Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2010 -00375
13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/16/2010
TIGARD Parcel: 1S134BC00401
Jurisdiction: Tigard
Site address: 12442 SW SCHOLLS FERRY RD 202
Project: Scholls Ferry Rehab Subdivision: Lot: 0
Project Description: Demo (5) sinks, install (2) sinks, (1) 2" floor drain and (1) primer.
Contractor: RELIANT PLUMBING & MECHANICAL Owner: PROVIDENCE HEALTH SYSTEM
11575 SW PACIFIC HWY STE 219 4400 NE HALSEY BLDG 1 SUITE 160
TIGARD, OR 97223 PORTLAND, OR 97213
PHONE: 503 - 215 -6282
HONE: 503 -246 -1201
FAX: 503 - 246 -1205
FEES
Quantity Description Date Amount
1 ea Floor Drain /Floor Sink/Hub 11/16/2010 $25.02
Specifics: 1 ea Primer 11/16/2010 $12.51
7 ea Sink 11/16/2010 $175.14
Type of Use: COM 1 12% State Surcharge - 11/16/2010 $25.52
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $238.19
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 -0090. You may obtain a copy of the rules
or dire uestions to ■UNC • :'ling 503.232.1987 or 1.800.332.2344.
Issu d By: Permittee Signature: `�, i��Gr
�f
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
Plumbing Permit Application C _
Building Fixtures - FOR OFFICE- USE ONLY
City of Tigard NOV �� DateBed /t �� /O Permit �/Y ao�o 0075
v 13125 SW Hall Blvd., Tigard, OR 97223
on y:
s 0 •• Plan Review
• Phone: 503.639,4171 Fax: 503.598.1Zn/ OF,.' Date/ By: Other Permit No.:
Inspection Line: 503.6394175 GA Date Read /B . runs: H See Page 2 for
Ti "GARD BUIL . DI NG } y g
Internet: ww tigard orgov D!VISI .1 Notified/ Supplemental Information
TYPE OF WORK ` FEE S
0 New construction ❑ Demolition For special information use checklist.
Description 1 Qty. 1 Ea. 1 Total
Q' Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF COi`1STRUCTIO \r SFR (1) bath 312.70
❑ 1 - and 2- family dwelling ❑ CommerciaUindustrial SFR (2) bath 437.78
building SFR (3) bath 500.32
❑ Accessory g ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB. SITE NFOR . IATION AND LOCATION; Site utilities:
Job site address: t4 1 21f 2 � p it S Rol Catch basin or area drain 18.76
Perri Drywell, leach line, or trench drain 18.76
City /State /ZIP: Ti e and d12• q 1 2713
t _ Footing drain (no. linear ft.: , ) Page 2
Suite/bldg. /apt. no.: 2.02 • 1 Project name: 5ebblifcvt Rerti0. 9 'sI 202 Manufactured hone utilities 50.03
-
Cross street/directions to job site: T Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
TT ` DES CR CP TION 1 OF :.Y Back
RK
ssater valve 12.51
'J.Q�01 Cc )5 r\ks } ( n5� -e•L1 (2." 51►tk5 i - }- 1 Clothes washer 25.02
Dishwasher 25.02
bra, - 1/? € pr t (Yl e4 Drinking fountain 25.02
f Ejectors/sump 25.02
®PROPERTI OWNER ( ; ❑ TE \ \ Expansion tank 12.51
Name: PrpV (d CY1 Lam- Fixture /sewer cap 5 25.02 / a.5 . /0
Floor drain/floor sink/hub 25,02 250
Address:
Garbage disposal 25,02
City /State /ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ' •❑ :CONTr1.CT PERSON Interceptor /grease trap 25.02
Business name:
Medical gas (value: $ ) Page 2
Contact name: Printer \. 12.51 1 I
Roof drain (commercial) 12.51
Address: Sin - sin/lavatory 2 25.02 50.64
City /State /ZIP: oar units (potable water) 62.54
Phone: ( ) 1 Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 25.02
COi<TR,,,,,, OR Water heater 37.52
Business name: R ,1 -1- pt
miol � mgclianIC&`I j In( . Waterpiping/DWV 56.29
Address: t 5 5J P ft j 5 z.Idl O ther: 25,02
City/State /ZIP: I ( ad 1 0 I g7 Z23 Subtotal �
Phone: (��J) 2.0 -126 I Fax: (�jp3) ?�.{p _ 1 ��C Minimum permit fee: $72.50 p2( !
CCB Lic.: t bCI S Plumbing Lic. no.: „QQ 1 (`j Plan review (25% of permit fee)
State surcharge (12% of pernit fee) p} 5
Authorized signature: r TOTAL PERMIT FEE ,...93s . / e
Print name: 6142,11341 PO Ski a Date: ((/ Z/i 6 T his permit application expires if a permit is not obtained within 180 days
11i after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
D Building \Permits\PLMN - PermitApp.doc 10:01 /09 440- 1616r(IO1O2JCOhLWEB) \-190 j{ G"?) Lk 0 -1A-40 •
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utitl t.es Qn' Fee;(ea) Total Square Footage. Permit _Fee
Footing drain - 1" 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52 Valuation Permit Fee
Storm & Rain Drain - 1st 100' 62.54
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Draiu - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
ether Inspections or; Fees Qrs: Fee (ea> rotas
each additional $100.00 or fraction thereof, to
and including $10,000.00.
Inspection of existing plumbing or for $10,001.0010 $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including $$25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to 850,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge -2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge -1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", Plan Revllew,for Plt tubing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees Please check all that apply.
Qua City by :(Fixture) Work Performed ❑ Any new commercial building with water service 2" and
FixtiureT3pe: Replace greater, except systems designed and stamped by licensed
Previous` :t Capped AOded EzistinR engineer.
Baptistry/Font
Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure
as defined in OAR918 -780 -0040.
- Jacuzzi/\Vhirlpool ❑ Medical gas and vacuum systems for health care facilities.
Car Wash -Each Stall
Drive Thnu ❑ Any multipurpose fire sprinkler system.
CuspidorAVater Aspirator ❑ Any complex structure as defined in OAR918 - 780 - 0040.
Dishwasher - Commercial Submit 2 sets of plans with any of the above.
- Domestic
Drinking Fountain
Eye Wash
Isom or Riser Diagram
Floor Drain/sink - 2" l 0 Isometric or riser diagram is required for new buildings
- 3 that meet the qualifications above.
Car Wash Drain
Garbage - Domestic
Disposal - Commercial
- Industrial Comments regarding fixture work:
Ice MachJRefrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial 4 ..b o C *Note: If the fixture work under this permit results in an
- Service increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be paid before the
Washer - Clothes
Water Extractor plumbing permit can be issued.
Water Closet - Toilet
Urinal
Other Fixtures:
C:\ Users \Amanda\AppData\Local\Microsoft\Windows \Temporary InterneQFiles\ Content. Outlook \UP5706DA\PLMF- PermitApp.doc
Accumulative Sewer Tally Parcel # 1S134BC00401
TenantName: Scholls Ferry Rehab, ** *CREDITS * ** This SWR# N/A .-
'Si'te Address: 12442 SW Scholls Ferry Rd, This PLM# '2010=00375
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 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 1 2 1 2
- 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 RP) 16 0 0 0 0 0
- Commercial (to 5 I - IP) 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 5 10 2 4 -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 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 [DU Count 0 0
Capped EDU Credit 0
'I'TI"ALS 0 0 5 10 3 6 - 2 - 4
Current Fixture Value -4 divided by 16 = -0.3 Current EDU 1 EDU = S 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -4 divided by 16 = -0.3 over (under) $ (1,230.00)
Enter EDU Change Here -0.3
Notes: ** *CREDITS * **
Authorized Name /Signature: Debbie Adamski • Date: " 11/16/2010
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:A Building \Sewer Tally \SewerTallySheet- 3600.xls 06/25/08