Permit { ..
lam_ •
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009 -00108
1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 05/05/2009
T < < " � D g Parcel: 2S101AC00700
Jurisdiction:
Site address: 12700 SW 72ND AVE
Subdivision: BEVELAND NO. 2 Lot: 13
Project: PAULY & ROGERS
Project Description: Add (1) sink to new addition.
Owner: FEES
ROGERS, ROY R Quantity Description Date Amount
13690 SW TWELVE OAKS CT 1 ea Sink 05/05/2009 $16.60
TIGARD, OR 97224 1 12% State Surcharge - 05/05/2009 $8.70
PHONE: Plumbing
56 ea Minimum Fee Adjustment 05/05/2009 $55.90
Contractor: - Plumbing
WESTERN PLUMBING
9460 SW TIGARD, AVE STE 101
TIGARD, OR 97223
PHONE: 503 - 639 -5296
FAX: 503 -684 -9015
Type of Use: COM
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 Notific. '= - -; ter. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Issued :y: , / Oi / Permittee Signature. A , INELFM ...we
CaII 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.
`04/29/2009 13:53 5036849015 WESTERN PLUMBING INC PAGE 01/03
v\E) r1r''
09 �u gRo0 -oS/
Plumbing Permit Application PP 2 �� 0 T'Olt orFli'R USE ONLY SW Tigard Bl d c \
, Tigard, OR 97223 t � GP � 4" t
� ��� y 9 0 ,y,� Pumii No : . Livia-it - /AM
Phone: 503.639.417I Fax; 503 .598.1960' t II � Q Plan Review
"I!GAR11 lnspccgonLine: 503.639.4175 r'"5\-/.`.. Date/By: Other Puu e2 �j 4 S'
et www tigard -or gov
Die xeadrBy
r rt l -. e p . i s s :4 1 Notified/Method: 2 f
Intern
,' i tal 1
, ..�� _, r __ .. ,__ � � • , {'} � , c� , i x , ip Su g � emea e nformahon
...V... . .. .,v ! 4. t t }� / f Y ..
❑ New construction • :,,,-,.z..^.7,
, M. .,. . ..::., , r , k� ' � )' � � x
Demolition For pednlIn
h., Addition/alteration/replacement Q Other: Description o n ` �`
r r»ratic s checklist
Addition/alteration/replacement
'''' in h r rynr r „ New 11
Total
_ t , ', t ,'-Ii.... ` + i r Ili
F r ` ,r r, a t n ,r t , r 7 e 1 2-family dwellings (Includes 100 Lt, for each utility connection)
X : >' _!- ..t>_ :.:r n ...,:.,. _` t9 r ': ft• .S ( I) b8th 249.20
CI Um
1- and 2- family dwelling /• Commerciadustrial. SFR (2) bath
O Accessory building ^ 3
0 Multi- family SFR (3) bath 399.00
.00
❑ Master. builder ❑ Oth Each ad bath/kitchen 45.00 -
i. . .fi t 1 f P} , n7 t -, r ,, -_- "• 7 x. Sr f Fresprinkler( sq.
J :.. : le,: : ..: : ..... r .,ir.7p .': 1 ,' t/ r1' 1 7 ;i Page
;: `.. , Site utilities
Job site address • , 1, i
�. tainl Catch basin or area drain 16.60
City /State/7.rp` .6: , i bliaA
=�+ tom Drywall, leach line, or wench drain 16.60
-
Suite /bldg./apt, no.: IL . Project name: fit _ , I.` lit Footing drain (no. linear R: ..___) Page 2 r
Cross street/directions to job ste: 4 ■ ^ Manufactured home utilities 110.00
Manholes - 16.60
- - Rain drain connector 16.60
�' ^ Sanitary sewer (no. linear ft.:,) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.: Water service (no. linear R: ) Page 2
Tax map /parcel no.: A S /O/A eno ?pep Future or item
:rr
.,.,: `� 7 i'...-,'!..!.';',..-7•'?" 9 . x,C � �, ( tt � Mn `� If 'C ,� �, s � Ab30rp8pn
a f s t Page 2
_.. . , . „ . r.. : ' Badcflow plevetttcr
Page 2
-
. Backwater valve 16.60
Ere A 1■11 r .. 11 h 1' . ,LL • Clothes washer 16.60
Dishwasher
. f . ., • , . x { t , z t •f : Dunkin fo 16.60
z
..» .r . ... 7 p•;.:: i O i � t . ‘
t ..._. ri i g uOtBtn ` � 16.60
Name Ejectors/sump 16.60
Address: Expansion tank 16.60 oft.
City/State/7,1P: -
Fixture/sewer cap 16.60
Floor drain/floor sink/hub 16.60
Phone ( ) Fax ( ) Garbage disposal
F .Y t ( ,t {' lE �1 ;- r) , I z? "" ` .. ,7,2 K'�. , r 16.60
'' .: s ? ,.... k t ... � .:,. , . w , x f .. . , ^f Fr ;.; s^ y t( ,,7.:::‘,..7,,-
u.'12
.. A,. .I ti 1'loseblb •
Business name: Ise maker 16.60
Contact name: - Interceptor/grease ^ptor /grease tip 16.60
Medical gas (value: $ ) Page 2
Address: -
Primer 16.60
City /State/ZIP; Roof drain (cotnmercia0
Phone: ( ) Sink/basin/lavatory 16.60
Fax; : ( ) ry t _ 16.60 i t, &,{)
E-mail: Tub /shower /shower pan 16.60
x t . hj t rE ( ti �" . r Y i , ?r r t er o " r J .. a
Urinal
.,,, t. ^ i r i
, 16 . 60
-
. . - ... , . �" h:_.: ''''-• 5 , � t .,. brie: r: water Clo3et
Business name: Western Plumbing, Inc. Water heater
16.60 -
Address: 9460 SW Tigard Avenue, Suite 101 .. Other
ity /State/z1Y: Tigard, Oregon 97223 Subtota llialkil
tr
Phone: (503) 639 -5296 Fax ( 503) 684 -90I5 Mum pin fee: $72.50
_ Residential backflow minimum permit tee: $36.25
CCB Lic.: 2439 Plumbing Lic. no.: 3429PB Plan review (25% of permit fee)
Authorized . signature k � �� ;, A i e, , { 1 , State surcharge (12% of permit fee) a
Print narttc: Dana Jensen CC7�tt .•t[ l TOTAL PERMIT FEE
Date: _ �}7rj - This permit application expires if a permit is not obtained withi
180 days after It has been accepted as complete.
t;tevnam a,wz na v� +ov,aa „ham *Fee methodology set by Tri- County Building Industry Service Board .
44o-4o i ern i efoucomIwv3)
•
-" ` 04/29/2009 13:53 5036849015 WESTERN PLUMBING INC PAGE 02/03
• Plumbing Permit Application- City. of Tigard
Page 2 - Supplemental Information
Fee Schedule Residential Fire Su P t ression ems
, _5 ,,. ; „.'f ,,T,;-_,:,:.,,,,,.;1,.1, 5 ,.,.:i.: „;- '`' rr ...t { tci b ' : stems:
T '
Footing dram -12 100 a .,,
55 Oto 000 $1I5.00
Footing drain - each additional 100' 46 2 001 to 3 600 $160,00
Sewer • 1st 100' 55.°0 3 601 to 7 00 5220.00
Sewer - each additional 100' 7 Ol and y er $309,00
46.40
Water Service -1st 100' 55.00
Water Service - each additional 100' 4640 Medical Gas S stems
: .40
& Rain Dram • 1St 100 55.00 l t ' Q : rr ;
, . ”, -,' i, ., r 1 t t 6 . al . r w mm ,.'.:.g..:::-.77'&44F.,.----.7;7...,',.7:::'117:,;:j
h me 1 .%.,. , ,,..
✓. k 1 i
Storm & Rain Dram each additional loo
$1,00 to $5.000.00 Minimum fee $72.50
46.40 35,001.00 to $10,000.00 $72.50 for the first 35,000.00 and $1.52 for each
' , t 1 ,,i 1 ` a',.. .; ` { ' f,:�ai1= t " t ;.,:,: i t i additional 3100.00 or fraction thereof; to and
Commercial Back Flow Prevention Device f 46.40 mcludia : $10 000.00,
$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 , rmit fee $36.2 27,55 and inciudin - $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 31,45 for
Inspection of existing plumbing or each additional $100.00 or fraction thereoff, to
s ciall re. uested in .. dons - . hour 72.50 and includin: $50000,00.
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:
i: ! H. „l 1 , %',,, 5 -, d r ir + "rah '.' I 1 �� k l, j . i 'n _ i
fixtures? Xf" es" ii or l - i �_
Are you capping, adding or replacing Plan he alrequired t pl any of the following.
please indicate work performed by fixture. Failure to
accurately re . ort fixtures could result in increased sewer fees * . 0 Any new commercial building with water service 2" and
, t ' s . t < T' t ,r, . 7 ,Y a ,t , t ; ., t, greater, except systems designed and stamped by licensed
i ti s Y . u 1 r ' 74 j r, engineer.
Baptistry/Font - u [] Any new exterior plumbing site utilities.
Bath - Tub/Shower ❑ Medical gas and vacuum systems for health care facilities.
- JacuzSh/Whidel ❑ Any multipurpose fire sprinkler system.
Car wash -Each Stall 0 Any complex structure as defined in OAR918- 780 -0040,
- Drive 7hru
Cuspidor /Water Asp_iraror Submit 2 sets of plans with any of the above.
Dishwasher -Commercial
- Domestic r, T , _
Drinking Fountain — .:::Li.,:',' .., r .a' �te < r- . .,Irr) F 9 r1 . l i [ t ` , /i i S 4, i. ..l •
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain/sink 2" that meet the • notifications above.
.3�
Car wash Drain Comments regarding filature work:
Garbage - Domestic
Disposal - Commercial -
- Industrial
Ice MachJRefn�, Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
•
Shower .Gang
- Stall *Note: lithe fixture work under this permit results in an
Sink - Bar/Lavatory ; _ increase of sewer EDUs, a sewer permit will be issued and
- Bradley • fees assessed for the sewer increase must be paid before the
- Commercial 1 plumbing permit can be issued.
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
^ Other Fixtures:
is , HUIW 1 ot6PermitAPLM- PemirApp.000 09722/06
04/29/2009 13:53 5036849015 WESTERN PLUMBING INC PAGE 03/03
City of Tigard
1111
a Building Division
13125 5W Hall Blvd,, Tigard, OR 97223
Phone: 503,639.4171 Fax; 503.598.1969
T t G l\ K D Inspection Line: 503.639.4175
Internet www.tigard- or.gov
PAYMENT AUTHORIZATION FORM
Permit No. (if available): .
Job Site Address: . I. at tit 1 a _
Project Name: ' .. � (Ai 111 464,'
Credit Card Information:
E VISA C] MasterCard " 6
Discover (Credit Coal Account N , •
. Expiration Date: 11- it
Cardholder Name (on card): William Dovers
Contact Phone No.: 503 -639 -5296
Address for this card is: 9460 SW Ti d Avenue, Suite 101
Zip code for this card is: 97223
E1e tries Trust co Inform dorm For electrical permit applications only.
Trust Account (CCB) No.:
•
Contractor Business Name:
Contact Phone No.:
I
hereby give the City of Tigard permission ro pay for the above referenced
permit with the credit card or electrical trust account numberprovided above.
Authorized Signature: li_ ..e
Name Printed: Williarrx Dovers
Date:
Please fax this completed and signed foam to 503.598.1960.
This form will be destroyed after your payment has been processed
L\ Building \ Forme: \PaymentAud riaadon.doe 10/31/07