Permit CITY OF TIGARD PLUMBING PERMIT
II a. COMMUNITY DEVELOPMENT Permit #: PLM2009 -00137
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/03/2009
T t t' ARE) 9 Parcel: 2S 102 DD00809
Jurisdiction: Tigard
Site address: 13940 SW 87TH CT
Subdivision: FILBERT PARK Lot: 2
Project: Gardner
Project Description: Connect existing house to sewer service. Septic tank is to be pumped and filled. Reimbursement
District #37 fee paid.
Owner: FEES
GARDNER, RICHARD A Quantity Description Date Amount
13940 SW 87TH CT 90 If Sewer Service 06/03/2009 $55.00
TIGARD, OR 97223 1 12% State Surcharge - 06/03/2009 $8.70
PHONE:
Plumbing
18 ea Minimum Fee Adjustment 06/03/2009 $17.50
Contractor: - Plumbing
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 No ' cation - • -r. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Issue By: 0 t 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 OFFICE USE ONLY
City of Tigard e Q n �
Ty Rec Dat ived ` 6 Permit No.: uiOI✓�� 137
II a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
It Phone: 503,639.4171 Fax: 503.598.1960 Date Other Permit No.AUL .,%
Inspection Line: 503.639.4175
T 1 G A R ll Internet: wW W.ti erd -or. oV Date Re ReadyBy: luris: B See Page 2 for
g g Notified/Method: Supplemental Information
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 El Multi-family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: ) 3 9 ti. 6 5 L > 8' 7 -a+ dr Catch basin or area drain 16.60
City/State /ZIP: Tl (..,4 p ej R , 7 ) )14 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Co .4 R d ,v 4"R 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.: go ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2
Tax map /parcel no.: Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
1 lv S - 4 Li.. Sgi> Z R. 1 i ts C_ Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Name: Ejectors /sump 16.60
L G N R R d GI' R D," Expansion tank 16.60
Address: 1 9 [.j p 5 /Ai $ 67 'r1 Fixture /sewer cap 16.60
City/State /ZIP: 7-) f , 0 .,/, A, (9 R, Y7 1). 4 Floor drain/floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
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
CONTRACTOR Water closet 16.60
Business name: _ / Water heater 16.60
Address:
er, it.
City/State /ZIP: S
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)
Authorized signature: 4 4. A State surcharge (8% of permit fee)
k�+C. TOTAL PERMIT FEE
Print name: R 'c ff JE R d 6 /C O . s 6 R, Date: .67,5 /e) 9 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.
L\ Building \'ermits\PLMF- PermitApp.doc 12/27/06 440- 4616T00 /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 - 1s 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
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
Fixture 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
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
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
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ 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.
- 3"
-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:
i:\ Building \Permits\PLM- PermitApp. doc 12/27/06
ACT t_____ a 11111111111111111111111E11111111111111 .
Date 06/08/09
Scheduled 06/12709 Septic Service
09:00:00 U®gh y I i fi C nvirot' 1l en1 L [Inc, Work Order # W094582
503- 252 -6144 Complete Industr
P.O. Box 30087 Salem 503- 363 -2464 Vancouver 360- 896 -5256 Waste Removal
Septic Tank Cleaning
Portland, OR 97294 www.rivercityusa.com Sump Line Cleaning
OR CCB# 147355 WA CCB# RIVERCR981 BT
Richard Gardner Richard Gardner
' SW 87th Ct. 13940 SW 87th ct., Tigard
• Ti g ard, OR
Contact: 503 - 639 -9307
50.3 -639 -9307
PO# 2 of 3
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Septic.Se _
Notes 1. Pump about 1000 gallon tank for decommision, , . - -, 1 ` t 7 a ' 4 ' G 0 ' ` 4
• . - x2 °; :k4.7I4:�; s ^ e : , X d A t .
2, bring about 150 ft of hose a .; 4'�TY4, and. "ra, .Nt; , , i' „ • 3. Tank behind house. e , v :�� w ' yx `, _,,,._,. r. ,, ,,:.., .„,.... .., -=,,i . ...,,,,, :‘,,,, ',. - -- .-. ;•,_ . v.. : ''''..;:k aik. 4.3.
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1 r. Total Charges
River City Environmental, Inc. is in no way responsible for damage to any vehicles, personal or real property.
Terms: Net 10 days. 1.5% per month will be charged on past due accounts (18% per annum).
Terms and Conditions The Right to Lien
The customer agrees to pay all invoices arising out of services, and any other special services herein within 10 days.
Thepustomer agrees to pay such extra and overtime charges as may be invoiced from time to time for services rendered, over and above the normal servicing
Schedule, on behalf of the customer.
The customer agrees to assume responsibility damage to customer's real or personal property arising from services which take place •
on customer's premises, where the drivers and vehicles of River City Environmental have been instructed to enter.
This includes, but is not limited to driveways, trees, power lines or poles and building structures.
If River City Environmental, Inc, finds it necessary to add liquid to the tank on jobsite, customer will be charged for the additional gallonage resulting from these condidtions.
Customer agrees' to: reimburse River City Environmental, Inc. for all reasonable attorneys fees court costs and other expense incurred by said company to enforce
collection or to serve their.rights'under thisagreement:
If this work order is not contested in writing within 10 days'the full amount is considered due and payable.
Customer agrees to the above conditions. A fax on the work order is considered an original. Redeemable in Multnomah County
Cheek # Visa M Amex Card # Exp Date Vcode
Work Autho i• .j:y (pleas-Ain ri ) Date / / �{/�'
Signature o, • ,ldl�u'�� =e_ At
Service Tech #1 �` r � Service Tech #2 Date / t ( / Time P .-- -
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