Permit C ITY OF TIGARD PLUMBING PERMIT
i DEVELOPMENT SERVICES PERMIT #: PLM2005 -00447
"h-- 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 9/9/2005
PARCEL: 2S112DD -00400
SITE ADDRESS: 15912 SW 72ND AVE B17 ZONING: I -L
SUBDIVISION: OREGON BUSINESS PARK I LOT: 017 JURISDICTION: TIG
Project Description: Fixtures.
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: B FLOOR DRAINS; 1 , TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: 3 OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 3 WATER LINE: ft
DISHWASHERS: 1 RAIN DRAIN: ft
Owner: FEES
KAUFMAN, LOTTIE L + Description Date Amount
SUBOTNICK, RUTH ET AL
BY PACIFIC REALTY ASSOCIATES [PLUMB] Permit Fee 9/8/2005 $149.40
PORTLAND, OR 97224 [TAX] 8% State Surcharp 9/8/2005 $11.95
Phone : Total $161.35
Contractor:
ADDISON PLUMBING
17506 SE RIVER RD. REQUIRED ITEMS AND REPORTS
MILWAUKIE, OR 97267
Phone : 503- 785 -1840
Reg #: LIC 151754
PLM 3 -449PB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law
requires • . • follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 . s01 -0010 t ough OAR 952 - 0001 -0100. You may obtain copies of these rules or direct uestions to 0 y
ca ing 503 - 246 -66• • or 1 -0 3 - 344.
Is - ued By: , _ , � „! La. _ ,'s / %„ _ _� • Permittee Signature: k.[
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.
CI TY OF TIGARD SEWER CONNECTION PERMIT
IA DEVELOPMENT SERVICES PERMIT #: SWR2005 -00281
� J II 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 9/9/2005
PARCEL: 2 S 112 D D -00400
SITE ADDRESS: 15912 SW 72ND AVE B17 ZONING: I -L
SUBDIVISION: OREGON BUSINESS PARK I LOT: 017 JURISDICTION: TIG
Project Description: 1.6 EDU increase. (REVISED FROM ORIGINAL PERMIT TO REFLECT THE CAPPING OF (1)
SHOWER STALL)
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 1.6
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
KAUFMAN, LOTTIE L +
SUBOTNICK, RUTH ET AL Description Date Amount
BY PACIFIC REALTY ASSOCIATES [SWUSA] Sewer Connection Fee 9/9/2005 $4,680.00
PORTLAND, OR 97224 Refund - [SWUSA] Sewer Conne, 9/9/2005 - $4,680.00
Phone: [SWUSA] Sewer Connection Fee 9/9/2005 $4,160.00
Total $4,160.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Ore• • • • i i : 'fication Center. Those rules are set forth in OAR 952 -001 -0010 through OAR 952 - 001 -0100. You
m•. obtain copies o thes= le • direct questions to OUNC by calling 503 - 246 -6699 or
/•
I .sued by ' I Permittee Signature: , �j ,
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.
Building Fixture C IV c' D '. 0 00
Plumbing Permit Application FOR OFFlcl: l)SI (.) I.,Y
City of Tigard �h �" U o 1( Dat /B d. i�
9 S 4'S d Permit No. 2a95'ODgiiti
13125 SW Hall Blvd., Tigard, OR 97223
Plan vie
Phone: 503.639.4171 Fax: 503 4 �fQ0 4.,t Plan Re
vi I:� Date/By. Other PermitNo.S'W oo('_,00 a81
24- Hour inspection Line: 503iiit. OSid G DIVISION -'I �.. Date Ready/By: Si See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 Total
El 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 WI 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 LOCATION Site utilities '
Job site address: 15q la Sw - 72„„k. ,Ave Catch basin or area drain 16.60
City /State/ZIP: 9,5„4Aa,...„), oz. 11 Drywell, leach line, or trench drain 16.60
Suite . apt. no.: (7 I Project name: Footing drain (no. linear ft.: ) Page 2
P J Coo K\ e L e� Manufactured home utilities 110.00
Cross street /directions to job site: Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear 11.: Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.: -
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Aad< 7A .J W.c - / 3 new L4.u ci-el / Break toa� -. ,ri „k Backwater valve 16.60
Clothes washer 16.60
Dishwasher 1 16.60 /6,,v
® PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: ' Ta.L `Tw-s - k Expansion tank 16.60
Address: I53So St., SeqDDuDi.._ Q `ft'3av Fixture /sewer cap r4 / 16.60
City /State/ZIP: forth dt2 Floor drai floor sink/hub a t 1 16.60 /6.60
Garbage disposal 16.60
Phone: (Son ) G2 � Fax: q. -L 3 (SE CZ4-77SS"
❑ 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:: ( ) ,.,12. . .si avato / I 16.60 6 6.4 c
Tub /shower/shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 3 16.60 q 9, g 0
Business name: fq,„k su..., 9L,..\,.....0,3 fA + Water heater 16.60
Address: I4o Hw.
a,e54.eo..j. Place c�_ ` QAO \ Other:
City /State /ZIP: IA 0 1 a \� - 44 9 Y Subtotal 1`/ 9 .'<0
Minimum permit fee: $72.50
Phone: (Sol) ) - - -- (FP-to Fax: (Se ) pzQ - 9 / Residential backflow minimum permit fee: $36.25
CCB Lic.: is- /7 Plumbing Lic. no.: 3,..../q s pB Plan review (25% of permit fee i
State surcharge (8% of permit fee) // , ! t)
Authorized signature: ,L, y,,e, TOTAL PERMIT FEE 1,1 .. 45
Print name: Ja...1 w,o --e-e I Date: Q-8 -OS 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 \Pennits\PLMF- PermitApp.doc 06/05 440-4616T(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' 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
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 55.00 $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 Back flow 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 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Complex Structures
Are you capping, adding or replacing fixtures? If "yes", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria
accurately report fixtures could result in increased sewer fees*. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building.
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool providing services to human beings.
Car Wash - Each Stall ❑ Plumbing installations, alterations or additions to food service
- Drive Thru facilities where new plumbing fixtures, including interceptors,
Cuspidor/Water Aspirator are being installed for the food service area.
Dishwasher - Commercial / ❑ Any new residential building containing three (3) or more
(:)ome dwelling units.
Drinking Fountain ❑ Any NFPA I 3-D multipurpose fire sprinkler system.
E e Wash -
floor sink
- 3"
Submit 2 sets of plans with any of the above.
•
-4
Car Wash Drain Isometric or Riser Diagram
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach./Retiig. Drains
Oil Separator (Gas Station) ( Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang '
-Stall /tar ammirmvrf,
Sink -B. avator 3 Dr''
- Bradley
Gomm esci$t
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor P
Water Closet - Toilet 3 increase of sewer EDUs, a sewer permit will be issued and
Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: plumbing permit can be issued.
i :\ Building\Pennits\PLM- PermitApp.doc 07/06/05
Accumulative Sewer Tally Parcel # 2S112DD -00400
Tenant Name: Cookie Lee This SWR# 2005 -00281 ,
Site Address: 15912 SW 72nd. Ave. This PLM# 2005 -00447
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
Baptisery/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 1 2 1 2
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 1• 2 1 2
-3inch 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 1' 2 0 -1 -2
Sink - Bar /Lavatory 2 0 0 3 6 3 6
- 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 z , 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 3 18 3 18
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 1 2 8 28 7 26
Current Fixture Value 26 divided by 16 = 1.6 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 26 divided by 16 = 1.6 over (under) $ 4,160.00
Enter EDU Change Here 1.6
Notes: 9/9/05* *REVISED * *TO REFLECT CAPPING OF (1) SHOWER STALL
Authorized Name /Signature: Barbara Butler /Debbie Adam ki Date: 9/8/2005/9/9/2005
Building Division
( Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
hich must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
is \Building \Sewer Tally\SewerTallySheet.xls 7/1/05
CITY OF TIGARD
PLM2005 -00447
BUILDING DIVISION PERMIT #: 9/9/2005
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 4 "1111 Inspection Requests (24 Hrs.): (503) 639 -4175 ..
10/24/2005 7:02AM 5
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
16912 SW 72ND AVE B17
SITE ADDRESS: OREGON BUSINESS PARK I 017 CLASS OF WORK:
SUBDIVISION: COOKIE LEE LOT #: TYPE OF USE:
PROJECT NAME: Fixtures. 9/9/05, Revised to reflect capping of (1) shower stall.
DESCRIPTION:
KAUFMAN, LOTTIE L +,
OWNER: ADDISON PLUMBING PHONE #: 503- 785 -1840
CONTRACTOR: PHONE #:
10/24/2005
Inspection Request Scheduled For: Date: Pour Time:
Cs% # I e % ng fDe?cription mad, � 89-"A 1$116 Me r age
Corrections/Comments/Instructions:
IX PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: CV � ' Date:)O p /v S . Phone #: (503) 718-
CITY OF TIGARD •
BUILDING DIVISION PERMIT #: PLM2005.00447
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 9/9/2005 •
Phone: (503) 639 -4171 //uAg
Inspection Requests (24 Hrs.): (503) 639 -4175 �:_..
INSPECTION WORKSHEET FOR DATE: 10/20/2005 TIME: 7:09AM PAGE: 12
SITE ADDRESS: 15912 SW 72ND AVE B17 CLASS OF WORK:
SUBDIVISION: OREGON BUSINESS PARK! LOT #: 017 TYPE OF USE:
PROJECT NAME: COOKIE LEE
DESCRIPTION: Fixtures. 9/9/05, Revised to reflect capping of (1) shower stall.
OWNER: KAUFMAN, LOTTIE L +, PHONE #:
CONTRACTOR: ADDISON PLUMBING PHONE #: 503 - 785 - 1840
Inspection Request Scheduled For: Date: 10/20/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
399 Plumbing final 018857 -01 503. 740.6116 N
Corrections/Comments/Instructions:
I \C is•wvc. c too / COL/ 4AL- , E..- 4 /�lvo✓ �✓Ai� 0134,4_,4,.9 s- Se_
c- »mac �d �t ✓,
P er q 3, 14 - r _ ti fir/ '(— ,p c/d- 1 - - - �" f P 1 i (.., art.,
� ✓ a-J- - t✓ / 2 0 ° F -rk e s L- ,i /`'t►T I '--e Gc) v tjc.
c Cn s_Ava 1 c.--/ M.c 4 ' 4 -4 '5 T t + 1 v
❑ PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: dZ 1 Date: / o / a.a) c1 r Phone #: (503) 718-
CITY OF TIGARD =`_. _
BUILDING DIVISION PERMIT #: pLM2005 00447
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 9/9/2005
Phone: (503) 639 -4171 ��a o
Inspection Requests (24 Hrs.): (503) 639 -4175 =- 112.
INSPECTION WORKSHEET FOR DATE: 9/21/2005 TIME: 7:03AM PAGE: EA
SITE ADDRESS: 15912 SW 72ND AVE B17 CLASS OF WORK:
SUBDIVISION: OREGON BUSINESS PARK I LOT #: 017 TYPE OF USE:
PROJECT NAME: COOKIE LEE
DESCRIPTION: Fixtures. 9/9/05, Revised to reflect capping of (1) shower stall.
OWNER: KAUFMAN, LOTTIE L +, PHONE #:
CONTRACTOR: ADDISON PLUMBING PHONE #: 503-785.1840
Inspection Request Scheduled For: Date: 9/21 /2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
320 Plumbing rough -in 016231 -01 503-740-8116 N
Corrections /Comments / Instructions:
PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: fi Date: 4
l 1// v Phone #: (503) 718-
CITY OF TIGARD
BUILDING DIVISION PERMIT #: PLM200&.00447
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 9/9/2005
Phone: (503) 639 -4171 gmemof
j � l
Inspection Requests (24 Hrs.): (503) 639 -4175 s:_..
INSPECTION WORKSHEET FOR DATE: 9/14/2005 TIME: 7 :09AM PAGE: 76
SITE ADDRESS: 15912 SW 72ND AVE B17 CLASS OF WORK:
SUBDIVISION: OREGON BUSINESS PARK I LOT #: 017 TYPE OF USE:
PROJECT NAME: COOKIE LEE
DESCRIPTION: Fixtures. 9/9/05, Revised to reflect capping of (1) shower stall.
OWNER: KAUFMAN, LOUIE L +, PHONE #:
CONTRACTOR: ADDISON PLUMBING PHONE #: 503 - 785.1840
Inspection Request Scheduled For: Date: 9/14 /2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
305 Plumbing underslab 015624 -01 503 - 740 -8116 Y
Corrections /Comments/ Instructions:
E -ASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: / 27 - ) 1 V Date: V / Phone #: (503) 718-
.