Permit Support Document (43) FOR OFFICE USE ONLY—SITE ADDRESS:
This form is recognized by most building departments in the Tri-County area for transmitting information.
Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Il Transmittal Letter
T I GA R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: Par 1 (V e4 f eV DATE RECEIVED:
DEPT: BUILDING DIVISION RECEIVED
FROM: P',t .t ( Pd-v oe(e- NOV 2 1 2022
COMPANY: Totkreati,rc1{'i 4 of 44,7
aC CITY OF TIGARD
BUILDING DIVIS (JJ,
PHONE: o 3'e7 " ` i6I
EMAIL: pe.e ?eft.etrei4 ; f-c cis. Ct.rv)
RE: (a;3 7 �1a1 /ai n LM a-a a-.)-- o o t-{a ,
(Site Address) (Permit Number)
74V74 De Val op - -r
(Project name or subdivision nam and lot number)
ATTACHED ARE THE FOLLOWING ITEMS:
Copies: Description: Copies: Description:
Additional set(s) of plans. Revisions:
Cross section(s) and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
Beam calculations. Engineer's calculations.
Other(explain):
REMARKS: �e55.-5e +p r -v;4.1,4) ('>r+I tit-
FOR OFFICE USE ONLY
Routed to Permit Technic' n: Date: Initials: L.J0
Fees Due: ❑ Yes No Fee Description: Amount Due:
$
Special
Instructions:
Reprint P-iniit (per PE): ❑Yes ❑ No ❑ Done
Applicant Notified: Date: Initials:
I:\Building\Forms\TransmittalLetter-Revisions 073120.doc
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
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: Capped Added Relocate
Baptistry/Font ElAny new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall 0 New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor Water Aspirator ElMedical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ 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
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
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -LavBar 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
Water Extractor fees assessed for the sewer increase must be paid before the
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:1Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
Plumbing Permit Application
Building Fixtures FOR OFEICl: rs►: ONLY
Received
City of Tigard Permit No.:PIM,jp]k_Qpy;le,
Date/By:
II la13125 SW Hall Blvd.,Tigard,OR 97223 PnRcv
--I Phone: 503.718.2439 Fax: 503.598.1960 Plan Review
Date/BY: "�r"Q-a qte 241.5 'ra./^.S Other Permit No.:
T 1 c I n li I) Inspection Line: 503.639.4175 Date Ready/By: )aris: VISee 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. 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-family dwelling IDConunercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building gMulti-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
Job site address: 5i17 S.(Si ma:n St Drywell,leach line,or trench drain / 18.76 /g 76
City/State/ZIP: -r- &- .1 OR.. 1�,13
Footing dram(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: I Project name: AV A M 1 is e& Ids a. 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 31.27
DESCRIPTION OF WORK Backwater valve 12.51
.r / Clothes washer )2, 25.02 550,yV
J-hhe i ay• PI40..6;Kt Dishwasher �5 25.02 625,g0
d Drinking fountain 25.02
Ejectors/sump / 25.02 25,0A
0 PROPERTY OWNER I ❑ TENANT Expansion tank 25 12.51 312.75
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub IL. 25.02 li(Rrj.32.
Address: Garbage disposal aa. 25.02 550-Y9
City/State/ZIP: Hose bib el 25.02 too,09
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 1 25.02 25,00,
Business name: Medical gas(value:$_) Page 2
Primer 3 12.51 37 53
Contact name:
Roof drain(commercial) 8 12.51 100,08
Address: r4Sink/basin/lavatory 63 - 25.02 /574,'
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/showerpan ;0, , 12.51 295,'L
E-mail: Urinal 25.02
Water closet a 6 25.02 60,52
CONTRACTOR
Water heater 15 37.52 9?8,0<z,
Business name: Water PFFlD
tP m WV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal �/8�r.clq
r
Phone:( ) Fax:( ) Minimum permit fee: $72.50
Plan review (25%of permit fee) 1.04,.4E___
CCB Lic.: Plumbing Lic.no.:
State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE %1r,frt)..__
Print name: Date: This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
\ "i�QU`Fee methodology set by Tri-County Building Industry Service Board.
I:Building\PermitslPLMU-PermitApp.doc 10,01/09 440-46I6T(10/02/COM/WEB) Ns,
VI
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 l0 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
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:
1
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 I Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
Baptistry/Font ElAny new commercial building with water service 2"and
Bath: Tub Shower a`� greater,except systems designed and stamped by licensed
-Jacuzzi/Whirlpool engineer.
ElCar Wash: Each Stall New exterior plumbing site utilities for any complex structure
-Drive Thru as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ElMedical gas and vacuum systems for health care facilities. 1
Dishwasher: -Commercial 3 ❑ Any multipurpose fire sprinkler system.
-Domestic /a ❑ 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" /6 Isometric or Riser Diagram
4' ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage -Domestic non-food +�a 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: -Lay/Bar non-food related
-Bradley
-Com/Serv/Util food related f
-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 -4 fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet ,, L. , plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
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
2,001 to 3,600 $169.69
Footing drain-each additional 100' 37.52 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
Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
Other Inspections or Fees 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
each additional$100.00 or fraction thereof.
(minimum charge-1/2 hour)
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 0 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 ❑ New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Thru 0 Medical gas and vacuum systems for health care facilities.
Cuspidor/Water Aspirator ❑ Any multipurpose fire sprinkler system.
Dishwasher: -Commercial ❑ Any complex structure as defined in OAR918-780-0040.
-Domestic
Drinking Fountain Submit 2 sets of plans with any of the above.
Eye Wash
Floor Drain/sink: -2"
3•• Isometric or Riser Diagram
0 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: -LavBar 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 plumbing permit can be issued.
Water Closet-Toilet
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
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