Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009-00177
.T I GAR D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/06/2009
Parcel: 2S113AA01100
Jurisdiction: Tigard
Site address: 16588 SW 72ND AVE, "BLDG# B11
Subdivision: OREGON BUSINESS PARK 1 Lot: 0
Project: Spec Space
Project Description: Relocate • = oor drains, (4) primers, (5) lays, and (4) w /c.
Owner: FEES
PACIFIC REALTY ASSOCIATES Quantity Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY
#300 4 ea Floor Drain/Floor Sink/Hub 07/06/2009 $66.40
4 ea Primer 07/06/2009 $66.40
PHONE: 5 ea Lavatories • 07/06/2009 $83.00
4 ea Water Closet 07/06/2009 $66.40
Contractor: 1 12% State Surcharge - 07/06/2009 $33.86
LEED CORP Plumbing
12606 NE 95TH ST
VANCOUVER, WA 98682
PHONE: 360 - 213 -0969
FAX: 360 - 213 -0967
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $316.06
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 Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a cop of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: 0 „,,, � (l Permittee 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.
r P1umbin Permit Application
Building Fixtures RECEIVED ,:o,i ..I:,(, Iiti,; ONLY
City of Tigard JUL 0 6 2009 Received ► _ P`"" "" ') .•�a • , r •
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.639.4171 Fax: 503.598.1 p B Ocher Permit No.:
Plan Review
Inspection Line: 503.639.4175 ITY OF TIGARD Ready/By:
,,a;�. III See Page 2 for
Internet: www.tigard.or.gov BUILDING DIVISIO N «ifud/Mntltod: / C _ Supplemental WormatIon
';ii• -T ' - �•B;s�t'.L ^. �. ': ,i,a:?.tri`•1 , �+y' ri: ?'d, iit:�''r' `. �" T . } ., .: •:, t �.�; : ;�vor wu .. c l , ^ .,� •..d.. , '1 : -w >, •� l:; o
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mJF .. Av -,,,,. ,/ , : a ..:.°A ,. c^.F N:!•!,-.0,.,-;,:,-..:-.:,. 1 i aT• Ol , �f Vies �y/ i _: ':1JG'.!7ti :' . N - f ,it1+.1 ,,.•T� { , .,w..•.. % .,..iT ` .
❑ New construction ❑ Demolition For spedaI information use checklist
, ddition/a teuation/replacemen ❑ Other. 1- Y �� (includes connection)
cn . tion ay . Total
.. , , . ,^ . ,t: _ New 1 2-family each utility
ew q dw in 100 ft for ea co 'on
_>4 :ti . v Y '': a.;i ,ailfh`oRY 4 OF N3i'RUCI_l'I or a 5tAti SFR (1) bath 249.20
❑ I- and 2- family dwelling Ai Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder ❑Other: Each additional bath/kitchen 45.00
zs X f t - �..... - Fire sprinkler L_ sq. ft.) Page 2
: t A c ' *- , 41,. x fl_ SITE� AND LO CA1 1O I� %i ,.`. :, . Gj ari ,i.' 3itt utilities
Job site address: /15P7 5 � .n . ~ 7 , ' Catch basin or area drain 16.60 •
City / State2IP: � t1>/z /Z .i> 0 2l- Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: 3. 5p& -z_P_ Footing drain (no. linear R : ) Page 2
Cross street/directions to job site: Manufactured home utilities 110.00
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear R: ) Page 2
Storm sewer (no. linear ft.: _) Page 2
Subdivision: 1 Lot Water service (no. linear R: ) Page 2
Fixture or Item
Tax map /parcel no.: -
i Y �µ .:.p : nN,ta:� c' .JS, e i,. Absorption valve 16.60
r: I.' ,•.,a. r « :t,.. .r. ,.,i . ' . n • , , ,5 4 �w Bac crow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
r r ; w ,3 ,• u w r Drinking fountain 16.60 I
': " :� 4.p iiiiiiER7Y ow�vER ' ','�- �;, /,MP p T1 , �N T � � t
.;•, ....,, .., r x > 4 1..fi3;# :+P !, ,,.«„ % E 16.60
Name:
Expansion tank 16.60
Address: Fixture/sewer cap 16.60
City/ State/ZIP: Floor drain/floor sink/hub li • 16.60
Phone: ( )
Fax: ( ) Garbage disposal 16.60
i ia, w -iD+ � irak `'� rY�f ,o i ��'`, Q' CON[/ e•� Hose bib 16.60
ERSQ ee ice maker 16.60
Business name:
Interceptor/grease trap 16.60
Contact name:
Address:
Roof drain (commercial) 16.60
City/State/ZIP:
Phone: ( ) I Fax: : ( )
Tub/shower/shower pan I
E -mail: Urinal 16.60
{:,.. Mrr.I..5 5� l '°.t Tip ,,. ,• .., `, Ar ,4, "n Sp "'" 4 ,..1 ''+
a t•'D,: ;.. .�,�:�r..��..� dr;?,:,.x?`>;�. CI �, �1E v..�:?'H.!d - ..,r..�.,�f�t ^:� :i b • •
Business name: ` C22 G2 ' _) Water heater 16.60
Address: //.6 o 6 A./6 F„.51-- r74 Other:
Subtotal
City /State/ZIP: 04"..e • 6-4/‘ 9., 002,‹
Minimum permit fee: $72.50
Phone: (,36o) ) (3 -,096 c j Fax: ( 36 0 ) d. /3 - 6 7 Residential backflow minimum permit fee: $36.25
CCB Lic.: / .7/ d / Plumbing Lic. no.: pe_c /� Plan review (25% of permit fee)
/ State surcharge (12% of permit fee)
signature: TOTAL PERMIT FEE 31(p, o
Print name: &J I Date: 7- ,! -- This permit application expires if a permit la not obtained within
110 days alter it has been steepled as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\ Bulldineermia\PLMF- PermiiApp.doe 12/27/06 440.4616T(10N2/COMIW®)
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 dram - 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 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: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Commercial Fixture Work: Review for Plumbing Installations
A re 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.
I •report fixtures could result in increased sewer fees *. 1:=1 Any new commercial building with water service 2" and
Quantity by (Fixture) Work Perfor. l
greater, except systems designed and stamped by licensed
F ixture Type: eplace`\ engineer.
Previoa .cap a Added xisri�� ❑ 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 Isometric Riser Diagram
Drinking Fountain g
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" 4 that meet the qualifications above.
-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 q
- 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.
Washer - Clothes
Water Extractor
Water Closet - Toilet W
Urinal
Other Fixtures:
Z uiiding \Permits\PLM- PermitApp.doc 12/27/06
Plumbing Permit Application o • -r
Building Fixtures Foli OFFICE USE ONLY
City of Tigard Received
`r g PermitNo.:
q 13125 SW Hall Blvd., Tigard, OR 97223 Date/By:
C • Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Date/By: Other Permit No.:
. T 1 G A R D Inspection Line: 503.639 Date Ready/By: luris. ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental lnformation
TYPE OF WORK • FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I 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 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: Catch basin or area drain 16.60
City /State /ZIP: Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Cross street/directions to job site:
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: I Lot no.: Water service (no. linear ft.: ) Page 2
Tax map /parcel no.:
Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER 0 TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name:
Expansion tank 16.60
Address: Fixture /sewer cap 16.60
City /State /ZIP: Floor drain /floor sink/hub 16.60
'Phone: ( ) Fax: ( ) Garbage disposal 16.60
❑ 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:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: Water heater 16.60
Address: Other:
City /State /ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
Authorized signature:
State surcharge (12% of permit fee)
TOTAL PERMIT FEE
Print name: Date: 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.
1 \ Building \Permits\PLMF- PermitApp.doc 12/27/06 440- 4616T(10 /02 /COM/WEB)
• P/vi2c4-cx1i
City of Tigard, Oregon 0 13125 SW Hall Blvd. ° Tigard, OR 97223
1;
September 11, 2009
Leed Corporation
12606 NE 95t St., Ste C -160
Vancouver, WA 98682
Attn: Ted Erickson
Re: Permit No. PLM2009 -00177
Dear Mr. Erickson:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 16588 SW 72n Ave.
Project Name: (3) Spec Spaces
Job No.: N/A
Refund: ® Check #100551 in the amount of $316.06.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Project required separate permits for each space. Refund 100% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
C \Building \ Refunds \ Administration \LtrRefund- Cancelpermit.doc 01/16/07
Phone: 503.639.4171 o Fax: 503.684.7297 o www.tigard- or.gov • TTY Relay: 503.684.2772
CITY OF TIGARD RECEIPT
1,
1 g 131 25 SW Hall Blvd., Tigard OR 97223
503.639.4171
TI GARD .
Receipt Number: 175184 - 09/11/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 - 00177 $ 316.06
Total: $- 316.06
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 100551 DHOWSE 09/11/2009 $- 316.06
Payor: Leed Corporation
Total Payments: $ - 316.06
Balance Due: $316.06
Page 1 of 1
CITY OF TIGARD RECEIPT
11 ,11
a : 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
Tt.,AR.D:
Receipt Number: 174254 - 07/06/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 -00177 Floor Drain /Floor Sink /Hub 245- 0000 - 431000 $66.40
PLM2009 -00177 Primer 245 - 0000 - 431000 $66.40
PLM2009 -00177 Lavatories 245 - 0000 - 431000 $83.00
PLM2009 -00177 Water Closet 245 - 0000 - 431000 $66.40
PLM2009 -00177 12% State Surcharge - Plumbing 100- 0000 - 207020 $33.86
Total: $316.06
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 1368 LSELLERS 07/06/2009 $316.06
Payor: Leed Corporation Mechanical Contractors
Total Payments: $316.06
Balance Due: $0.00
•
Page 1 of 1
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Leed Corporation DATE: 7/16/09
12606 NE 95 St., Ste C -160
Vancouver, WA 98682 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 174254 Case #: PLM2009 -00177
Date: 7/6/09 Address /Parcel: 16588 SW 72 ^d Ave.
Pay Method: Check Project Name: (3) Spec Spaces
EXPLANATION: Per applicant's request as they will be applying for separate permits for each space.
Refund 100% of permit fees.
REFUND INFO;RMAT,ION: <,
Fee t escriiption Receipt Revenue:Aecount No: Refund
xainp�e : (BUILD] Perirut Fee Example: 245- 0000 - 432000 ;' $Amount
Plumbing Permit Fee 245- 0000 - 431000 $282.20
12% State Surcharge 100 - 0000 - 207020 33.86
TOTAL REFUND: $316.06
APPROVALS: •
If under $500 Professional Staff
If under $7,500 Division Manager •OL
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA'SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date: :;?;;' ;:. By:
Case Refund Processed: Date: ' 4 /4",. 'e j' By: .< -- --
1: \ Building \ Refunds \RefundRequest doc 04/13/09
FROM (WED)JUL 19 2009 12:92/5T. 12:61 /No. 76000003713 P 1
f ■
Community Development tY ment RECEVED p
Request for Permit Action JUL 1 5 2009
CITY-OF-TIGARD
TO: CITY OF TIGARD BUILDING DIVISION
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner ❑ Applicant gi Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) IEZ7J 4906,44 ink.)
Mailing Address: / d 6 A-1 ?S $/ J* e 4 O
City/State /Zip: - -e . ( ,76 707-
Phone No.: 21 0- J/2 " 4969
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
////❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: PPS/ c 7 ~ ° / 7 ?
Site Address or Parcel #: /1 7 5 ?A Pi ✓a
Project Name: 3 $9E - $, 0444
Subdivision Name: Lot #:
EXPLANATION: P/z 0 , -er 7 // ,Q t ca re 0 2 sic? t ,
5'C C / /102009 - - DO/ E / e oo 9 — DD/ 90 .
Signature: ... --` Date: - 5 0 ',
Print Name: r ,--2, ,'�' /,'w....,
RsfunsiZo>iq
1. The Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Paycr in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
1:()12 OI :ICI: l:til: ONI,I
Rte to S s Admin: Date AffilSZ MINVial Rte to Bl.: Admin: Date IMIZI B ,.,��
Refund Processed: Date 7AFAZI B ,, Invoice Processed: Date B
Permit Canceled: Date y,, /p 9 By " Parcel Tag Added: Date By
Receipt # Date , / Method Amount $
I:\ Building \ Forms \RcgPermitAction,doc Rev 07/26/07