Permit CITY OF TIGARD
PLUMBING PERMIT
�� DEVELOPMENT SERVICES PERMIT #: PLM2004 -00454
' 'I I � 13125 SW Hall Blvd., Tigard, OR 97 (503) 639 -4171 DATE ISSUED: 9/30/2004
SITE ADDRESS: 16100 SW 72ND AVE B -18 PARCEL: 2S113AA -00500
SUBDIVISION: OREGON BUSINESS PARK I ZONING: I -L
BLOCK: LOT: OOA JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: B FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: 1 OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 1 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Plumbing TI, capping (1) water closet, (1) lay & installing (1) new breakroom sink.
FEES
Owner:
Description Date Amount
PACIFIC REALTY ASSOCIATES [PLUMB] Permit Fee 9/30/2004 $72.50
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [TAX] 8% State Surchari 9/30/2004 $5.80
Total $78.30
Phone:
Contractor:
DEAN WARREN PLUMBING & REMODEL
PO BOX 14701
PORTLAND, OR 97293 REQUIRED INSPECTIONS
Phone : 503 - 492 - 9514 Rough -in Insp
Top -out Insp
Reg #: LIC 154919 Insp existing /capped fixtures
PLM 26 - 736PB Final lnspection
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 you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR
952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
2469.
Iss e d By: Permittee Signature:x
Call (503) 639 -4175 by 7:00 P.M. for an inspection neede a next business day
Building Fixtures
Plumbing Permit Application FOR OFFICE USE ONLY
Received Plumbing u
Datte/By: By: ;10 04 Permit No.: 6/7 f O
Planning Approval Sewer r
City of Tigard Date/By: Permit No.:
T 13125 SW Hall Blvd. Plan Review Other
igard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post Land Use
/�^�"I4ar��' I' +� Date/By: Case No.:
Internet: www.ci.tigard.or.us -. � eel 1 � Contact J /� ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 - Name/Method: 7 /LA Supplemental Information.
TYPE OF WORK FEE* SCHEDULE (for special information use checklist)
❑ New construction ❑ Demolition Description 1 Qty. 1 Fee(ea.) ( Total
tkl Addition/alteration /replacement ❑ Other: New 1- & 2- family dwellings
CATEGORY OF C (includes 100 ft for each utility connection)
SFR (1) bath 249.20
❑ 1 & 2- Family dwelling ❑ Commercial/Industrial SFR (2) bath 350.00
DAccessory Building ❑ Multi - Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Fire sprinkler - sq. ft.: Page 2
Job site address: / (, /t 0 3w - 7t'� Site Utilities
Suite #: 1 Bldg. /Apt. #: Catch basin/area drain 16.60
Project Name: p o 5 DrywelVleach line/trench drain 16.60
Pro
�(� Footing drain (no. linear ft.) Page 2
Cross street/Directl s to job site: Manufactured home utilities 110.00
ane.., 66 "3i- J t / Manholes 16.60
/311 1..1 q/ evotierCJ Rain drain connector 16.60
Sanitary sewer (no. linear ft.) Page 2
S ubdivision: I Lot #: S torm sewer (no. linear ft.) Page 2
Tax map /parcel #: P6 11644 • Dosc0 Water service (no. linear ft.) _ Page 2
Fixture or Item
DESCRIPTION OF WORK Absorption valve 16.60
c . / 1 - kJ. C - Backflow preventer Page 2
Re ( L / ?Lc' i 9 - .,, e 4 4 1 4 , 4 Backwater valve 16.60
Clothes washer 16.60
fr Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OWNER 1 0 TENANT Ejectors/sump 16.60
Name: 1 tr,a t- Expansion tank 16.60
Address: / 63 ro v. / s"v,ta 3 cue . Fixture/sewer cap 16.60
City/State/Zip: Floor drain/floor sink/hub 16.60
Y P Garbage disposal 16.60
Phone: Fax: Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON Ice maker 16.60
Name: Interceptor /grease trap 16.60
Address: Medical gas - value: $ Page 2
Primer 1 16.60 / C49
City /State /Zip: Roof drain (commercial) 16.60
Phone: Fax: Sink/basin/lavatory 1
16.60 / C. Co
E -mail: Tub /shower/shower, pan 16.60
CONTRACTOR Urinal 16.60
Business Name: Q �dvr►r,Pt�t �..- Water closet j 16.60 /4, Co
Water heater 16.60
Address: p.0.4,,,,, GIGS Other:
City /State /Zip:,fi rel 7 ? ) 9.7 other:
Phone: N S 2- -Fpy Fax: 2 _9 c...7,24 e Plumbing Permit Fees*
Subtotal $ l i 9.
CCB Lic. #: / 919 Plumb. Lic. #: L4.- x- /l8 Minimum Permit Fee $72.50 $ , v
Authorized cp Residential Backflow Minimum Fee $36.25 7 Z et-- Signature: Date: ! Plan Review (25% of Permit Fee) $
oil a-e a z State Surcharge (8% of Permit Fee) $ t--
(Please print name) TOTAL PERMIT FEE _ $ r
Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans with isometric or
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri -County Building Industry Service Board.
i:\Dsts\Permit Forms\PimPermitApp.doc 01/03
Plumbing Permit Application - City of Tigard
•
Page 2 - §upplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: 1
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
additional $100.00 or fraction thereof, to and
Fixture or Item Qty. Fee (ea) Total 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
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 $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to • , • •
accurately report fixture s could result in increased sewer fees *.
Quantity by (Fixture) Work Performed Comments regarding fixture work: 4.14
Fixture Type: Replace
New Moved Existing Capped
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
- 3"
-4"
Car Wash Drain *Note: If the fixture work under this permit results in an
Garbage - Domestic
Disposal - Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice Mach. /Refrig. Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley
- Commercial
- Service /
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet J
Urinal
Other Fixtures:
iADsts\Permit Forms\PlmPermitAppPg2.doc 01/03
Accumulative Sewer Tally Parcel # = 2$ 9 - ' 3Aq ' h 2` ,f
Teat " talr Payl2ss . ' s r:� * x xX T -� �"� ,�-n, - , c. :' g e ?, t+,M
r . - .3z %',:.:1-,:,'",<.,.: x - z 4 � Thi SW R #,;, � 1 ��. � "; ,� � �. ,. f � � •� � , ;
ite Add ess , r 16100 - SOIM- 6d */#. '.: ` •:� '", ::.•°` N This PLM# 20 C "" 9 V V
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
.`• _ . ` . .:: 0 v. .__.. . '_
Baptisery/Font 4 _ . ', 0 ° 0 0 0
Bath -Tub /Shower 4 0 ` , _ , - - _ 0 : ` 0 0 0
- Jacuzzi/Whirlpool 4 0 ', 1 , ; � 0 0 0 0
Car Wash - Each Stall 6 0 ' ' "'' 0 a � 0 0 0
- Drive through 16 •; 0 ` ' _+ ,<� 0 ,i4'. . ' ` 0 0 0
Cuspidor/Water Aspirator 1 ,; t , 0 4 1 ' , 0 '�" n 4 0 0 0
Dishwasher - Commercial 4 , „ 0 t> 0 'f & ? -4 ;, ' ' 0 0 0
- Domestic 2 V:= _ 0 0 0 ' . ? ` ' 0 0 0
Drinking Fountain 1 4.' : "§'y 0 li i'V}- 0 4 .: 0 0 0
t 4,
Eye Wash 1 C . .4 -1 0 ,' 0 �.�,``` �.:' � 0 0 0
y , x, ti °;s•a
Floor Drain /Sink - 2 inch 2 - ,S ', cT. 0 A 0 ; ;k ,, ; Y, . 0 0 0
- 3 inch 5 . 0 , ; 0 .: ' 0 0 0
- 4 inch 654. 0 i'.�". 0 4'1, 0 0 0
- Car Wash Drn 6 " ' ;; . 0 ;,; . 0 Ov Y• 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 : '`k, ; . 0 ;{ 0 0 0 0
- Commercial (to 5 HP) 32 j K ; ,c I 0 , y 0 z� ;5 N:-:Z 0 0 0
- Industrial (over 5 HP) 42 ,t fir °A 0-"eh 0 ,-;.,„-:::::;:-44.„. *�v 0 0 0
Ice Machine /Refrigerator Drain 1 W s;
t „< 0 4;� 0 - % 0 0 0
Oil Sep (Gas Station) 6 *-1 0 4,4 0 'f';',00 0 0 0
Rec. Vehicle Dump station 16 M : 0 , 0 : 0 0 0
Gang (per head) ° .., ; w5 5: 0 0 0 0
Shower -Gan ) 1 t »"�� $9 � 0 }
- Stall 2 c ; iz , a 0 k 0` ". 0 0 0
Sink -Bar /Lavatory 2 t`Vi10, 0 w 2 g 0 -1 -2
Bradley 5 <„ 0 0 :- . . > �. • ° f 0 0 0
- Commercial 3 W1.0, 0 I. r 0 ': _`' 0 0 0
y-�"�� 4 0 r s >�e 0 v. 1 n
- Service 3 . - ,, ; s 3 1 3
Swimming Pool Filter 1 ll 0 . N 0 S 0 0 0
Washer - Clothes 6 ' x 0 �, 0 0124M 0 0 0
Water Extractor 6 : 0 * A, 0 ` >_ 0 0 0
5 ;,13,0_,_,‘, • _ 4 e may. 3 -r . ,
Water Closet - Toilet 6 , �1 0 1A, 6 _ , t -, 0 -1 -6
Urinal 6 . , `t` .n, 0 ::' 0 ,# ,,,. 0 0 0
Previous EDU Count `& -o- 0 0
Capped EDU Credit . ' ., ,
TOTALS 0 0 2 8 1 3 -1 -5
Current Fixture Value -5 divided by 16 = -0.3 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -5 divided by 16 = -0.3 over (under) $ (750.00)
Enter EDU Change Here ,, „,,47$: <'
Notes: CREDITS!!
S nature: g ) ef , Date: $
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.
i:\Building\Sewer Tally \SewerTallySheet.xls 7/1/04
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested L - ! / / — AM PM BUP
Location 1 � . ( DD 7a �i Y.v Suite MEC
Contact Person Ph ( ) — 1 PLM e/10
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Ftg Drain Access: ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall i
Fire Sprinkler
Fire Alarm -
Susp'd Ceiling
Roof / / / le
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Ii
PART FAIL
CHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE 0 Please call for reinspection RE: 0 Unable to inspect — no access
Fire Supply Line I/
ADA Date v Inspector Ext
Approach/Sidewalk
Other:
Final DO NOT R MOVE thls Inspection record from the job site.
PASS PART FAIL