Permit t — n
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009 -00133
Date Issued: 06/01/2009
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503 639 4171 parcel: 2S102DD01601
Jurisdiction: Tigard
Site address: 8840 SW EDGEWOOD ST
Subdivision: Lot: 0
Project: Jensen
Project Description: Connect to sewer
Owner: FEES
JENSEN, DAVID L AND LOIS C Quantity Description Date Amount
8840 SW EDGEWOOD
TIGARD, OR 97223 100 If Sewer Service 06/01/2009 $55.00
1 12% State Surcharge - 06/01/2009 $6.60
PHONE: Plumbing
1 hr Hourly Plumbing Rate 06/01/2009 $62 50
Contractor: 1 ea Hourly Plumbing 12% 06/01/2009 $7 50
OWNER Surcharge
PHONE:
FAX
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $131 60
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 ru -s adopted by the Oregon
Utility Notification Center Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100 You mad obtain a copy of the rules
or direct questions to OUNC by calling 503 246.6699 or 1.800 332 2344
Issued By: ` Permittee Signature:
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.
Plumbing Permit Application
Building Fixtures FOR OFFICEIUSE,ONLY� Y
C of Tigard JUN 01 2 009 Received Date/By j Permit No..Lm •
I
V 13125 SW Hall Blvd , Tigard, OR 97223 , •R 4b,
P hone' 503 639 4171 Fax 503 598 Plan Review
' ��(I'Y OF TIGARD Date/By Other Permit Noay 2 T �
7` v � 7 ,��''f{
T I GARD Inspection Line 503 639 4175 BUILDING DIVISION Date Ready /By ions la See Page 2 for
. Internet www tigard - gov Notified /Method C. Supplemental Information
TYPE.OF WORK . . FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description Qty I Ea Total
g f Addition/alteration /replacement ❑ Other: New 1- 2 - family dwellings (includes 100 ft for each utility connection)
` s CATEGORY OF CONSTRUCTION , i . SFR (1) bath 249 20
N(1- and 2- family dwelling ❑ 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, LOCATIO s ; ,' - y , ; Site utilities
Job site address: By v ' S W g Qg,\" 0 0 0 Catch basin or area drain 16 60
City /State /ZIP: 1 `C-- A 210 Drywell, leach line, or trench drain 16.60
Suite/bldg./apt. no.: Project name: Footing drain (no linear ft _ ) Page 2
Js Manufactured home utilities 110 00
Cross street/directions to job site:
Manholes 16 60
Rain drain connector 16 60
anitary sewer (no linear ft 1G Page 2 W
Water service (no linear ft ) Page 2
Subdivision: 1 Lot no.:
Fixture or
Tax map /parcel no.:
Absorption valve 16.60
.. DESCRIP O W .' ., , ,
...
Ca N NI 11V1) SR W Backwater valve 16 60
Clothes washer 16 60
Dishwasher 16 60
❑" PROPERTY: OWNER _ 'r ' I ., ' ❑ . TENANT
ENANT, 1
.
Drinking fountain 16 60
Ejectors/sump 16 60
Name: Expansion tank 16 60
Address: Fixture /sewer cap 16 60
City /State /ZIP: Floor drain/floor sink/hub 16 60
Phone: ( ) Fax: ( ) Garbage disposal 16 60
° - ' , ❑- APPLICANT' „ x Hose bib 16 60
'
., ❑ 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:: ( ) Sink/basin/lavatory 16 60
Tub /shower /shower pan 16 60
E -mail: Urinal 16 60
CONTR ACTOR
• - , _ ,- � - Water closet 16 60
Business name: Water heater 16 60
Address: Other. ( - , 5C)
City /State /ZIP: • , _ Subtotal 111 . 50
Minimum permit fee $72 50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee. $36 25
CCB Lie.. Plumbing Lic. no
Plan review (25% of permit fee)
State surcharge (12% of permit fee)
Authorized signature:
TOTAL PERMIT FEE I.3
Print name: -- ZP I v \ I L , vSSN Date:6,, i ,o9 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
I \Building\Permits\PLMF- PermiiApp doc 12/27/06 440- 4616T(10 /02 /COM/WEB)
S W V Pi2r 3 V 3 . C)o -I U c_)o 0
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities'. Qt' Fee (ea) Total Square Footage: Permit Fee: • ': r • -
Footing drain - 1s 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 5 00 7,201 and greater $309.00
Sewer each addni 1;4b 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: Q ' 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
additional $100 00 or fraction thereof, to and
Fixtia>re =xir" "'`Item -
,Qty. - Fee.(ea) '-'Total' 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
Subtotal: $50 00 and up $742 00 for the first $50,000 00 and $1 20 for
each additional $100 00 or fraction thereof
Commercial Fixture Work: Plan Review for'Plumbing Installations'
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
Fixturee Type: a Replace engineer.
Pirevions ' Capped' Added New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic -
Drinking Fountain . ` - Isometric or Riser Diagram ..
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" 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
- Bradley *Note: If the fixture work under this permit results in an
- 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
\Bwldmo \Permits \PLM- PermttApp doc 12/27/06
M I CITY OF TIGARD
COMMUNITY DEVELOPMENT
Ta'GARD° 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171
RECEIVED
JUN 0 8 2009
Plumbing Signature Form CITY OF TItaARD
PLANNtf ��GIENGINEERING
IMPORTANT PERMIT NOTICE
Permit #: Pt M2OOet • (5G‘3
Date Issued: Co ' • O9
Parcel:
Site Address: g+8►.{d Edc�et_oo
Subdivision:
Lot:
Jurisdiction: 1 ∎ - d
Zoning:
Project Name: 3 . ✓\Se'n
Description: 0 ri J2.6-
Your company has been indicated as the plumbing contractor for the permit referenced above. In order for the
plumbing permit to be valid, please have the appropriate individual from your company sign below and return this
Plumbing Signature Form prior to the start of the work. Please mail the form to: City of Tigard, Building Division,
13125 SW Hall Blvd., Tigard, OR 97223, or you may fax the form to: 503.624.3681. 5•3 59 , l' C
If you have any questions please call 503.718.2433.
No plumbing inspections will be authorized until this completed form is received
OWNER: Da,t)■C� e.InZerTh PLUMBING CONTRACTOR:
cry • i ,oymz °e
3a8to
Phone #: 93 63 x 9f /5 Phone #: J1 OLN) 37
Reg #: '
AN INK SIGNATURE IS REQUIRED ON THIS FORM
' N E E C r 77 E •
Signature of Authorized Plumber Name (printed)
• JOB INVOICE
ORVALL T. CAPE
BYER'S SEPTIC TANK SERVICE, INC. PLMaeal - 00/33
P.O. BOX 549
OREGON CITY,. OREGON 97045. NO.. DATE ORDERED
CUSTOMERS ORDER
(503) 656 -3326 (o- c!-
ORDER TAKEN BY DATE,PROMISED
� A.M.
b - ❑ P.M.
BILL TO PHONE •
6 G. -1 g3 -39.Z 1
ADDRESS MECHANIC
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CITY 04, . 29..? HELPER •
JOB. NAME, AND LOCATION • emu! ❑ DAV WORK
�•" ❑ CONTRACT
DESCRIPTION OF WORK
❑. EXTRA
OUANT. DESCRIPTION OF MATERIAL USED PRICE _ .AMOUNT`
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• TOTAL.
MECHANICS @ MATERIALS
HELPERS Q TOTAL
LABOR •
• I hereby acknowledge,the satisfactory TOTAL LABOR TAX
completion of,the,above described work. ,
SIGNATURE DATECOMPLETED ,,
TOTAL