Permit Support Document (3) Pltlmbina Permit Applicat
Building Fixtures ; 1 ()1< (,FI,`I(°Ir, 1°si: t)1I,1`
City Of Tigard 4 20 ,ecci,ed j r Permit Nr G�y02o/4_fTO3 O
r•it 13125 SW Hall Blvd.,Tigard,OR 972 Date By; C..O.y�Ie /----- -)ii ,
� '!
1 a Phone: 503.718.2439 Fax: 503. PlanReviei✓ CkherPermit
Inspection Line: 503.639.4175 'I OF TIG' Date Ready/By:! +! tuns to See t� �r�/��
Date/By - L 1
IIIIA1ti, Y Y Page
Internet: www,.ligard-or.gov INC DIVISION Notiliied/Method: Supplemental Informationki
TYPE OF WORK FEE* SCHEDULE
EJ New construction CI Demolition For special information use checklist
. Description ._.__� Qt Ea. Total
❑Addition/alteration/replacement 0 Other: Newi Z-
�. •.frimil>dwellings(includes 100 ft.for each utility mnnccucrn) k
CATEGORY OF CONSTRUCTION SFR(I i bath 312.70 '..„
❑ I-and 2-family dwelling ®Commercial/industrial SFR( }bath 437.78 y A
SFR(3)bath 500.32 �S
El Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other.
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities;
Job site address: 13125 SW Pacific HWY-/2e EED twang Catch basin or area drain 18.76
Drywcll,leach line,or trench drain 18.76
CityiState/ZIP:Tigard Oregon 97223 A AA/7/ ,A" /f/15 /EPIC - --
.-- Footing drain(no.linear ft: 1 Page 2
Suite/bldg,/apt.no.: Project name:Specialty Retailer Manufactured home utilities 50.03
Cross street/directions to job site:School St Manholes __ 18.76
M - __ �._.. tRuin drain connector 18.76
Sanitary sewer(no,linear ft. .z,..4/ Page 2
, -` Storm sewer(no.linear ft.: ) Page 2
31 ter 27 1�
_ . ��� �. •- prevenWater service(no.linear l 1 Page 2
" I
Subdivision: Lot no.:200 '�
_ 1 fixture ur Items
.
Tax map/parcel no.:2S102CE300200 Backflow � _
DESCRIPTION OF WORK Backwater valve 12.51
--.• ---- Clothes washer 25.02
New single story Specialty Retail Store
Dishwasher 25.02
Dunking fountain 1 25.02 25.02 ,/
Fjcetors/sump 25.02
0 PROPERTY OWNER 0 TENANT Expansion tank l 12.51 12.51 ,/
Name:Leadership Circle Fixture/sewer cap 25.02
Floor drain/floor sink/hub 24 25.02 600.48 /
Address:P.O.Box 239
Garbage disposal 25.02
City/State/ZIP:Montrose,CO 81402 I lose bib 4 25,02 100,08 ✓
Phone:(970)249-3398 Fax:( ) Ice maker 1 12 51 12.51
® APPLICANT 0 CONTACT PERSON Intercepuxtgrease trap 1 25.02 25 02 v
Rosiness name: - Medical gas(value:$__,_) Page 2
\ 0IIY"-1-41' 1+:.0, 4 L.`°' Primer ^3 ry 12 51 yir3
l" 1t,,,.1 uA 1 14(.1, v 1'�
Contact name: V\
"�' -.,.._.. Roof drain(commercial) � 12.51 �(),O� ✓
Address: 83 {c- Le Y•\u fco t"r ' 6, Sinklbasin/lavutory 13 25.02 325,26 V(^City/State/ZIP: ; 42 rq k.oa,,,,1 a 6 "Zt LI Solar units(potable water) 62.54
-
Phone:(913) 7 y 2--�'5-45-7 Fax::( ) Tub/shower/shower pan I 12.51 12.51 V
� ,�`} Urinal 1 25.02 25.02 a/
E-mail: �,4iiA* -r-;cawlq,.4c 0.08_
'�.°--.�. �rl.,,!� (,-�'��"'�^?�--C.4 _ Water closet 4 25.02 100.08 ✓'
CONTRACTOR -.- - - --
_ v_.. _._ Water heater 2 37.52 75.04✓
Business name:TBD pp•g/ - �.__
_,_ .rv.....,_..,._,._ Water tin DWV _ _ 5629
Address: Other: p
___. .w.. ... _._.__. ..... r�1�,leJ,.sr��,c�r0.;r,z�,._. ,._..1_.,..., 25.02_.,..�._.�. org+ii3
' y _..(._. ) ( Reece r. .... r Minimum permit fee: $72 50 �,7 D.S'(a
Cit /State,ZIP: L ( to A., kawa+�r t
Phone: Fax: ) la ( a P ) r43¢72.
Plumbing State surcharge(IZ/o of permit fee) It( .(�6
CCB Tic.. Plumbing Lie,no.: `
Authorized signature 2„e i. ,M: _, TOTAL TAL PERMIT FEE a aa,4
1 This permit application expires if it permit is not obtained within 80 days
[Print name:Kevin Stambach Date:06/14/16 i after it has been accepted as complete.
-
~� *Pee methodology set by"1 ri-County Building Industry Service Board
I-U3uildingiPcrmits\PLMU-PermitApp Joe 10/01/09 490.1616T(I 0l02/COMIWnn)
Plumbing Permit Application - City of Tigard.
Page 2 -Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty.
Tntal Square Footage: 1 Permit Fee:
Fee(ea) ,
Footing drain-I"100' 50.03 0 to 2,000 .90
_. 2,001 to 3, 00 ts.S121
169.69Footing drain-each additional 100' 37.52_. .. 3.601 to 7,200 $233.20
Sewer-1st 100' I 62.54 62.54 7,201am
7,2Ut aneatcrm_ $327.54
Sewer-each additional 100' 4 37 52 t50,08
Water Service-1st 100' 1 62.54 62.54 Medical Gas Systems:
Water Service-each additional 100' 3 37.52 112.56
Storm&Ram Drain-1st 100' 62,54 Valuation: ' Permit Fee:
w-__..-.... ._ $1.00 to$5,000.00 I 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
"" " each additional$100.00 or fraction thereof,to
Other Inspections or Fees Qty Fee(ea) Total and includit $lO,UW,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 themof,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$25,000,00 and$l,45 for
hours(minimum charge-2 hours) each additional$100,00 or fraction thereof,to
Retmpection Fees 90.00/hr and including$50,000 00
Additional plan review for revisions 90.00/hr $50,001 00 and up i S742,00 for the first$50,000.00 and$120 for t
(minimum charge - I/2 hour) I 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*.
i __
Quantity by Fixture T (te Plan Review for Plumbin' Installations
Fixture Type for Replace! Plan review is required for anyof the following.
Work Performed: Capped Added Relocate q
Baptistry/Font Please check all that apply.
Bath -fub/Shower 1 ✓ ® Any new commercial building with water service 2"and
Jacu�ai/Whirl pool greater,except systems designed and stamped by licensed
Car Wash -Each Stall p _ " engineer.
-Drive Thru ® New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator
as defined in 0AR918-780-0040.
Dishwasher -Commercial ❑ Medical gas and vacuum systems for health care facilities.
-Domestic 0 Any multipurpose fire sprinkler system.
Drinking Fountain I ✓ 0 Any complex structure as defined in 0AR918-780-0040.
Eye Wash _. _ _.,... •n_ w
Floor Drain/sink -2" 8 " Submit 2 sets of plans with any of the above.
-3" 2
a" 3 Isometric or Riser Din' <inCar Wash Drain ,
xGarbagc Domestic-non-food tM Isometric or riser diagram is required for new buildings
Disposal -Domestic-food related that meet the •ualifications above.
Commereial-food related
-Industrial-food related
fee Mach,/Refrig•Drains f•1-t 1
Oil Separator(Gas Station) Comments regarding fixture work:
Rec,Vehicle Dump Station
Shower -Gang " �-
-Stall
i Sink/Lav -Non-food related "4
-Bradley 5 I - 1
-Commercial-food related 3
-Service ry
:Swimmingpol Filter g
*Note: If the fixture work under this permit results in an
Washer-Clothes
Water Extractor ®' increase of sewer EDUs,a sewer permit will be issued and
_WaterCloset-Toilet 4 f fees assessed for the sewer increase must be paid before the
Urinal _l_� plumbing permit can be issued.
Other Fixtures:
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Accumulative Sewer Tally
�` SWR# ESTIMATE ONLY
r� 'I'cnant Name: Specialty Retail
�'77 Site Address: 13125 SW Pacific I Iwy PLM#
Parcel#:
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptistry/Mont 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 1 4 1 4
-Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: -Mach 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 0 0 0
-Domestic 2 0 0 0 0 0
Drinking fountain 1 0 0 1 1 1 1
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 8 16 8 16
-3 inch 5 0 0 2 10 2 10
-4 inch 6 0 0 3 18 3 18
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 IIP) 16 0 0 0 0 0
-Commercial(to 5 1 IP) 32 0 0 0 0 0
-Industrial(over 5 11P) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 12 12 12 12
1,iving 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:
-Lav/Bar-Non-Food Related 2 0 0 4 8 4 8
-Bradley 5 0 0 5 25 5 25
-Com/Serv/Util-Food Related 3 0 0 4 12 4 12
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water I.xtractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 4 24 4 24
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped LDU Credit 0
TOTALS 0 0 0 0 45 136 45 136
Current Fixture Value 136 divided by 16= 8.500 Current I?DU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous F,DU
Change 136 divided by 16= 8.500 over (under) $ 43,350.00
Enter EDU Change Here 8.500
*Round FDUs 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.Ol.
Notes:
Authorized Name/Signature: Dianna llowse Date: 6/14/2016
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.
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