Permit (4) CITY OF TIGARD PLUMBING PERMIT
'PI 8 COMMUNITY DEVELOPMENT Permit#: PLM2023-001 1 5
Date Issued: 3/27/2023
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 1S134CD03900
Jurisdiction: Tigard
Site address: 12020 SW 121ST AVE
Project: CEBULA Subdivision: LERON HEIGHTS NO.3 Lot: 69
Project Description: (1)shower pan for new tile shower.
Contractor: OWNER Owner: CEBULA, KENNETH P&LISA WAI YIN
12020 SW 121 ST AVE
TIGARD,OR 97223
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Tub/Shower/Shower Pan 03/27/2023 $12.51
Specifics: 1 12%State Surcharge- 03/27/2023 $8.70
Plumbing
Type of Use: SF 60 ea Minimum Fee Adjustment- 03/27/2023 $59.99
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total S81.20
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 Application
Building Fixtures FOR OFFICE USE ()NIX
Received
City S Tigard Date/By: O
370 r/�', Permit No.:� ?an au t 5
IN13125 SW Hall Blvd.,Tigard,OR fiEIVEC tc Plan Review Other Pernvt No.:
■ Phone: 503.718.2439 Fax: 503. Date/By:
Inspection Line: 503.639.4175 Date Ready/By: huts ®See Page 2 for
T I�,A I D Notified/Method < Si. lemmata'Information
Internet: wvnv tigard or gov ,
y., . s L�KJ ' h,�,. . r0' .t" t I)ii.1„4
.
For special injorntmion use checklfcL
0 New construction ❑trriotr
Ilurvnr Description I Qty. I Ea. I Total
RI Addition/alteration/replacement U:ittll DING DIVISION New 1-2-family dwellings(includes 100 ft.for each utility connection)
(1) .7
L K s 7 n kTt ai- c1 Aa til't'::, i. I r.•, SFR bath 0
312 312.7
g ' l SFR(2)bath
437
8
1-and 2-family dwelling 0 Commercial/industrial SFR(3)bath 500.32
Accessory building 0 Multi-family Each additional bath/l itchen 25.02
❑Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2
.;t' --t .?r � , •,,,- , ,,,os _ Site utilities: 18.76
1� S 1 CatchC basin or area drain
Job site address: _� ' ��p24✓yu� ell,leach line,or trench dram 18.76
City/State/ZIP: 1 ( ct� lJ[� J t 2 2 Footing drain(no.linear ft.:_) Page 2
Suite/hidg./apt.no.: J I Project name: I c.1 Manufactured home utilities 50.03
1 I2/t A v. I,'UA Manholes 18.76
Cross street/directions to job site: V•, 18 76
Rain drain conwer(no.r linear- ��I� - tom" 'v' - -- 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:
Backflow preventer 31.27
Tax map/parcel no.: • Backwater valve 12.51
25.02
r .. s, IFAT•_=�,,r--,--- Clotheswesher
Y (6-(/(0,3 ' )cktllfIl Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Expansion lank • 12.51
,03I :II t c) - '� i( °�1_. Fixture/sewer cap 25.02
Name: Y..yr)K,n,Qkh C,e)b t I a._ Floor drain/floor sink/hub !✓ 25.02
Address: t 9-02N SL 12.1. > n Garbage disposal 25.02
2 Hose bib 25.02
City/State/ZIP: �i ��� Q� }2�J Ice maker 12.51
Phone:(150)) ?i.-,jb Fax:( ) 25.02
li r v-t s:` we Interceptor/grease trap
+i± xC� ! (Fu s� y �t
.s Medical gas(value:$ ) Page
Business name: Primer 12.51
Contact name: V.4/1-41-ekK, CP„A I Roof drain(commercial) 12.51
i
Address: `2c'20 S. «iI" - Sink/basin/lavatory 25.02
City/State/ZIP: -[i Solar units(potable water) 62.54
6�.Lt (`� �l�ZZ3
Tub/shower/shower pan 1 12.51 12' S(
Phone:( ) U` G1 O$ I Fax::( ) Urinal 25.02
E-mail: tC
trail: ( �1 �� K Water closet 25.02
$'�- -e. �' :,' r:,,- r t s, c A' Water heater 37.52
Business name: (' as ova(( Water piping/DWV
Address:
Other: 25.02 S-1
Subtotal IA
-
Other. Minimum permit fee: $72.50 72-5'0
Phone:( ) Fax:( ) Plan review(25%of permit fee) /< /3
CCB Lic.: Plumbing Lic.no.: State surcharge(12%of permit fee) - "
Authorized signature: TOTAL PERMIT FEE 4 ,, .?3
,---Print name: Date: 1z7/23 This permit application expires if a permit is not obtained within ISO days
�j after it bas been accepted as complete.
'Fee methodology set by Tri-County Building Industry Service Board.
I\Build InglPerrnits/PLMU.PerrtdiAlry.dac 10/01/09 490-06161(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 -Supplemental Information
Fee Schedule: Residential Fire Su t r ression S stems:
yp,r • '. Yij
x. ., ... tf;..+_ �ttt,i A��ISr~', -.�� .1'_}�Sd'•'.";'^: it%I'l.Lt9�S�w '�r'. .�. »A$'.au".=,.5 .,"g..
Footing drain-1"100' 50.03 0 to 2,000 $121.90
Footing drain-each additional 100' 37.52 2,001to 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-let 100' 62.54 Medical Gas S stems:
Water Service-each additional 100' 37.52 sii.xr'R
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
Ar, "s t),�� #:1��'1'` - r js:.' each additional$100.00 or fraction thereof to
t t�C,�j¢ e t # `2 .r I . , fa 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*. '.7*--ohlivoronrmirimiviltly677.
3 Qt7auNty2�ttc�7ype '1 Plan review is required for any of the following.
t €, `
,411!.0271 Please check all that apply.
t*OlRPe"rfol4iu}ed ` s'c8 ee r c� Rebcale .
• � ❑ Any new commercial building with water service 2"and
Baptistry/Pont greater,except systems designed and stamped by licensed
Bath: -Tub/Shower engineer.
-Jacuzzi/Whirlpool ❑ New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Tluu
Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities.
Dishwasher. -Commercialirator ❑ Any multipurpose fire sprinkler system.
Domestic El 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" 3xsrac 9X14 yJ 51f ` i'C4•
4" ■ Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Comments regarding fixture work:
Ice Mach./Refrig.Drains
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -1 av/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:
I:1Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
Property Owner Statement
p Y
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
LSa Cbc
Print Na of Permit A cant
II7
Signa ermit Applicant Date
Permit#: A_�.,2tj13`-00!! . F
Address: (.LO? J _' /?/ �`r'
Issued by: r> Date: �/j7/1"3
This Copy for Permit Offices
ti. Information Notice to Owners About
Iw,.I:er`4VM° Construction Responsibilities
r "'�::
�'' (ORS 701.325 (3))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503-378-4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503-947-1488.
• Oregon's Business Identification Number(BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, go online to the Oregon Business
Registry. For questions, call 503-945-8091.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 800-452-0288.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, go online to www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough-in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
PO Box 14140, Salem, OR 97309-5052
Telephone: 503-378-4621 —Fax: 503-373-2007
Website Address: www.oregon.gov/ccb
f/property owner adopted 9-2016 This Copy for Permit