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Permit • . a CITY OF TIGARD PLUMBING PERMIT 1! `- COMMUNITY DEVELOPMENT Permit #: PLM2009-00091 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639 Date Issued: 04/15/2009 Parcel: 2S114AC00700 Jurisdiction: Tigard Site address: 17005 SW 92ND AVE Subdivision: COOK PARK Lot: 0 Project: Cook Park Project Description: Cap plumbing fixtures, destroyed due to fire. Capping (2) 3" floor drains, (3) lays, (4) toilets and (1) urinal. Charging minimum fee per Brian Blalock. Owner: FEES TIGARD, CITY OF Quantity Description Date Amount 13125 SW HALL BLVD 1 ea Fixture /Sewer Cap 04/15/2009 $16.60 TIGARD, OR 97223 1 12% State Surcharge - 04/15/2009 $8.70 PHONE: Plumbing 56 ea Minimum Fee Adjustment 04/15/2009 $55.90 Contractor: - Plumbing LORENTZ BRUUN CO INC 3636 SE 20TH AVE PORTLAND, OR 97242 PHONE: 503 - 232 -7106 FAX: 503- 230 -0914 Type of Use: COM Class of Work: DEM 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 work is sst sp�eended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility lotification Center. Th. - ules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a cop o e ules Issued /4 / Permittee Signature: Ab Call 503.639.4175 by 7:00 a.m. for an inspection that busine 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. • Jiunnbing Permit Application )"4" t) , 9 oOO /O . Building Fixtures Ice + FOR OFFICE USE ONLY jj���� R eceived �/ y ^ V Permit No.: W' t p/ City of Tigard a�`-'� Date /By: 7 a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Date/By: III _ - Phone: 503.639.4171 Fax: 50319105 2009 Other Permit No TI GA RD Inspection Line: 503.639.4175 Date Ready /By: lu i . ® See Page 2 for Internet: www.tigard - or.gov n>{ TIGARD Notified/Method: lIG Supplemental Information . TYPE %:I 1G DIVISION , ' - - • . ; ' - FEE* SCHEDULE . • ❑ New construction ❑ Demolition For special information use checklist Description I Qty. I Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2-family dwellings (includes 100 ft. for each utility connection) . _ - CATEGORY OE "CONSTRUCTION- SFR (1) bath 249.20 ❑ I - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 ❑ Master builder ❑Other: Each additional bath/kitchen 45.00 Fire sprinkler ( sq. ft.) Page 2 -JOB, SITE INFORMATION .AND LOCATION - - '. Site utilities Job site address: _ � 1 z /7a,... e /70, b� 9 4-) `Catch basin or area drain 16.60 City /State /ZIP: Drywell, leach line, or trench drain 16.60 �te/ bldg. /apt. no.: ,Project name: G�Okr O `!� Footing drain (no. linear ft.: _) Page 2 j Manufactured home utilities 110.00 4 3 Cross street/directions to job site: Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: Lot no.: Water service (no. linear ft.: _ ) Page 2 Fixture or item Tax map /parcel no.: Absorption valve 16.60 • n DESCRIPTION OF WORK, - ' ' Backflow preventer Page 2 A GA ,e,v/t 4 4 .J vl /PC � 4 5 Backwater valve 16.60 ri ��� - -p l a pp �C pn v Clothes washer 16.60 Dishwasher 16.60 PROPERTY OWNER - Drinking fountain 16.60 ❑ s L ',:', 1 ' , - , '❑ TENANT _/ Ejectors /sump 16.60 Name: �4��` • pi,- 741‘,4,,,,c( Expansion tank 16.60 Address: Fixture /sewer cap 16.60 City /State /ZIP: Floor drain /floor sink/hub 3" t 16.60 Phone: ( ) Fax: ( ) Garbage disposal 16.60 ❑ APPLICANT 1 , Hose bib 16.60 . ' - . � ❑ CONTACT PERSON,' '_ Ice maker 16.60 Business name: Interceptor /grease trap 16.60 Contact name: Medical gas (value: $ ) Page 2 Address: Primer 16.60 City /State /ZIP: Roof drain (commercial) 16.60 Phone: Prime basin/lavatory 16.60 16.60 ( ) Fax: :( ) Tub /shower /shower pan E -mail: Urinal / 16.60 t - CONTRACTOR - ; I Water closet 16.60 O Business name: 4949..e/t/7/2.... �p t k f�p7'LS T. e . Water heater 16.60 Address: 30 0/ E . 7 p ' illre Other: City /State /ZIP: p,.. f 4 .i, ��/C. 4 ?- � Subtotal T 6 7 Minimum permit fee: $72.50 Phone: (57;9) 232 -'71 ©4„ Fax: 6a ? ) 6 ._ J o y / ,J Residential backflow minimum permit fee: $36.25 7a •S D CCB Lic.: , (Il • 33 ('o Plumbing Lic. no.: Plan review (25% of permit fee) _- f' \ State surcharge (12% of permit fee) 1 ,70 Authorized signature: i TOTAL PERMIT FEE - l . a 6)' Print name: gd 6 � Q g 5 Date: l /5'_ 65-T 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. i.\Building\Permits\PLMF- PermitApp.doc 12/27/06 440- 4616T(10 /02 /COM/WEB) • Plumbing Permit Application - City of Tigard a ; • Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: tlhties� � Fee ea - Total Site iJ yx , - �. >" Squ Fo A °` Peranat.Fee Footing drain - Is` 100' 55.00 0 to 2,000 $115.00 Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00 3,601 to 7,200 $220.00 Sewer - 1st 100' 55.00 7,201 and greater $309.00 Sewer - each additional 100' 46.40 Water Service - 1st 100' 55.00 Medical Gas Systems: Water Service - each additional 100' 46.40 Valuation: ,: ", Permit Fee:, . } N 5 `F Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each = additional $100.00 or fraction thereof, to and Fixturelor • Item:. Q+r = Fee (ea) Total including $10,000.00. Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to (minimum permit fee $36.25) 27.55 and including $25,000.00. Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000 00 $379.50 for the first $25,000.00 and $1 45 for each additional $100.00 or fraction thereof, to Inspection of existing plumbing or and including $50,000.00. specially requested inspections - per hour 72.50 Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for each additional $100.00 or fraction thereof. Commercial Fixture Work: Plan Review` for` Plumbing Installations . . Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following. please indicate work performed by fixture. Failure to Please check all that apply. accurately report fixtures could result in increased sewer fees*. ❑ Any new commercial building with water service 2' and :`° •a Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed Fiafure.Typecl " `. ': ",. Replace: engineer. • - Previous,, Capped ' 'Added - Existing ❑ New exterior plumbing site utilities for any complex structure Baptistry/Font as defined in OAR918 780 - 0040. Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities. - Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system. Car Wash - Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040. -Drive Thru Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher - Commercial -Domestic _ Drinking Fountain Isometric or Riser D " - Eye Wash ❑ Isometric or riser diagram is required for new buildings Floor Drain /sink - 2" that meet the qualifications above. -3" 4 Car Wash Drain Garbage - Domestic Comments regarding fixture work: Disposal - Commercial - Industrial Ice Mach. /Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar /Lavatory - Bradley *Note: If the fixture work under this permit results in an - Commercial increase of sewer EDUs, a sewer permit will be issued and - Service fees assessed for the sewer increase must be paid before the Swimming Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet -. Toilet Urinal Other Fixtures: i \Building \Permits \PLM- PermitApp doc 12/27/06 s Accumulative Sewer Tally Parcel # 2S114AC00700 Tenant Name: City of Tigard - Cook Park This SWR# N/A Site Address: 17005 SW 92nd Ave This PLM# 2009 - 00091 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/Font 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 - Each 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 - Commercial 4 0 0 0 0 0 - Domestic 2 0 0 0 0 0 Drinking Fountain 1 0 0 0 0 0 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 0 0 0 - 3 inch 5 0 2 10 0 -2 -10 - 4 inch 6 0 0 0 0 0 - Car Wash Drn 6 0 0 0 0 0 Garbage Disposal - Domestic (to 3/4 HP) 16 • 0 0 0 0 0 - Commercial (to 5 I -IP) 32 0 0 0 0 0 - Industrial (over 5 I -IP) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 - 0 0 0 0 Oil Scp (Gas Station) 6 0 0 0 0 0 .. Rec. Vehicle Dump station 16 0 0 0 0 0 - Shower - Gang (per head) 1 0 0 0 0 0 - Stall 2 0 0 0 0 0 Sink - Bar /Lavatory 2 0 3 6 0 -3 -6 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 0 0 0 - Service 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer - Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet 6 0 4 24 0 -4 -24 Urinal 6 0 1 6 0 -1 -6 Previous EDU Count 0 0 Capped EDU Credit 0 'l'OTALS 0 0 _ 10 46 0 _ 0 -10 -46 Current Fixture Value -46 divided by 16 = -2.9 Current EDU 1 EDU = $ 3,100 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change -46 divided by 16 = -2.9 over (under) S (8,990.00) Enter EDU Change Here -2.9 Notes: ** *CREDITS * ** Authorized Name /Signature: Debbie Adamski Date: 4/16/2009 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. I f credits exist, this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I.A Building \Sewer Tally \Sewcrl'allySheet- 3100.xls 06/19/08 Accumulative Sewer Tally Parcel # 2S114AC00700 Tenant Name: City of Tigard - Cook Park * *REVISED ** This SWR# N/A Site Address: 17005 SW 92nd Ave This PLM# 2009 -00091 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/Font 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 - Each 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 - Commercial 4 0 0 0 0 0 - Domestic 2 0 0 0 0 0 Drinking Fountain I 0 0 0 0 0 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 0 0 0 - 3 inch 5 0 2 10 0 -2 -10 - 4 inch 6 0 0 0 0 0 - Car Wash Dm 6 0 0 0 0 0 Garbage Disposal - Domestic (to 3/4 HP) 16 0 0 0 0 0 - Commercial (to 5 HP) 32 0 0 0 0 0 - Industrial (over 5 HP) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 0 0 0 0 Oil Sep (Gas Station) 6 0 0 0 0 0 Rec. Vehicle Dump station 16 0 0 0 0 0 Shower - Gang (per head) 1 0 0 0 0 0 - Stall 2 0 0 0 0 0 Sink - Bar /Lavatory 2 0 3 6 0 -3 -6 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 0 0 0 - Service 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer - Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet 6 0 4 24 0 -4 -24 Urinal 6 0 1 6 0 -1 -6 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 10 46 0 0 -10 -46 Current Fixture Value -46 divided by 16 = -2.9 Current EDU 1 EDU = $ 3,100 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change -46 divided by 16 = -2.9 over (under) $ (8,990.00) Enter EDU Change Here -2.9 Notes: ** *CREDITS ** *4/28/11, 2.1 EDU credits applied to PLM2011- 00135, remaining balance is -.8 Authorized Name /Signature: Debbie Adamski Date: 4/16/2009 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I: \Building \Sewer Tally \ SewerTallySheet-3100.xls 06/19/08