Permit CITY OF TIGARD MASTER PERMIT
IIIs a COMMUNITY DEVELOPMENT Permit#: MST2021-00089
T I G A R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/01/2021
Parcel: 1S134DC09600
Jurisdiction: Tigard
Site address: 11545 SW CORNELL PL
Subdivision: TIGARD PARK Lot: 12
Project: Bryant
Project Description: Convert existing bedroom into a closet and bathroom. Relocate 2 interior doors. Add vanity,
shower,toilet. Electrical permit to be pulled separate. Water meter upsize required before final
BUILDING
Floor Areas Reauired Setbacks Required
Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors:
Total: 0 sf Value: $10,000.00 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 2 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain 0 Storm Sewer: 0
Tubs/Showers: 1 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: Catch Basins: 0
Bckflw Prevntr. 0
Footing Drain: 0 Ice Maker. 0 Hose Bib: 0 Backwater Value: 0
Other Fixtures: 0
Drywell-Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Fum<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Fum>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add1500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All N
Other: N Other Description: Ecompasing:
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ALT SF VB R-3 0
Owner: Contractor:
BRYANT,ROSS&DONNA JEAN OWNER Required Items and Reports(Conditions)
11545 SW CORNELL PL ROSS BRYANT
TIGARD,OR 97223 11545 SW CORNELL PLACE
TIGARD,OR 97223
PHONE: PHONE: 971-227-5676
FAX:
Total Fees: $603.05
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� V G� obtain- a
copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
�Issued By: N \P' (�C, Permittee Signature: on G1��U Lc'L
Call 503.63 .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.
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USF: ONLY
City of Tigard D ived
Permit No.:
r 13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits:
■ Phone: 503.718.2439 Fax: 503.598.1960
24-Hour inspection Line: 503.639.4175 0 metrical 0 Plumbing ❑ Mechanical
TIGARD Internet: www.tigard-or.gov
❑ Other.
TILE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW NO N/A
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ■ ■ P�'
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. 0 0 i l
3 Verification of approved plat/lot ❑ ❑ is
4 Fire district approval required. Name of district: • 0 . ❑ 1
5 Septic system permit or authorization for remodel. Existing system capacity 0 ❑
6 Sewer permit.
7 Water district approval. ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. 0 0
9 Erosion control ❑plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 ❑
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state IL ❑ ❑
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size
sheet attached to the plans with cross references between plan location and details. Plan review cannot he completed if
copyright violations exist.
11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if 0 0 05,
there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements
and driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction
indicator;lot area;building coverage area;percentage of coverage;impervious area;existing structures on site;and
surface drainage.
12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size 0 ❑
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, 0 ❑
furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc.
14 Cross section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- ❑ ❑
floor,wall construction,roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings
and foundation,stairs,fireplace construction,thermal insulation,etc.
15 Elevation views. Provide elevations for new construction;minimum of two elevations for additions and remodels. 0 0 (a
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full-size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing(prescriptive path)and/or lateral analysis plans. Must indicate details and 1 o for non- 1 ❑ 0 N,
prescriptive path analysis provide specifications and calculations to engineeringstandards. n 1lfe "
17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing 0 0 (S
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered 0 0 NI
systems,see item 22,"Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists 0 0 fg
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. 0 0
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas piping schematic is required 0 ❑
for four or more appliances.
22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or ❑ 0
architect licensed in Ore Ion and shall be shown to be a u.linable to the .ro•ect under review.
JURISDICTIONAL SPECIFICS
23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or II"x 1T'. ■ ❑ VI
24 Two(2)sets each are required for Items 16. 19,20 and 22 above. 0 ❑ Et
25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 0 ►_I
26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. ❑ I.
27 "Drawn to scale"indicates standard architect or engineer scale. 0 0
28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard 0 54
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 0 0 jai
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, 0 0 ►'
including decks,patio covers(over non-impervious surface)and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9,1995.
1:Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(l l/02/COM/WEB)
, Mechanical Permit Application FOR OFFICE USE ONLY
opCity of Tigard n,i. „
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Oaa>By Other Permit:
Ti G A R D Inspection Line: 503.639.4175 Date Ready/By: tarn: Ed See Page 2 for
Internet www.tigard-orgov NotitiedP4lethod: -I 'a. Supplemental information
fl
TYPE
OF WORK COMMERCIAL.FEE*SCHEDULE—LSE CHECKLIST
❑New construction Addition/alteration/replacement Mechanical permit fees*arc based on the value of the work
performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition Other r,. Ikanea€materials,equipment,labor overhead,and profit.
aay��( CATEGORY OF CONSTRUCTION Value:S 76,dp
1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building SIESIDEAPIYt,1.EQUIt'liiiElt iT f SYSTEMS FEES*
Multi-family ❑Master builder ❑ Other. For special information use checklist
Description Qty. Ea I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Job site address: Jl�5' ' cr�+,el/ y� Air conditioning 46.75
f Furnace 100,000 BTU(ductsivents) 46.75
City./State/ZIP: j5exy, ? j (PF /7%73 Furnace 100.000+$TU(ducts/vents) 54.91
Suite/bldg./apt no,: Project name: Heat pump 61.06
Duct work 23.32
Cross sheet/directions to job site: S jet) ,/ f/ti/'
Hydronic ic hot water system 23.32
Residential boiler(radiator or
l3 hydronic) 23`.32
Unit heaters(fuel-type,not electric),
\t in-wall,in-duct,suspended,etc. 46.75
' _ Flue/vent for any of above 23.32
Subdivision: T> eit / f�— Lot no.: f� Other. 23.32
�cll �,( appliances:
l� Tax map/parcel no.: J� , Ali QG O icoe, Water heater 23.32
DESCRIPTION OF.WORK asfn_ Geplace+insert 3339
), / �j � �
Flue vent for water heater or gas
\V Y� � /77 �x������/ J`� fireplace 23.32
V _j7erc, bon-ij{,x-e ,/f�/ / fyf v(OJ � .�s rL Log lighter(gas) 23.32
z2 t— 7 .5 )1�e�'� _) a�j ��)2�� , Woodipellet stove 3339
l.L C� '-=Y.u�7 Wood fitcplace/inser 23.32
Chimney/liner/flue/vent 23.32
[ ,PROPERTY OWNER ❑ TENANT Other 23.32
\� IFes �jr l Eovironmeataleahaust and ventilation:
Name: [ f/ Range hood/other kitchen
V Address: if/47/6— 1-- 74_2/ /� equipment 33.39
Clothes dryer exhaust 33.39
City/State/ZIP: �,/�j 9�2a Single-duct exhaust(bathrooms, r
477() sss++r000 —3< 7 C:./ Fax:( )
toilet compartments,utility rooms) / 23.32
i Phone:�t ft �r(O APPLICANTAtticltaawlspacelans 23.32
V 000NTACT PERSON Other 23.32
pt Business name: Fuel piping:
Contact name: +g�5 437t y ��T 574.15 for first four;54.03 for each additional
{� / 1 Q Gosheatptc.
��Ui" Address: IJ�/s � C��J"�C// /� , Gas heat pump
i ,l j6_, 1 O.tjj �J 2? Wall/suspended/unit heater
City/State/ZIP: �r�/ re ( '� 7 Water heater
SPhone:(976 p?j47,•lv 7 Fax::( ) Fireplace
{ ) E-mail: Range .
.4 CONTRACTOR Barbecue
Clothes shyer(gas)
Business name: Other:
Address: MECHANICAL PERMIT FEES*
Ili Subtotal
City/State/ZIP: Minimum permit fee($90.00)
Phone:( ) Fax:( )AL Plan review(25%of permit fee)
Stale surcharge(12%of permit fee)
CCB lie.: TOTAL PERMIT FEE
This permit application expires if a permit Is not obtained within 180
Authorized sig"re: days after it has been accepted as complete.
r- y J ) ` Fee methodology set by Tri-County Building Industry Service Board
Print name: /)..7 f'7-[/`-�/1 Date: `Z0 j i
I:'Building\Penniu'MEC_PennttApp 0_520.docc 440-4617T(11/01KOM/WE8)
Pl)knnbin2 Permit Application
,Building Fixtures RECEIVED FOR OFFICE USE ONI.I
City of Tigard Raetveil
Dale Ks,
3\\�'\ ra �` r.n,: + IVKT LDLI voo8q
13125 SW Hall Blvd.,Tigard.OR 97223MAR 1 5 2021 1
- " Pan Review
Phone: 503.718.2439 Fax: 503.598.1960 I (Aker Permit No.:
Inspection Line: 503.639.417. Date Rea
Ili,-‘.1;1) p CITY T OF t laAfl Date Ready Hy: I ® See Page 2 for
!married tskckr,tigard or.gos .{� � \ �4:it.+,P Supplemental Information
TYPE OF WOIEI� FEE* SCHEDULE
❑ \. < > >tnu �n ❑ Demolition
torspecialinformationusechecklist
-- Description Qty. I La. 1 Total
�y
,fir
,1.di Ilion altelatinn rcnlacemk:nt ❑<)rh>rr- _-,-_- ... New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
family cox clime. SFR(2)bath 437.7$
I-and 0 Commercial industrial
SFR(3)bath 500.32
❑Accessory building 0 Multi-family
Each additional bath'kitchen 25.02
❑Master builder ❑Other: Fire sprinkler(_sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION 1 Site utilities:
x Job site address: 1 tG 45 Si co,(� ('arch basin or area drain I$76
��gg Drywell,leach line.or trench drain 18.76
City/State(ZIP: 0 V'�Q I 0I" 61122,S Footing drain trio.linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name: ivi.,iaht- -, Acetyl • Manufactured home utilities 50.03
Cross street directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer t no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water ser-ice(no.linear ft.: I Page 2
Subdivision: Lot no.: Fixture or item;
Tax map/parcel no,:
Backflowpreventer 31.27
DESCRIPTION"OF WORK Backwater aloe 12.51y���y� ` Clothes washer 25.02Y(1,0[40OA 0 144AZ NJtRWV tork., 14 11 fr #I' s,i tbI -t Dishwasher I 25.0202
1 �S'1^i:WU( • ►5(, i .(.itc.ii Drinking fountain 25.02
Ejectors sump25.02
t Ez ansion tank 12.51
+ .PROPERTY OWNER CI TENANT h P
Name: ?,,OSS 1 -" Fixture sewer cap 25.02
Floor drain floor sinkfiub 25.02
Address: 5(45 tAt) ✓
Garbage disposal 25.02
City/State/ZlP: TO Vtlarrti q'I 2-2-3 Hose bib 25.02
Phone:( 1 i i. s:t Ice maker 12.51
',CI APPLICANT i K CONTACT PERSON Intcrceptorigrease trap 25.02
Business name: �V`a �� ye yy{ � � Medical gas i salve:5 T) Page 2
S V O{I V t 1� Primer 12.51
Contact name: J
^ u /^ Jnf`I ,,1 Roof drain Icontntercial) 12.51
Address: 3 I N Ne Staylt.,1 &�tectd� C', Sinkbasin'lavatory 2- 25.02 50,tat)
City/State/ZIP:Wa/{lt.U,1Vi I 4012_ Orl)24 ( Solar units(potable water) 62.54
Phone:(0j) o,..1^(D5ss i Fax: :( 1 I Tub,showerisshower pan ` 12.51 It .S
1,mmul S a0.41.41 , JGf A, CYY1 Urinal 25.02
CONTRACTOR Naterciuset 25.02 �s•01•
I' -- - Water heater 37.52
Business name. HootO.G/eL ,►,.�/D�,� �/�p /L 'Cl���,.{i ----I Water piping/DW V 56.29
Address:31{t.i. 1 VG S�Yiri t"k cku,) µ • Other: 25.02
City/StatelZlP: t✓ltl'Ineetvi1 o . q't)Z� Subtotal
Phone:(t) g�,(IpS�S ''�`�l�j Fax:( ) `l Minimum permit fee: S72.50
CCB As
Lie.: 220 o `.f4 L2_ Plumbing Lic.nu.. F13Z„?jq Plan review (25°-e of permit fee)
State surcharge 1 12%of permit fee)
Authorized signatur I OTAL PERMIT FEE
Print name:GrV i ' {�V w�' t�/ Date:�'i 1J
i This permit application expires if a permit is not obtained nithin 180 days
V after A has been accepted as complete.
*Fee methodology set by Tn-('nuns Building Industry Service Board.
I:nunding,Permitx'd'LMI•PermnApp.dee 1tPo1 on .too-miIoTI 10.02-('OM;'5EBi
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-l'l00' 50.03 Oto2,000 $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 7201 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 S5,00I.00 to$10,000_00 $7250 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 S25,000.00 $1413.50 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 S50,000.00 $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-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
❑ Any new commercial building with water service 2"and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall 0 New exterior plumbing site utilities for any complex structure
Drive Thin as defined in OAR918-780-0040.
Cuspidor/Water Aspirator 0 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 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: day/Bar non-food related
-Bradley
-Com/Serv/Util food related
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filler 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:
1:1BuildingPemvts\PLMF_PennitApp.doc 08/04/2011 2
Holly Van De Wege
From: Jill Bentley
Sent: Wednesday, March 31, 2021 1:10 PM
To: Julie Drinkwater
Subject: FW:Water Meter Worksheet for remodel
Attachments: 11545 SW Cornell Water Meter ADU 121420.pdf
Follow Up Flag: Follow up
Flag Status: Completed
Below is the email I sent to Ross and #Building on 12/14/20. Thanks for providing the date, etc.
Kind Regards,
Jill
(she/her/hers)
.,. A Wu;,, Jill
BE 1qd CAN BE ANY City of Tigard-Utility Billing
4'4 `� Senior Accounting Asst
TIfiARll (888)826-7211 Payments
a:.,. - (503)718-2460 UB Main
, ; ,lAtttigard-or.gov
C (503)718-2494
` �+ 5W Hall d Tigard, R 97223
From: UB Online
Sent: Monday, December 14, 2020 8:29 AM
To: Ross Bryant <rossabryant@yahoo.com>
Cc:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov>
Subject: RE: Water Meter Worksheet for remodel
Good Morning Ross,
Attached is the approved and signed worksheet.
Kind Regards,
Jill
(she/her/hers)
A WO,. Jill
• 1610UCAN8EAHrrkrk� a • City of Tigard -Utility Billing
Senior Accounting Asst
(888)826-7211 Payments
(503)718-2460 UB Main
jWb@tigard-or.gov
(503)71B-2494
E (p P 13125 SW Flall Blvd.
iRt a Tigard,OR 97223
1
From: Ross Bryant <rossabryantPyahoo.com>
Sent: Saturday, December 12, 2020 9:33 AM
To: UB Online<UBOnlinepay@tgard-or.gov>
Subject:Water Meter Worksheet for remodel
Caution!This message was sent from outside your organization.
UB
We are planning to remodel a downstairs bedroom to add a 3rd bathroom to our home (toilet, double sinks, and
shower). Attached is our Water Meter Worksheet. Please review and let me know if corrections are needed.
Thank you,
Ross Bryant
11545 SW Cornell PI.
Tigard, OR 97223
Customer Number 004604-000
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules"City General Records Retention Schedule."
2
r
RECEIVED
Water Meter Fixture Unit Worksheet for Additions/Remode/s/A 'i 5 zuz
CI Y OF TIGARD
Please complete the following information: BUILDING DIVISION
Customer Name: kr7do,".6 L'A'V,9n '
Service Address: Street/Suite#: //9' j b..1 Coifte// Y. . _
City: 4 State: Qln Zi .f'.
Phone Number: 4 /--2,7--5'6'76 Email: , � 41-1a7'`Ct2 1 0,0f 7
Please fill in the number of each fixture you currently have. Please fill in the number of fixtures you Proper to add.
Multiply the quantity by the point value to arrive at the current Multiply the quantity by the point value to arrive at
total. the proposed total.
Fixture Unit Current Point Current Proposed Point Proposed
Quantity Value Total Addition Value Total
Bar sink x 1 _ x 1 =
-
Bidet _ x 1 = x I -
Clothes washer j x 4 = 1/ x 4 -
Dishwasher r x 1.5 = J 5- x 1.5 -
Hose bib 1 x 2.5 = 7, x 2.5 =
Hose bib,each / x I = ! x I = —
Kitchen sink ( x 1.5 = J,j" — x 1.5 =
Laundry sink x 1.5 = x 1.5 =
2 _
Lavatory a x 1 = a _ x I - -i
Water closet, 1.6 GPF ,2 x 2.5 = j j x 2.5 - .2. 5-
Bathtub/whirlpool x 4 = x 4 =
Shower stall x 2 = I x 2 2
Bath/shower combo __2 x 4 = S x 4 = —
Current Points: i2r 4 Proposed Increase: G� r•y
Current Points+Proposed Increase- 32- -New Total Points = Required Meter Size Sly
Meter Sizes: Ito 30 points=5!8" 30.5 to 37 points-V" 37.5 and over points= I"
!/
New Meter Size Needed for New Total Points: 3/y Cost: $ ? ?-`5.- (see page I)
i
Current Meter Size per Utility Billing: ' ' Cost: $ 9/ '®6' (see page 1)
New Meter Size Cost minus Current Meter Size Cost= $ // Cli/e f
(This is Yew Cost to Increase Meter Size Due to Additional Fixture Units)
FOR OFFICE USE ONLY � y e,
Current Meter Size Confirmed with UB.l ae'`t l 12/14/2020
Signature of UB Representative Date
illialirtmerorrns/t4'a'rrmetcrs-f17o119 Add.dOCx Paget
Water Meter Fixture Unit Worksheet for Additions/Remodels/ADUs
Please complete the following information:
Customer Name: �0.y; 4'y.9zir `--
Service Address: Street/Suite#: //6''r 51,..) c"-G>r.ne// ,
e_ty: �"r.,,, state: 4�,3,1
zip: "��
Phone Number: 477 227-5.6'76 Email: pets 5 ,r✓�oC/7724 , 0
� 0 .e."'
Please fill in the number of each fixture you currently have. Please fill in the number of fixtures you propose to add.
Multiply the quantity by the point value to arrive at the current Multiply the quantity by the point value to arrive at
total. the proposed total.
Fixture Unit Current Point Current Proposed Point Proposed
Quantity Value Total Addition Value Total
Bar sink x 1 = x 1 =
Bidet x l = x I =
Clothes washer I x 4 = ,ej x 4
Dishwasher I x 1.5 = ] 5" x 1.5 =
Hose bib 1 x 2.5 = /7, x 2.5 =
Hose bib,each / x I = / x I
Kitchen sink i x 1.5 = /, 5- x 1.5 =
Laundry sink x 1.5 = x 1.5
Lavatory �. x 1 = 2 2 x I = a
Water closet. 1.6 GPF 2 x 2.5 = ,j / x 2.5 - 2. 5
Bathtub/whirlpool x 4 = x 4 =
Shower stall x 2 = / x 2 = 2
Bath/shower combo 2 x 4 = 'i x 4 =
Current Points: t25;5- Proposed Increase: i 5-
Current Points+Proposed Increase= :,2 =New Total Points =Required Meter Size ��l
Meter Sizes: 1 to 30 points=5/8" 30.5 to 37 points='b" 37.5 and over points= 1"
7/ "
New Meter Size Needed for New Total Points: / Cost: $ / 1 R3 (see page 1)
Current Meter Size per Utility Billing: 5/4, Cost: $ 9/ y®fj (see page I)
New Meter Size Cost minus Current Meter Size Cost= $ /' 0�T
(This is Your Cost to Increase Meter Size I)ue to Additional Fixture Units)
a**************************************Mkt************************************** *****
FOR OFFICE USE ONLY
Current Meter Size Confirmed with UB J Beery 12/14/2020
Signature of UB Representative 1)trx
I:/Building/forms/WaterMeters_070tt4 AdddoCX Page 2
Property Owner Statement
Regarding Construction Responsibilities ECEwED
Oregon Law requires residential construction permit applicants who are not licensed with a 5 202J
Construction Contractors Board to sign the following statement before a building permit,can
issued. (ORS 701.325 (2)) F TIGARD
31J11 DING,BlVlSlnN
This statement is required for residential building,electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement.This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
� f gryecrr
Print Name of Permit Applicant
Signature of Permit Applicant Date
Permit#:
Address: ♦ 31116 ;i•
x =
Issued by: Date.
This Copy for Permit Offices