Permit (3) CITY OF TIGARD PLUMBING PERMIT
1114 s COMMUNITY DEVELOPMENT Permit#: PLM2021-00188
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 6/24/2021
T f i;A li T.? 9 Parcel: 2S103DD00700
Jurisdiction: Tigard
Site address: 13769 SW PACIFIC HWY
Project: Dutch Bros Coffee Subdivision: None Lot: None
Project Description: Interior plumbing for a new coffee building:
Contractor: KOEHLER GENERAL CONTRACTING LLC Owner: GROUND 99 LLC
3336 COUNTRYMAN CIRCLE NW 610 SW ALDER ST STE 1221
ALBANY, OR 97321 PORTLAND, OR 97205
PHONE: 541-231-6009 PHONE:
FAX:
FEES
•
Quantity Description Date Amount
1 ea Backflow Preventer 06/15/2021 $31.27
Specifics: g ea Floor Drain/Floor Sink/Hub 06/15/2021 $225.18
1 ea Ice Maker 06/15/2021 $12.51
Type of Use: COM 1 ea Interceptor/Grease Trap 06/15/2021 $25.02
Class of Work: NEW 1 ea Rain Drain-Single Family 06/15/2021 $12.51
Type of Const: Dwelling
Occupancy Grp: 4 ea Sink 06/15/2021 $100.08
Stories: 1 ea Water Closet 06/15/2021 $25.02
1 ea Water Heater 06/15/2021 $37.52
1 Plan Review 06/15/2021 $117.28
1 12%State Surcharge- 06/15/2021 $56.29
Plumbing
Total $642.68I
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 952-001-0010through 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: 4714fC j/?‘G
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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Plumbing Permit Application g L - (J
Building Fixtures ������� FOR OFFICE osh: ONLY
Received n
City of Tigard Date/By: 5 L� 1' Permit No.: 4 .),1_ / j
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review et
/ V O
1 C ' Phone: 503.718.2439 Fax: 503.598.1960 OZt Other Remit (^ ,
MAY 4 Z Date/By: 6 $ �� ACG, P.�UaI-
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I T i c.n Rn Inspection Line: 503.639.4175 Date Ready/By: r rare: ® See age z for
Internet: www.ti and-or. ov /
g g NotifiedRvfethod: f✓ j Supplemental� ARU �rr/a �r ram_
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TYPE OF WORK80 "" _qB,*, fAEDLLE
�} >k'hr,n>L2•i �1'lrri} ct _ _
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
% CI 1-and 2-family dwelling .Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
• ❑Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
\\- CI Master builder El Other: Fire sprinkler(_sq.ft.) Page 2
yy ripp JOB SITE INFORMATION AND LOCATION Site utilities:
lk' Catch basin or area drain 18.76
Job site address '55 W Pacific Hwy
City/State/zip: Tigard, OR 97224 Drywell,leach line,or trench drain 18.76
'a Footing drain(no.linear ft.: ) Page 2
d Suite/bldg./apt.no.: Project name: Dutch Bros. Coffee 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
`sik'
Storm sewer(no.linear ft.: Page 2
Water service(no.linear ft.: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.: )� ,, !� y. Backflow preventer 1 31.27 31.27
SIC �n17t '
DESCRIPTION OF WORK Backwater valve 12.51
\' . . Clothes washer 25.02
Plumbing fixtures for new Dutch Bros. Coffee building. Install coffee
O production equipment and single occupant restroom. Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
II PROPERTY OWNER - Expansion tank 12.51
Name: Ground 99 LC Fixture sewer cap 25.02
Floor drain/floor sink/hub 9 25.02 225.18
Address: 13640 Birdshill Rd Garbage disposal 25.02
Cityistate/zIP: Portland, OR 97219 Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 1 12.51 12.51
❑ APPLICANT ':. CONTACT PERSON Interceptor/greasetrap 1 25.02 25.02
N Business name: Studio 3 Architecture, Inc. Medical gas(value:$ ) Page 2
Primer 12.51
in Contact name: Matt Johnson
Roof drain(commercial) 1 12.51 12.51
NAddress: 275 Court St NE Sink/basin/lavatory 4 25.02 100.08
-Z city/state/zIP:Salem, OR 97301 Solar units(potable water) 62.54
/:V.sPhone:(503) 390-6500 Fax::( ) Tub/shower/shower pan 12.51
1 Urinal 25.02
E-mail: matt@studio3archtitecture.com
Water closet 1 25.02 25.02
CONTRACTOR Water heater 1 37.52 37.52
Business name: • n r' 6-!{1ftrefI. Water tin WV 56.29
PP P�
Address: a 709 NE Cot��f... Blvd 3336 Coen if� w'y ere/r Metier; 25.02
City/state/zIP;.€e,ivullia, OR 97330 ' bf/47c�. 0K 774A/ subtotal 469.11
chi- 72.50
Phone:(5.41 ) 224-825724 4.0,- ( ` ) (i/.z,3 Minimum permit fee:permit fee)
Fax: 7
CCB Lie.: 20.0,35 . ?C13L 4' i Plumbing Lie.no.: '5lG Plan review ( 2%ofpermitfee) $56. 98
v\ State surcharge(12%of permit fee) $56.29
Authorized signature: //1 TOTAL PERMIT FEB $642.68
Print name: //vv Date: This permit application expires if a permit is not obtained within 180 days
Matt Johnson 5/4/2021 after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
11B11i1ding\Permits\PLMU-PennttApp.doc 10/ti/09 440-4616T(10/02ICOM/WEB)
It ilii I;QCp i nic r-e..i-t.
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 S121.90
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' 62s4 Medical Gas Systems:
Water Service-each additional 100' 37.52 a
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) rural additional
$100r fraction thereof,toeaainclud g 00o
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 El Any new commercial building with water service 2"and
Bath: -Tub/Shower greater,except systems designed and stamped by licensed
engineer.
-Jacuzzi/Whirlpool
ElCar Wash: Each Stall New exterior plumbing site utilities for any complex structure
Drive 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 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"
MEC9Isometric or Riser Diagram
9 d 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 1
-Bradley
-Com/Serv/Util food related 2
-Service 1 *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 1 plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doe 08/04/2011 2
Accumulative Sewer Tally
II p Tenant Name: DUTCH BROS COFFEE SWR# 2021-00145
TIGAFtD Site Address: 13769 SW PACIFIC HWY PLM# 2021-00188
Parcel#: 2S103DD00700
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptisery/Font 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher: -Commercial 4 0 0 0 0 0
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 0 0 0
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 9 54 9 54
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/41IP) 16 0 0 0 0 0
-Commercial(to 5 I IP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 0
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 0 0 0
Rec.Vehicle Dump station 16 0 0 0 0 0
Shower: -Gang(per head) 1 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 1 2 1 2
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 3 9 3 9
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 1 6 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 14 71 14 71
Current Fixture Value 71 divided by 16= 4.438 Current EDU 1 EDU= $5,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 71 divided by 16= 4.438 over (under) $ 25,752.00
Enter EDU Change Here 4.440
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 6/15/2021
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I:\Building\Sewer Tally\ScwcrTallyShcct_5800_070119.xlsx