Permit (2) CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2018-00512
Date Issued: 2/23/2022
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel 2S110AC01101
Jurisdiction: Tigard
Site address: 11290 SW BULL MOUNTAIN RD
Project: Jacksons Food Stores 530 Subdivision: None Lot: None
Project Description: Interior plumbing for a new convenience store and fueling facility:Capping(1)car wash drive thru,(3)3"floor
drains,(3)car wash drains,(2)Ice machines, (5)sinks,and 2 water closets;Adding(11)2"floor drains,(1)3"
floor drain,(3)ice machines,(1)Oil separator,(7)sinks, (3)water closets,and(1)urinal; Installing(9)backflow
Contractor: MIKE PATTERSON PLUMBING Owner: PACWEST ENERGY LLC
PO BOX 850 3450 COMMERCIAL CT
GLADSTONE, OR 97027 MERIDIAN, ID 83642
PHONE: 503-655-4306 PHONE: 208-888-6061
FAX:
FEES
Quantity Description Date Amount
g ea Backflow Preventer 01/18/2022 $281.43
Specifics: 1 ea Expansion Tank 01/18/2022 $12.51
16 ea Fixture/Sewer Cap 01/18/2022 $400.32
Type of Use: COM 12 ea Floor Drain/Floor Sink/Hub 01/18/2022 $300.24
Class of Work: NEW 2 ea Hose Bib 01/18/2022 $50.04
Type of Const: 2 ea Ice Maker 01/18/2022 $25.02
Occupancy Grp: 1 ea Interceptor/Grease Trap 01/18/2022 $25.02
Stories: 4 ea Primer 01/18/2022 $50.04
1 ea Urinal 01/18/2022 $25.02
3 ea Water Closet 01/18/2022 $75.06
1 ea Water Heater 01/18/2022 $37.52
325 Misc Other Fee 01/18/2022 $325.26
2 ea Roof Drain(Commercial) 01/18/2022 $25.02
5 ea Sink 01/18/2022 $125.10
2 ea Lavatories 01/18/2022 $50.04
1 Plan Review 01/18/2022 $451.91
Total $2,476.47
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: —Permittee Signature:
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.
I*
` .- Plumbing Permit Application ECEI
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Building Fixtures FOR oFFICF LSF tl�l.v
City of Tigard RDateBy: // �((f p- Per j X)/ I Qy)57)
y p Y / ��
II NI 13125 SW Hall Blvd.,Tigard,OR 97223 N O V 1 201_ plan Rcvie �--'
I - Phone: 503.718.2439 Fax: 503.598.1960 Date/By: it-a? 6 04 'ram
T I G 1 ti I) Ins ection Line: 503.639.4175 1 gem B r �(..,�.. Juris: HI See age 2 for
Internet: www.tigard-or.gov f,I'ITV OF ?-A gnfied/Method 5 f ,,1/ Supplemental Information
TYPE OF WORKSI III DI DIVISION.S Certvkf. t / j FEE' SCHEDULE
®New construction ®Demolition ri i4 f i .ram-"/ rrr special information use checklist
�i" Description I Qty. I Ea. I Total
❑Additionialteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
❑ I-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑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:
Catch basin or area drain 18.76 45.04
Job site address: 11290 SW Bull Mountain Rd
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,OR 97224 Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: I Project name:Jacksons No.530 Manufactured home utilities 50.03
Cross street/directions to job site:Pacific Hwy Manholes 18.76
Rain drain connector 18.76 r4.7752
It l 7M7 e/9 S ,-/A EG� f+�.,t_ r Sanitary sewer(no.linear ft.:246) Page 2 13aa59
W �J(jam. O Storm sewer(no.linear ft.:61) Page 2 28746-
Water service(no.linear ft.:145) Page 2 -400796.
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.:2S110AC01101 Backflow preventer 8 31.27 250.16
Backwater valve 12.51
DESCRIPTION OF WORK
Clothes washer 25.02
Install plumbing fixtures and plumbing system for new convenience store and Dishwasher 25.02
)--
Fueling facility Drinking fountain 25.02
A--� Ejectors/sump 25.02
(\. El PROPERTY OWNER I 0 TENANT Expansion tank I 12.51 12.51
"GG�� Fixture/sewer cap 25.02
Name:PacWcst Energy,LLC dba.Jacksons Food Stores,Inc.
i i Floor drain/floor sink/hub 11 25.02 275.22
Address:3450 E Commercial Ct. Garbage disposal 25.02
City/State/ZIP:Meridian,Idaho 83642 Hose bib 2 25.02 50.04
�ikj Phone: (208)888-6061 Fax:(208)888-3585 Ice maker 2 12.51 25.02
"fp[1 ® APPLICANT r4 CONTACT PERSON Interceptor/grease trap 1 25.02
�L�7 Medical gas(value:$_) Page 2 25.02
Business name:Barghausen Consulting Engineers,Inc.
-2'
Primer 3 12.51 37.53
Contact name:Ms.Caryl J.Pinner Roof drain(commercial) 2 12.51 37.53
I Address:18215 72nd Avenue S Sink/basin/lavatory 7 25.02 150.12
City/State/ZIP:Kent,WA 98032 Solar units(potable water) 62.54
Phone:(425)656-1063 Fax::(425)251-8782 Tub/shower/shower pan 12.51
Urinal 1 25.02 25.02
E-mail:cpinner(ttbarghausen.com
Water closet 3 25.02 75.06
CONTRACTOR Water heater 1 37.52 37.52
Business name:TBD / 11r[r'.'1 -- '3c.1„J /...p.,�.r,.`i Waterpiping/DWV ..-1... � 8'
Address: J2 d, rArsx -r -1 Other: 25.02
City/State/ZIP: 15i,...e(Jim Air 4jn y 7 Q}7 Subtotal 1526.19
f Minimum permit fee: $72.50
($ ) 4,5-s-- f(. Fax:
Phone: 3� ( Plan review (25%of permit fee) 381.55
CCB Lie.: Plumbing Lic.no.: o
{1 _. State surcharge(12%of permit fee) 183.14
Authorized signature: ( 1 y(!. v a /C :? 1 e.,_.------- TOTAL PERMIT FEE 2090.88
-r='
This permit application expires if a permit is not obtained within 180 days
Print name:Caryl Pinner Date: after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PerntitApp.doc 10/01/09 440-4616T(10i02/COM/WEB)
Plumbing Permit Application - City of Tigard r
,
Page 2 -Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee:
Footing drain-l''100' 1 50.03 50.03 0 to 2.000 $121.90
Footing drain-each additional 100' 2 37.52 75.04 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer-1st 100'
1 62.54 62.54 7,201 and greater $327.54
Sewer-each additional 100' 2 37.52 75.04
Water Service-1st 100' 1 62.54 62.54 Medical Gas Systems:
Water Service-each additional 100' 1 37.52 37.52 ..
Storm&Rain Drain-1st 100' 1 62.54 62.54 Valuation: Permit Fee:
$1.00 to$5,000.00 Minimum fee$72.50
Stone&Rain Drain-each additional 100' 6 37.52 225.12 $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
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*.
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Re lace/
Work Performed: Capped Added Relocate Plan review is required for any of the following.
Baptistry/Font Please check all that apply.
Bath Tub/Shower El Any new commercial building with water service 2"and
Jacuzzi/Whirlpool Whirlpool greater,except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thm t 0 New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918-780-0040.
Dishwasher -Commercial ❑ Medical gas and vacuum systems for health care facilities.
-Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain 0 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" 3 11
Isometric or Riser Diagram
Car Wash Drain 3 li,
Garbage Domestic-non-food LI 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 2 3
Oil Separator(Gas Station) 1 Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/tav -Non-food related 3 5
-Bradley
-Commercial-food related 1 1
-Service I 1
Swimming Pool Filter
Washer-Clothes *Note: If the fixture work under this permit results in an
Water Extractor increase of sewer EDUs,a sewer permit will be issued and
Water Closet-Toilet 2 3 fees assessed for the sewer increase must be paid before the
Urinal 1 plumbing permit can be issued.
Other Fixtures: i
P:\17000s\17858\planning\PH\Commercial Bid Permits-JFS 530\Plumbigg Permit App-Building.doc
Plumbing Permit Application
' , building Fixtures FOR OFFICE USE OBI l
City of Tigard Received I� q �t
IIII = Date/By: Permit No.:rL M ekCJ�$ Q SIa• 13125 S W Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: "_r�fl_ 04 Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
New construction Demolition For special information use checklist
Description I Qty. 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-family dwelling ,,'eSCommerciaUindustrial
SFR(2)bath 437.78
❑Accessory building El Multi-familySFR(3)bath 500.32
❑Master builderEach additional bath/Idtchen 25.02
0 Other: Fire sprinlder
p ( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 1 i, Lqo s s� Ll� t-2�i ,i-*`� Catch basin or area drain 18.76
City/State/ZIP: S l C Drywell,leach line,or trench drain 18.76
Suite/bldg./apt.no.: v Project name: 5 0 Footing drain(no.linear ft.:_) Page 2
�ru jc S c' . (SIG r Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
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 ✓q 31.27 a91.43
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I 0 TENANT Expansion tank ✓ / 12.51 Ia, S/
Name: Fixture/sewer cap mid 25.02 Opp,32
Floor drain/floor sink/hub /a 25.02 300.24
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib „"'"'a 25.02 .s''.04
Phone:( ) Fax:( ) Ice maker 12.51 as,03,
0 APPLICANT 0 CONTACT PERSON Interceptor/grease trap / I 25.02 ol;,0 1
Business name: Medical gas(value:$_) Page 2
Primer ,/'4 12.51 so,0 leContact name: 02a�Sr d2
Roof drain(commercial) � 12.51
Address: d Sink/basin/lavatory fl 7 25.02 1r75 J(t
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: :( ) Tub/shower/shower pan 12.51
E-mail: Urinal f 25.02 ,n a
Water closet ✓3 25.02 95,0 6
CONTRACTOR 7 37e S2
Water heater , i 37.52
Business name: Water piping/DWV ` 56.29
Address: Other: Ste otte, �(, r F.eti25.02 3u-t 13 .ts t a(♦'7
f1
sa
City/State/ZIP: S/s Subtotal tO d7,14.
Phone:( ) Fax:( ) Minimum permit fee: $72.50
Plan review (25%of permit fee) 'J5Lr 7(
CCB Lic.: Plumbing Lic.no.:
State surcharge(12%of permit fee) 216. 9a
Authorized signature: TOTAL PERMIT FEE aft 74,97
Print name: Date: This permit application expires ifs permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
LAu = 2
Id9uildingTermiss\PLMU-PermitApp.doc 10/01,09 440-4616TO 0/02/COM/WEB)
Sirtk$i5
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:
Footing drain-1'100' 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 $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 $1.00 to$5,000.00 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 fast$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 review 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
CINew exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall
-Drive Thru i as defined in OAR918-780-0040.
El Medical gas and vacuum systems for health care facilities.
Cuspidor/Water AspiratorCp al CI Any multipurpose fire sprinkler system.
Dishwasher:
Domestic CIAny 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" I I
-3" 3 i Isometric or Riser Diagram
4" ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain .3 that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains a 3 Comments regarding fixture work:
Oil Separator(Gas Station) s
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav/Bar non-food related 3 5
-Bradley
-Com/Serv/Util food related / i
-Service I I *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 a .3 plumbing permit can be issued.
Urinal I
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2