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Permit CITY OF TIGARD PLUMBING PERMIT "' � COMMUNITY DEVELOPMENT Permit #: PLM2010 00374 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/11/2011 Parcel: 2S110DCO2400 Jurisdiction: Tigard Site address: 11565 SW DURHAM RD 110 Project: Dr. Tollenaar - Chiropractic Clinic Subdivision: Lot: 0 Project Description: Interior plumbing: capping (1) sink and adding (1) clothes washer. Contractor: MODERN PLUMBING Owner: MOODY 2005 TRUST 11120 SW INDUSTRIAL WAY BY PAUL W & LINDA L MOODY TRS TUALATIN, OR 97062 9811 NE 114TH CIR VANCOUVER, WA 98662 PHONE: 503 - 691 -6166 PHONE: FAX: 503 - 691 -6771 FEES Quantity Description Date Amount 1 ea Clothes Washer 11/16/2010 $25.02 Specifics: 1 ea Fixture /Sewer Cap 11/16/2010 $25.02 22 ea Minimum Fee Adjustment - 11/16/2010 $22.46 Type of Use: COM Plumbing Class of Work: ALT 1 12% State Surcharge - 11/16/2010 $8.70 Type of Const: Plumbing 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 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 direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: • 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. • Nov. 12. 2010 4:25PM Modern Plumbing No. 4882 P. 1 Plumbing Permit Application aS - a I 061 0 I Budding Fixtures RECEDE ti rtllr 01 1 1(1: tISF °Nil City or Tigard Received t p I p , 13125 SW HaII Blvd., Tigard, OR 97223 NOV 1 2 2010 Date/By: i1 / f Jl tJ /}` PL/V) 0U(k — clo 371 Plan Review Phone: 503.639.4171 Fax: 503.598.1960 Date/B Other Permit No.: j�� �Q�j( 1 Inspection Line: 503.639,4175 CITY OF TIGARD Date Ready/By: Juris: HI Pnge 2 f ur i t c ; Attt) • Internet. www.tigard- or.gov BUILDING D. IVISI ®N- Notilied/Mcthod: -r-j -t4) Suppletnehtal information TYPE OF WORK FEE" SCHEDULE ' •' ['New construction ❑ Demolition tor special information use checklist Description 1 Qty. 1 Ea. I Total Addition/alteration /replacement Q Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) ' . ' ' CAT EGORY OF CONSTRUCTION ,. • , SFR (1) bath 312.70 1- and 2-family dwelling -- Y g Commercial/industrial SFR (2) bath 437.78 SFR (3) bath 500.32 0 Accessory building ❑ Multi- family Each additional bath/kitchen 25.02 El Master builder ❑ Other; Fire sprinkler ( sq. ft.) Page 2 • JOB SITE INFORMATION AND LOCATION Site utilities: Yob site address: U r Q Y Catch basin or area drain 18.76 r City /State /ZIP: ` Q Drywell, leach line, or trench drain 18.76 / J f ` Footing drain (no. linear ft. . ) Page 2 Suite/bldg. /apt. no -: t/ b Project name: Manufactured home utilities 50.03 Cross street/directions to job site: /2- • 70 Z.- L EV,/, 1 ©,. Manholes 18.76 6 47/2-0/p/2 77 Rain drain connector 18.76 614 A/i 6_ Sanitary sewer (no, linear ft.; Page 2 Storm sewer (no. linear ft.: ) Page 2 Water service (no. linear ft.: ) Page 2 Subdivision: Lot no.: Fixture Or item: Tax map /parcel no.: Backflow preventer 31.27 DESCRIPTION OF WaRK ' . . Backwater valve 12.51 • r Clothes washer I 25,02 . L ;( IL' ' (N • • „A . iv . • U u l Dishwasher 25.02 - f (s) c [c3 -se. ( 1,)0 S Le r Drinking fountain 25,02 Ejectors /sump 25,02 ' ❑ PROPERTY OWNER' '' CJ:. TENANT • Expansion tank . I2.51 Name: Fixture/sewer cap I 25.02 or)- Address: Floor drain/floor sink/hub 25.02 Garbage disposal 25.02 City/State/ZIP: I Hose bib 25.02 Phone: ( ) Fax: ( ) Ice maker 12.51 . : ❑ APPLICANT ' . . ••'• IN CQNTAa; PERSON , . Interceptor /grease trap 25.02 Business name; Medical gas (value; $ �) Page 2 Contact name: Primer 12.51 Roof drain (commercial) 12.51 Address; Sink/basin/lavatory 25,02 City /State/ZIP: Solar units (potable water) _ 62,54 Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51 -mail: Urinal_ _ 25.02 . Water closet 25.02 CONTRACTOR Water heater 37,52 Business name: fl Ord e f r P I u m, k In / Water piping/DWV 56.29 Address: 0 e' a 4; 1_,J[L Other: 25.02 City / State/ZIP: LA a( . t1 0 cj 7 0 6 L Subtotal Phone: (S (sCj I Cr, I C Cfs, Fax; (51Y >) r 7 6 7) Minimum permit fee: $72.50 72.5D CCB Lie,: . G' r /� Plan review (25% of permit fee) � I? Iutnbing Lic. no_: -1J State surcharge (12% of permit fee) g Q Authorized signature: TOTAL PERMIT FEE `;'i 2,0 Print name: D e 6 D ate: This permit application expires if a permit is not obtained within 18O days ^ ` - I / ♦/ (7 alter it has been accepted as complete. "Fee methodology by Tri -County Building Industry Service Board, // 410 /712 pp.do Ho <�2cIL% ezvvi ,1 -/1 ogy set . o 1 :\Buudia¢1?u nie\r'LMU -Permit e 0/01/09 C(2d Q, . ;7 , .a616Too /07/COMM B) Cc - 0( fir Nov. 12. 2010 4:25PM Modern Plumbing No, 4882 P. 2 Plumbic- Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule Residential Fire Su ression S .Site Utilitle9 Sty. 00 Tota iEee l . , �'St el<IIS T Square: F g Footing drain -1" 100' 0.0413 a ''P rmiit `ee „. ' : 50.03 0 to 2,000 $I21.90 Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69 Sewer - 1st L00' 62.54 3,601 to 7,200 $233.20 7,201 and y • ater $327.54 Sewer - cach additional 100' 37.52 Water Service -1st 100' 62.54 Medical Gas S stems: Water Service - each additional 100' 37.52 :, Storm & Rain Drain - 1st 100' 62.54 SllUatlO P e rWlt'Fe' Storm Rain grain -each additional 100' 37.52 $1.00 to $5,000 00 Minimum fee $72.50 $5,001.00 to $10,000,00 $72.50 for the first $5,000.00 and $1.52 for 17 the>r.'Tgp eetion5ior' Fees '.;Qb•. I1 •(ee) Total each additional $100.00 or fraction thereof, to Inspection of existing plumbing or for and includin_ $10 400.00, which no fee is specifically indicated 90.00/hr $10,001.00 to $25,000.00 $148.50 for the first $10,000,00 and $1.54 for (minimum charge specifically 1/2 hour) each additional $100.00 or fraction thereof, to Inspections outside of normal business 90.00/hr and including $25,000.00, hours ion minimum char - 2 hours) $25,001.00 to $50,000,00 $379.50 for the first $25,000.00 and $1.45 for hours Fees 90.00/hr each additional $100.00 or fraction thereof, to 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 $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are ou capping, ' ;' , an'.Revii -f :Plum.. y adding or replacing fixtures? If "yes ", r: bt;�.I�st>�lYi;tiaiow �;f'',.', please indicate work performed by fixture. Failure to plan review is required for any of the following. accurately report fixtures could result in increased sewer fees *. Please check all that apply. • t Quan by Fixture) Work,Performed :.. CI Any new commercial building with water service 2" and Fixture iypt Aepla a greater, except systems designed and stamped by licensed ' Previous.'. capped" .' •Added', ':''Exishn ' engineer. • Baptistry/Font Bath - Tub /Shower - ❑ New exterior plumbing site utilities for any complex structure , b/S i/Whirlpoal as defined in OAR918 -780 -0040, Car Wash -Each Stall ❑ Medical gas and vacuum systems for health care facilities, -Drive Thru ` ❑ Any multipurpose fire sprinkler system. Cus idor/Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040. Dishwasher - Commercial '- Domestic Submit Z. sets of plans with any of the above. Prinking fountain y Eye Wash 2' t ''' "`�^ ' ' "'�Y' °'i$ t rya i. ^#,��p:, �i M 'rd ^: °r.:.};:,'ia'�+L =ri ,',1'I��It'r.F�l ag!.yf.'` "�., Floor Drain/sink 2" ❑ Isometric or riser diagram is required for new buildings - 3" q • that meet the qualifications above. Car Wash Drain • Garbage - Domestic Disposal - Commercial - industrial _ Comments regarding fixture work: Ice MachiRefrig. Drains Oil Separator (Gas Station) �_ lApVe. b � 1 C }p 511 C . Rec. Vehicle bump Station Shower -Gang �� `t ■ s',.. ! t }c2.4I -Stall Sink - Bar/Lavatory _ - Bradley Commercial(' *Note: If the fixture work under this permit results in an - Service Swimmin Pool Filter increase of sewer EDIJs, a sewer permit will be issued and Washer - clothes - fees assessed for the sewer increase must be paid before the Water Extractor plumbing permit can be issued. Water Closet - Toilet Urinal Other Fixtures: - t AV, . L4 T:( Building \Pcrmits\PLMF- permitApp.doc 2 Accumulative Sewer Tally Parcel # 2S110DCO2400 - Tenant Name Dr. '1'ollenaar - Chiropractic Clinic This SWR# SWR2010 - 00159 Site Address: 11565 SW DURI -IAM RD., Sl'I 110 This PJ..M# PLM2010 - 00374 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 /Fnt 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 - I inch 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 - C( n 4 0 0 0 0 0 - Domestic 2 0 0 0 0 0 Drinking Mountain 1 0 0 0 0 0 Eye Wash 1 0 • 0 0 0 0 Floor Drain /Sunk - 2 inch 2 0 0 . 0 0 0 - 3 inch 5 0 0 0 0 0 - 4 Inch 6 0 0 0 0 0 - Car Awash Drn 6 0 0 0 0 0 Garbage Disposal - I ), mesnc (to 3/4 HP) 16 0 0 0 0 0 - Commercial (to 5 I IP) 32 0 0 0 0 0 - Industrial (over 5 1 -1P) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 0 0 0 0 Oil Sep (( ;as Station) 6 0 0 0 0 0 Rec. Vehicle Dump station 16 0 0 0 0 0 Shower - („;ang (per head) 1 0 0 0 0 0 - Stall 2 0 0 0 0 0 Sink - Bar /Lavatory 2 0 0 ,' 0 0 0 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 0 0 0 - Service 3 0 1 3 0 -1 -3 Swimming Pool Filter 1 0 0 0 0 0 Washer - Clothes 6 0 0 . 1 1 6 1 6 Water I ;xrractor 6 0 0 0 0 0 Water I I set - Toilet 6 0 0 0 0 0 Urinal 6 0 0 0 0 0 Previous I'.DU Count 0 0 Capped I .DU Credit 0 '1'0"1'.A1 S 0 _ 0 1 3 1 _ 6 0 3 t:urrent Fixture Value 3 divided by 16 = 0.2 Current 1 /DU 1 EDU = $ 4,100 Previous Fixture Value 0 divided by 16 = 0.0 Previous F:DI) Change 3 divided by 16 = 0.2 over (under) S 820.00 Enter EDU Change Here 0.2 Notes: Authorized Name /Signature: BRi \NDI?N TAGGAR'T Date: 11/16/2010 • Building Division Note: . I 'hc property owner shall retain the ORIGI N:AI . sewer tally record. 1 f credits exist, this document will serve as a voucher which must be submitted ru the ( :iry of Tigard Building Division to redeem credits towards future system development charges. l:ABuilding \Sewer Tally \ScwerTallvShect- 361111.xis 116/25/011