Permit N.
suiALDUING 02051v:210o N L'.*----'--
1/0 /1..
T
Request for Permit 'irj
RECE
_„.
..,.:.:...,.,
„.. .... ....,,,,,,,.:. City of Tigard . comml .:\l'I'Y DEVELOPMENT DEBAR:1.1111M
CITY OF
t Action
,) 13125 SW flail Blvd. •Tigard,Oregon 97223 • 303-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax; 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: 0 Owner 1StApplicant 0 Contractor 0 City Staff
( heck( )one
REFUND OR Name:
INVOICE TO: (Business or Individual) V Mc"1"— L —C
Mailing Address: 2 2....4c-- ,\„„)F7 \I ,--,,t--r- 2.c•,L.(
t
..
3 '
City/State/Zip: 't,Ai\k.,,, ,,t,c 0 ) (P)9_, CA1 1 2 LI
• Phone No.:
ASE ' ' ACTION FOR THE ITEM(S) CHECKED (1):
. 41 CANCEL DID PERMIT APPLICATION.
D PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 'PL)4A 2.C.20 -Cr).7". ;2 -7
Site Address or Parcel #: 11
(5
Project Name;
a V-.10,:i e ?.---d>..,ri\--
Subdivision Name: Lot#:
EXPLANATION: IN -)V -V c
Signature: . ..742- „..k..."--- X.,..,,i 0,—i Date:
Print Name:
Refund Policy
I. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80`)/D of the application or permit fee for issued permits prior to any inspection requms.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks fin processing refund requests.
aiimatta3maurmmimmrrr
Route to Sys Admin: Date By Route to Records: Date.2 ce , By
Refund Processed: Date /V 4-- By 4 Invoice Processed: Date Be
Permit Canceled: Date reitA 0 BV49 Parcel Tag Added: Date By
i
i:\Buikling\FOrms\Rey PC Tr111(.\C tiOn_ j151 tic
Plumbing Permit Application 0 / / 2 2-0
Building Fixtures RECEIVE 1 FOR ((FLU t sl.- OyI 1
City-of Tigard �0�� Received
DatelB Permit
IN =q 13125 SW Hall Blvd.,Tigard,OR 97223
y' /k �� Whet L ICQLt�.��
C Phone: 503.718.2439 Fax: 503.598.196 Plan Review
0CITYOFTIGARD Date/By: Other Permit /27070•,00/y/
Inspection Line: 503.639.4{75
T 1 G a R D NG DIViSION Date Ready 8 BUiLDI ' Y: Juri>: 67 sec Page 2 tor
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULF.
❑ New construction I ❑Demolition _ For special information use checklist. __
ty.
Description i Ea_checklist._
.SAdditioni'alterationireplacement 0 Other: New I-2-family dwellings(includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I 1 bath 312.70
❑ 1-and 2-family dwelling ..t2'ommerciabindustrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessorybuilding 0 Multi-family
__.._....____..__ Each additional bath kitchen _15.02
❑ Master builder 0 Other: Dire sprinkler( sq.ft.) Page 2
JOH SITE INFORMATION AND LOCATION Site utilities:
Job site address:
Catch basin or area drain 18,76
11 r ,'� �tS, � ) ihywcll,leach line,or trench drain 18.76
City/State/ZIP: -1-'s() ['.,_C 4. e tt.-- Gt l Z..Z
Footing drain(no.linear ft.: ) Page 2
Suite+bldg.!apt.no.: Project name: s1
I� ri"I'' -
reah'Crr( �(.15 c c,tri kt Manufactured home utilities 50.03
Cross street/directions to job site: ('ft4-S C- (3 6-*1 14--- Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Stonn sew er(no.linear ft.:_) Page 2
Water sery ice(no.linear fl.: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.: Back flow preventer J 31.27
DESCRIPTION OF WORK Backwater valve 12.51
_ Clothes washer 25.02
t-Oc",sltC ,,4\i9tt'n1 A/S., Crs't C/A- 1,SK4X (t' ys t1.)Er 5. Dishvashcr 15.02
Drinking fountain I 25.02 n t:4. r•
Ejectors/sump 25.02
Pi1OPF.RT1' OWNER F. - 0 TENANT Expansion tank 12.51
-, Fixture/sewer cap 25.02
1
Name:/ `:t..,
Address:t/_ j 1 _.... ,} Floor drain/floor sink hub rice Li 25.02 jf' .4,
(0(0C) IJG( *-1� ►2]'Iv,C 1.-tip CS �?1 vA Garbage disposal 25.(12
City'State/ZIP: 'j" �. 3- ^>
<,.��S 1 � �J �_> � '-z Hose bib 15.02
Phone:( I Fax: ( 1 Ice maker 12.51
PPLICANT 0 CONTACT PERSON Interceptor grease trap 25.02
Business name: --))� � �Y„--C Medical gas(value:$ .1 Page 2 ��
Contact name: 47 Primer 12.51 -_
lt4\C v rt� - l�>` CS
,_ y Roof drain(commercial) 12.51
Address:'c&ZCtf I h V E, Ev_e_rtfee() Pk,,,,.)q 1 �.A_C 26Ci Sink/basin,`lavatory $ 25.02 -15 Q(L
City/State/ZIP: i, \`sue c 0> 0 Gt--1 (2.,I...i Solar units(potable water) 62.54
Phone:(Gjij ) L(, - z.ZZ2....„ Fax: :( ) Tub'shower/shower pan 12.51
Urinal 25.02
E-mail:axe°,1f°`.5 `>, `5ya-Tc.,nv.5 t ( .''t ---
CONTRACTOR Water closet u 25.02 Ix)
Water heater 1 37.52 S 1.SZ.
Business name: >MST. i (_.L-L Waterpiping'DWV 56.29
Address: 2 i' E 6 Je cz Y-ce n p „ 1 S 2,0u Other: 25.02
C ity'State/ZIP: FA i‘‘s> j,„,.-U, IL c-t 1 u _ Subtotal Subtotal 221 12
Phone:(G,07),) t,(( (,G -- 2, 2,Z.- Fax:( ) _ Minimum permit fee: $72.50
CCB Lie.: 1- c I Plumbing Lie.no.: �(,(-Li Sit pi Plan rev
State surcharge(I2%( 2%of permit fee)
of permit fee)
Authorized signature: A-T. ,"„ ,... o2 , j TOTAL.PERMIT TEE.
r-, This permit application expires if a permit is not obtained within(ln days
Print name:.mG„r't(, t;_.e v C) Date:0--(1.t iitZU after it has been accepted as complete.
*Fee methodology set by'Fri-County Iluitdin5 Induary Service Board.
I:Buildinx'3ermits,PLMi!-PemtitApp.doc lultlt'u') 44t 4sihrIIo'02'`)M/WEt)
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 5121.90
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
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 90,00hr $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 tin revisions 90.00/hr $50,001.00 and up $74200 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: k upped Added Relocate
❑ Any new commercial building with water service 2"and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
engineer.
-Jacuzzi/Whirlpool
Car Wash: -Each Stall 0 New exterior plumbing site utilities for any complex structure
as defined in OAR9 18-780-0040.
-Drive Thru
CuspidodWatcr Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial El Any multipurpose fire sprinkler system.
Domestic El Any complex structure as defined in OAR918-780-0040.
Drinking Fountain 1
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2" '>
Isometric or Riser Diagram
4„ 0 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
IceMachlRefrig.Drains Comments regarding fixture work: �A
Oil Separator fGas Station) 4LL- 'NEW' h je 77 fl—£3 ?EX— t i4 i 4,
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -LavrBar non-food related 2-
-Bradley.
-Com/Serv/Util food related
-Service I *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: 1A ,,It 1
L\BuildingWermits\PLMF_PermitApp.doc 08/04/2011 2