Permit (23) CITY OF TIGARD PLUMBING PERMIT
111
COMMUNITY DEVELOPMENT Permit#: PLM2023-00499
T f GAR J_j 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/28/2023
Parcel: 1 S134CB04600
Jurisdiction: Tigard
Site address: 12310 SW NORTH DAKOTA ST
Project: Kennedy Subdivision: ANTON PARK Lot: 8
Project Description: Replace water heater. Work by owner
Contractor: Owner: KENNEDY,JONATHAN&CARMEN
12310 SW NORTH DAKOTA ST
TIGARD,OR 97223
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Water Heater 11/28/2023 $37.52
Specifics: 1 12%State Surcharge- 11/28/2023 $8.70
Plumbing
Type of Use: SF 35 ea Minimum Fee Adjustment- 11/28/2023 $34.98
Class of Work: OTR Plumbing
Type of Const:
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: f�,te` �.�1(/ Permittee Signature:
/ Call 503.639.4175 by 7:00 a.m.for the next available inspecti 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 Applicirl.:� ;
Building Fixtures +fin FOR OFFICE,; USE ONLY
City of Tigard 40.,„ 2 2/23 Received �,/
' : Date/By: Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223Pl t1 �,g/� 23 +"/ p �1
Phone: 503.718.2439 Fax: 50 f 9OF TIGARD an Review
Date/By: Other Permit No.:
Inspection Line: 503.639.4175 G Ty Slob;
I I<,A IL f) 1 ����� � 1, s„ Date Ready/By: uris: ® See Page 2 for
Internet: www.tigard-or.gov
Notified/Method: 'i 12,
/ Supplemental Information
•,4A nY 6 a r `a t y ,. t w t' �, a .. a , •1 p �r 1 ,'i:
❑New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑Addition/alteration/replacement i/Other
� New 1-2-family dwellings(includes 100 ft.for each utility connection)
SFR 1 bath
312.70
❑ 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building ❑Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder Other: Fire sprinkler( sq.ft.) Pa e 2
„ x x r, ^' x e '''"'":"1.' g S
�� � Site utilities:
Job site address: (�`� 0 .5.. .d. J O` �A kI{ A 5,J Catch basin or area drain 18.76
y �, v it Qt "�3 Footing
1,leach line,or trench drain Page 2
City/State/ZIP: �'[�
Suite/bldg./apt.no.: Project name: /J
Footing drain(no.linear ft.:_) 2
d_r\s. t/✓tt��C/ fT-L�et -Q-'-^ 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
�� „..,,,,,,,,,„.. ..a .:.. , 7-r * :; Backwater valve 12.51
i:i k.' ,`_ .-.... : .7. . ,E . %" Clothes washer
K-il , 25.02
�'' - 1 1-x -t J1 �''t � ham,/�� Dishwasher
25.02
~ l q11 Jz m 1 y `9 Drinking fountain 25.02
Ejectors/sump 25.02
"'-) 77 _: Expansion tank 12.51
Name: -r.„ 4� ._ � / Fixture/sewer cap 25.02
Address: \f�� r\ A r1 y�� Floor drain/floor sink/hub 25.02
//f 3 f D �� . o' t '�1 b`�Nfl C� Garbage disposal 25.02
City/State/ZIP: 7j4j,7j
prL-- 7 2-2 3 Hose bib
25.02
Phone�(� , Fax ( ) Ice maker 12.51
�; ," r]4 Interceptor/grease trap 25.02
Business name: pok) W nit Page 2
Contact name: Primer 12.51
Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
�r �, " ;, Water closet 25.02
,r<,. . M . :. ;`Ott, .,.,.4 „ <' sd� ,fir' ',. . :* ',� Water heater 1 37.52
Business name: - 1 /5Ic-
//�") Water piping/DWV 56.29
Address:
Other: 25.02
City/State/ZIP: au)l wi Subtotal
Minimumpem,it fee: $72.50
Phone:( ) Fax:( )
Plan review (25%of permit fee)CCB Lic.: Plumbing Lic.no.:
"---- State surcharge(12%of permit fee)
Authorized signature: F TOTAL PERMIT FEE
Print name: \l U ti , ke---ii Y1,- // Date: ((I /n This permit application expires if a permit is not obtained within 180 days
/j� 111 after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\BuildingTermits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule:
�es> enh al <r aa Sup re ss>on Systems:
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 S stems:
Water Service-each additional 100' 37.52 t t
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
. .: ., 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* , o
Quantity by Fixture.Type Plan review is required for any of the following.
Fixture type for Replace/ Please check all that apply.
k l Wor erfprmed ' Capped Added Relocate" ❑ 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 ❑ 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"
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: -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 plumbing permit can be issued.
Water Closet-Toilet
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:
(12‹
I own, reside in, or will reside in the completed structure and my general contractor is:
ULt�i1 �.ev1n4X
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.
Print Name of Permit Applicant
u( 3
Signature of Permit Applicant Date
Permit#: FL-0 ► 001- - Gy 5 /
31 U �� ) �, _ •�.
Address: �a � vr�
Issued by: L�� Date: 1I/ /a 3 ti.i
This Copy for Permit Offices