Permit Permit Application VOID /'/'7A,-
Plumbing -
Site Utilities ® FOR OFFICE USE 'ONLY'
Tigard Received ]
II
City of ► O� Plan Review v iew I U r /0 Permit No.: pip 0 10- 0 3
,p4, a 13125 SW Hall Blvd., Tigard, OR 9 '"v � ,
� ' , Plan R
C Phone: 503.639.4171 Fax: 503.59:. ,i � � � Other Permit No.:
to /By:
T 1 G A R D Inspection Line: 503.639.4175 oC� ` ��� ate Ready /By: lur s: fa See Page 2 for
Internet: www.tigard- or.gov cC \�� N otified/Method: (/ Supplemental information
TYPE OF WORK G'Cy���C? FEE* SCHEDULE
® New construction ❑ Demolit \- F or special information use checklist.
L� Description 1 Qty. 1 Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2 - family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
❑ I- and 2- family dwelling ® Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORM ATION AND LOCATION Site utilities:
Job site address: 9000 SW Durham Rd Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City/State/ZIP: Tigard, OR 97224
--r; (pa) HI* LTG 'o ( Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: Pool 1 Project name: Aquatic Cntr. W.S. RepC Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Exit 290 off of 1 -5. East to 72 " . NW on Durham Road. Rain drain connector 18.76
Project Located at Tigard High School Sanitary sewer (no. linear ft.: _ ) Page 2
Storm sewer (no. linear ft.: _ ) Page 2
Water service (no. linear ft.: 200) 1 Page 2 100.06
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Bore from Future City water meter ( by others) under High School Parking Lot to Dishwasher 25.02
west side of aquatic center building. Tigard - Tualatin School Dist. to supply Drinking fountain 25.02
plumber for tie- in to the water center. Ejectors/sump 25.02
® PROPERTY OWNER I ❑' TENANT Expansion tank 12.51
Name: Tigard - Tualatin School District Fixture sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 6960 Sw Sandburg St.
Garbage disposal 25.02
L, City/State /ZIP: Tigard , OR 97223 Hose bib 25.02
;.. Phone: (503)431 - 4017 Fax: (503)431 - 4020 Ice maker 12.51
. ;.- - ® APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: Armadillo Underground, Inc. Medical gas (value: $ ) Page 2
. Primer 12.51
I Contact name: Chris Grissom - Project Manager
Roof drain (commercial) 12.51
Address: P.O. Box 12219 Sink/basin/lavatory 25.02
M City/State /ZIP: Salem , OR 97309 Solar units (potable water) 62.54
4 Phone: (503) 588 -8050 Fax: : (503) 362 -1008 Tub /shower /shower pan 12.51
NA E -mail: chrisg @armadillounderground.com Urinal 25.02
( CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: Armadillo Underground, INC. Water piping/DWV 56.29
Address: P.O. Box 12219 Other: 25.02
City/State /ZIP: Salem , OR 97309 Subtotal 100.06
Minimum permit fee: $72.50
4
Phone: (503) 588 -8050 Fax: (503) 362 -1008 Plan review (25% of permit fee) 25.15
CCB Lic.: 62731 Plumbing Lic. no.: q 0 6 J J Y State surcharge (12% of permit fee) 12.01
Authorized signature: / TOTAL PERMIT FEE 137.22
Print name: Chris Grissom - Project Manager Date: 10/13/2010 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.
eiv.ber c, e 6( g ‘")
I: \Building \Permits \PLMU- PermitApp.doc 10;01/09 4 0- 4616T(l0/02/CO B)
1 ‘ c,0.a - (vc. .fi-t CI),
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Tom 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' 1 62.54 62.54 Medical Gas Systems:
Water Service - each additional 100' 1 37.52 37.52
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $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 $50,000.00 $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: 100.06
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", Plan Review fo Plumb I nstalla ti ons
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.
Quantltyby(Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: Replace greater, except systems designed and stamped by licensed
Previous Cam Added Existlaa engineer.
Baptistry/Font
Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure
- Tub/Shower as defined in OAR918- 780 -0040.
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive tall ❑ Any multipurpose fire sprinkler system.
Cuspidor /Water Aspirator ❑ Any complex structure as defined in OAR91 8-7 80-0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash Isometric or Riser Diagram
Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings
3 that meet the qualifications above.
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial
Industrial Comments regarding fixture work:
Ice Mach. /Refrig. Drains No Fixtures
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink -Bar/Lavatory
- Bradley
- Commercial *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 \Chris Grissom \Documents\Proposals\2010 \Tiagard _ Durham H�_ Aug 20 2010 \PLMU - PermitApp.doc
Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: n Owner n Applicant n Contractor gl City Staff
(check one)
REFUND OR Name:
i/
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓): V 0 1 0
1 CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available). /V/ 7/10
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: 1'C ih'j (90f O 6O 5
Site Address or Parcel #: 9 D )O c : 9 1 - 0 7 ) u2/ 11-
Project Name: fj N-!�'o legoo-/
Subdivision Name: Lot #:
EXPLANATION: D Ae2 tiogk c)(4.3,/tie
Our Au gild. 1P62-41/7 j9i 1Nt c/ C ion v t e rect. `
CT/L
,)
l
Signature: �/� LQ -G c Date: to/A7/60
Print Name: ��/ -/ e
Refund Policy
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.
c) 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 Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date ip R / d By 1 Rte to Bldg Admin: Date // /7 /d By 47 •
Refund Processed: Date A:/ 9 By .. Invoice Processed: Date By
Permit Canceled: Date ///27l jo By, 3 Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07