Permit 1.
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CITY OF TIGARD • SEWER CONNECTION PERMIT
A l DEVELOPMENT SERVICES PERMIT #: SWR2006 - 00096
:� �I DATE ISSUED: 5/23/2006
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 2S110BD - 01500
SITE ADDRESS: 11670 SW BULL MOUNTAIN RD ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Connect existing house to sewer lateral. No reimbursement district.
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: FEES
KELLY & TA ORFIELD
14728 SW 117TH PLACE Description Date Amount
TIGARD, OR 97224
[SWUSA] Sewer Connection Fee 5/23/2006 $2,600.00
[SWINSP] Sewer Inspection Fee 5/23/2006 $35.00
Phone: 503 -598 -3911 Total $2,635.00
Contractor: �'1,Rlr
13-Mil I�G �l' iT
IRIS IsN ®'r A111 TIS, QUIR�
A PLUMBINGT pCONNECrICI
Contact #: FOR A L�i G�L 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.
I ued by: ! ill. li /// !/ Permittee Signature: f�(�1 L v ` I '
v -°`
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.
Building Fixtures •
Plumbing Permit Application FOR OFFICE USE ONLY ' -
' ' City of Tigard Received 7 75 No Permit No.:6L 04 _060
a 13 125 SW Hall Blvd. Tigard, OR 97223
Blvd., , Date/By:
11 4 Phone: 503.639.4171 Fax: 503.598.1960 Plan Review
Date/By: Other Permit No.:
T f G A RD
Inspection Line: 503.639.4175 Date Ready/By: El See Page 2 for
Internet: www.tigard - or.gov Notified/Method: 11 / Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. Total
❑ Addition /alteration/replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional .ath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
• JOB SITE G 'INF � ORMATION AND LOCATION l Site utilities
Job site address: 1 1'0 [7-1 `= � i �Ut.t. 1 L 'T(i 1 l�) /7 , Catch basin or area .lain /16.60
City /State /ZIP: Drywell, leach line, or : ench drain / 16.60 '
Suite/bldg. /apt. no.: Project name: �'1Q : £ Footing drain (no. linear t.: ) Page 2
`ti L Manufactured home utilitie /110.00 .
Cross street /directions to job site: Manholes f 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
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION. OF. WORK Backflow preventer Page 2
C-0+ 1 tN . L I �)c (S i N a 1 e TG `. £ie_ Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
arPROPERTY OWNER . I 0 TENANT Drinking fountain 16.60
- Ejectors/sump 16.60
Name: 'V Lo / - 1 42.3 ULI= I cc. LT) Expansion tank 16.60
Address: 1 if - 9,g 6 I n t= L Fixture /sewer cap 16.60 •
City /State /ZIP �c e f�7 D 2 q 7 a"2- 4 Floor drain /floor sink/hub 16.60
Phone: ( ?j) 59 S -- 39 r I Fax: ( ) Garbage disposal 6.60
- ❑ . APPLICANT ❑ CONTACT PERSON Hose bib 60
Ice maker I 60
Business name:
Interceptor /grease trap 16. 0
Contact name: Medical gas (value: $ ) Page
Address: Primer 16.60
City /State /ZIP:
Roof drain (commercial) I 16.60
Phone: ( ) Fax:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
. , , CONTRACTOR ' . Water closet 16.60 1.
Business name: Water heater 16.60
Address:
I Other:
City /State /ZIP: - Subtotal
Minimum permit fee: $72.50
Phone: ( ) 1 1011 Fax: ( ) Residential backflow 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 FEE
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.
1:\ Building \Permiu\PLMF- PermitApp.doc 04 /06/06 440 -4616T(10 /02/COM/WEB)
Plumbing 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:. F . e"
Footing drain - I' 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 •
. 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
additional $100.00 or fraction thereof to and
Fixture or Item Qty. Fee(ea) Total 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 El 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.fRefrig. 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
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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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i:\ Building \Permits\PLM- PertnitApp.doc 07/06/05
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Building Division •
T l GARD Request for Permit Action or Refund
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor / 5 City Staff
(check one)
REFUND TO: Name: �/�
(Business or Individual) HFL.Ly /./7 / 9/ 9
0 0 Mailing Address: / � //7 P .
•
7 - q -�A✓E City /State /Zip: 776 -4
47'7/040 Phone No.: ,rri - z - 3V/
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: 200 6 - C>00 y'6 SQ- /I
Site Address or Parcel #: / / 7e _s` A LG /177-A/ 'e
Project Name: Q /eF /
Subdivision Name: Lot #:
EXPLANATION: �,� 0/4z,I j � t � (/'7c2OO
Ci ceve- GL_ cc�-�• A 4 'n-'- - .a/o_c/L 76 C 171 (7
t i,7 a C .e-L. oa / 74' , Ca
49-11/Akri , e; - ey/O 07 -ems � � 7 /00D •
Signature: Date: .. /�5`O 6
Print Name: . : L, ‘r
Refund Policy
1. The Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payer in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date By
Refund Processed: Date s /a4, 06 By 4"/ Invoice Processed: Date By
Permit Canceled: Date 4/7 06 By - Parcel Tag Added: Date By
Receipt # �(� ,2yfe Date 619,x/04 M C, ,_ Amount $
L:\ Building \Forms \RegPermitAction - Bldg.doc Rev 05/24/06