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n CITY OF TIGARD PLUMBING PERMIT
` s COMMUNITY DEVELOPMENT Permit#: PLM2021 00482
Date Issued: 12/2/2021
Tr GA R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 1 S 135BD00100
Jurisdiction: Tigard
Site address: 9600 SW OAK ST 500
Project: Lifestance Health Subdivision: ASHBROOK FARM Lot: 5
Project Description: Interior plumbing for TI:CAPPING(1)sink;ADDING(2)ice makers and(1)water heater;and REPLACING(1)sink
and(1)hub.
Contractor: ICON PLUMBING LLC Owner: KING CAPITAL INVESTMENTS LLC
1415 WISTERIA RD ATTN KING, THOM
WEST LINN, OR 97068 19250 NE PORTAL WAY
PORTLAND, OR 97230
PHONE: 503-539-4151 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Fixture/Sewer Cap 11/30/2021 $25.02
Specifics: 1 ea Floor Drain/Floor Sink/Hub 11/30/2021 $25.02
2 ea Ice Maker 11/30/2021 $25.02
Type of Use: COM 1 ea Sink 11/30/2021 $25.02
Class of Work: ALT 1 ea Water Heater 11/30/2021 $37.52
Type of Const: 1 12%State Surcharge- 11/30/2021 $16.51
Occupancy Grp: Plumbing
Stories:
Total $154.11
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: H04.1.4d Va.o.. De 1,Al Permittee Signature: Ow A
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 Applica iECEIVED Go
Building Fixtures 1()N OI I1( 1 I SI (1\I 1
NOV 3 ZUL I11
R4•eeived
City Tigard oatea,,: t ay l f `1 0q
S
13125 SW Hall Blvd.,Tigard.OR 9.+Mi}j'�/ e p
e Phone: 503.718.2439 Fax: 503.5,a. 6b OF I uAR� Plaelty: ss
Inspection Line: 503.639.4175 I ILDING ^ Date'Bv: /6 ' '� L-p2
TIC]!1R17 1U DIVISIO'` DateReadyiR) - ® See Page 2tor
Internet: w-ww.tigard-or.gov Notified Meth �//�i�� , Supplemental information
TYPE OF WORK FEE* SCHEDULE
For special information use checklist.❑Nev.construction ❑Demolition
Description 1 Qty. 1 Ea. 1 Total
ddition'alteration tLpi,i cman: ❑Uth,:i New I-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
ID 1-and 2-family dwelling I XCommercial.industrial SFR(2)bath _- 437.78
SFR(3)bath 500.32
❑Accessory building 0 Multi-family
- Each additional bath'kitchen 25.02
❑Master builder , ❑Other: -
Fire sprinkler(_sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Joh site addles:q 1..c G 0 Ste' OCX k S„I --" Catch basin or area drain 18.76
--- ' Drywell,leach line,or trench drain I8.76
City/State LIP: T\ 9 Ct- r Ci I 0 R. "! 1-7-2-3 j
Footing drain(no.lin=11.: ) Page 2
Suiteibldg.iapt.no.: V)U Project name: L .�5 4.,u kUir:L _t -.1 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear fi.:_I Page 2
Storm sewer(no.linear It:_1 Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map parcel nit.: Backflow presenter 31.27
DESCRIPTION OF WORK Bnckwatervale 12.51
1.- - - ` - _ - Clothes washer 25.02
•`- 2-S k^ ci A- VN1/H • O"A~ t''' 4 -i Dishwasher 25.02
S k CNN , . l1^44.f 2-•l our*-cif S ,4 1 1.I4 I•-1 Drinking fountain 25.02
Ejectors`sump 25.02
❑ PROPF'it_I l (PAN VI: ---._-_ 0 TENANT Expansion tank 12.51
Name: 'ixture'sewer cap 25.02
Floor draittitloor sink/hub 1 25.02
Address:
Garbage disposal 25.02
City/State,Z_IP Hose bib 25.02
Phone:I 1 i Fax ( I Ice maker .1„ 12.51 2_5,0 Z
4PPUCANVT tI;�jj Interceptor/grease trap 25A2
x4tf F 1.z .
Medical gas(value:$_) Page 2
Business name 4. curl V Gr,,1. t As C
Primer 12.51
Contact name: 'Weil Vls' �"�r-4,�yy
l� Roof drain(commercial) 12.51
Address: 41 V T Sink/basin/lavatory 1 25.02 ZS•J'2_.,
City/State/ZIP:VJ.S-V t...4.J•..e--) 0(2 91 :)1a Solar units(potable water) 62.54
Phone:((7j 1 S3q y i s---) [ has :( .... -) Tub'sttowershowcr pan 12.51
I E-mail: C 0rl '(A rr,4.,1!(( .�-f 2_( co,CL Ct Urinal 25.02
m) Water closet 25.02
CONTRACTOR
-
--- Water heater l 37.52 3"1..52..
Business name:-Tir.,,c)r..1 pi n„ _ Water P iF &'m DWY' 56.29
Address: IS t -_-__ Other: 25.02
1n/GS{ L�r-
City/State,ZWP: w- O `��U(a Subtotal $1,,,,
� -
Phone:( ) S lq -L ./5 j Fax:( • ) Minimum permit fee: $72.j0
��y Plumbing Lic.nu.: Plan review (25°A of pemtit fee) 21 st 1 CCB Lie.: 7.
--- -'r /�5S Statesurcharge(In,ofpermitfee) 1O.cI
Authorised signature �_ TOTAL PERMIT FEE i t q.1143
�'']'�� �'JJJ ' 1 I This permit application expires if a permit is not obtained within ISO dais
Print name: /r L/ u� C� i' -y Date: I` J��(� J after it has been accepted as complete.
f *I-.cc methodology set by Tri-County Building Industry Service Board.
t:'riutlitng,Permits'.PLMI;•PennnApp doe I TOI/tN 440-4616)i 1Uia2!C"UM1WEBI
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental information
Fee Schedule: Residential Fire Suppression Systems:
I Qty. Fec(ea) Total
Site Utilities Square Footage_ Permit Fee:
1uotiugdram- liar 50.00 0to2.000 $121.90
Footing drain-each additional IOU' 37,52 2,001 to 3,(0(1 $169.69
i 3,601 to 7,200 $233.20
Sewer-I st 100' 62.54 7,201 and greater $327.54
Sewer-each additional 100' 37.52
Water Service-I st 100' 62.54 Medical Gas Systems:
Wale!Service-each additional I(XI' 37.52 ?r
Storm&Rain Drain- 1st 100' 62.54 0. Permit
$L0o to$5,000.0 0 Minimum fee
$72,50
Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,0000.00 and$1.52 for
t '" each additional$I00.00 or fraction thereof,to
Qty. Fee(ea) Total and including$10,000.00.
Inspection of existing plumbing or for $10.001.00 to$25,000.00 S l4R.50 for the first$10,000.00 and$1.54 fur
which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to
(minimum charge-112 hour) and including$25,000.00.
Inspections outside of normal business 90.(X)/hr S25,001.00 to$50.000.00 S379.50 for the first$25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional 1100.00 or fraction thereof,to
Reinspection Fees 90.00/hr and including$50,000.00.
Additional plan review for revision, 90.00/hr $50,001.01)and up 5742.00 for the first$50,000.00 and$1.20 for
(minimum charge-1/2 hour) each additional$100.00 ur fraction thereof.
Subtotal:
Commercial Fixture Work:
Are wru 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 Plung Istallations
Quantity by Fixture Type Plan ref lees is required fur any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: tapped Added Relocate
Baptistry/Font/F ❑ Any new commercial building with water service 2"and T\
nyont greater,except systems designed and stamped by licensed
Bath: -Tub Shuwcr
engineer.
-Jacuzzi/Whirlpool ❑ New exterior plumbing site utilities for any complex structures CA-
Car Wash: -Each Stall as defined in QAR918-780-0040.
-Drive Thru
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities. YN
Dishwasher: Commercial El Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in C)AR918-780-004(l. ,
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2"
3" Isometric or Riser Diagram
4,.
❑ I,t+tnctrtr ur rust tli:r_rain Is required for new huil(iinp te\ Cyr
-Car Wash Drain
a:rrhace 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) /+otaIi/�(0) 1' dd,, r✓ (� t/r/S.Y///'�
Rec.Vehicle Dump Station �likL1L/ 41 4 J
Shone[ -Gang
-Stall
Sink. -LavBar non-food related l 1
-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 secs er 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 he issued.
Urinal
Other Fixtures: 14( kiV
2—
I:U3uilding'-Permits\PLMF_PermitApp.doc 08/04/2011 7
IN Accumulative Sewer Tally
Tenant Name: I,iFESTANCE HEALTH SWR# N/A
TI GAR D Site Address: 9600 SW OAK STREET PLM# PI,M2021-00482
Parcel#: 1 S 135BD00100
Fixture \aloe 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 0 0 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 HP) 16 0 0 0 0 0
-Commercial(to 5 FIP) 32 0 0 0 0 0
-Industrial(over 5 11 P) 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:
I -Lay/Bar-Non-Food Related 2 0 1 2 0 -1 -2
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 1 2 0 0 -1 -2
Current Fixture Value -2 divided by 16= -0.125 Current EDU 1 EDU= $6,085.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -2 divided by 16= -0.125 over (under) $ (791.05)
Enter EDU Change Here -0.130 *
*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:***CREDIT***
Authorized Name/Signature: JULIE DRINKWATER X2804 Date: 11/30/2021
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\SewerTallySheet_6085_070121.xlsx