Permit CITY OF TIGARD PLUMBING PERMIT
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` ° • COMMUNITY DEVELOPMENT Permit #: PLM2009 -00059
TIGA R D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 03/20/2009
Parcel: 25101 DA00104
Jurisdiction: Tigard
Site address: 1333S.W 68TH PKWY
Subdivision: FARMERS INSURANCE Lot: 0
Project: Triangle Pointe
Project Description: Fixture count walk- through.
Owner: FEES
TRIANGLE POINTE LLC Quantity Description Date Amount
901 NE GLISAN ST #100 1 hr Hourly Plumbing Rate 03/20/2009 $62.50
PORTLAND, OR 97232 1 ea Hourly Plumbing 12% 03/20/2009 $7.50
PHONE: 503 - 297 -8791 Surcharge
Contractor:
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp: B
Stories:
Total $70.00
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 Notif tion Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Iss ed By: ,
E _` / Perrnittee 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.
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Plumbing Permit Application ��j
Building Fixtures FCEl r LD FOR OFFICE USE ONLY
Receiv
City of T igard �� 6 9 E /e z Permit No` .. y�o ?-,4
0 13125 SW Hall Blvd., Tigard, OR 9722 AR 2 ' 0 2009 Plan Date/By: Revie
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0 Plan R Other Permit No.:
Phone: 503.639.4171 Fax: 5 03 . 598 . 1 60 Date/By:
Inspection Line: 503.639.4175 a OF 11 TtGARD
T I G �� R D Date Ready/By: luris RI See Page 2 for
Internet: www.tigard - or.gov
RUILDIISIG DNISION Notified/Method: 7 / Supplemental Information
TYPE OF W(7Rir FEE* SCHEDULE
❑ New construction ❑ Demolition For spedai information use checklist
Description 1 Qty. 1 Ea. 1 Total
ErAddition /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 a tommercial/industrial SFR (2) bath 350.00
❑ Accessory building 1:1 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: 12-5 33 41,,`-J 0 '9-4-,5 9AviZjr -UJ Catch basin or area drain 16.60
City /State /ZIP: 1 b oj ps I:= c`1 2-1.- 3 1 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: 1 p � pc,' pre 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.: ) 1 Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
P(_Um 6(.6(.., Pl imi.9f� Dc'\ (C.fjjo U AeS Backwater valve 16.60
(1 X Tt.t. i Cock. tJ 'r Lt DI - 1/2t.�. . Clothes washer 16.60
Dishwasher 16.60
[3- PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: 112 -1 p".1( Pet nhI LLL Expansion tank 16.60
Address: 1 c:I. 1 t.1E cei LA SA/%1 fit , $ 4.1 I it. L ___ Fixture /sewer cap 16.60
City /State /ZIP: Peett- .,rio cv(L 9- Z Floor drain/floor sink/hub 16.60
Phone: (P) 21'7 8 ( Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 1 16.60
Business name: O P . r . J V/61-40q/ t sNr
M Interceptor /grease trap 16.60
Contact name: Op1] Ca o - SiV2 Medical gas (value: $ ) Page 2
Address: 9 p) i. }e. h u« It • Seen (cam Primer 16.60
City/State /ZIP: Pb(L j 3r7 cat - 172,32- Roof drain (commercial) 16.60
Phone: ( )2 ' 4 i t 7 Z ( I Fax: ( ) Sink/basin/lavatory 16.60
t Tub /shower /shower pan 16.60
E -mail: Gl IGbtr b.errn e d ¢a, coh . usiA Urinal 16.60
0 M' • CTOR Water closet 16.60
Business name: I Water heater 16.60
Address:
Vitt , r Other: • / [�� @ 9S/6 a . 4, .
City /State/ZIP: - Subtotal
Minimum permit fee: $72.50 (D�
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) (9
State surcharge (12% of permit fee) 7- SD
Authorized signature: ) t TOTAL PERMIT FEE 7 76 .cO
Print name: J r jy J C it, o Date: 3:21). CFI This permit application expires if a permit is not obtained within
f 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
I:\ Building \Pennits\PLMF- PermitApp.doc 12 /27/06 440- 4616T(10 /02/COM/WEB)
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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 - l 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
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 $I.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 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.
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-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.
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Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
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Other Fixtures:. • •
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i:\ Building \Permits\PLM- PermitApp.doc 12/27/06
a
Accumulative Sewer Tally Parcel # 2S101DA00104
Tenant Name: Triangle Pointe LLC This SWR# N/A
Site Address: 13333 SW 68th Parkway This P1.M# 2009 - 00059
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptistry/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 72 1152 1152
Capped EDU Credit 23.3 372.8
TOTALS 0 1152 0 0 0 0 0 779.2
Current Fixture Value 779.2 divided by 16 = 48.7 Current EDU 1 EDU = 5 3,100
Previous Fixture Value 1152 divided by 16 = 72.0 Previous EDU
Change -372.8 divided by 16 = -23.3 over (under) $ (72,230.00)
Enter EDU Change Here -23.3
Notes: This worksheet is to adjust existing EDU count. Fixture count walk through performed by Brian Blalock on 3/20/09. Per fixture count
actual EDU rate should be 48.7.
Authorized Name /Signature: Debbie Adamski Date: 3/20/2009
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \ Building \Sewer Tally \Sewer I'allyShcet- 3100.xls 06/19/08
T.
Accumulative Sewer Tally Parcel #
Tenant Name: This SWR#
This PLM#
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptistry/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 1 4 1 4
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 15 15 15 15
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 31 62 31 62
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 1 -IP) 16 0 0 2 32 2 32
- Commercial (to 5 I-IP) 32 0 0 0 0 0
- Industrial (over 5 I-1P) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0.
- Stall 2 0 0 1 2 1 2
Sink - Bar /Lavatory 2 0 0 53 106 53 106
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 4 12 4 12
- Service 3 0 0 6 18 6 18
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 66 396 66 396
Urinal 6 0 0 22 132 22 132
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 201 779 201 _ 779
Current Fixture Value 779 divided by 16 = 48.7 Current EDU 1 EDU = S 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Changc 779 divided by 16 = 48.7 over (under) $ -
nter EDU Change Here
Notes: r 1 t e,e, Cpu 1 ,r"-- Pi-L. �'At...1E. _ X13 f to &>�t - Loe .k, -o 0 3 0 09 •
Authorized Name /Signature: Date: 2 I I Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \ Building \Sewer Tally \Sewer 1'allyShcct- 3100.xls 06/19/08
-;.4 - te ... ) ,„JL - LT --- X,,,, litt t744-e_ea Az.
Accumulative Sewer T a ll y -7 /47-le eic
Tenant Name: This SWR# , h--K_ d j / /
Address: This PLM #:
Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New
# Value Capped off value added # added #s total
Count off #s count value values
Baptistry/Font 4
Bath - Tub /Shower 4
- Jacuzzi/Whirlpool 4
Car Wash - Each Stall 6
- Drive Through 16 0 (/ 11
Cuspidor/Water Aspirator 1 Na � r
Dishwasher - Commercial 1 4 ( �J ) .
tic 2
- Do stic
Drinking Founta'�D i _ 1 T•;
Eye Wash 1 ----
Floor Drain/sink - 2 inch 1 i41 21 I2 l 9 I
- 3 inch
- 4 inch 6
- Car Wash Drn 6
Garbage Disposal 16
- Domestic (to 3/4 HP -
- Commercial (to 5 HP) 32
- Industrial (over 5 HP) 42
Ice Machine /Refrigerator Drains 1
Oil Sep (Gas Station) 6 1
Rec. Vehicle Dump Station 16
Shower - Gang (Per Head) 1 11
-Stall ZI 2
Sink - Bar /Lago 3 3 2 ✓ /
- Bradley 9.5..-
� /, - Commerc al 1111 � 3 I P \ .
if - ervice 1 lel 3
Swimming Pool F -------__ 1
Washer - Clothes 6 \
Water Extractor — 6
COWater Closet - Toil S 3 3 y 3 3 6 (C
Urinal C3 J 6 (P-. 2
TOTALS -
Total fixture values: divided by 16 = .EDU
HISTORY
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR# /
PLM# EDU# • SWR# PLM# EDU# SWR#
is \dsts\swrtaly.doc
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