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Permit Plumbing Permit Application Building Fixtures Fort orru t USE ONLY ilti City of Tigard '�'� y, 4d d _ AiL7 �1?-1_o R .�• P•• e: Permit No. • 13125 SW Hall Blvd.,Tigard,OR 97223r an�gplan Review • Phone: 503.718.2439 Fax: 503.598.1960 ELC Date/By: ((/ OtherPermit No.: A• Inspection Line: 503.639.4175 4' ", y���(/g 77 i i G A R L) rya�Bate Ready/By: had. 0 See Page 2 for - Intcrnet: www.ngard-or.gov try,) QFTGNAttifkd/Method: ( - 1,yy ' ], Supplemental Information P TYPE OF WORK 44.nartiGtrAilawlipbirx, FEE* SCHEDULE ❑New construction 0 Demolition For special information use checklist. Description I Qty. I Ea. I Total ®Additioit/alterationreplacement 0 Other: New I-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(I)bath 312.70 0 1-and 2-family dwelling VI Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 ❑Accessory building 0 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: 111--t e T SLJ 6.8 ay ()kw Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76 City/State/ZIP: 'j'(6.040.1). 0 R Q' Z'L 3 Footing drain(no.linear ft.:_,_) Page 2 Suite/bldg./apt.no.: Z T I Project name: (,o Y„.( c ,n.LC Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 q-r Rain drain connector 18.76 ✓J Sanitary sewer(no.linear ft.:_) Page 2 Storm sewer(no linear ft.:_) Page 2 Water service(no.linear ft.: Page 2 Subdivision: Lu< l 3 4,DDo3'ic.Fs J Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater 12.51 Clothes washer 25.02 Me, ' S:det K -t Ake?%;ponet s . ('IA J;(1 1,1 r.a A /i Dishwasher © 25.02 }S 0, el.,,....L:.7 1-o re... La Cookl Se' C(o,,7vt 4,4,-_1sh4 I I . Drinking fountain 25.02 `ei.Shot tI n/i v.f Si i (e .¢ fi ret-C p a C C S Ejectors/sump 25.02 0 PROPERTY OWNER ❑ TENANT Expansion tank 12.51 - Name: Fixture/sewer cap 25.02 ,�,dil SHchr\cdsreIA) QA.9m;nTies - Floor drain/floor sink/hub 25.02 x,0),„ Address: ?sr ena.,iTfr-Oil1 al set Garbage disposal 6 25.02 City/State/ZIP: SA,%J 4RA/1e4s(of cA 5 Y/oN Hose bib 25.02 Phone:(.Ors ) $7'L- 7-QQ•Q Fax:( ) Ice maker 12.51 "APPLICANT Er-CONTACT PERSON interceptor/grease trap 25.02 Medical gas(value:S ) Page 2 �y j3 Business name: 'o R nit ?I Vr•...am./(r Primer 0 12.51 Contact name: O.$-( AJJ flogL\It(LStenI Roof drain(commercial) 12.51 Address: i q i ri() Sv) C.P o L E (24' Sink/basin/lavatory O 25.02 g5--1,d,x, City/State/ZIP: rl- je 4t r^ . D it G 7 o 4 Z Solar units(potable water) 62.54 Phone:(co 3) (,,Q 2._ 4.(13 4 Fax::(co? ) &9 i ,Z JZ 8 Tub/shower/shower pan 12.51 E-mail: t_1 s-d S 0gA\( ?.M1A . f b/%t Urinal 25.02 (T Water closet 25.02 CONTRACTOR Water heater 37.52 3'7.s�„ Business name: RAN/CM R m S i)t..Wu pIji,• Water piping/DWV 056.29 Address: [ ei 9fi s` t e.ea L . t'Zd r Other: 25.02 City/State/ZIP: 'rJa^I4.iw Oft ei 0 L 2 Subtotal )75-13 Minimum permit fee: $72.50 Phone:(co) )_692 . e•ii34 Fax:( Yo3) bq (' 1.52i5 Plan review (25%of permit fee) CCU Lie.: -. 5 P. -Z Plumbing Lic.no.:j_(6�t Fi3 U V State surcharge(12%of permit fee) d/, 02 Authorized signature: TOTAL PERMIT£E Iq(r•Lc-- ''I This permit application expires if a permit is not obtained bin 180 days Print name: lrfel/ti Ls/Le ,W Date:�e n-tOZ L after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board, IaBuitdisgTemii4,PLMU-PcnniApp.doc 10'01.'09 440-4616T(10/02/COM/WEi) Tenant Name: LOYAL SOURCE Sewer Tally SWR# N/A PLM# 2022-00500 Site Address: 11740 SW 68TH PKWY T i e n It n Parcel#: 1 S136DD03400 Fixture 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 0 0 0 0 0 -Jacuzzi/Whirlpool 4 ° 0 0 0 0 Car Wash: -Each Stall 6 -Drive through 16 0 0 0 0 0 ° 0 0 0 0 Cuspidor/Water Aspirator 1 0 0 0 0 0 Dishwasher: -Commercial 4 -Domestic 2 0 0 0 0 0 1 0 0 0 0 0 Drinking Fountain 0 Eye Wash 10 0 0 Floor Drain/Sink: -2 inch 2 0 0 -3 inch 0 0 0 0 0 -4 inch 6 0 0 0 0 0 0 0 0 0 0 -Car Wash 6 Garbage Disposal: -Domestic(to 3/4 HP) 16 0 0 0 0 0 -Commercial(to 5 HP) 32 0 0 0 0 0 0 0 0 0 0 -Industrial(over 5 HP) 42 Ice Machine/Refrigerator Drain 1 0 0 0 0 0 16 0 0 0 0 0 Living Unit 0 Oil Sep(Gas Station) 6 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 0 -1 2 -Bradley 5 0 0 0 0 0 ° 0 0 0 0 -Com/Serv/Util-Food Related 3 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 0 Previous EDU Count 0 0 Capped EDU Credit 0 0 1 2 0 0 -1 -2 TOTALS 1 EDU= $6,625.00 Current Fixture Value -2 divided by 16= 0.725 Current EDU Previous Fixture Value 0 divided by 16= 0.000 Previous EDU Change -2 divided by 16= 0.125 over (under) $ (861.25) 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: ***CREDIT*** Authorized Name/Signature:BRANDEN TAGGART X2449 Date: 12/8/2022 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_6625_070122.xlsx