Permit Support Document (2) V o i0 RECEIVED
-2/0/ZD
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JUN 2 9 2017
• , Request for Permit Action
qCITY OF TIGARD
; i i i 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • ; , l
G DIVISION
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: ❑ Owner ® Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Vega Architecture
Mailing Address: 25107 Genesee Trail Rd
City/State/Zip: Golden, CO 80401
Phone No.: 720.390.3891
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Av' 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).
El REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit)
.20!!n-cao a 96-
Permit#: 24g--
l3/Ic-arm/A00'err
Site Address or Parcel#: 13125 SW Pacific Highway;Tigard, OR 97223 -ze-rRe'J
Project Name: Specialty Retailer
Subdivision Name: 200
Lot#:
EXPLANATION:
The developer and tenant have decided against building the pre-engineered metal building that was
submitted in 2016 in order to construct the new tenant prototype building that has recently submitted.
Signature: p° Date: 06.29.17
Print Name: lsher
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
/2 4 l ACV/Q ,S-u.E — COMP cam- en ;/i%//(,
Route to Sys Admin: Date By Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Building\Eonns\RegPermitAeticm_092314.doc
. Plumbing Permit Applicatior> p E A ile
Site Utilities I' ry (� G FOR OFt)FF1( F. 1'til•: ()NIA
JUN 1 U 16
Received�/dre 4P6 o MMYJ/ , (/4c2'
City of Tigard DateBy: Permit No
111 . . 13125 SW Hall Blvd.,Tigard,OR 97 3 r Plan Review/
Phone: 503.718.2439 Fax: 503.598 I OF [WARD Date/By: g-J -/G v Other Permit No +j47-eQigg
TIGARD Inspection Line: 503.639.4175 BjJILJfJ rf DIVISION DateReadyBy: Juris: 0 See Page 2 for
w Internet: ww.tigard-or.gov g fl DIVISION 1 Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
For special information use checklist.
El New construction ❑ Demolition
Description Qty. Ea. Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
El I-and 2-family dwelling ElCommercial/industrial SFR(2)bath 437.78
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 Site utilities: 7/01056.
•Job site address:13125 SW Pacific Highway-/leJJf6r /'/3' PPZ/F!G Catch basin or area drain ✓ ,erE, 18.76 4?-3-�.0
Drywell,leach line,or trench drain 18.76 a•3%t3
City/State/ZIP:Tigard OR 97224
Footing drain(no.linear ft / Page 2 -244314i-
Suite/bldg./apt.no.: Project name:Specialty Retail Manufactured home utilities551 50.03
Cross street/directions to job site:SW Pacific Highway and School Street Manholes / 2 18.76 37.52
Rain drain connector ✓/0,. / 8 18.76 150.08
(�cd\`� Sanitary sewer(no.linear ft:;> ) Page 2 100.06 y
.....____3) Storm sewer(no.linear ft. 1.)!IQ`,119S,A Page 36240
Water service(no.linear ft.:.. ')) Page 2 62.54
Subdivision: J Lot no.:200 _ Fixture or item: 44'4 ✓
Tax map/parcel no.:2S102CB00200 DESCRIPTION OF WORK Backflow preventer / '3. 31.27 Ga,54.
Backwater valve ./ / 12.51 0,51
P Clothes washer 25.02
Construction of new buliding,parking lot,and utilities. Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER 0 TENANT Expansion tank 12.51
c� Fixture/sewer cap 25.02
Name:Tigard-Tualatin School District#23J
Floor drain/floor sink/hub 25.02
Ns
Address:6960 SW Sandburg Street
Garbage disposal 25.02
City/State/ZIP:Tigard OR 97223 Hose bib 25.02
V Phone:(503)431-4000 Fax:( ) Ice maker 12.51
® APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name:Leadership Circle LLC Medical gas(value:$ ) Page 2
Primer 12.51
�llg-
Contact name:Monet Ragsdale gip. 4,. r(.•I. '� .-- Roof drain(commercial) 12.51
Address:PO Box 239 .t?j a Y 4. �4'
' /1s, Csz/ c,rC/Q... IC $Ct),. Sink/basin/lavatory 25.02
City/State/ZIP:Montrose CO 81402 Solar units(potable water) 62.54
Phone:(970)249-3398 Fax: :( ) Tub/shower/shower pan 12.51
E-mail:monet@leadershipcirclellc.com Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52 /
Business name:TBD Water piping/DWV 56.29 4i .5O,tIO./
Address: Other: 25.02 -71006�,�
City/State/ZIP: Subtotal .�n,3,•V'
Phone:( ) Fax:( ) Minimum permit fee: $72.50 -9 '
✓ L/ i:.6' Plan review (25%of permit fee) .,�.i�81�,
CCB Lie.: Plumbing Lic.no.: �f•�
,.Fist~, State surcharge(12%ofpermit fee)
Authorized signature: 7.//` �- TOTAL PERMIT FEE 1'
%ai L/ [ i- /� Date d.�/, -.1/4 This permit application expires if a permit is not obtained within 180 da s
Print name:!! t' ' ���---+++„'Y CCC Lf� (' after it has been accepted as complete.
*Fee method yby Tri-County BuiilVl)ldiinngg Industry Service ard./`��,►rJ,�,�/
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Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule:
Site Utilities Qty. Fee(ea) 'Total Residential Fire Suppression Systems:
Footing drain- 15`100' 1 50.03 50.03 SquareFootage: Permit Fee:
✓i f.::1,a) L 0 to 2,000 $121.90
Footing drain-each additional 100' ,or'5 37.52 •.1 04)8 w 2,001 to 3,600 $169.69
Sewer-1st 100' i, n I 62.54 62.54 4 3,601 to 7,200 $233.20
14✓ 1 7,201 and greater $327.54
Sewer-each additional 100' 1 37.52 37.52 k
Water Service- 1st 100' 1 62.54 62.54 +
Water Service-each additional 100' 37.52 �( Medical Gas Systems:�
Storm&Rain Drain-1st 100' \' Di Valuation: Permit Fee:1 62.54 62.54
$L00 to$5,000.00 Minimum fee$72.50
Storm&Rain Drain-each additional 100' $437.52 30&.i fi $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 0,./''o- each additional$100.00 or fraction thereof,to
Inspection of existing plumbing or for and including$10,000.00.
which no fee is specifically indicated 90.00/hr $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for
(minimum charge 1/2 hour) each additional$100.00 or fraction thereof,to
Inspections outside of normal business 90.00/hr and including thefirst$25,000.00.
hours(minimum charge 2 hours) $25,001.00 to$50,000.00 $379.50 for first$25,000.00 and$1.45 for
spection Fees 90.00/hr each additional$100.00 or fraction thereof,to
Reinand 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: 8)5s ilq
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*.
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace/ '
Work Performed: Capped Added Relocate Plan review is required for any of the following.
Baptistry/Font Please check all that apply.
Bath Tub/Shower 0 Any new commercial building with water service 2"and
Jacuzzi/Whirlpool greater,except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918-780-0040.
Dishwasher -Commercial 0 Medical gas and vacuum systems for health care facilities.
-Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ Any complex structure as defined in OAR918-780-0040.
Eye Wash
Floor Drain/sink -2" Submit 2 sets of plans with any of the above.
-3"
Isometric or Riser Diagram
Car Wash Drain -
Garbage Domestic-non-food El Isometric or riser diagram is required for new buildings
Disposal -Domestic-food related that meet the qualifications above.
-Commercial-food related
-Industrial-food related
ice Mach./Refrig.Drains
Oil Separator(Gas Station) Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav -Non-food related
-Bradley
-Commercial-food related
-Service
Swimming Pool Filter *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
Water Closet-Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
C:\Users\Karen\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\I9LC4EPT\Site Plumbing.doc
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Site Utilities — Plumbing Permit Application
Plan Submittal Requirements
TIGARD
A plumbing permit for site utility plumbing work is required for sanitary sewer, storm sewer
and potable water systems on private property.
1. SITE PLAN and vicinity map showing the geographic location (fully dimensional, drawn
to scale) labeled with:
A. Z map&tax lot# ® project name ® site address ® suite number
® zoning ® applicant name ® phone number
B. North arrow.
C. Scale (architectural or engineering only).
D. Street names.
E. Building pads with project location.
2. PLUMBING PLANS -Two (2) complete sets, civil only.
All details listed below shall be incorporated into the plumbing plans:
A. Storm drainage plan showing:
1) Finish elevations throughout the developed site.
2) Grade breaks determining area serving each catch basin.
3) Location of catch basins.
4) Pipe size.
5) Type of material.
6) Slope of piping.
7) Manholes and field drains.
8) Cleanouts provided for each 100 feet or fraction thereof.
9) Roof drain laterals specifying cleanouts at each upper terminal.
10) Location of existing or proposed connection to a public sewer line.
B. Utilities plan showing:
1) Sanitary sewer line location,pipe size, type of material, slope of piping, manholes
and cleanouts provided as required for storm.
2) Size and location of domestic water piping and drainage.
3) Proposed location of connection to a public water or sanitary sewer line.
I:\Building\Permits\PLMF-PermitApp.doc 12/30/05
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RECEIVED
D O W L JUN 7 2016
TRANSMITTAL
CITY Of IIGARI
Project Specialty Retail-Plumbing Permit BUILDING DIVISION
Office Locations No.:
Date: 6/7/16
ALASKA City of Tigard
Anchorage To: 13125 SW Hall Blvd
Juneau Tigard,OR 97223
Fairbanks Regarding: Site Utilities-Plumbing Permit Submittal
Ketchikan
Kodiak We are
Palmer sending you ElAttached ❑ Under Separate Cover
Via ARIZONA Delivery the following items:
Tempe ❑ Shop ❑Prints ®Plans ❑ Specifications
Tucson drawings
❑ Copy of ❑COLORADO Letter Change Order CISamples ®Other
Golden Copies Date Description
Gunnison 1 6/7/16 Signed Plumbing Permit Application
Montrose
1 6/7/16 Permit Fee Deposit-$337.81
MONTANA 2 6/7/16 Full Size Civil Plans—Onsite Utility Improvements(dated 6/1/16)
Billings
Bozeman
Butte
Great Falls
Helena These are transmitted as indicated below:
Miles City
❑ For approval 0 Approved as submitted ❑ Resubmittal Copies for approval
NORTH DAKOTA El For your use El Approved as noted ❑ Bids due Copies to distribute
Dickinson ❑ Return ElReturned for corrections Corrected prints
® Review and Comment ❑ Prints returned after loan to us
OREGON
❑ Other:
Bend
Portland Message:
WASHINGTON / Copy to: Printed Name: Matthew Zinzer
Redmond Printed Name: Signature:
'���_
Seattle
WYOMING
Gillette
Lander
Laramie
Sheridan
971-280-8641 • 800-865-9847(fax) • 720 SW Washington Street, Suite 750 • Portland, Oregon 97205 • www.dowl.com