Permit CITY OF TIGARD PLUMBING PERMIT
' * COMMUNITY DEVELOPMENT Permit #: PLM2011 -00104
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/05/2011
Parcel: 2S102CD02706
Jurisdiction: Tigard
Site address: 9695 SW OMARA ST
Project: Worley Subdivision: Lot: 0
Project Description: Repipe 3 bathrooms.
Contractor: OWNER Owner: WORLEY, MARTHA W
9695 SW O'MARA
TIGARD, OR 97223
PHONE:
PHONE: 503 - 639 -6563
FAX:
FEES
Quantity Description Date Amount
1 ea Water Piping /DVW 04/05/2011 $56.29
Specifics: 1 12% State Surcharge - 04/05/2011 $8.70
Plumbing
Type of Use: SF 16 ea Minimum Fee Adjustment - 04/05/2011 $16.21
Plumbing
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 work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility No ' - • 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 questions to *UNC b Iling 503.232.1987 or 1.800.332.2344.
Issu- By: C� K) , /Vl / J Permittee Signature: >( /I)///
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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
Building Fixtures FOR OFFICE USE ONLY
8 City of Tigard R eceived
Permit No.:
• 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: � / L/ //�Ql�Q7
Plan Revie
I ll Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No.:
T 1 G A R D Inspection Line: 503.639.4175 Date Ready/By: Juris ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction El Demolition For special information use checklist
Description I Qty. I Ea. I Total
Addition/alteration/replacement El Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
12'1- and 2- family dwelling El Commercial /industrial SFR (2) bath 437.78
building SFR (3) bath 500.32
❑ Accessory g ❑ 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:
Job site address: 96gs $w d t 1 c-f Catch basin or area drain 18.76
I Drywell, leach line, or trench drain 18.76
City/State /ZIP: -n B c A. 9 7 z, ,
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: lAa,(ZLE.. 7 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
q 0 # /( j ' D h _ Rain drain connector 18.76
N� 1 Dona-14e , 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
DESCRIPTION OF WORK Backwater valve 12.51
dale./ Clothes washer 25.02
1412'e.Avid 6 d..0roans Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
[PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: M LAD. (�D ./ Fixture /sewer cap 25.02 q 1p 9 ��- ) 0 ( OW24 �� Floor disposal sink/hub I 25.02
Address: - �
� Garbage ge dispsposs al 25.02
City/State /ZIP: _ l l a p Q 2 q 73.7 'rj Hose bib 25.02
Phone: ( 5- 03 ) ( p39 - 65-6, 5 Fax: ( ) Ice maker 12.51
( / APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: $ ) Page 2
Business name: ‘ y vy) p G a lt_
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
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02
l Water heater 37.52
Business name: C � ti € 2 Water piping/DWV i 56.29 5 * a'
Address: Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( )
Minimum permit fee: $72.50 7. 5
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee) - 76
Authorized signature: TOTAL PERMIT FEE I
Print name/411144 Oa/7r, Date:4 This permit application expires if a permit is not obtained within 180 days
�I'/ • / c--„e This
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 (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
P 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 ", 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 ❑ New exterior plumbing site utilities for any complex structure
Bath - Tub /Shower as defined in OAR918 -780 -0040.
- Jacuzzi/Whirlpool
Car Wash -Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive Thru ❑ 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:
I:\ Building \Permits\PLMF- PermitApp.doc 2
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:
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
license with the Construction Contractors Board.
. I 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.
/1g k Goo rkel
Print Name of Permit Applicant
4,(Ade, -
Signature of Permit Applicant Date
'V'
Permit #: TL F1 Ao II - 00164 `' ix-elle/I OD/7/
OF
10 dw O / 1 4 4 / '``' `*
Address: T ., '
PrQb, OJ2 9743 , ., 0 -1.a .;,z
Issued b Date: g/5/// '. f 5 ' /
This Copy for Permit Offices