Permit C ITY OF TIGARD PLUMBING PERMIT
�, DEVELOPMENT SERVICES PERMIT #: P 18/200 -00062
'' -.f 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/18/2005
SITE ADDRESS: 07501 SW DARTMOUTH ST 100 WINCO PARCEL: 1S136DC -04500
SUBDIVISION: PP1995 -013 ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: FLOOR DRAINS; 4 TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: 1 OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 1 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Demo (1) restroom. Capped: (1) lay, (1) water closet, (1) 2" fl. drain. Relocate: (2) 2" hub drains & (1) 3" trench
at cooler box expansion - back room of dairy.
FEES
Owner:
Description Date Amount
WAREMART INC
BY BURKE + NICKEL [PLUMB] Permit Fee 2/18/2005 $99.60
3336 E 32ND ST #217 [TAX] 8% State Surcharl 2/18/2005 $7.97
TULSA, OK 74135 Total $107.57
Phone:
Contractor:
GRIDLINE PLUMBING + HEATING
4343 SE 37TH AVE REQUIRED ITEMS AND REPORTS
PORTLAND, OR 97202
Phone : 771 - 8790
Reg #: LIC 00074105
PLM 26 -449PB
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
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR
952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
246 -6699.
Issued By: y / z Permittee Signature: r c {;
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
FROM :GRIdLINE PLBG- FAX NO. :5037718790 Feb. 16 2005 12:20PM P2
PlumbingPermit Application
City of Tigard
te received• l' — Permit no.:�
i l�ai
C .00
"AI ' i j Sewer Da permi no.: Building permit no.:
Address: 13125 SW Hall Blvd,
City of Tigard Phone: (503) 639 - 4171 Project/a 1. no_: _______,
/1:40/ CO( � PP Expire dale:
ax: (503) 598-1960 2 Date issued;
,;�mS .� ss7 503 5 FEB 16 2005 By: Reccip[ no.:
6� P
Land use approval CI
Case file no__
r Payment type:
it
'IN PE OF PER M I I '
U 1 & 2 family dwelling or accessory J G` ommercial/industrial ' ' ' , U Multi - family CI Tenant improvement
U New construction ddition /alteration/replacement ❑ Food service ❑ Other:
JOB SITU INI ORA1ATiON iii: Si lik'.null: (f special iulon ■ation nu. chccldist)
Job address: 1 ,; Oot Descri lino t,1, . Fee ea. Total
Bldg. no.: Suite no.: l New - and 2-family dw gs only:
Tax map /tax lot/account rim.: (includes 100 ft. for eachutilityconnection)
SFR (1) bath
Lot: f Block: I Subdivision: SFR (2) bath '
Project name: `Jj [ &j o F, `5 SFR (3) bath
City /county: 77,4,/ I ZIP: Each additional bat /kitchen
Description and location of work on premises: Ae.lecatx 0.€42/A Site utilities: --1---,.,
4 r .e .5g4ke• r4 4- Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
NJ I\I ltiN(; CON I RACTOK Footing drain (no. tin. ft.)
Manufactured home utilities
Business name: r L ., r .. ".� t ,, t , 4 Lr Manholes
Address: - . ,E ' /f /9V Rain drain connector
City: � rji.ft I-4 NC Stated / ZIP: 7,,7 - Sanitary sewer (no. lin. ft.)
Phone_ , _ • i Faze. / G ,, E -mail: Storm sewer (no. lin. ft.)
�AT
• Plumb. bus. reg. no : r 9 Water service (no. tin. ft_)
City/metro lie. no.: b z maraimom Fixture or item
Contractor's representative signature: . - # :reZ//'''' ' Absorption valve
Back flow preventer
Print name: jet 4) 1)1.) '/ ) ' ✓ ✓ Dateg- /6 -6) Backwater valve • -
CONTACT PERSON Basins/lavatory
Name; it,iiiki Vitt-4W Clothes washer
Address: 4 Dishwasher AAR
Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone .. _ 1 J Fax: E - mail: Expansion tank
O%% NM at Fixture/sewer cap
Name (print): Floor drains/floor sinks/hub , '' .p.
Mailing address: _ Garbage disposal
Hose bibb
City: rStatd: J ZIP: Ice maker
Phone: 1 Fax: . 1E-mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular - Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sum,
1•:N ;1Nhail Tubs/shower /shower pan
Name:
Urinal
Water closet
Address: Water heater
City: State: ZIP: Other: j/711;I] " .. ,t9
Phone: Fax: E -mail: Total
Not all }urks.600s OCCCpf crCdil cords, Please can Jurisdielion for male information, Notice: This permit application Minimum fee $
U Yrsa "(MasterCard Pl an re view (at %) $
expires if a permit is not obtained
credit cant rumba. ate surcharge (8`Yo
Expires within I80 days after it has been ) •••• $
Name of cardholder as shown on credit card
accepted a4 complete_ TOTAL $ /97 57
$
Cordholder signalme Amount
4404616 (603/COM)
Accumulative Sewer Tally Parcel # 1S136DC -04500
Tenant Narrre: Wirrco Foods This SWR#
Site Address: 7501 SW Dartmouth # 100 This PLM# 2005 -00062 , , ,
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 -r-: 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 `f : ,, ,',',„k'.: � 0 0 0
- Industrial (over 5 HP) 42 0 0 . ,, 1; 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 `:' 1' 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 1 2 , v 0 -1 -2
- 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 ,a 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 v 1 6 0 -1 -6
Urinal 6 2: 0 0 0 0 0
Previous EDU Count ' : ,:'...-, 0 0
Capped EDU Credit 0
TOTALS 0 0 3 10 0 0 -3 -10
Current Fixture Value -10 divided by 16 = -0.6 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -10 divided by 16 = -0.6 over (under) $ (1,500.00)
Enter EDU Change Here ',-‘0.6 ;
Notes:
Signature:.`. ,("', ', °, � ,r, ',..: `:.a Date: _.
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.xls 7/1/04