Permit 4, CITY OF TIGARD PLUMBING PERMIT
t COMMUNITY DEVELOPMENT Permit #: PLM2011 -00071
T !GARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/10/2011
Parcel: 2S112BD01700
Jurisdiction: Tigard
Site address: 15050 SW 79TH AVE
Project: CARLSON Subdivision: DURHAM ACRES Lot: 38
Project Description: Installing sewage pump and connecting to sewer.
Contractor: OWNER Owner: CARLSON, BRUCE & VICKI
15050 SW 79TH AVE
TIGARD, OR 97224
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
100 If Sewer Service 03/10/2011 $62.54
Specifics: 1 ea Ejectors /Sump 03/10/2011 $25.02
1 12% State Surcharge - 03/10/2011 $10.51
Type of Use: SF Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $98.07
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: P rmittee Signature:
Call 503.639.417 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 p r. ject.
Approved plans are required on the job site at the time of each inspection.
.. V Plumbing Permit Application _ `1
Site Utilities FR O OF OFFICE 1St; ()NE)
Cit of Tigard ( Re
- Permit No.:
7 • 1 3125 SW Hall Blv d., Tigard, OR 97223 4 J S O� Date /By: /6 Ii �J/ -A. ,,,) - .... 7 t
g l ` Plan R eview
Phone: 503.718.2439 Fax: 503.598.196 , O Date/By: Other Permit No.:
T I GARD Inspection Line: 503.639.4175 1 Date Ready /By: I ' See Page 2 for
Internet: www.tigard- or.gov 4 `1�Y A, Notified/Method: Supplemental Information
T' P1 OF WOI FEE* ' CltEnJ
For special information use checklist:
❑ New construction ❑ Demolition
Description I Qty. I Ea. I Total
® Addition/alteration/replacement ❑ Other: New 1-2-family dwellings (includes 100 ft. for each utility connection)
CAT1 ORY OF CONSTRUCTION SFR (1) bath 312.70
® 1- 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 IIN I, INIATION AND LOCATION Site utilities:
Job site y address: 15050 sw 79 ave. Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City /State /ZIP: Tigard, OR 97224 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: rely-1504j Manufactured home utilities 50.03
Cross street/directions to job site: 79 ave south of Bonita Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: 11) ) 1 Page 2 62.54
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.: 2S 1 12BD Backflow preventer 31.27
Backwater valve 12.51
DESCRIPTION OF WORK
Clothes washer 25.02
Install new sewage injection pump and basin, and connect to existing sewar line Dishwasher 25.02
in SW 79 ave Drinking fountain 25.02
Ejectors /sump 1 25.02 25.02
' TE,NANT Expansion tank 12.51
Fixture /sewer cap 25.02
Name: Bruce Csrlson
Floor drain/floor sink/hub 25.02
Address: 15050 sw 79 ave. Garbage disposal 25.02
City /State /ZIP: Tigard OR 97224 Hose bib 25.02
Phone: (503)6241133 Fax: (503)6240903 Ice maker 12.51
„ Interceptor/grease trap 25 02
�,,, � �' �� � CONTACT I?�AI
Medical gas (value: $ Page 2
Business name:
Primer 12.51
Contact name: 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
Urinal 25.02
Email
Water closet 25.02
' S,i .'.,, t "RAFOR Water heater 37.52
Business name: Q Water piping/DWV 56.29
Address: Other: 25.02
Subtotal 87.56
City /State /ZIP:
Minimum permit fee: $72.50 •
Fax: Phone: ( ) ( )
Plan review (25% of permit fee)
CCB Lic.: Plumbing Lic. no.: 0 10.51
State surcharge (12% of permit fee)
Authorized signature: TOTAL PERMIT FEE 98.07
'/V 3 Date: 3 This permit application expires if a permit is not obtained within 180 days
Print name: Az-v-4. e 6 f _c sr z Di 1 / after it has been accepted as complete.
J 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. Qty. Fee (es) 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' 1 62.54 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 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
Q ty (ea) Total each additional $100.00 or fraction thereof, to
Other Inspections or Fees 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:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace! Plan review is required for any of the following.
Work Performed: Added Relocate
Baptistry/Font Please check all that apply.
Bath Tub /Shower ❑ Any new commercial building with water service 2" and
Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918- 780 -0040.
Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ Any complex structure as defined in OAR918- 780 -0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above.
- 3"
a" Isometric, or Riser Diagram
Car Wash Drain ❑ Isometric or riser diagram is required for new buildings
Garbage - Domestic- non -food
Disposal - Domestic -food related that meet the qualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav - Non -food related
- Bradley
- Commercial- food related
- Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer - Clothes
Water Extractor increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
C : \Users\BRUCEC-1 \AppData \Local \Temp \PLMU - PermitApp -1.doc 2
li Site Utilities — Plumbing Permit Application
Plan Submittal Requirements
TIGARD
A plumbing permit for site utility plumbing work is required for sanitary sewer, storm sewer
and potable water systems on private property.
1. SITE PLAN and vicinity map showing the geographic location (fully dimensional, drawn
to scale) labeled with:
A. ❑ map & tax lot # ❑ project name ❑ site address ❑ suite number
❑ zoning ❑ applicant name ❑ phone number
B. North arrow.
C. Scale (architectural or engineering only).
D. Street names.
E. Building pads with project location.
2. PLUMBING PLANS - Two (2) complete sets, civil only.
All details listed below shall be incorporated into the plumbing plans:
A. Storm drainage plan showing:
1) Finish elevations throughout the developed site.
2) Grade breaks determining area serving each catch basin.
3) Location of catch basins.
4) Pipe size.
5) Type of material.
6) Slope of piping.
7) Manholes and field drains.
8) Cleanouts provided for each 100 feet or fraction thereof.
9) Roof drain laterals specifying cleanouts at each upper terminal.
10) Location of existing or proposed connection to a public sewer line.
B. Utilities plan showing:
1) Sanitary sewer line location, pipe size, type of material, slope of piping, manholes
and cleanouts provided as required for storm.
2) Size and location of domestic water piping and drainage.
3) Proposed location of connection to a public water or sanitary sewer line.
I:\ Building \Permits\PLMF- PermitAPP.doc 12/30/05
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
1 1 I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
- / will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
Print Name of Permit Applicant
Z ,
3/( 1
Signature of Permit Applicant Date /
Permit #: ibl)d l l <Jll(37 I f F!—C- ?tNl — 00 )0)
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Address: 1 705c ,
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Issued by: (3 7 1 • Date: 3/ I of I
This Copy for Permit Offices
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15875 114th Ave. Ste C .
Clackamas, OR 97015-
phone: (503) 650 -7377 •
fax: (503) 650 -7378
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