Permit w
CITY OF TIGARD
PLUMBING PERMIT
n
At COMMUNITY DEVELOPMENT Permit #: PLM2010 -00149
TtGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 05/06/2010
Parcel: 1 S 136DC00400
Jurisdiction: Tigard
Site address: 11580 SW 72ND AVE
Subdivision: FRUITLAND ACRES Lot: 17
Project: Alcorn
Project Description: Connect existing house to sewer service, 100'. Reimbursement District #46 fee paid 5/6/10.
Owner: FEES
ALCORN FAMILY TRUST Quantity Description Date Amount
19325 SW ROSA RD
ALOHA, OR 97007 100 If Sewer Service 05/06/2010 $62.54
1 12% State Surcharge - 05/06/2010 $8.70
PHONE: 503 - 270 -6813 Plumbing
10 ea Minimum Fee Adjustment - 05/06/2010 $9.96
Contractor: Plumbing
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
35m Ss. csIT■ ht4 Pis
",O Pik 5
X50 SAN► 5� ''�
pki,‘s
5 . 2 1 • ( Total $81.20
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 copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: 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.
Lir Stinky INVO]IEC)
Environmental Service`s
COMPLETE SEPTIC SERVICE ` DATE
19631 S. Kolar Dr.
Oregon City, OR 97045 ( 7 (.✓
NUMBER
Molalla: (503) 829 -8458 a Oregon City: (503) 658 -0518
Fax: (5 03) 722-7186 RECEIVED
S 1 /r ) co ry
k.4 MAY 26 2010
4/ / ` '2 V L WS
66) , fin /y/ ]� CITY OF TIGARD
• So I .7'V — T ASE DETACH AND RETURN TN YOUR REMITTANCE $ E V V �1NG DIVISION
BALANCE FORWARD
00d e _pu p -5 e*O c " c "
-f • e R -P j / d Cc)
//d ,"S e c / . J /S8v / / s - So
PAY LAST AMOUNT
X
IN THIS COLUMN
SIGNATURE X
Terms: The loth of the month following purchase. 2% finance charge on ail past due accounts 24%
annual. In the event this invoice is not paid as agreed and the account is placed in the hands of
attorney for collection, then LW Stinky Environmental Service shall be entitled to recover its ha 6-i Y®P�
reasonable attorney fees, in addition to court costs, in any legal action commenced to collect debt. Li�/ 6-
Altri fief ir
c20 % do /y7
� CITY OF TIGARD PLUMBING PERMIT
s
` •® : = . COMMUNITY DEVELOPMENT Permit #: PLM2010 -00149
q; Date Issued: 05/06/2010
41 G 'lR is 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
, Parcel: 1S136DC00400
Jurisdiction: Tigard
Site address: 11580 SW 72ND AVE
Subdivision: FRUITLAND ACRES Lot: 17
Project: Alcorn
Project Description: Connect existing house to sewer service, 100'. Reimbursement District #46 fee paid 5/6/10.
Owner: FEES
ALCORN FAMILY TRUST Quantity Description Date Amount
19325 SW ROSA RD
ALOHA, OR 97007 100 If Sewer Service 05/06/2010 $62.54
1 12% State Surcharge - 05/06/2010 $8.70
PHONE: 503 - 270 -6813 Plumbing
10 ea Minimum Fee Adjustment - 05/06/2010 $9.96
Contractor: Plumbing
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 wor ' nded for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notific ' n Center. Th se r -s are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct stions to OUNC b " allin 5.3.246.6699 or 1.800.332.2344.
Issued y: 0 _ // tI , Permittee Signature: j
'rC/�jc,‘__
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.
Plumbing Permit Application
Building Fixtures '` � , I ; c� .c i l t l ' i ,c i u � >' 14 i � ' r ;> > - , r • 's3u;R '4fe1 .ttkei: 4,' "c: Y.. .4 sin. " .iw v. .. -Xf ic.A4. 'v )1k
? Received �
_ City of Tigard Date/By: S (, ,Q / Permit No.: L M' aolp OOl
q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review q'"p
� _ C Phone: 503.639.4171 Fax: 503.598.1960 DateBy: Other Permit No.: I..
GI '. c>oo& 7
Inspection Line: 503.639.4175 Date Ready/By: See Page 2 for
1.• B Internet: www.tigard - or.gov Notified/Method: ` (CA Supplemental Information
. - TYPE OF WORK - FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 Total
❑ Addition /alteration/replacement �( Other: c- eu CONNt vF New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
1- and 2- family dwelling 1=1 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 INFORMATION AND LOCATION Site utilities:
Job site address: // $' go S (Ai 7 .. s_.,1 V J� Catch basin or area drain 18.76
O p p Z Drywell, leach line, or trench drain 18.76
City /State /ZIP:
Ti g q f,4 I / 7 2 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: v I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
NO IA a r 3 A 1 lox 0' 7.2, ,4 'Wig Rain drain connector ! 18.76
Sanitary sewer (no. linear ft.`40') Page 2 COA,5
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.: /5 J ; ‘9e1 I C 00 y0 G _Backflow preventer 31.27
. DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
( 'J c) .1-14 S •e/., f Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
g] PROPERTY OWNER I" ❑ TENANT Expansion tank 12.51
d Fixture /sewer cap 25.02
� /T
Name: 2 m , , v
� � n �
� Floor drain/floor sink/hub 25.02
Address: II ).,)X ^b SA iz �
II lr0 Garbage disposal 25.02
City /State /ZIP: AL,) i icti n , 7 7 007 Hose bib 25.02
Phone: („6 '7o -6g L; Fax: (5 d3) Vg -4z h3 Ice maker 12.51
". APPLICANT A CONTACT PERSON- . Interceptor /grease trap 25.02
Business name: Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: FLrn.e f A (G RA) Roof drain (commercial) 12.51
Address: / ci .2 S ___<w p 0 A R ,I Sink/basin/lavatory 25.02
City /State /ZIP: N Z 0A 4 0 � ` q do 7 Solar units (potable water) 62.54
Phone: ( Yd/) .2 7U - 6 L,2 Fax:: (S0_1/2) qg - y ,63 Tub /shower /shower pan 12.51
E -mail: EIJrl•FrAto /✓ v 0 Uer(z6N ‘,..,D__-1- Urinal 25.02
. Water closet 25.02
"CONTRACTOR
Water heater 37.52
Business name: Q G) 1U k- Water piping/DWV 56.29
Address: Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50 ' fa• 50
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee) • ?O
Authorized signature: J ___„11_4-.---- TOTAL PERMIT FEE i , AO
1 Date: 6"-:5"---/ 0 This permit application expires if a permit is not obtained within 180 days
Print name:
�f m e LO/eY" after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
I\ Building \Permits\PLMU- PermitApp.doc 10/01/09 440- 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 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
Storm &Rain Drain - 1st 100' 62.54 Valuation: - Permit Fee:
$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 includin . $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 Review for Plumbing 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.
Quantity by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: Replace greater, except systems designed and stamped by licensed
• Previous Capped Added Existing engineer.
Baptistry/Font
Tub /Sowr ❑ New exterior plumbing site utilities for any complex structure
Bath - hower
Tub /S erlpool 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 OAR918- 780 -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
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:
1:\ Building \Permits\PLMF - PermitApp.doc 2