr $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", Plan Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees*. Please check all that apply.
Quantity by(Fixture)Work Performed ❑ Any new commercial building with water service 2"and
Fixture Type: Replace greater,except systems designed and stamped by licensed
Previous Capped Added Existing engineer.
Baptistry/Font ❑ New exterior plumbing site utilities for any complex structure
Bath -Tub/Shower as defined in OAR9l 8-780-0040.
-Jacuzzi/Whirlpool
Car Wash -Each Stall ❑ Medical gas and vacuum systems for health care facilities.
-Drive ❑ Any multipurpose fire sprinkler system.
❑ Any complex structure as defined in OAR918-780-0040.
Cuspidor/Water Aspirator
Dishwasher -Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain y
Eye Wash Isometric or Riser Diagram
Floor Drain/sink -2" ❑ Isometric or riser diagram is required for new buildings
that meet the qualifications above.
-4"
Car Wash Drain
Garbage -Domestic
Disposal -Commercial
-Industrial Comments regarding fixture work: rr
Ice Mach./Refrig.Drains RCS'( t:�ebdin cot,, rYstrade-. 'f�'(els/.'e. .1
Oil Separator(Gas Station) -a�►O �:X�.r�t �G a[d f
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink -Bar/Lavatory
-Bradley
-Commercial *Note: If the fixture work under this permit results in an
-Service increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be paid before the
Washer-Clothes
Water Extractorplumbing permit can be issued.
Water Closet-Toilet 251
Urinal
Other Fixtures:
http://www.tigard-or.gov/city_halI/departments/cd/docs/PLMF-PermitApl doc