Permit •
• CITY OF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2006 -00080
DATE ISSUED: 5/4/2006
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2S103CB -02500
SITE ADDRESS: 13235 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: WILLAMETTE NO.2 LOT: 028 JURISDICTION: TIG
Project Description: Connect existing house to new sewer lateral.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner:
CODIE YAPUNCICH FEES
13235 SW 121ST AVE Description Date Amount
TIGARD, OR 97223
[SWINSP] Sewer Inspection Fee 5/4/2006 $35.00
[SWUSA] Sewer Connection Fee 5/4/2006 $2,600.00
Phone: 503- 290 -6441 Total $2,635.00
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Contact #:
FO R REQUIRED ITEMS AND REPORTS
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow 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 copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
(
Issu d by: / a/i "V// Permittee Signature:
Call 503 - 639 -4175 by 7:00 a.m. for an inspection 14' %��`n ss 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.
Building Fixtures
Plumbline Permit Application
City of Tigard R � i v� f a b 4 Permit No.: j * ,a6go
al 13125 SW Hall Blvd., Tigard, OR 97223 D an R e
1111 0
Date/By: Review Other Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 �g
T I G A R D Inspection Line: 503.639.4175 Date Ready/By:
;;1 H See Page 2 for
Internet: www.tigard - or.gov Notified/Method: 10 Supplemental Information
TYPE OF WORK 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 OF CONSTRUCTION SFR (I) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) b 350.00
❑ Accessory building ❑ Multi- family SFR (3 bath 399.00
Each ad • ' bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: i �,a5 ,51..0 I ai 1 no L- Catch basin or area drain 'ili
City /State /ZIP: —"FT 61 A (Z D (R 9 - 9 - ' 7 j Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name: Footing drain (no. linear 1 • ) Page 2
Manufactured ho,. utilities 110.00
Cross street /directions to job site: Manholes 16.60
Rain r, : in connector 16.60
S. tary sewer (no. linear ft.: _) Page 2
St rm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.: Wa -+ service (no. linear ft.: ) Page 2
Fixture o
Tax map /parcel no.:
Absorption valve — 1576(1
DESCRIPTION OF WORK Backflow preventer Page
i, i C,C) c - r /0 ; C // t� / 1 / Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fou in 16.60
PROPERTY OWNER I ❑TENANT Ejector ump 16.60
Name: (1G (` e r t.poiAc i S Ex Sion tank 16.60
Address:
1 �j 2 . 2 ) ,� d I a 1 � 4 ✓ C Fix'ure/sewer cap 16.60
City /State /ZIP: 7 ` ._,_. t ci -72,? 3 Floo ain/floor sink/hub 16.60
Phone: (�� 3) a 7 _. 6 , 1/L// Fax: ( )
Garbage 1 16.60
❑ APPLICANT l ❑ CONTACT PERSON Hose bib 16.60
Ice maker 60
Business name:
Interceptor /grease trap .60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (comm al) 16.60
Phone: ( ) I Fax::( )
Sink/basin/lav ory 16.60
Tub /show shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water close 16.60
Business name: Water heater _---- 16.60
Address: Other:
r total
City /State /ZIP: Min' permit fee: $72.50
Phone: ( ) Fax: ( ) Residential back 1 - minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature:
TOTAL PERMIT..BEE
Print name: Date: 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.
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PlumbinE 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' 55.00 0 to 2,000 $1 15.00
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:
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
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and
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: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Complex Structures
Are you capping, adding or replacing fixtures? If "yes", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria.
accurately report fixtures could result in increased sewer fees*. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building.
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool providing services to human beings.
Car Wash - Each Stall ❑ Plumbing installations, alterations or additions to food service
- Drive Thru facilities where new plumbing fixtures, including interceptors,
Cuspidor/Water Aspirator are being installed for the food service area.
Dishwasher - Commercial ❑ Any new residential building containing three (3) or more
- Domestic dwelling units.
Drinking Fountain ❑ Any NFPA 13 - multipurpose fire sprinkler system.
Eye Wash
Floor Drain /sink 2" Submit 2 sets of plans with any of the above.
-3"
-4 „
Car Wash Drain Isometric or Riser Diagram
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: plumbing permit can be issued.
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