Permit (10) CITY OF TIGARD
�Z� PLUMBING PERMIT
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COMMUNITY DEVELOPMENT Permit#: PLM2013-00315
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/12/2013
Parcel: 1 S136DA00800
Jurisdiction: Tigard
Site address: 11538 SW PACIFIC HWY
Project: Black Rock Coffee Bar Subdivision: PFAFFLE PLAZA CONDO Lot: 2
Project Description: Connect new pre-fab coffee drive-in to site utilities,sewer,storm&water. 11/13/13: REPRINTED to add(1)
backflow device. 11/20/13,reprinted to correct address from 11540 to 11538 SW Pacific Hwy.
Contractor: PORTLAND ROAD&DRIVEWAY CO INC Owner: HIGH HAT RESTAURANTS, INC
10500 SE JENNIFER ST 11530 SW PACIFIC HWY
CLACKAMAS, OR 97015-9511 TIGARD,OR 97223
PHONE: 503-650-5006 PHONE:
FAX: 503-650-8022
FEES
Quantity Description Date Amount
100 If Sewer Service 09/12/2013 $62.54
Specifics: 100 If Storm and Rain Drain 09/12/2013 $62.54
100 If Water Service 09/12/2013 $62.54
Type of Use: COM 1 ea Backflow Preventer 11/13/2013 $31.27
Class of Work: ALT 1 12%State Surcharge- 11/13/2013 $26.27
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $245.16
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
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: C 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.
• 'I,
CITY OF TIGARD I PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2013-00315
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/12/2013
Parcel: 1S 136DA00800
Jurisdiction: Tigard
Site address: 11540 SW PACIFIC HWY
Project: Black Rock Coffee Bar Subdivision: PFAFFLE PLAZA CONDO Lot: 2
Project Description: Connect new pre-fab coffee drive-in to site utilities,sewer,storm&water. 11/13/13: REPRINTED to add(1)
backflow device.
Contractor: PORTLAND ROAD& DRIVEWAY CO INC Owner: HIGH HAT RESTAURANTS, INC
10500 SE JENNIFER ST 11530 SW PACIFIC HWY
CLACKAMAS, OR 97015-9511 TIGARD, OR 97223
PHONE: 503-650-5006 PHONE:
FAX: 503-650-8022
FEES
Quantity Description Date Amount
100 If Sewer Service 09/12/2013 $62.54
Specifics: 100 If Storm and Rain Drain 09/12/2013 $62.54
100 If Water Service 09/12/2013 $62.54
Type of Use: COM 1 ea Backflow Preventer 11/13/2013 $31.27
Class of Work: ALT 1 12%State Surcharge- 11/13/2013 $26.27
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $245.16
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
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
/le ew ef- re)e./ee9-7-70^7
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.
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POKTLAND
AND DRIVEWAY COMPANY INC.
FAX TRANSMITTAL
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Number Of Pages (Including Cover Sheet)!
1 0500 S.E. Jennifer Street
Clackamas, Oregon 97015
Phone (503) 650-5006 Fax (503) 650-8022
CCB #2271
CITY OF TIGARD PLUMBING PERMIT
a: COMMUNITY DEVELOPMENT Permit#: PLM2013 00315
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/12/2013
Parcel: 1 S136DA00800
Jurisdiction: Tigard
Site address: 11540 SW PACIFIC HWY
Project: Black Rock Coffee Bar Subdivision: PFAFFLE PLAZA CONDO Lot: 2
Project Description: Connect new pre-fab coffee drive-in to site utilities,sewer,storm&water.
Contractor: PORTLAND ROAD& DRIVEWAY CO INC Owner: HIGH HAT RESTAURANTS, INC
10500 SE JENNIFER ST 11530 SW PACIFIC HWY
CLACKAMAS, OR 97015-9511 TIGARD, OR 97223
PHONE: 503-650-5006 PHONE:
FAX: 503-650-8022
FEES
Quantity Description Date Amount
100 If Sewer Service 09/12/2013 $62.54
Specifics: 100 If Storm and Rain Drain 09/12/2013 $62.54
100 If Water Service 09/12/2013 $62.54
Type of Use: COM 1 12%State Surcharge- 09/12/2013 $22.51
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $210.13
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
or direct qu UNC by calling 503.232.1987 or 1.800.332.2344.
Issued y: 1 Permiftee Signature: /I}.
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 • . "EIVED rc)R t)hr'Ir.l: use, ()Nix
Received
City of Tigard 9 Permit No.: ,
71
S-
ol 13125 S W Hall Blvd.,Tigard,OR 97223,,- 1 9 f:
Date/By: 3 /`�p�o f 3-06 3 S
C Phone: 503.718.2439 Fax: 503.598.1900 J 1 Plan Review Other Permit No.: /�
Date/By: ,W2.90/3-60/ y
T I G A R D Inspection Line: 503.639.4175 TIGARD Date Ready/By: lutist El See Page 2 for
Internet: www.tigard-or.gov CITY OF Notified/Method: Supplemental Information
TYPE OF wadi DING DIVISION 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 ❑Cornmerciallindustrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
Each additional bath/kitchen 25.02 Q
❑Master builder ❑Other: Fire sprinkler(-_sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities: W
Job site address: (I`�'10 SW .P W1- 17w Catch basin or area drain 18.76 Q
Drywell,leach line,or trench drain 18.76
City/State/ZIP: 7c2.1 pl , Q 7--ti Footing drain(no.linear ft.: ) Page 2 '�.
Suite/bldg./apt.no.: J Project name: /pit 4p4' Manufactured home utilities 50.03 v
t,,
r
- --Cross-street/directions to-job site: Manholes 18.76 W-
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:/00) Page 2 6,2.5-5,
- - Storm sewer(no.linear ft.:/DO) Page 2 epp,.59
Water service(no.linear ft.:/0) Page 2 (PA Sy
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
(DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
3,1h-.l vtil-- f/(C'C,b cvEdee 0"1/-
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
O:_PROPERTY,OWNER; I ❑'TENANT • Expansion tank - 12.51
Fixture/sewer cap 25.02
Name: 3Akj Sp (1L,,,A7-✓
Floor drain/floor sink/hub 25.02
Address: ( 3 G tI . 14,-(/ v` i
Garbage disposal 25.02
City/State/ZIP: bq k, Ii svgs ' ;OK. 4 103 6" Hose bib 25.02
Phone:(d)03) 1170-1 S1-6 Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
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
CONTRACTOR 1 Water closet 25.02
Water heater 37.52
te
Business name: for+(,-of (ZpaJ APr,m.N-.7 rat, Waterpiping/DWV 56.29
Address: /0 ' O 0 - 6-- ieviv (,r s 7 Other: 25.02
City/State/ZIP: C t-,,c,s 70 t2 ‘00 15 Subtotal /g7.6,9
Phone:(,i5) (a 50 -1,00 6 Fax:( ) Minimum permit fee: $72.50
CCB Lie.: Z Z yZ/ Plumbing Lic.no.: Pg-? Plan review (25%of permit fee)
///1 State surcharge(12%ofpermit fee) ,2 51
Authorized signature: \1 elite 304 _-., TOTAL PERMIT FEE A1().13
/ This permit application expires if a permit is not obtained within 180 days
Print name: Date:
4 / Z// after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
1:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
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-151 100' 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
Storm&Rain Drain-1st 100' 62.54 Valuation: Permit Fee:
$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
P 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: 1 ,Ur � /J - ` -t�J
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to CSC
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 ❑ Any 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 ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040. •
Cuspidor/Water Aspirator ❑ Medical 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
❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage Domestic non-food 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: -LavBar 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 fees assessed for the sewer increase must be paid before the
Water Extractor
WaterCloset-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
•
Location:
Record Type:
Inspection Type:
Comments:
Inspection Date:
Record ID:
Result:
City of Tigard
13125 SW Hal Blvd.
Tigard, OR 97223 Tel: 503.718.2439
11538 SW PACIFIC HWY, TIGARD, OR, 97223
Commercial - Plumbing
399 Plumbing final
2013-11-20 00:00:00
PLM2013-00315
PASS - No C of O
Building Codes sticker #1020942, prefabricated building approval noted.
Violation Summary:
Inspector Contractor