Permit CITY OF TIGARD PLUMBING PERMIT
11, COMMUNITY DEVELOPMENT Permit #: PLM2011 -00173
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/03/2011
Parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 140
Project: OMEP Subdivision: TIGARD TRIANGLE CENTER Lot:
Project Description: Relocate (1) sink, relocate (1) floor drain and cap (1) 2" floor sink.
Contractor: DEAN WARREN PLUMBING & REMODELING INC Owner: PACIFIC REALTY ASSOCIATES
PO BOX 14701 ATTN: N PIVEN
PORTLAND, OR 97293 15350 SE SEQUOIA PKWY #300
PORTLAND, OR 97224
P
PHONE: 503 - 624 -6300
HONE: 503 - 236 -4152
FAX: 503 - 296 -2218
FEES
Quantity Description Date Amount
1 ea Fixture /Sewer Cap 06/03/2011 $25.02
Specifics: 1 ea Floor Drain /Floor Sink/Hub 06/03/2011 $25.02
1 ea Sink 06/03/2011 $25.02
Type of Use: COM 1 12% State Surcharge - 06/03/2011 $9.01
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $84.07
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 ■ : • ca 1. -nter. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or dl -ct questions to O C • call g : e 232.1987 or 1.800.332.2344.
Iss ed By: ` • / A / , L Permittee Signature: f_:„,,
Ae-
_
Call 503.639.4175 by 7:00 a.m. for the next available in - • ction 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.
Jun 03 11 04:10p Dean Warren Plumbing And 5032962218 p.1
Plumbing Permit Application
Building Fixtures _ .
City of Tigard R / oI I r L parmit c. /Aft!( - de)173
1111 13125 SW Hall Blvd., Tigard,OR 97223
■ Phone: 503.718.2439 Fax: 503.598.'1960 _ Plan Review
ate/By:
Other Permit No.:
TIC; D Inspection Line: 503.639.4175 Date Ready/By: :La's: I !d See Page 2 for
Internet: www.tigard-or.gov L i „: 1 Notified/Method: Supplemental Informatioa
r
TYPE OF,, t I°,16 DIVISION FEE"' SCHEDULE
For special information use checklist.
❑ New construction ❑Demolition
Description I Qty. ; Ea I Total
Sd Addition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bash 312.70
❑ 1- and 2- family dwelling gl Commercial /industrial SFR (2) bath 437.78
1=1 Accessory building SFR (3) bath 500.32
ry g ❑ Multi- family
Each additional bativkitehen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft) Page 2 I
JOB SITE INFORMATION AND LOCATION Site utilities:
Z 5U• " S u/ C SC"' " 4--A•-! 3 ! Catch basin or area drain 18.76
Job site address: t
City /State/ZIP: Drywell, leach line, or trench drain 18.76
�` ar • C7�7 9 ) 2 �y Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: 1 Project name: Qi-i i,P Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear it: ) Page 2
Storm sewer (no. linear ft.: __) Page 2
Water sery ice (no. linear ft.'. _) Page 2
Subdivision: Lot no.: Fixture or item;
Tax map/parcel no.: Aft f 1 1(47D03 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
A. e, fCre i Ci : 04141 Dishwasher 25.02
/.e(Gc 4 f f. FP Drinking fountain 25.02
C ( {f 5 Ejectors/stunp 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap f 25.02
/� Floor drain /floor sink /hub / 25.02
Address: f 5-3 S c 5 '- S e9u.t d
�""4 Garbage disposal 25.02
City /State /2IP: p,4,.. a/7_ 1 ? 2- yef Hose bib 25.02
Phone: (SZ-y) ‘2cf _ 4 OC, Fax: ( ) Ice maker 12.51
❑ APPLICANT
/ CI CONTACT PERSON Interceptor /grease trap 25.02
Business name: 71,3„.. t`�r3+� ,4� /c.t,,C42.� 4,4.41,„/*,/ Medical gas (value: S ) Page 2
/ Primer 12.51
Contact name: , 5 - c, e
Roof drain (commercial) 12.51
Address: ifi, c /14 ...7c ( CtiOasin/lavatory f 25.02
CityiState /ZIP: A f , oft_ 7 7 . 5 3 Solar units (potable water) 62.54
Phone: (. -e ) 7g c_ c e 6 G Fax:: (5--c- 1 6_ y 2/ g Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: Water piping/DWV 56.29
Address: Other: L 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50 7,7 ' ao
Plan review (25% of permit fee) '
CCB Lic.: / 5-4i l9 Plumbing Lic. no.: 2 C-`7 3 c Ae State surcharge (12% ofpetmit fee) r 0 f
Authorized signature: TOTALPERMITFEE •
Thi permit application expires if a pemtit is not obtained within 180 days
Print name: �G� ae� Date: G ._ f f after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board
I:' Building •• 3'ermits'PLMU- PermitApp.doc 10/01,09 440 -40 I 6T(tC:'0'JCOM/WEtl)
Accumulative Sewer Tally Parcel # 2S101AD03200
Tenant Name: OMEP This SWR# N/A
Site Address: 12909 SW 68th Pkwy #140 This PLM# 2011 - 00173
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 1 2 0 -1 -2
- 3 inch 5 0 0 0 0 0
- 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 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 0 0 0 0
- 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 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS _ 0 0 _ 1 2 0 0 _ -1 -2
Current Fixture Value -2 divided by 16 = -0.1 Current EDU 1 EDU = $ 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -2 divided by 16 = -0.1 over (under) $ (410.00)
Enter EDU Change Here -0.1
Notes: Credit for capping.
Authorized Name /Signature: Debbie Adamski Date: 6/3/2011
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- 4100.xls 07/01/10