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Permit , `� CITY OF TIGARD SEWER CONNECTION PERMIT DEVELOPMENT SERVICES PERMIT #: SWR2005 -00095 r .� � 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 3/2112005 PARCEL: 2S 103BC -03300 SITE ADDRESS; 12300 SW ALBERTA AVE ZONING: R - 4.5 SUBDIVISION: CANOGA PARK LOT: 007 JURISDICTION: TIG Project Description: Sewer connection TENANT NAME: CWS NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 1 TYPE OF USE: SF NO. OF BUILDINGS: INSTALL TYPE: LTPSWR IMPERV SURFACE: Owner: FEES OLIVER, CHARLES A /BETH M 12300 SW ALBERTA ST Description Date Amount TIGARD, OR 97223 [SWUSA] Swr Connection Fee 3/21/2005 $2,500.00 [SWINSP] Sewer Inspection Fee 3/21/2005 $35.00 Phone: 503 - 590 - 7035 Total $2,535.00 Contractor: REQUIRED ITEMS AND REPORTS Phone: 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. Issued by: A do , _ 4 L Permittee Signature/C � , Q 4Q�.-----■ Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business 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. wilding Fixtures 1 Numb 1 . I� / ' n . L 2 - i„� 0 , at ... FOR ,OFFICE O USE ONLY e Y City of Tigard Received r Plan Review �? 13125 SW Hall Blvd., Tigard, O Ar 3 1 200(� 5 y' t � 7t)5 "...'" Permit No ��® �� % Phone: 503.639.4171 Fax: 503. t 9 / / y,td /j�.' Date/By: y: Other permit No.: 24- Hour Inspection Line: 503.639.4175 Internet: www.ci.tigard.or. is ITY OF ��� - Date Ready/By: Jun': H See Page 2 for Notified/Method: nei Supplemental Inf .k._ ,k wit ik � .1 .. .„- ..:r;- ; .:..�„ . SCHl±DlY1E F o r spec i nformat ii ❑ New construction ❑ Demolition information use checklist. ❑ Addition/alteration/replacement El Other: Description Qty. Ea. Total x ,- E. o 4 r , y z }r r e L yy New 1 -2- family dwellings (includes 100 ft. for each utility connection) ? ,c r -s .., , , :, §- V,..,l lTJ2 „O igd 426rl ON 1 SFR (1) bath 249.20 .12''1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 El Accessory building ❑ Multi - family SFR (3) bath 399.00 ❑ Master builder Each additional bath/kitchen 45.00 ❑ Ot her: s,t " J SITE FOR I T N N v` . I Fire sprinkler ( sq. ft.) Page 2 „+ ,;.{: t ae, ^r ;. , , . ... a LOCxAfi h x r ' a S utilities 1 Job site address: ! S',..3 a l 1,14,_.... m � 4 Catch basin or area drain 16.60 City/State /ZIP: (C .1,rcit ' 912.. C ` r - 4-.1 { .1 2-4) *2.4::, Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2 Cross street/directions to job site: Manufactured home utilities 110.00 Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2 Tax map /parcel no.: Fixture or item ;r :. , , r , Absorption valve 16.60 r , , � D SCRLP O - '4i RK .a r ` „ 1 -....>. ,, �.. a mo w. -' Backflow reventer �'` Page 2 P A kiL.(� (. Y 7 1/14 .A r 1 (i1.-- Bacicv✓ater valve 16.60 t Clothes washer 16.60 / Dishwasher 16.60 �� - mss' , a0. Drinking g k � 1'RO,I'ERT OW NER :I " ,.: Tt ,A v, ng fountain 1 b.60 _ rat ": J fir+, ... 4N". . �. � �k TENAN . r.?: .a ...� . � ,C� E /sump 16.60 Name: C‘..‘ 4 1,,Q P A . l Jt ; �-e.,r „ Address: Expansion tank 16.60 t Z 3 ©0 St,J A l h / -4- G S+ Fixture /sewer cap 16.60 City/State /ZIP: t" - ��r� & V q 4-a.2„3 ► a2/ Z Floor drain /floor sink/hub 16.60 Phone: (S()3 ) 5 9 D -- - 3v1 s Fax: ( ) Garbage disposal 16.60 , ,,,. °` c"' $'6- , 1 ..PNxA0 < - , 1r� : 4 -v. I 1- ,,, :<. r ;;.' ', VIer _, , 4 Hose bib .� i APPITCriNT ,r C ©rT CT F I 16.60 a, .ti .- mss.. v �.,:.a.'t ::4,„ '8x - �.- ,s.._ . -�... �,:�, _�...�! �. �..�: -:, ;� .��h Ice maker 16.60 Business'name: Interceptor /grease trap 16.60 Contact name: Medical gas (value: $ ) Page 2 Address: Primer 1 6.60 City/State /ZIP: Roof drain (commercial) 16.60 Phone: ( ) Fax: : ( ) Sink/basin/lavatory 16.60 E -mail: Tub /shower /shower pan 16.60 Urinal i i$p . F'. . '' : ::.,?k�` "' � : >.��z ^..:a_s's�^.--'� �::, .„ 3,,:, q:4-6431„1514.1N' _ 16.60 x -° l . r '� ,. J t *- . CONTRALTO Via. <- :r4 APIA g/, � � i::6r �e. I A� -,. � � . ��� >._ z_., °.. "../,..�,�..� 16.60 Water close Business name: � -- 1 , ,�,� n ,'�� l I...„. j j , / /,- 7 Water heater 16.60 Address: s �v i vi � ►�f�ll Other: - City/State /ZIP: Subtotal Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 Plan review (25% of permit fee) CCB Lie.: Plumbing Lic. no.: Authorized signature: �- -� . �.Q - State surcharge (8% of permit fee) �L ��'`��- TOTAL PERMIT FEE rj ' . CO Print name �v/ - , D. t•o-e -- Date:3 ....a (., t� This permit application expires if a permit is not obtained w' 180 days after it has been accepted as completes *Fee methodology set by Tri -County Building Industry St i:\ Building \Perntits\PLMF- PermitApp.doe 12/03 440- 4616T(t o /02/COM/WEB) I • • Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: IE `` : attar .tom.' , . wow ee (C8 n`i'Otii f�,ti ;� ,. w Ste�Utilities .3 qu.a ootitage Footing drain - 1' 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 P_erwil j ee 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 k ' `, f-": - eei ( () ' ea `� t+kTotal ". additional $100.00 or fraction thereof, to and F l t :Wor aIteme; µ' a . t - _.. ,.., = '_�: 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: 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 * . x 1,Quantit. y (£uitu" e) 'o*.k rform d 15 xture4,p A e ` Moved 3 Extstmg Capped p Comments regarding fixture work: o 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 Garbage - Domestic Disposal - Commercial *Note: If the fixture work under this permit results in an -Industrial increase of sewer EDUs, a sewer permit will be issued and Ice Mach. /Refrig. Drains Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the Rec. Vehicle Dump Station plumbing permit can be issued. Shower -Gang -Stall • Sink _ - Bar/Lavatory Quantity Total - Bradley Commercial Isometric or riser diagram is required if fixture quantity Service total is >9. Swimming Pool Filter Washer - Clothes Water Extractor Plan Review Water Closet - Toilet Plan review is required if fixture quantity total is >9. Urinal Other Fixtures: i: \Building'Pem its\PLM- PemritApp.doc 3/03