Permit n CITY OF TIGARD PLUMBING PERMIT
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' • : -? COMMUNITY DEVELOPMENT Permit #: PLM2009 -00184
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/13/2009
Parcel: 2S 103 BC08800
Jurisdiction: Tigard
Site address: 12830 SW BLUE HERON PL
Subdivision: BLUE HERON PARK Lot: 5
Project: Penner
Project Description: Installation of residential backflow preventer.
Owner: FEES
PENNER, JOHN M & LILLIAN A Quantity Description Date Amount
12830 SW BLUE HERON PL
TIGARD, OR 97223 1 ea Backflow Prevention - RES 07/13/2009 $27.55
PHONE: 1 12% State Surcharge - 07/13/2009 $4.35
Plumbing
9 ea Minimum Fee Adjustment - 07/13/2009 $8.70
Contractor: Plumbing
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: OTR Type of Const:
Occupancy Grp:
Stories:
Total $40.60
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utilit olification Cente . ■hose rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy o a - rules
o irect questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
_cei sued By: �\ Permittee Signature: G r ✓� _ / � Z!
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
RECEIVED
FOR O FFI C E USE O .
CI Of Tigard q 2009 ived 7( i s A ,-.
/
``r g 3 J Date Rece /By 67 Permit No.: ( � J �
N .
v 13125 SW Hall Blvd., Tigard, OR 97,114,L
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No..
TIGARD Inspection Line: 503.639 CITY OFTIGARD Date Ready/By. Juris ® See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method:
Supplemental Information
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❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. Ea. Total
Addition/alteration /replacement ❑ Other:
a � „ � � _; ,� ,y yYY = ;` rW of ✓ �, New 1 - 2 - family dwellings (includes 100 ft for each utility connection)
t
: , ' �� t= a CA7EG z -, 0E � "C01Y$TRUCTIOIV Aa ,v ' " ,'_ , „ SFR (1) bath 249.20
�+"�'Ya .• s?ii" ,�wM...ee.- 1W�Eah.:.::', .W S. n1.,i,T �::�?.,}i T3- i- F;.Wd-..: �2s`.sni �$5.. ..v".S`
•J I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder ❑Other: Each additional bath/kitchen 45.00
.,,. Fire sprinkler ( sy ft.)
Page 2
°"'s ' -'" '` 22 O A, WFORl�1 ift5 <AI IW A'I700,,, e I " =z s
..cr aJk,$; ;: > a-,,=^- .,,. ..w,:..;;c::;.�_x,, ,,,:s. a. Rai,^ wn.'', ; �C 4. ',A,,,° -, A= " , r:' , ;' , 11 ' ,a S i te utilities
Job site address: I 2_ 03 0 3 (A) i ( yam (-1 e - Pl , Catch basin or area drain 16 60
City /State /ZIP: 'DT, r 02 9 7 22 3 Drywell, leach line, or trench drain 16.60
I Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name:
Manufactured home utilities 110.00
Cross to job site: Manholes 16.60
GUtd, Vl t `I' P) I 1,4, 4 & rl, ? 1 . (II Rain drain connector 16.60
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: `j Water service (no. linear ft.: , ) Page 2
Fixture or item
Tax map /parcel no.:
,,
Absorption valve 16.60
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- `:° r ' ;:g.:Z. ,� ,. ' DESCRIPTION,0*,4- ;W®I2i ,,,„ u;z s SlIf `_
���r� �,� � -rP' i Backflow preventer / Page 2
2- [ a " { 4- 1 W 1. , VA 0(, t -v1A. � �- k) i) Backwater valve 16.60
f l P v . f . t � y‘' -a r -. ��A eV'' in 'Stir t Clothes washer 16.60
A I V I Dishwasher 16.60
,, „ ,:t. , ti- .-.:._ iirt. ; ,,:. �. c ":r<.4ii:;�, r-ri ¢., ;r.;_=:,;, .:. •,�.t KVi" >, itM.:t Drinking fountain 16 60
c : iPRUPERTY O , 1 . .., ,, ,; . Q € ';_:: m .
R :..t .it: sn Y ;: e :. a: t ti $ ;_;, < 0TENA:NT;s :f.T
'~ �j Ejectors /sump 16.60
Name: \rd G,. n,�i U 1 . 1 loll ri j�r I Expansion tank . 16.60
Address: 1 - 4 J 0 S j '13 t Ike 4 e (� PI , Fixture /sewer cap 16.60
City /State /ZIP: 7 Q f A ) 0 R 9 2''-3 Floor drain /floor sink/hub 16.60
Phone: ( 503 g Fax: ( ) Garbage disposal 16.60
g'' ,;sF �r��::r- .:,x, z�.a , .c'� r' �s + .%* 1, },= xx� �;:� ;e. .= �� ,ts;>. = "�;z v:�k� . ... b 16.60
� Nose bi
f y . 147171 raNi ANT m „ , V � CONTA P ERSQN $ "` , Hose bi er 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: S I A'Le G�5 al O'1tA -- Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax:: ( )
Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
.., ;�r4 „r .,n�; � 65�;y, , i, �`.,xr�,:�__- : +:L.,r'a �- .. - 4<ri:;.':. Y ,�,.
Urinal 16.60
r : "' � a;z: .. •yes; i t` t. -� '
..�. _ :a , . , M1 .. it CONTRr1CTOR V. „. .. i;>' " :; .:,:. >.
... .s,., - > Wa, � °.ass s; ro...v ..- 's" v� - leg Water closet 16.60
Business name: 3 0 , A 1(e_2 Water heater 16.60
Address: Other:
City /State /ZIP:
Subtotal
Minimum permit fee: $72.50 t3 / o 75�
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 CO
Plan review (25% of permit fee) ,�^•
CCB Lic.: lumbing Lic. no.: � /
State surcharge (12% of permit fee) ` •,si
Tik Authorized signatur :
�� TOTAL PERMIT FEE 1 . (Q0
Print name: <1O�t/m < M 1444 Date: 7 .. l 3 -0 9 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\PLM- PermitApp doc 12/27/06 440- 4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
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Site Uhhitl r Fee (ea) Total OOt `
_.. _. _..... S�darg F ..�� � e : �Pe it age ,� �...,r��„
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
,1 >�`a, �,9y=� :'•3:, �e..�.'r�xTU�,�:x�� L'ws��*,,�,_.: �.�.; -�
V"alua�404 . y _ Pgrm tfgg. ; ..;r , *
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
� 5 ' Q y , 1 i ee F (eat � Ti tai additional $100.00 or fraction thereof, to and
:1X.tUi' OCteI11 _:. . ,5y a 9v �,,. „.. _.m : 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
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
specially requested inspections - per hour 72.50 and including $50,000.00.
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.
Commercial Fixture Work:
Are ou capping, addin or replacing fixtures? If "yes",
Y adding P g �Plaev> <ew;xor,l�lumb><ngInstallt>fons
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees * . Please check all that apply.
CI Any new commercial building with water service 2" and
yFtxiure Type d �0 vio fsnR4114, 4 greater, except systems designed and stamped by licensed
i le ous Cappedf +,'Added 1 Ezisting2,
Baptistry/Font engineer.
1:1 Bath Tub /Shower New exterior plumbing site utilities for any complex structure
Jacuzzi /Whirlpool as defined in OAR918- 780 -0040.
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive Thru 1=1 Any multipurpose fire sprinkler system.
Cuspidor /Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
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Eye Wash cs *,AVAsomgtlgg or 1 e, Dla ra . at •
Floor Drain /sink - 2" ❑ Isometric or riser diagram is required for new buildings •
that meet the qualifications above.
-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 \Buildmg\Permits\PLM- PermitApp.doc 12/27/06