Permit CITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit#: MST2021-00363
Date Issued: 09/15/2021
T I :' h n 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 2S111AD05700
Jurisdiction: Tigard
Site address: 8710 SW PINEBROOK ST
Subdivision: PINEBROOK TERRACE Lot: 80
Project: Vandiver&Glascock
Project Description: Convert 18 sf of garage area into a half bath. Trade permits to be pulled separately.
BUILDING
Floor Areas Required Setbacks Required
Stories: 0 Bedrooms: 0 First: 18 sf Basement: 0 sf Left: 0 Parking Spaces: 0
Height: 0 Bathrooms: 1 Second: 0 at Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 0 Detectors:
Total: 18 sf Value: $2,350.44 Rear: 0
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Drains: 0 Storm Sewer: 0
Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0
Bcktw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Drywell-Trench Drain: 0 Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Fum>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp SrvclFeeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr 0
Ea add!500 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: NI 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:
ADD SF VB R-3 18
Owner: Contractor:
VANDIVER,WILLIAM BARON OWNER Required Items and Reports(Conditions)
GLASCOCK,ELIZABETH LEAVITT
8710 SW PINEBROOK ST
TIGARD,OR 97224
PHONE: PHONE:
FAX:
Total Fees: $306.30
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
• Qco_nnl_nnln thrniinh OAR O59_nn1-MQn Vnii mmi nhfain n rnm,of the rnI nr Airnrl n,mefinne fn r'n IAII^.by r iiinn Ant 919 10A9 nr 1 Ann• 119 91dd
Issued By: 44erny Vn,vt.Do.ldlogo Permittee Signature: Ovti 4ppl catwn
Call 503.639.4175 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 lob site at the time of each inspection.
Building Permit Application RECEIVED 9/2/z)
Residential SEP 01 2021
City of Tigard CITY OF TIGARD Received
774412-/ A4 PermitNoil5T2p 2j-003/p3
11 q 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
�UILDING DIVISION / '2 Other Permit:
Phone: 503.718.2439 Fax: 503.598.19 DateMy: lb /T�
I , 'Isl.,,D Inspection Line: 503.639.4175 Date Ready/By: , �� h7rr-��r El Sec Page 2 for
Internet: www.tigard-or.gov Notified/Method: ' J l4Suppkmental Information
� 7 L ft. /L,(J e9t`(
TYPE OF WORK - REQUIRED DATA:I-AND2-FAfi1ILY DWELLING,
0 New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
yLAddition/alteration/replacement 0 Other. equipment,materials,labor,overhead,and the profit for the a 1/
CATEGORY OF CONSTRUCEION work indicated on this applic ion. 2 t 35a. ( 1
"41-and 2-family dwelling 0 Conunerciallindustrial Valuation: $ `
❑Accessory building 0 Multi-family �
Number of bedrooms:
El Master builder ❑Other:
Number of bathrooms: l2,
,IOB SITE INFORMATION AND LOCATION Total number of floors: 1
Job site address: 7/0 ,5(flf P!!,1&z, (G 67- New dwelling area: i g square feet
City/State/ZIP: 776.A.AIDQ/ 972_24- Garage/carport area: square feet
Suite/bldg./apt no.: 1 Project name: HALF APt7Ti Covered porch area: square feet
Cross street/directions to job site: HA..a. 8L Deck area: square feet
Other structure area: square feet I
_ REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: f ,)/V FE)C e. . ^y-�-i A.e. Lot no.: Permit fees*are based on the value of the work perfotu cd.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
fiOD i -Lim L21'7Zf OFF KITS!-F�[i PUS'C-f�'/�16- Valuation: $
IN1 c - - A-A EA/ ON EX7577/111 Existing building area: square feet
r-OcrrPit _ rity ( ilt;71 fl i,� ny . O roi,vg2) New building area: square feet
j$ PROPERTY OWNERS ❑ TENANT X / ' -umber of stories:
Name: vvi(,LlA/7 j€3. vA,(2)lU,—D2 EU2Jk8E-m 4• 61,.45T `'&construction:
Address: 9716) SW P P•1612..06VG cr Occupancy groups:
City/State/ZIP: -776. b/ iffv: 9 7 2-2,4 Existing:
Phone:(503) -.5-!C , //55 s Fax:( ) New:
APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES*
(Please reler telex sche$ale)
Business name: N/A Structural plan review fee(or deposit): /y , 7 -7
Contact name:
FLS plan review fee(if applicable):
Address:
Total fees due upon application:
City/State/ZIP:
Amount received:
Phone:( ) Fax::( )
E-mail: l3VAN b 11/i✓IZ CzM�i IL .Cbl r� PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Business name: N/� Submit two(2)sets of roof plan with connection details
(! and fue department access,along with the 2010 Oregon
Address: Solar Installation Specially Code checklist.
City/State/ZIP: Permit Fee(includes and administrative fees):an review
$180.00
Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lie.: / /11t Total fee due upon application: $201.60
r ��1- - - l �y � � �(]
Authorized si natlre:� C.L.( 9._ - This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: �/ Date: Q't 2U7" *Fee methodology set by Tri-County Building Industry
�1(,L(/ I� V.Q��t�� 1 � Service Board.
I:\Balding`Permits\BUP-RESPermitApp.doc 02/24'2011 440-4613T(11/02/COM(WEB) ,d?
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received
IN Date/By: Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits:
0 Phone: 503.718.2439 Fax: 503.598.1960
TIGARD 24-Hour Inspection Line: 503.639.4175 ❑ Electrical 0 Plumbing ❑ Mechanical
Internet: www.tigard-or.gov ❑ other.
TIlE FOLLOWING ITEMS \RE: RI QI'IRED FOR PLAN REVIEW 1es No :N.A
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ 0 g
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. 0 0 .El
3 Verification of approved plat/lot. ❑ ❑
4 Fire district approval required. Name of district: 0 DI 0
5 Septic system permit or authorization for remodel. Existing system capacity . I 0 IS
6 Sewer permit. 0 0
7 Water district approval. 0 ❑ 0
8 Soils report. Must carry original applicable stamp and signature on file or with application. 0 0 0
9 Erosion control ❑plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 0
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state R ❑ ❑
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 be completed if
copyright violations exist.
II Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if 0 0 ❑
there is more than a 4-ft.elevation differential,plan must show contour lines at 2-8.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 0 ❑
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, 0 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 arid spacing such as floor beams,headers,joists,sub- 0 0 0
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 ❑
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 locations;for non- 0 0 0
prescriptive path analysis provide specifications and calculations to engineering standards. �r
17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,Spacing,and bearing h 0 ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered 0 0 0
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 0
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. 0 0 El
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required ❑ 0 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 ❑ 0
architect licensed in Ore•on and shall be shown to be a to licable 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 I I"x 17". 0 ❑ 0
24 Two(2)sets each are required for Items 16, 19,20 and 22 above. 0 0 0
25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 0 0
26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. 0 ❑ 0
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 ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, ❑ ❑ 0
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.
C\Building\Pemtits\BUP-RESPerrnitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
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
/ y 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.
VJ1\ BAN\ \4fAN) p / dZ
Print Name of Permit Applicant
Signature of Permit Applicant Date
•
Permit#: MSTZO2-1 - OO 3103 OF
Address: //d 5 Gv p/ /VC../3 /� >:
`.`e'er':
Issued by: V Date: 1C45-\Z1 $B
This Copy for Permit Offices
InformatiOn Notice to Owners About
Construction Responsibilities
(ORS 701.325 (3))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503-378-4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503-947-1488.
• Oregon's Business Identification Number(BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, go online to the Oregon Business
Registry. For questions, call 503-945-8091.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 800-452-0288.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, go online to www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance:As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough-in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
PO Box 14140,Salem,OR 97309-5052
Telephone: 503-378-4621 —Fax:503-373-2007
Website Address:www.oregon.gov/ccb
f/property_owner adopted 9-2016 This Copy for Permit
Ai RECEIVED a
try =44. SEP072021 ' 1 _
• CITY OFTIGARD
BUILDING DIVISION CI i V Of `i 4 RE
ThF
Water Meter Fixture Unit Worksheet for Additions✓Remodels/ADUs
Please complete the following information:
Customer Name: kit P11Ar i Vett►DiV�e.tZ
Service Address: Street/Suite#: ?j 1I 0 �'Wr._,4„:9„.... S
7,
City t r4 State: `,�/ —. Zip:
?-� 2 Ti
Phone Number: g. 7 j jTQ- � Email: V d U�7`t' � Y�[�4. i r1Lfl
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 1 = x l =
Clothes washer x 4 = x 4 = +~
Dishwasher j x 1.5 = l x 1.5 =
Hose bib _1 x 2.5 = 2.5� x 2.5 =
Hose bib,each - x 1 = )y19tx 3 % x 1 = I
Kitchen sink i x 1.5 — 1,4 x 1.5 =
Laundry sink x 1.5 = x 1.5
Lavatory ( x 1 = f , x 1 =
44,
Water closet, 1.6 GPF J x 2.5 = 2 1 x 2.5 =
Bathtub/whirlpool x 4 = x 4 =
Shower stall x 2 x 2 =
Bath/shower combo I x 4 = 4 x 4 =
Current Points: 20.0 Proposed Increase: 11 r
24.5
Current Points+Proposed Increase= >r(r,rte . =New Total Points =Required Meter Size
Meter Sizes: 1 to 30 points-5/8" 30.5 to 37 points=3" 37.5 and over points= 1"
New Meter Size Needed for New Total Points: Vio Cost: $ (see page 1)
Current Meter Size per Utility Billing: 67 i' Cost: $. { (see page 1)
New Meter Size Cost minus Current Meter Size Cost= $ W/!
(This is Your Cost to Increase Meter Size Due to Additional Fixture Units)
FOR OFFICE USE ONLY
Current Meter Size Confirmed with UB .j 'M Beset 09/07/2021
Signature of US Representative Date
1:/Bullding/Aarms/WaterMeters 070519 Add.docx Page 2
4
J
Dianna Ornelas
From: UB Online
Sent: Tuesday, September 7, 2021 8:47 AM
To: #Building Permit Technicians
Subject: RE: MST2021-00363 - 8710 SW Pinebrook St - Vandiver&Glascock
Attachments: 8710 SW Pinebrook St 090721.pdf
Good Morning,
Attached is a corrected and approved water meter fixture unit worksheet for 8710 SW Pinebrook St.
No meter upgrade is currently required based on the proposed additional fixture units.
Kind Regards,
Jill
(she/her/hers)
+n A Wui,, Jill
6 1W CAM8E 4NyT ' City of Tigard -Utility Billing
M^" 44fr
. a Senior Accounting Asst
TIGARp (888)826.7211Payments
(503)718-2460 UB t:1ain
jillb@tigard-or.gov
�/ �u� (503)718-2494
BGCC 1�'I�4 Tgard13125 s OR W H Blvd.all 97223
From:#Building Permit Technicians <TigardBuildingPermits@tigard-or.gov>
Sent: Monday, September 6, 2021 9:57 AM
To: bvandiver@gmail.com
Cc: UB Online<UBOnlinepay@tigard-or.gov>
Subject: MST2021-00363 -8710 SW Pinebrook St-Vandiver&Glascock
Hello William,
The permit has been created and the plan review submittal fee due is$146.77 (see attached invoice).
The fees can be paid online at https://aca-prod.accela.com/TIGARD/Welcome.aspx by searching for the permit record
number MST2021-00363 under the Building tab.
Once the fees are paid, the plans will be routed for plan review. Please allow approximately 4 weeks for processing. The
permit technicians will contact you when the permit is ready to issue and with instructions to pay the remaining permit
fees due.
I have also copied our Utility Billing department to route a copy of the water meter worksheet for their approval prior to
permit issuance.
Thank you.
Dianna L. Ornelas
1
Y
Building Division Services Supervisor
City of Tigard I Community Development
13125 SW Hall Blvd I Tigard, OR 97223
503-718-2430 Direct 1503-718-2439 Permits
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
Dianna Ornelas
From: #Building Permit Technicians
Sent: Monday, September 6, 2021 9:57 AM
To: bvandiver@gmail.com
Cc: UB Online
Subject: MST2021-00363 - 8710 SW Pinebrook St - Vandiver& Glascock
Attachments: MST2021-00363.pdf; WaterMeterWorksheet_8710_SW_Pinebrook.pdf
Hello William,
The permit has been created and the plan review submittal fee due is$146.77 (see attached invoice).
The fees can be paid online at https://aca-prod.accela.com/TIGARD/Welcome.aspx by searching for the permit record
number MST2021-00363 under the Building tab.
Once the fees are paid, the plans will be routed for plan review. Please allow approximately 4 weeks for processing. The
permit technicians will contact you when the permit is ready to issue and with instructions to pay the remaining permit
fees due.
I have also copied our Utility Billing department to route a copy of the water meter worksheet for their approval prior to
permit issuance.
Thank you.
Dianna L. Ornelas
Building Division Services Supervisor
City of Tigard I Community Development
13125 SW Hall Blvd I Tigard, OR 97223
503-718-2430 Direct 1503-718-2439 Permits
i
RECEIVED
r 0 ,3 ;;1,
CITY OF TIGARD
,' H; FN OR I SICn'
Water Meter Fixture Unit Worksheet for Additions/Remodels/ADUs
Please complete the following� information: /�
Customer Name: kit F) / A iv( ` et r F D ! VE //�
Service Address: Street/Suite#: g II D 5- rt rz van ok_ S c-
Ci • I, It/4 State: E)/7--_ Zip:? S zI
Phone Number t___'. -•
570_7j -to Email: c"' f r/ f eaxi
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 1 = x 1 =
Clothes washer I x 4 = 4 x 4 =
Dishwasher t x 1.5 = jlrij x 1.5 =
Hose bib x 2.5 = x 2.5 =
Hose bib,each Li x I =---+' --- L x 1 =
Kitchen sink ( x 1,5 = I, 4. x 1.5 =
Laundry sink x 1.5 = x 1.5 =
Lavatory I x 1 — 1 9 x 1 =
Water closet, 1.6 GPF j x 2.5 = i x 2.5 = t,r �!
Bathtub/whirlpool x 4 = x 4 =
Shower stall x 2 = x 2 =
Bath/shower combo x 4 = _a. x 4 =
Current Points: I .4' Proposed Increase: hi 1
Current Points+Proposed Increase= Z =New Total Points =Required Meter Size
Meter Sizes: 1 to 30 points=5/8" 30.5 to 37 points='/4" 37.5 and over points= 1"
New Meter Size Needed for New Total Points: 6/iv Cost: $ (see page 1)
Current Meter Size per Utility Billing: Cost: $ (see page 1)
New Meter Size Cost minus Current Meter Size Cost= $
(This is Your Cost to Increase Meter Size Due to Additional Fixture Units)
*************************************************************************************
FOR OFFICE USE ONLY
Current Meter Size Confirmed with UB
Signature of UB Representative Date
1:/Building/Forms/WaterMeters_070119 Add.docx Page 2