Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
II
Request for Permit ActionV 0 I
T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov 5? ,
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TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@,tiiggard-or.gov
FROM: El Owner ❑ Applicant ❑ Contractor R'"Z:ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE T ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: itiZtV j "'(,;t1 '05 t Sk)LA0 .4 ''OO
Site Address or Parcel#: //fQ1i S-CJ -24)- -} rye.%
Project Name: 4-2 Cj✓ jj
Subdivision Name: Lot#:
EXPLANATION: sPZ/49 '}--005 1.4jr Grp---,1 ve-i/01‘4,t1,f
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,.ter Signature: Date:o�j�a��/ �. $ 1'
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< Print Name: /�, ,�� -7-'' ,
" Refund Policy
1. 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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%of the application or permit fee for issued permits prior to any inspection requests.
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 for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date a-3 ,-= By j.- Route to Records: Date k 2 7 d-/ B.J6,
Refund Processed: Date A/ ,s9 By 46 Invoice Processed: Date By
Permit Canceled: Date A 2 e4/ By,�d Parcel Tag Added: Date By
I:\Building\Forms\RegPernvtAction_1 0518.doc
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Plumbing Permit Applica , �? �� E_ 12 7 20
Building Fixtures $'ECEIVED FOR OFFICE. USE 0N1.1
City of Tigard �E� 202� ReceivedDat �Q ��/j .,,,..Z�r C
g^ e /2 �e� Permit N .. Jr Y
III r 13125 SW Hall Blvd.,Tigard,OR 9722 Plan Review �
Phone: 503.718.2439 Fax: 503.59 0 Other Permit ,t+,Q 7) )_� z 10 2em
Inspection Line: 503.639.4175 �1�`'OF TIGARD Other 4i
T I G A R D Date Ready/By: hurls 171 See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method. MI6- Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. I Total
®Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
❑ 1-and 2-family dwelling ®Commercial/industrial SFR(2)bath 437.78
buildingSFR(3)bath 500.32
❑Accessory ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Pagc 2
j$Gl ti JOB SITE INFORMATION AND LOCATION Site utilities:
f I )
Job site address:�'t�5 SW 72nd Ave.
Catch basin or area drain 18.76
✓ Drywell,leach line,or trench drain 18.76
City/State/ZIP:Portland, OR Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apl.no.: I Project name:Rose City Confections 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: I Lot no.: Fixture or item:
Tax map/parcel no: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Plumbing for TI Clothes washer 25.02
Dishwasher 1 25.02 a-S.O
- Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub 2 25.02 SO.oy
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) lee maker 12.51
® APPLICANT 0 CONTACT PERSON Interceptor/grease trap 1 25.02 2c•6Z.
Business name:Local Plumbing Co. Medical gas(value:$_) Page 2
Primer 12.5 I
Contact name:Brandy Solano Roof drain(commercial) 12.51
Address:20833 SW Olds Place Sink/basin/lavatory 5 25.02 /� ,) )
City/State/ZIP:Sherwood, OR 97140 Solar units(potable water) 62.54
Phone:(503)462-2067 Fax::(503 )642-5954 Tub/shower/shower pan 12.51
E-mail: brandys@localplumbingco.com Urinal 25.02
CONTRACTOR Water closet 1 25.02 aS`t5 2,
Water heater 1 37.52 3).S 1-
Business name:Local Plumbing Co. Water piping/DWV 56.29
Address:20833 SW Olds Place Other: 25.02
City/State/ZIP:Sherwood, OR 97140 Subtotal ag 1,')i
Phone:( ) Fax:(503 1 642-5954 Minimutm permit fee: $72.50
503 642-2067
Plan review (25%of pennit fee)
CCB Lie.: 72253 Plumbing Lic.no.:34-197PB
State surcharge(12%of permit fee) 3 4,S 3
Authorized signature: .5,4tom/` S. TOTAL PERMIT FEE 11))..
Print name:Brandy Solano , Date:p ,- / • This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building industry Service Board.
I:\Building,Pmnits',PLMU-PerurnApp.doe 10!01'09 440-4616T(1O'D'COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total S uare.Footage: Permit Fee: _
Footing drain-l r 100' 50.03 0 to 2,000 S 121.90
Footing drain-each additional 100' 37.52 2,001 to 3,6 10 $169.69
3,601 to 7,200 $233.20
Sewer-1st 100' 62.54 7,201 and eater S327.54
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 tc$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other ec Ins tions 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 S 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 S25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first S25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to
Reinspection Fees 90.00/hr and including S50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 rind up $742.00 for the first$50,000.00 and$1.20 for
(minimum charge-1/2 hour) each additional S 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 chock all that apply.
Work Performed: Capped Added Relocate
❑ Any new commercial building with water service 2"and
Baptistry/Font -Tub/Shower greater,except systems designed and stamped by licensed
Bath:
engineer.
-Jacuzzi/Whirlpool
Car wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive as defined in OAR918-780-0040.
Cuspidor/Water Aspirator 0 Med:cal gas and vacuum systems for health care facilities.
Dishwasher. Commercial 0 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" 2
3' Isometric or Riser Diagram
4" 0 Ison'etric 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) 7 Ty P E" St K) le- a.
r
Rec.Vehicle Dump Station � - t tl T1 .,S r Ai IC.
Shower: -Gang 3-C't
-Stall
Sink: -Lav/Bar non-food related 3 r 1 141- S
-Bradley / .0- R-t=L C ( C i)
-Com/Serv/Util food related r
-Service *Note: li 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 1 plumbing permit can be issued.
Urinal
Other Fixtures:
i:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
111 Accumulative Sewer Tally
= Tenant Name: Rose City Confections SWR# 2020-00200
T i G A[t D Site Address: 14945 SW 72nd Ave PLM# 2020-00505
Parcel#: 2S112AC01900
Fixture Value Previous Previous Credits Capped Fixture I'ixture New New
# value count capped#s value count added# added value total#s total values
Baptisery/Font 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher: -Commercial 4 0 0 1 4 1 4
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 0 0 0
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 0 0 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 HP) 16 0 0 0 0 0
-Commercial(to 5 HP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 0
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 0 0 0
Rec.Vehicle Dump station 16 0 0 0 0 0
Shower: -Gang(per head) 1 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lay/Bar-Non-Food Related 2 0 0 3 6 3 6
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 1 3 1 3
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 5 13 5 13
Current Fixture Value 13 divided by 16= 0.813 Current EDU 1 EDU= $5,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 13 divided by 16= 0.813 over (under) $ 4,698.00
Enter EDU Change Here 0.810 *
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: Dianna Omelas Date: 12/18/2020
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I:\Building\Sewer Tally\SewerTallySheet_5800_070119.xlsx