Permit Support Document Y CITY OF TIGARD ES PLUMBING PERMIT
COMMUNITY DEVELOPMENT
2�g2Z Permit#: PLM2022-00033
Date Issued: 2/3/2022
T I GAR D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 2S1026C00107
Jurisdiction: Tigard
Site address: 10295 SW BROOKSIDE CT
Project: Brookside Subdivision: WALNUT ACRES Lot: 6
Project Description: Move toilet over in bath.2/9:REPRINTED to include(3)tub/shower/shower pan replacements
Contractor: MY PLUMBER LLC Owner: SAMSON CONSULTING LLC
14604 NE 129TH ST 11640 SW TERRACE TRAILS DR
BRUSH PRAIRIE,WA 98606 TIGARD, OR 97223
PHONE: 360-991-9991 PHONE:
FAX:
FEES
Quantity Description Date Amount
3 ea Tub/Shower/Shower Pan 02/03/2022 $37.53
Specifics: 1 ea Water Closet 02/03/2022 $25.02
9 12%State Surcharge- 02/03/2022 $8.70
Type of Use: SF Plumbing(manual)
Class of Work: ALT 10 ea Minimum Fee Adjustment- 02/03/2022 $9.95
Type of Const: Plumbing
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: 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.
Plumbing Permit APPlicatiill
E.uEIV ,
Building Fixtures
City of Tigard :i i! " -inn" Received Z q O.�(2 Permit No.: T
1114 ■ 13125 SW Hall Blvd.,Tigard,OR 97223, Plan
g pie,
>t Phone: 503.718.2439 Fax: 503.598. OF rl GAIN L Date/By: Other Permit No.:
TIGARD Inspection Line: 503.639.4175 +3UILDING DIVI�JI('' Date Ready/By: ' yyK4i, kris: di See Page 2for
Internet: www.tigard-or.gov Notified/Method: ip4 si Supplemental Information
TYPE OF WORK FEE* SCHEDULE
For special information use checklist.
❑New construction ❑Demolition
Description I Qty. I Ea. I Total
®Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
2 I-and 2-family dwelling ❑Commercial/industrial
SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family Each additional bath/kitchen 25.02
❑Master builder 0 Other Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 102 IS 1.t)of ects)dq {c Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP: "-'I( -( 1 DR_ o,"223 Footing drain(no.linear ft.:_J Page 2
Suitelbldg./apt no.: �J I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear fl.:_) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear It: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax Inap/patcel no.: BackFlowprevm[er 31.27
Backwater valve 12.51
DESCRIPTION OF WORK
,�` �r�` Clothes washer 25.02
•Piease adr_ ►V l/(ir 19Iv p.Ca lit Dishwasher 25.02
PnL- M 2_022--,- 00033 Drinking fountain 25.02
ltJ t✓CTLl4 Lr tms Ejectors/sump 25.02
0 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name:
Floor drain/floor sink/bub 25.02
Address: Garbage disposal 25.02
City/State/LIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT ❑ CONTACT PERSON h1erceltor/grease trap 25.02
Business name: �/t :PLO v e '- j„(_C Medical gas(value:$ ) Page 2
Printer 12.51
Contact name: A.fir A fi i �t ff- S� 1 Roof drain(commercial) 12.51
Address: I 6410 IUD. Fourth {/oi Blvd_ Sink/basin/lavatory 25.02
City/State/ZIP: V'aLr)(00 Vvf\ w A 913bciz- Solar units(potable water) 62.54
Phon Fax::( ) Tub/shower/shower pan 3 12.51 37.53
E-mail: a,X)�{((1�W 0014) ir -!'1C._.cQ✓V) Urinal 25.02
Wider closet 25.02
ONTRACTOR Water heater 37.52
Business name: Water piping/DWV 56.29
Address: Other: 25.02
Subtotal
City/State/ZIP:
Phone:( )
Fax:( ) Minimum permit fee: $72.50
Plan review (25%of permit fee)
CCB Lie.: Plumbing Lic.no.: State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: Date: This permit applicafation
it haasres If a perrnit is been accepted as not
complete.
obtained within Ito days
`Fee methodology set by Tri-County Balding Industry Service Board.
I:nluildingNemdls'PLMt1-PemdUpP.doc 10101N9 440.4616T(10i02/cowwEB)
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-l'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' 3752
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
each additional$100.00 or fraction thereof,to
Other Inspections or Fees Qty. Fee(ea) Total
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 review is required for any of the following.
Fixture Type for Replace Please check all that apply.
Work Performed: Copped Added Relocate
Baptistry/Font:
Any new commercial building with water service 2"and
Batpti b/ greater,except systems designed and stamped by licensed
hShower engineer.
-Jacuzzi/Whirlpool
Car Wash: -Each Stall 0 New exterior plumbing site utilities for any complex structure
Drive Thm as defined in OAR918-780-0040.
Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities.
Dishwasher: -Commercial 0 Any multipurpose fire sprinkler system.
-Commercial-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
4 El Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice MachiReftig.Drains Comments�reJg'�arding fixture work:
Oil Separator(Gas Station) p�n'�"=p' ti\[M,l to *Albino il'J LriNii
Rec.Vehicle Dump Station j f"l f-i�2-r-ro-37J �J {�
Shower: -Gang ' ^^ VV
-Stall
Sink: -Lav/Bar non-food related
-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:
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