Permit (17) CITY OF TIGARD PLUMBING PERMIT
11/1
COMMUNITY DEVELOPMENT
Permit#: PLM2023-00224
Date Issued: 6/8/2023
T I i A R L) 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 2S111 BD00315
Jurisdiction: Tigard
Site address: 9850 SW PEMBROOK ST
Project: Bartoletta Subdivision: PEMBROOK HEIGHTS Lot: 5
Project Description: Relocated hose bib, 1 sink, 1 shower valve and re-pipe whole house.
Contractor: Owner: BARTOLETTA, FRANK V III
9850 SW PEMBROOK ST
TIGARD, OR 97224
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
ea Hose Bib 06/08/2023 $25.02
Specifics: 1 ea Sink 06/08/2023 $25.02
1 ea Tub/Shower/Shower Pan 06/08/2023 $12.51
Type of Use: SF 56 Misc Other Fee 06/08/2023 $56.29
Class of Work: ALT 1 12%State Surcharge 06/08/2023 $14.26
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $133.10
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
Received j �//� Permit No.: �m✓J�9--- •
111 City of Tigard Received
i / /�f j A�
■ 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Other Permit No.:
11 Phone: 503.718.2439 Fax: 503.598.1960 Date/By:
Inspection Line: 503.639.4175 Date Ready/By: )uris: ®See Page 2 for
T I G n i i> Notified/Method: Supplemental Information
Internet: W Ww tlgard or gov � , �( �' s_ IPA', ;�(% t F)[E t.;p;. . r,.z,..�
n � �. c For special information use checklist
0 New construction 0 Demolition Description I Qty. I Ea. I Total
pit Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
SFR(1)bath 312.70
,`� - -;c [ cre)� / r� :Ec) 1)`r;4LA( r� t ,::� 437.78
SFR(2)bath
In -and 2-family dwelling 0 Commercial/industrial- 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
J :,'>i( t` ,La`.7‘it\'t J ,ti,b E ` '1 IC1i'°` Site utilities:
Catch basin or area drain 18.76
Job site address: 1 'i Us 5 t,A.) t'3'`r A 1),�e,, 74- Drywall,leach line,or trench drain 18.76
City/State/ZIP: ,:iz-;'A (L' , t( ' Footing dram(no.linear ft.:_) Page 2
J
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: j 'k,,..i 111 AVL> Manholes 18.7618 76
Rain drain connector
Page Sanitarysewer�mo.ainearft.:_,J__--- - 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
`1 t�s 7-c`7 xs cc)�r -1 ; 0.Cz
Clothes washer 25.02
yy ,1.r 25.02
- .h.c.Z t ( t L\ &t 2CL1 •5 v)"ti j i 11 (-6,,}t 1 �g e Dishwasher
t j ° Drinkingfountain 25.02
,(y`( �jil:�e.t."�' v t`vl� °�"'lG'' G"`tr Ck "i �tK 25.02
Ejectors/sump
t 1 • ,1 t). ` 4 •
r Expansion tank • 12.51
c)r • c t
��t ` '�hl ' � � Fixture/sewer cap 25.02
Name: c,r tvi V ��rm 'l;�'t:` � Floor drain/floor sink/hub 25.02
Address: 25.02
q `S. ,`, <� rev,4 yiit: (-!1- -7'� Garbage disposal
(J R. ci '7 Z 2-4 Hose bib 25.02
City/State/ZIP: � t)�1�L l
( Ice maker 12.51
Phone:( ) 't G t Fax ) ' Interceptor/grease trap 25.02
A.. r 7 E:\AI @ , a ''' .. -, et---' - r .�d', --'-' , Medical gas(value:$ ) Page 2
e
Business name: Primer 12.51
Contact name: Roof drain(commercial) 12.51
Address: Sink/basin/lavatory ton 25.02
Solar units(potable water) 62.54
City/State/ZIP: 12.51
1„.Phone:( ) 1 Fax::( ) Tub/shower/shower pan �Urinal 25.02
E-mail: ti Water closet 25.02
` ` ) 'e c�U r`; r c x„.51'' v M'' ' `.W: Water heater 37.52
Business name: ,riIR i-D 0l� N r- Water piping/DWV 56.29
Other: 25.02
Address: Subtotal
City/State/ZIP: Minimum permit fee: $72.50
I Phone:( ) Fes'{ ) Plan review(25%of permit fee)
CCB Lie.: Plumbing Lic.no.: State surcharge(12%of permit fee)
TOTAL PERMIT FEE `�,1
Authorized sign re:
/Print name L� /' This permit application expires if a permit is not obtained withi 180 days
�- I Date: Qj `G2 after it has been accepted as complete.
i",/
°Fee methodology set by Tri-County Building industry Service Board.
1:1Building1Permits\ELMU-PermitApp.doc 10/01/09 4404616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 -Supplemental Information
Fee Schedule: Residentialn Fire Su i i ression S stems:
t„_>j C�'!�{ „�Y,l�-* $Oz• 't, tF'p Y �y. 1
f G„r ++,r�-1�:� F •€ �;..�5`..s 1.,:-.�-5�'w:.,', _ ..,! is 1t�K�;e.n� ` � . .
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 14 eater $327.54
Sewer-each additional 100' 37.52
Water Service-1st 100' 62.54 Medical Gas S stems:
Water Service-each additional 100' 37.52 X
. r"t, •
Storm&Rain Drain-1st 100' 6254 } :s
_ $1.00 to$5,000.00 Minimum fee$72.50
Stoma&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
77(1x lY.ii 4113 � .3ti.,a°t jT' ��i1x ,.f 1.f
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 char:e-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 char:e-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 $74each a 0 for the first$50,000.00orfraction
and$1.20 for
minimum char:e-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*.
�,,, @"ii`anNtf► ,pe, ? Plan review is required for any of the following.
F�ztrire �e,4dr . "a xti ' WOW Please check all that apply.
�iVO It PErfo7 iea r '._ #` ;i5 _. ear • G +a Riasgle+,..
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 0 New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Thru
W 0 Medical gas and vacuum systems for health care facilities.
Cuspidor/Water Aspirator Dishwasher: -Commercial al ❑ Any multipurpose fire sprinkler system.
❑ Any complex structure as defined in OAR918-780-0040.
Domestic
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2" s P
4" ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the •ualifications 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 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:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
Property Owner Statement
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
I 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.
r
rr avaL 6Ckl"-id Acipt.
Print Name of Permit Applicant
�� 6—g - 2-U -3
Si ature of Pe mit Applicant Date
Permit#: .1
; .
Address:, '°‘°iri%:i:
‘01
Issued by: Date: [ t 3
This Copy for Permit Offices
'= 4* Information Notice to Owners About
Construction Responsibilities
(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, call 503-945-8091 or go to
http://www.oregon.gov/DOR/BUS/docs/211-055.pdf for the appropriate forms.
• 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 503-947-7815.
• 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, call the IRS at 1-800-829-4933 or visit their website at 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 9-23-08 This Copy for Permit Applicant