Permit 141 CITY OF TIGARD PLUMBING PERMIT
# COMMUNITY DEVELOPMENT Permit#: PLM2021-00449
T 1 GA R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/28/2021
Parcel: 1 S 136CD00101
Jurisdiction: Tigard
Site address: 11675 SW PACIFIC HWY
Project: AFC Subdivision: None Lot: None
Project Description: Interior plumbing for TI:Capping(1)2"floor drain/sink,(3)sinks,and(1)water closet;Adding(1)drinking
fountain,(14)sinks,(1)clothes washer,and(3)water closets; Installing(2)roof drains and(1)water heater.
Contractor: DP PLUMBING INC Owner: COLUMBIA STATE BANK
15825 NE SPRINGBROOK PO BOX 2156 MS 3300
NEWBERG,OR 97132 TACOMA,WA 98401
PHONE: 503-537-9492 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Clothes Washer 10/28/2021 $25.02
Specifics: 1 ea Drinking Fountain 10/28/2021 $25.02
1 ea Fixture/Sewer Cap 10/28/2021 $25.02
Type of Use: COM 2 ea Roof Drain(Commercial) 10/28/2021 $25.02
Class of Work: ALT 14 ea Sink 10/28/2021 $350.28
Type of Const: 3 ea Water Closet 10/28/2021 $75.06
Occupancy Grp: 1 ea Water Heater 10/28/2021 $37.52
Stories: 1 12%State Surcharge- 10/28/2021 $67.55
Plumbing
Total $630.49
Required Items and Reports(Conditions)
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 obtain a copy of the rules
Issued By: Ho-Ll y Vim,De,Wege Permittee Signature: Ow Apptitzt„tio-set,
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 job site at the time of each inspection.
:r W , .
Plumbing Permit Ap licatio EC E(v 7,
Building Fixtures FOR (Si 1 1( I? USE 1ONLV
City of Tigard ocr 2 8 WLi Received ' H Permit N.,
III + 131Z5 SW Hall Blvd.,"Tigard,OR 97223 PlanDate By:Review
t g,t Aver I.. l�
.® Plan Review Other Permit No. ,�,g1
Phone: 503.718.2439 Fax: 503.598.19CITY OF TIGARD Date/BY: O4 lC)?D
I'I GAItt7 Inspection i.ine: 503.639.4175 Date Ready/By: tans fa See Page 2 for
Internet vt wtv.tigard-or.gov BUI DING QIVISIO,,Notified/Mcthod: a Supplemental Information
TYPE OF WORK- FEE* SCHEDULE;
❑New construction 0 DeSitl______ Fa special information use checklist
Description I Qty. I Ea. I Total
Iz Addition/alteration/replacement ❑Ot t: 's Ay 1}I New 1-2-fanny dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRU ION SFR(1)bath 312.70
❑1-and 2-family dwelling [I Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
El Accessory building ❑Mul3t-family
Each additions]bathhitchen 25.02
❑Master builder ❑Other: Fire sprinkler sq.ft.) Page 2
JOB SITE INFORMATION AND ird OCATION ? Site utilities:
.lob site address: IP II e 7S- 5w t-tll.t f-rc I Catch basin or area drain 18.76
City/State/ZIP: T Iky'well,leach line,or trench drain 18.76
Footing drain no.linear fl.. ) Page 2
Suite/bldg./apt.no.. t Project name: A. 'c Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain cornector 18.76
Sanitary sewer(no.linear ft..!) Page 2
Storm sewer(no.linear tl.._) Page 2
Water service(no.linear ft.. ) Page 2
Subdivision: i/ ( Lot no.: Fixture or item:
Tax map/pareel no.: !j/560 C.000 it)I Backflow pre enter 31.27
DESCRIPTION OF WORK Backwater vat e 12.51
Plff-- r f I // f Clothes wash l 25.02 �s 4
Ui146 Tar 6 to 3 Germs l 3 TOr( 3', Dishwasher 25.02
e$WL kSt rot trf �(td f 4t J i w Wa S�tEh Drinking fountain j 25.02 ^tea
I to d rAlok /d)4A .� ,�ems) Ejectors/sump 25.02
❑ PROPERTY OWNER(�f I` I ��"• ❑ ENANT', Expansion tank 12.51
Name: Fixture/sewer cap i 25.02 13-4)3--
Floor drain/flcor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PFRSON Interceptor/grease trap 25.02
Business name: Medical gas(„slue:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 9., 12.51 j its
Address: I Sink/basin/lavatory 19 25.02 3
City/State/ZIP Solar units(potable water) 62.54
Phone:( ) Fax: lj ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 3 25.02 "e-661
CONTRACTOR Water heater I 37.52 3'7 '1
Business name: p t�� a Water t m WV 56.29
�^��^• �= p P
Address: ���] C ('p iti6 0 Other: 25.02 City/State/ZIP. t � , it-1 671I3z1 Subtotal 5-(2 7�j
Phone:( �J)( pq'Y4'F 9 Fax.( ) Minimum permit fee: $72.50
GCB Lic.. A 0,4 Plumbing Lie.no.. 1/W 7/ Plan review (25'/,of pemnii fee)
State surcharge(12%of pen nit fee)qq����4,7. q'
Authorized signature: 11.641/ TOTAL PERMIT FEE S1JC�30.'i I
Print name: �4� Date: /�'/ This permit1ppltcationc beifapermitisnotobtained within I80 days
' / f 'Fee metodology set by Tri-County Building industry Service Board.
I:/Buildutg\Femurs/PLMU-ParmiiApp.doc 10/01/09 440.461 (10/021COM/WEB)
PI'5 4 0061 iNC6eY114&e
Plumbing Permit Application - ity of Tigard
Page 2 -Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total Square Footage. Permit Fee:
Fouling drain-l"100' -0.03 0 to 2,000 $121.90
Footing drain-each additional 100' :7.52 2,001 to 3,600 $169.69
Sewer-1st 100' 2.54 3,601 to 7,200 $233.20
7,201 and greater $327.54
Sewer-each additional 100' .7.52
Water Service-1st 100' 2.54 Medical Gas Systems:
Water Service-each additional 100' .7.52
Valuation: Permit Fee: ,
Strnm&Rain Drain•1st 100' 2.54 $1.00 to$5,000.00 Minimum fee$72.50
Storm He Rain Drain-each additional 100' 7.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other Inspections or Fees Qty. F. (us) Total each additional$100.00 or fraction thereof,to
Pand including$10,000.00.
Inspection of existing plumbing or for S10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for
which no fee is specifically indicated 9 .00i11r each additional$100.00 or fraction thereof,to
(minimunn charge-1/2 hour) and including$25,000.00.
Inspections outside of normal business 9 .00/hr $25,001.00 to$50,000.00 $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 9 .00/hr and including S30,000.00.
Additional plan review for revisions 9 .00ilnr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
(minimum charge- 1i2 hour) each additional S100.00 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 requited for any of the following.
Fixture Type for Replace/ Please cheek 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
en gin ecr
-Jacuzzi/Whirlpool
Car Wash: -Each ❑ New exterior p umbing site utilities for any complex structure
-Drive Stall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: -Commercialirator El Any multipurpose lire sprinkler system.
-Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain i
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drainisink: -2' 1
•3" Isometric or Riser Diagram !
-4.,
-Car Wash Drain ❑ Isometric or riser diagram is required for new buildings
Garbage Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regt rding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav/Bar•non-food related I 0
-Bradley
-Com/Serv/Util food related i
-Service ! G) *Note: If 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 If fees assessed for the sewer increase must be paid before the
Water Extractor 1
Water Closet-Toilet I 165) lg plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 I 2
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44
Rl i
Plumbing Permit A Pplicatio CEIVE
Building Fixtures OCT 15 2021 I:i)H 01:1.1( is t',r: 0.1.N.
City of Tigan JJ Y OF TIGAH� Received
_Permit No
!Iligal 13125 SW hall Blv Tigard,OR 9 3 Plan Review
Phone: 503.718.24 Fax: 5033jl1$NG DIVISIO Date/By Other Permit Nc
T I c n K D Inspection Line: 5( .639.4175 II Date Ready/By ® See Page rim-
Internet: www.tiga I-or.gov j Notified/Method: 'j( r Supplemental Information
•TYPE OF WORK FEE" SCHEDULE
❑New construction ID Demolition For special information use checklist.
Description I Qty. I En. I Total
g Additiontalteration'replacemei ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
El1-and 2-family dwelling (,a Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 1 500.32
❑Accessory building ❑Multi-family
1 Each addition.1 bath/kitchen 25.02
❑Master builder I ❑Other: Fire sprinkler sq.ft.) Page 2
JOB SITE II, AND LOCATION I Site utilities:
n• - r Catch basin onarea drain 18.76
Job site address: 14 �� 1°7�G�1�G '�tyy,
p � /r Ihywell,leads line,or trench drain 18.76
City/State/Z.IP: 'Naomi q 7722 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.. ro)ect name: ilaikolkikaPC Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
1 Rain drain cot lector 18.76
L
Sanitary sewe (no.linear ft.:_) Page 2
1 j Storm sewer((to.linear ft.:_) Page 2
I Water service kno.linear fl.:_) Page 2
Subdivision: I lot a .: Fixture or item:
Tax map parcel no.: Wallow presenter 31.27
Backwater vat/ye 12.51
DE PTION OF WORM{
PLr + J Clothes washer I 25.02
Viw�O �Or b tip u3 ladst 3 7'�f4t. i Dishwasher 25.02
It) s ' r 1 rh op' t1 I k f/1 t l ING S tQ! Drinking fountain I 25.02
t Lila I.AIskr- I Ejectors/sump! 25.02
❑ PROPERTY OWN, R I 1 ❑ TENANT Expansion tat 12.51
Name: Fixture/sewerbap ✓�y 25.02
Floor drain/t1 or sink/hub 25.02
Address: Garbage disposal 25.02
City/State/ZIP' Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT P RSON interceptor/grease trap 25.02
Business name: Medical gas( aim:S_) Page 2
Primer 12.51
Contact name:
Roof drain(c nunercial) 12.51
Address: Sink/basin/la ory I Li 25.02
City/State/ZIP: 1 Solar units(p table water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
�� nielii.�� � ��1 Water closet I 3 25.02
�k'ONT CTOR ! t
Business name: op (�
Water heater I 37.52
((06 rw it Water piping!)WV 56.29
Address: Other: 25.02
City/State/ZIP'� y pit- 7i3L I Subtotal
1
Phone:( �) q- 4q' Fax.( ) Minimum permit fee: $72.50
CCB Lie.. a;LI Plumbing Lie.no.. p`7/7/ Plan review (25%of pemnit fee)
�e State surcharge(12%of pennit See)
Authorized signature; �, I s1'V IU'l AL PERM FEE
Print name tea Date: to/!� f This permit t(ppikation expires if a permit is not obtained within 180 days
C flre'(/ir ,/7/Z after It has been accepted as complete.
11 *Fee met odolo set b Tri-Count BuildingIndust Service Board
SY�' Y Y ry�'
I:\Building\Permiu\PI,ML-PennitApp.doc IW /09 440-401d'I'(I0N2/COM/WEB)
i'
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I
Plumbing Permit A pplication - 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-I"100' 50.03 0 to 2,000 $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 ' 7,201 and greater S327.54
Sewer-each additional 100' 37.52
Water Service-1st 100 62.54 Medical Gas Sy teas:
Water Service-each additional 1(A 37.52
Storm&Rain Drain-1st 100' 62.54 Valuation: 1 Permit Fee:
$1.00 to$5,000.00 4 Minimum fee$72.50
Storm&Rain Drain-each addition 11 100' 37.52 $5.001.00 to$10.000.001 $72.50 for the first$5,000.00 and$1.52 for
Other Ins ections or l ees Qty. Frie(ea) Total each additional$100.00 or fraction thereof,to
1► I and including$10,000.00.
Inspection of existing plumbing or �r $10,001.00 to$25.000.00 $148.50 for the first$10,000.00 and$1.54 for
which no fee is specifically indicat 1 90.00/hr I each additional$100.00 or fraction thereof,to
(minimum charge-1/2 hour) and including$25,000.00.
Inspections outside of normal bush ;as 90.00/hr S25.001.00 to$50.000.00 $379.50 for the first$25,000.00 and SI.45 for
hours(minimum charge--2 hours) each additional S100.00 or fraction thereof,to
Reinspection Fees 90.001hr and including$50.000.00.
Additional plan review for revision 90.001v $50,001.00 and up I $742.00 for the first$50,000.00 and$1.20 for
(minimum charge-1/2 hour) each additional S100.00 or fraction thereof.
ubtotal:
Commercial Fixture Fork:
Are you capping,adding o replacing fixtures? If"yes",
please indicate work perfo mod by fixture. Failure to
accurately report fixtures ould result in increased sewer feCs*. Plan Review for Plumbing Installations
Quantity ill Fixture Type Plan review is requi'ed for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Pciformed: Gapped Aided Relocate
Baptistry/Font ❑ Any new con ercial building with water service 2"and
greater.except •ystents designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpoa engineer.
Each Stall 0 New exterior p ut/Ming site utilities for any complex structure
Dr
Car wash:
-Each Shall as defined in O tR918-780-0040.
ivCuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ 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"
Isometric or Riser Diagram
-4•
❑ Isometric or riser diagram is required for new buildings
Car Wash 1? in that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food relat rl
-Commercial food re tied
-Industrial food relat d
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lay/Bar non-food relate I 1 0 i
-Bradley .
Con Sery lJtil food t h ad
-Service f *Note: If the fixtUre work under this permit results in an
Swimming Fool Filter increase of sewer tDUs,a sewer permit will be issued and
Washer-Clothes I fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet ( 5,. % plumbing permit can he issued.
Urinal
Other Fixtures:
I::Building,Permits\PLMF_Pen iitApp.doc 08iO4/201 I 2
Accumulative Sewer Tally
.114 C Tenant Name: AFC SWR# 2021-00278
Site Address: 11675 SW PACIFIC HWY PLM# 2021-00449
TIGARD
Parcel#: 1S136CD00101
Fixture Value Previous Previous Credits Capped Fixture Fixture 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 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 1 2 0 -1 -2
•
-3inch 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 IIP) 32 0 0 0 0 0
-Industrial(over 51IP) 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:
-Lav/Bar-Non-Food Related 2 0 1 2 10 20 9 18
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 2 6 4 12 2 6
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 1 6 3 18 2 12
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 5 16 19 57 14 41
Current Fixture Value 41 divided by 16= 2.563 Current EDU 1 EDU= $6,085.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 41 divided by 16= 2.563 over (under) $ 15,577.60
Enter EDU Change Here 2.560
*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: BRANDEN TAGGART X2449 Date: 10/28/2021
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:A Building\Sewer Tally\SewerTallySheet_6085_070121.xlsx