Permit a CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2010 -00274
T L 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/24/2010
Parcel: 1 S 133 DC 17200
Jurisdiction: Tigard
Site address: 13194 SW LAURMONT DR
Subdivision: VILLAGE AT SUMMER LAKE NO. 1 Lot: 27
Project: Voorhees
Project Description: Backflow for irrigation.
Owner: FEES
VOORHEES LIVING TRUST Quantity Description Date Amount
BY VOORHEES, JOHN J & KATHRYN A TRS,
13194 SW LAURMONT DR 1 ea Backflow Preventer 08/24/2010 $31.27
PHONE: 1 12% State Surcharge - 08/24/2010 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 08/24/2010 $41.23
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 taw. 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 -0100. You may 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: ,I e p
Call 503 .639.4175 by 7:00 a.m. for an inspection that busin'rs 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 �� � t,��` �� w ; 1 O 1 1 g ifi l ti t l k : F , H.
Rece ived
City of Tigard Permit No
I l l
n 13 125 SW Hall Blvd., Tigard, 0
� Date/By: ' _y _ ibis to..... _I �.
Plan Review
II ' Phone: 503.639.4171 Fax: 5C . 8.1960 VA Other Permit No.:
DateBy:
Inspection Line: 503.639.4175
T fG A R. D �,1 hj Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov
1\ R Notified/Method: IT j Supplemental Information
TYPE OF WO .i Q A � � ®t FEE* SCHEDULE
vt.o on
For special information use checklist
❑ New construction t t . '
Description Qty. 1 Ea. 1 Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION • SFR (1) bath 312.70
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( _ sq. ft.) Page 2
' JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: /.?/ 9'f S.W. I / - v QH 0111 r 412 • Catch basin or area drain 18.76
City /State /ZIP: � Drywell, leach line, or trench drain 18.76
6.14 /2. D 0 R 9 7z Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: /41 / 1 h' LC S Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Backflow preventer / 31.27 3 J ?-7
Tax map/parcel no.: t
. DESCRIPTION OF WORK Backwater valve 12.51
L LL Clothes washer 25.02
I K
( lf n� 4r Jr t r f%lct�'1ck.A. Dishwasher 25.02
VV Drinking fountain 25.02
Ejectors /sump 25.02
N: PROPERTYiOWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap 25.02
J0%/L K0/ v.DoJ2 i
Floor drain/floor sink/hub 25.02
Address: 1 9, , u' A F}v R/.4Oln' 1� 12
Garbage disposal 25.02
City /State /ZIP: 1i C-A R 11 0 2 . 9 7,-a -3 Hose bib 25.02
Phone: (co, )5/_/ . 0 704.- Fax: ( ) Ice maker 12.51
' ❑ APPLICANT • , . ❑ CONTACT•'PERSON Interceptor /grease trap 25.02
Business name: S eti G'i t Medical gas (value: $ ) Page 2
�' + t Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 25.02
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 25.02
. • CONTRACTOR •
Water heater 37.52
Business name: (J1 "4 lN I p to J Water piping/DWV 56.29
Address: Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50_ 77 ,S
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee) 3 7t,
Authorized signatur =1, ++rr TOTAL PERMIT FEE El
Print name: l .. D ate: 'J This permit application expires if a permit is not obtained within 180 days
ON J ' ti n 0 2 ,/, C L 7 �id after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
1:\ Building \Permits\PLMU- PermitApp.doc 10/01/09 440 -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' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $ 10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other ec
Ins tions or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
Inspections and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial 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 Thru ❑ 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
Disposal - Commercial
- Industrial Comments regarding fixture work:
Ice Mach./Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink -Bar/Lavatory
- Bradley
- Commercial *Note: If the fixture work under this permit results in an
- Service increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be aid before the
Washer - Clothes p
Water Extractor plumbing permit can be issued.
Water Closet - Toilet
Urinal
Other Fixtures:
1:\Building\Permits\PLMF- PermitApp.doc 2
si Information Notice to Owners About
.,w nstructin Responsibilities
1. (ORS 701.055 (5))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503 - 378 -4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503 - 947 -1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to
http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms.
• 'Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503 - 947 -7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough -in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052
Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007
Website Address: www.oregon.gov /ccb
f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant
. ,
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
' reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
�6 H J, UO D J ? N LTS'
Print Name of Permit Applicant
:-A)?,taTAX-- . —
nature Permit Applicant Dat
Permit #: PlZni ) 4
1 Su l • Lourrr�Nt' �
Address: r• ���.��,;,�i �,
Issued by: (.T Date: J J aL( it o
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This Copy for Permit Offices