Permit CITY OF TIGARD PLUMBING PERMIT
`'1 ' COMMUNITY DEVELOPMENT Permit#: PLM2021-00501
Date Issued: 12/14/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S101AA09800
Jurisdiction: Tigard
Site address: 12570 SW 69TH AVE 200
Project: NW ADHA Treatment Center Subdivision: 1996-024 PARTITION PLAT Lot: 2
Project Description: Interior plumbing for TI: ADDING(1)breakroom sink.
Contractor: GREEN BOX MECHANICAL Owner: LG2AG HOLDINGS LLC
3265 NW 29TH AVE 12570 SW 69TH AVE
PORTLAND, OR 97210 TIGARD, OR 97223
PHONE: 503-222-0555 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Sink 12/08/2021 $25.02
Specifics: 1 12%State Surcharge- 12/08/2021 $8.70
Plumbing
Type of Use: COM 47 ea Minimum Fee Adjustment- 12/08/2021 $47.48
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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: Flol l y Va.v1.,De Wege, Permittee Signature: �w App-Li c cvh crw
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.
RECEIVE[
Plumbing Permit Application limmsmiiiiiii0
Building Fixtures NOV 2 9 2021iiimil'u
City of Tigard CITY OF T1GA Received G� l EA/ /IA „nk-, ��0)/'���
• 13125 SW Hall Blvd.,Tigard,OR 972 0'W' LAviviv Dan �Y'i�('1� '�':�{/l
Plan Review /I^^
_ Phone: 503.718.2439 Fax: 503.598. 9 DDate/By: Prji .
1.I ti R r� Inspection Line: 503.639.4175 Date ReadyBy / Juris ®See Page 2 for
Internet: www.tigard-or.gov Notified Method L� Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑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(1)bath 312.70
1-and 2-familydwellingSFR(2)bath 437.78
❑ ®Commercial/industrial
SFR(3)bath 500.32
0 Accessory building 0 Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other:
Fire sprinkler(_sq.R.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address:12570 SW 69th Ave., Portland, OR 97223 Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard, OR 97223 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.:A00 I Project name:Grau Plumbing Manufactured home utilities 50.03
Cross street/directions to job site: M/ /4 Y/P/g Irdfoit'ock Manholes 18.76
Cr bek y 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
Clothes washer 25.02
install rough in and fixture for sink in break room Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name:Sucession Resource Group
Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:12570 SW 69th Ave. Garbage disposal 25.02
City/State/ZIP:Tigard, OR 97223 _ Hose bib 25.02
Phone:( 503)427-9910 Fax:( ) Ice maker 12.51
-APPLICANT a-CONTACT PERSON Interceptor/grease trap 25.02
Business name:6 yr co d o� //f 4 feet Medical gas(value:$_) Page 2
Primer 12.51
_
Contact name: t"Y..c L e.cu ( kl�f� ` Y Roof drain(commercial) 12.51
Address: 3 65 - /1 1/1/ ,2 9 7L Sink/basin/lavatory 1 25.02 25.02
City/State/ZIP:4-K-rt A 0/ 17410 Solar units(potable water) 62.54
Phone:( 6/13 AAA. asS-ss- Fax::( ) Tub/shower/shower pan 12.51
E-mail: r'ke.eiv p r ire_n -6 0 f <e e-h 4GI Cal. e 0/4^ Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name:Green Box Mechanical Water piping/DWV 56.29
Address:3265 NW 29th Ave Other: 25.02
City/State/ZIP:Portland, OR 97210 Subtotal 25.02
Phone:(503)222-0555 Fax:( ) Minimum permit fee: $72.50 72.50
CCB Lie.:214076 Plumbing Lie.no.:PB1841 Plan review (25%of permit fee)
z State surcharge(12%of permit fee) 3.00
Authorized sign et &�e afore: TOTAL PERMIT FEE 100.52
Print name:J.C. Koo ekoff Date:11/29/21 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.
1'\Building\Permits\PLMU-PermitApp doe 10/01/09 440-4616T(10/02/COM/WEB)
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Plumbing Permit Application - City of Tigard
Page 2- Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee:
I ooting drain-I" 10(1 50.0 3 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 $327.54
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 $I oo to`5 on0.00 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
Other Inspections 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 $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$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$1.45 for
hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to
Reinspection Fees 90.00/hr and 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:
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 re s less is required for any of the following
Fixture Type for Replace/ Please check 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
engineer.
-Jacuzzi/Whirlpool
Car Wash: -Each Stall ❑ New exterior plumbing site utilities for any complex structure
as defined in OAR918-780-0040.
-Drive Thru
Cuspidor Water Aspirator ❑ Medical 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"
3" Isometric or Riser Diagram
❑ Isometric or riser diagram is required forneNti
-Car Wash Drain builrlinc>
Garbage Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav/Bar non-food related t
-Bradley
-Com/Serv/Util food related
-Service *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 fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
Julie Drinkwater
From: mike@greenboxmechanical.com
Sent: Monday, November 29, 2021 8:52 AM
To: #Building Permit Technicians
Subject: Commercial Plumbing Permit Application
Attachments: Grau Plumbing Permit.pdf
Categories: Julie, Priority
You don't often get email from mike@greenboxmechanical.com.Learn why this is important
Caution!This message was sent from outside your organization.
Attached is a permit application for plumbing work.
Please let me know if you have any questions.
Mike Llewelyn
General Manager
3265 NW 29th Ave.
Portland,OR 97210
Office 503-222-0555
Cell 503-504-7236
mike@greenboxmechanical.com
www.greenboxmechanical.com
green • ox
MECHANICAL
Electrical, Plumbing and HVAC Services
1
t
Accumulative Sewer Tally
_ 4 Tenant Name: NW ADHD TREATMENT CEN l'ER SWR# SWR2021-00319
Site Address: 12570 SW 69TH AVENUE PLM# PLM2021-00501
Parcel#: 2S 101 AA09800
Fixture Prcvu us 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 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
i
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 1 2 1 2
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
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 1 2 1 2
Current Fixture Value 2 divided by 16= 0.125 Current EDU 1 EDU= $6,085.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 2 divided by 16= 0.125 over (under) $ 791.05
Enter EDU Change Here 0.130 *
*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: JULIE DRINKWATER X2804 Date: 12/8/2021
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:\Building\Sewer Tally\SewerTallySheet_6085_070121.xlsx