Permit ",, CITY OF TIGARD SEWER CONNECTION PERMIT
C OMMUNITY DEVELOPMENT PERMIT #: SWR2007 -00119
OPMENT
TIGAKDj 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 5/22/2007
PARCEL: 2S 103DA - 02300
SITE ADDRESS: 10880 SW DERRY DELL CT ZONING: R -3.5
SUBDIVISION: DERRY DELL PLAT 2 LOT: 025 JURISDICTION: TIG
PROJECT: MCCUTCHAN
Project Description: Connect existing house to sewer service. Reimbursement District #29 fee paid 5/22/07.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner:
ALBERT MCCUTCHAN FEES
10880 SW DERRY DELL Description Date Amount
TIGARD, OR 97223
[SWUSA] Sewer Connection Fee 5/22/2007 $2,700.00
Phone: x■ ,;".'ireyver Inspection Fee 5/22/2007 $35.00
.�+ . L13451N tot Total $2,735.00
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Contractor: I��� 1 ipt /1r$ IS ® 1`
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Contact #: REQUIRED ITEMS AND REPORTS
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through
OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issue by: 1 / / Permittee Si nature: / 44 1 � "�'` =' e"
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
m; .. , CITY OF TIGARD
SEWER CONNECTION PERMIT
. ,
r, PERMIT #: SWR2007 -00119
° DEVELOPMENT C OMMUNITY DEV O
iT1GARD: 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 5/22/2007
g PARCEL: 2S103DA -02300
SITE ADDRESS: 10880 SW DERRY DELL CT ZONING: R - 3.5
SUBDIVISION: DERRY DELL PLAT 2 LOT: 025 JURISDICTION: TIG
PROJECT: MCCUTCHAN
Project Description: Connect existing house to sewer service. Reimbursement District #29 fee paid 5/22/07.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
ALBERT MCCUTCHAN
10880 SW DERRY DELL Description Date Amount
TIGARD, OR 97223
[SWUSA] Sewer Connection Fee 5/22/2007 $2,700.00
[SWINSP] Sewer inspection Fee 5/22/2007 $35.00
Phone:
Total $2,735.00
Contractor. IS NOT A PLUMBING PERMIT.
A PLUMBING PERMIT IS REQUIRED
FOR A LEGAL CONNECTION.
REQUIRED ITEMS AND REPORTS
Contact #:
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through
OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issue by: Ai ! Permittee Signature: )(7174%
, ,4 C ."<-
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Plumbi :': ;'Permit Application yam
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Cl of Tigard Permi No .: n M
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�` a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
. 0 .4 Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No.:
"»' i. ? Inspection Line: 503.639.4175
T I G A RD, Date Ready /By: .1 '' ® See Page 2 for
lisoks129,ut Internet: www.tigard- or.gov Notified/Method: q id , Supplemental Information
t.
TYPE. OF WORK 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 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
•
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional b.th/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
• JOB SITE INFORMATION AND LOCATION • Site utilities
Job site address: /0 ego --1 e..) 7,g,Q V -- /mg L(, Catch basin or area • rain 16.60
City /State /ZIP: Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. li , ar ft.: ) Page 2
Manufactured home u ilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. line. ft.: Page 2
Storm sewer (no. linear ft.. ) Page 2
Subdivision: Lot no.: Water service (no. linear ft. Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow: preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER ❑TENANT. - Drinking fountain 16.60
Ejectors /sump 16.60
Name: � / � ►- f Al �i G / /s9 r/
Expansion tank 16.60
Address: / d g Q std berry 1) .e- _ /1 (/' / Fixture /sewer cap 16.60
City /State /ZIP: e 4 *Pd 6/a � 2 `g Floor drain/floor sin. ub 16.60
Phone: ( 5 - 0 3 4 , ge i .■ 3 0 $ Fax: (5 3) 2 a 3 - G3 Y' ?5 Garbage disposal 16.60
; APPLICANT . Hose bib 16.60
❑
❑ CONTACT PERSON
Ice maker 16.60
Business name:
Interceptor /greas• trap 16.60
Contact name: Medical gas (va e: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (co ercial) 16.60
Sink/basin/lavat ∎ ry 16.60
Phone: ( ) Fax::( )
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
' CONTRACTOR . Water closet 16.60
Business name: Water heater 16.60
Address: Other:
City /State /ZIP: j. Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: Date: This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
1: \ Building \Permits\PLM- PermitApp.doc 12/27/06 440- 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) ? oral Square Footage: Permit Fee:
Footing drain - 1 100' 55.00 0 to 2,000 $ 1 15.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems: •
Water Service - each additional 100' 46.40
Storm &Rain Drain - 1st 100' 55.00 Valuation::'- • Permit Fee:
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain- each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Future or, Item Qty. Fee (ea) Total" • additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for •
Subtotal: each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", • Plan Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees * . Please check all that apply.
- Quantity by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type .. • Replace greater, except systems designed and stamped by licensed
. . Previous . Capped Added. Existing engineer.
Baptistry/Font
Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure
-Tub/Shower as defined in OAR918- 780 -0040.
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive tall ❑ Any multipurpose fire sprinkler system.
Cuspidor/Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash Isometric or Riser;Diagram
Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings
that meet the qualifications above.
- 4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory *Note: If the fixture work under this ermit results in an
- Bradley p
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued. •
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\Building\Permits\PLM- PermitApp.doc 12/27/06