Permit 4 t ITY OF TIGARD PLUMBING PERMIT
I
��� +1 DEVELOPMENT SERVICES PERMIT #: PLM2003 -00478
F �' l 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 12/22/03
SITE ADDRESS: SW NO ADDRESS PARCEL: 2S111BD 01701
SUBDIVISION: ALDERBROOK FARM ZONING: R -3.5
BLOCK: LOT: 005 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS: 1
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 520 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of 520' of private storm sewer and catch basin.
FEES
Owner:
Description Date Amount
RYAN, SCOTT PATRICK
1711 NW 100TH ST [PLMPLN] Plan Review 9/10/03 $71.75
SEATTLE, WA 98177 [PLUMB] Permit Fee 12/22/03 $287.00
[TAX] 8% State Tax 12/22/03 $22.96
Phone : Total $381.71
Contractor:
COYOTE EXCAVATING INC
PO BOX 714
NEWBERG, OR 97132 REQUIRED INSPECTIONS
Phone : 503 572 4564 Storm Drain Insp
Storm Drain Insp
Reg #: LIC 150793 Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Issue By: ,0: 6 04/M-gtt, Permittee Signature: • le&..
Call (503) 639 4175 by 7 :00 P.M. for an inspection needed the next • •siness • .y -
■
I' Site Utilities .
• .,.. , • FOR OFFICE USE ONLY
Plumbing: Permit As : i, . tion Received q � � � Plumbing nn ,{ter /J
r HEC r DDate/By: d a,Az.3 Permit No.: /4/41.0 3 4770 p
Planning approval Sewer
City of Tigard Date/By: Permit No.:
13125 SW Hall Blvd. SEP 10 2003 Plan Review/J 05 .. � Other
o
Tigard, Oregon 97223 Date /By: p.4 b3 Permit No.: .)
Post - Review Ladd Use
Phone: 503- 639 -4171 Fa�CI-A.06 dgob / v �p iv „ I i; Date/By: f -/S -OJ G Case No.:
Internet: www.ci.tigard.c1119FLDING DIVISION °o•1 iI Contact uii s.. ®See Page 2 (or
24 -hour Inspection Request: 503- 639 -4175 Name /Method: ( 7 6 Supplemental Infor
Cary' /9 _g /&---cAs 4�4 \
t : - :).: - ,TESW: " " -.7 : : : - 7 =1 SCHEDULEz fors ecial lnformattontuse checkiist .
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�~iw.�,: _.�� ��,a� =� s,1�°� �. .1'p:F�O���'QRK� °� -. � :.��•���.�3,' . , _ ° - _ _ _�_ - __ _ _ .
❑ New construction ❑ Demolition Description I Qty. I Fee(ea) I Total
❑ Addition/alteration/replacement El Other: ` (iii uds ioo 'lrt r hhlutuWy �onge o f ' : > �
n i „' ;„ .,,•'' CATEGORY;OF,GONSTRUCTION .;, >,
dwelling SFR (1) bath 249.20
1 & 2-Family g ❑ Commercial/Industrial SFR (2) bath 350.00
RAccessory Building ❑ Multi- Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
'''a;" 5 : :`::, t JOB SITiE' INFORIYIATION;atid LOCATION ww , Fire sprinkler - sq. ft Page 2
Job site address: , t 1. A:T5DP?65 5 ' ' 1E nN,, . ;:; ; Site#CJiiliiies .. w, : gn:;.;
Suite #: I Bldg. /Apt. #: Catch basin/area drain / 16.60
Drywell /leach line /trench drain 16.60
Project Name: i4 an /roper f j710 SN / d,''') Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110.00
M u p d o c, K 9 9H4 /91/e, Manholes • 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.) Page 2 0
Subdivision: Lot #: , Storm sewer (no. linear ft.) 4 Page 2 \
Tax map /parcel #: 2,5 l o r ?O I Water service (no linear ft.) Page 2 `�
1 �b .� ,..imi m. :, t .�- n , `_ :� # „x. r F;tm? ul
( ' p , Absorption valve 16.60
/ P" / Backflow preventer Page 2
Backwater valve 16.60 l C
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
,"' C A kOT OWNER. : fi ®.TENANTl, Ffs _ ' iat Ejectors /sump 16.60
Name: fcoir ,g a Expansion tank 16.60
Address: 9 9 yo ye,. /`c 4 ■o(oIC J Fixture /sewer cap 16.60
City /State /Zip: 7/ O� 9'7Z 9 Floor drain/floor sinldhub 16.60
- 3 Fax:
Garbage disposal 16 60
Phone:
CSC V 619 �{? Hose bib 16 60
�_- _ _. � ,, .E
CONTACT PERSON Ice maker 16.60
APPLICANT `r;,WS . . w 4
Name: Alit /�l '�f A , ' r1 , 7ft /hPtou'Gei Interceptor /grease trap 16.60
Address: jcs A.te 4CP.1 i' &ri'vee Medical gas - value: $ Page 2
Primer 16.60
City /State /Zip: / (/Q wf �e7 QR Roof drain (commercial) 16.60
Phone: (5C2.953 7- 492 7 Fax: (so.0 Sf 7 49Z 7 Sink/basin/lavatory 16.60
E -mail: i" a n- 0 j. / � 74 6 0 w A gaff, h e Tub /shower /shower pan 16.60 •
z � wi • . xi. <s C ONTRACTOg :g : � 11 . �� `.` :. „_ Urinal 16.60
Business Name: ee yp t _ E j( ,fT)\r
Q6 / )� Water closet 16.60
Q Water heater 16.60
Address: Po 1/ other:
`�J Phonetgo /Z - �Ca1 �f Fax: 62 �17/.,3 Other:
r ... .mx.
t� . PlumbingaPermit Fees ...:. ,'
/
CCB Lie. #: /57J 777, Plumb. Lic.#: )J//- Subtotal $ � Minimum Permit Fee $72.50 $
Authorized / / i �� � Residential Backflow Minimum Fee $36.25 �Z 7. (90 ,y
Signature: Date: (� Plan Review (25% of Permit Fee) $ '7 / •'7 5 %`
A l 0 1 o�4 ,4, 4 f/ State Surcharge (8% of Permit Fee) $ -0./.. 9 (
(Please print name) TOTAL PERMIT FEE $ 3 8: /• 7/
Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans with isometric or .
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri- County Building Industry Service Board.
is \Dsts \Permit Forms \P1mPermitApp.doc 01/03
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
. :, , ,>
Fee Schedule: Residential Fire Suppression Systems:
A ' S1te Utilttle §` t .r tr;. QtY Fr (e01 Total ' ;SgU are . 'Footage..; .. . _ Permit=F
Footing drain - 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
5 .
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 , , , ; ='x " Term'
Storm & Rain Drain - 1st 100' 55.00 5S1,0 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' i 46.40 d 3a co $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
' �. %k ma y,. - •, 'r + Fee (ea) -;, additional $100.00 or fraction thereof, to and
e.FixtureorItem,,,„ ,, ;, •
;Qty Totals 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 $50,001.00 and up • $742.00 for the first $50,000.00 and $1.20 for
Subtotal: ,V ,Q�') each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to .
accurately report fixtures could result in increased sewer fees *.
P`Qua tity5by (Fixture) Work;rerfornied t Comments regarding fixture work:
*Fixture ^Types 'Replace t
e..?,aiii, ZI. _ ; : . . , New : a Moved. �lsh g e Capper ..
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall _
-Drive Thru
Cuspidor /Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
•
Eye Wash
Floor Drain /sink - 2"
- 3"
4 "
Car Wash Drain *Note: If the fixture work under this permit results in an
Garbage - Domestic
Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial , fees assessed for the sewer increase must be paid before the
Ice Mach. /Refrig. Drains 5 plumbing permit can be issued.
Oil Separator (Gas Station) •
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal _
Other Fixtures:
is \Dsts\Permit Forms\P1mPermitAppPg2.doc 01/03