Permit CTY OF TGARD PLUMBING PERMIT
` DEVELOPMENT SERVICES PERMIT #: PLM2004 -00072
Z Ak DATE ISSUED: 2/17/04
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 16035 SW PACIFIC HWY PARCEL: 2S115BA -00500
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION: KIN
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: B FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: 1 OTHER FIXTURES:
TUB /SHOWERS: 1 SEWER LINE: ft
WATER CLOSETS: 1 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Bldg. fixtures: Replace (3) fixtures and cap (1).
FEES
Owner:
Description Date Amount
16035 SE PP SW PACIFIC HWY
1 [PLUMB] Permit Fee 2/17/04 $72.50
16035
KING CITY, OR 97224 [TAX] 8% State Surcharl 2/17/04 $5.80
Total $78.30
Phone : 503 620 - 2185
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : Top -out Insp
Final Inspection
Reg #:
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Issued By: Liji—d-Cit.•0 fr Permittee Signature: k
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day C--'
Building Fixtures
Plumbing Permit Application FOR OFFICE USE ONLY
Received NCO 1"2". City of Tigard Date/By 7 O�
Date/By / PePermit t N .. -
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie
Phone: 503.639.4171 Fax: 503.598.1960 At' +� DateBy: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 ' e`I �� Date Ready /By: Juf m See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: 12C�SupplementalInformation
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checkiisr.
Description 1 Qty. 1 Ea. 1 Total
Additi io alterati eeplacement ❑ 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 ,j Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: /c o,3J• 5: C - $0n. e". r7 Catch basin or area drain 16.60
City/State/ZIP: � -.., ,... U. _ Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I 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
^� � v- C14-P (/) Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 1 6.60
Ejectors /sump 16.60
Name: 72, l(/ p 7: -f e_ �/., Expansion tank 16.60
Address: // jr e c i 4- e G cl/L- / Fixture/sewer cap 16.60 `
City/State/ZEV/IA- - CAT C.&. _ 77 c",..?-7- Floor drain/floor sink/hub 16.60
Phone: (5253) 4 3 e. - a e._ 7 G. Fax: ( ) Garbage disposal 16.60
Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON
Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax: : ( ) Sin asin/lavptory Q 16.60
Tub /shower /shower pan CAP / 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet / 16.60
Business name: O ?Ai ,v-e---- Water heater 16.60
Address: Other:
Subtotal
City/State/ZIP:
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 ,A•50
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee) 5 .S't2
Authorized signa . e: �� i TOTAL PERMIT FEE 7f.20
Print name: �� d dam) % �a-1 e- �
7 Datr This permit application expires if a permit is not obtained within
` 180 days after't has been accepted as complete.
*Fee methodology set by 'f ri-County Building Industry Service Board.
i:\ Building \Permits'PLMF- PermitApp.doc 12/03 440- 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 - 1' 100' 55.00 0 to 2,000 $115.00
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
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 55.00 $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
Q ty. Fee (ea) Total additional $100.00 or fraction thereof, to and
Fixture or Item 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, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by (Fixture) Work Performed
Fixture Type: Replace
New Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
-3 „
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink -Bar/Lavatory Quantity Total
- Bradley Isometric or riser diagram is required if fixture quantity
- Commercial total is >9.
- Service -
Swimrning Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
i: \ Building \Pemtiu\PlM- PcrmitApp.doc 3/03