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Permit CITY OF TIGARD SEWER CONNECTION PERMIT yT, DEVELOPMENT SERVICES PERMIT #: SWR2004 -00357 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/24/2004 SITE ADDRESS; 09215 SW EDGEWOOD ST PARCEL: 2S102DC 00402 SUBDIVISION: EDGEWOOD ZONING: R - 4.5 BLOCK: LOT: 016 JURISDICTION: TIG TENANT NAME: USA NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 1 TYPE OF USE: SF NO. OF BUILDINGS: INSTALL TYPE: LTPSWR IMPERV SURFACE: Remarks: Connect existing house to sewer service. Owner: FEES BUNGER, ROBERT MANFRED + BONNIE JEAN TRUSTEES Description Date Amount 9215 SW EDGEWOOD ST [SWUSA] Swr Connectic 11/24/2004 $2,500.00 TIGARD, OR 97223 [SWUSA] Swr Connectic 11/24/2004 $0.00 Phone: 503- 639 -4825 [SWINSP] Sewer Inspeci 11/24/2004 $35.00 [SWINSP] Sewer Inspeci 11/24/2004 $0.00 Contractor: Total $2,535.00 Phone: Reg #: Required Inspections 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 ot r in co.': of these rules or direct questions to OUNC by calling (503) 246 -6699. Issu -. by: / 40 A , Permittee Signature: Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day ''Plumbing Permit Application FOR OFFICE- •, _ .: USE ONLY City of Tigard Received 01.49/971 Pemut No J 7 13125 SW Hall Blvd., Tigard, OR 97223 Date/By. , �. � Plan Review Phone 503 639.4171 Fax: 503 598.1960 / /H, A v I i' DateBy• Other Permit No : 24- Hour Inspection Line 503 639.4175 e .' I i www.ci.tigard.or.us �.. Date ed /Met Ready/By S See Page l Information Internet. www.ci.ti g Nottfied/Method ha Supplementalnformation a. "s" ,:C'>-x' _ i.Z fpr .,.. �; ;; ., - a'�s ', :N'."� E•x 'refire'= _ 'xr r a ., , ";• . .> : � - - , - , '» ": °` s wf' , ;; r' „'f C- . *.z;` :.: - '� .. Nom- - - I. < , *� - -' - �;;a , �r ` YP OFW . OT2T C;�,; � ='. ; E .. :S I3E UL - FxSa',�.-a.z' � �. -•, -. N'r��'.�i� ^� , �.�z�'�� •m ? �': , w �'», , s iLK ,° .'- �� .n'z "5n �S r�3o-x� , k,�. r. ".. ,s :&'u.�.� «- .. �f ❑ New construction ❑ Demolition For special information use checklist. _Description Qty I Ea Total ❑ Addition/alteration/replacement ❑ Other New 1-2-family dwellings (includes 100 ft. for each utility connection) 4°F 'm"t : ''ate , <,:, `",��''�`. 3 " t � ar~,� - - t: s § �,': �w s2'. a>,. er' sr+`«", �a^ w= tio" y.<. ° ,u : `,',. ;s?' ":rzTx .�s% �,<��., i "� s -° lr 1 ` fi , r, s`CA z pji' C ONgTRUG"TTO IY," "tt:.' 4 V I, -,` "" 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 bath/kitchen 45 00 ❑ Master builder ❑ Other: ' r .,.. '77- sK ,.§•^. „ Frt 4 6 i - arz .^^* . ;= ., ', , r =. � .: c_'s ,� l s'�;! M�, . _ » =,,1 , Fire spnnkler ( sq ft.) Page 2 t • 'r ' = y , = * d O B S ITE I1�T OI2 IVIAT;T40,,, , . ,, , '. 00?iTTO N : „ i m, , : ,1 Ci 2 ( 5 5 °•- ,;..:. �,� -:.-� =�,as -:::y 3;�;e z *'mot, <: Site utilities � � . = °; Job site address: � :1 r e ke IDc, 1 A S creel Catch basin or area drain 16 60 City /State /ZIP: T i A ©`2,J C` -7•Z 2 3 ,..... , sa Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: 1 I Project name: Footing drain (no linear ft ) Page 2 Manufactured home utilities 110 00 Cross street/directions to job site: Manholes 16 60 Rain drain connector 16 60 ii 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 , 1, =D S'CRI W ° °_ = ' `:``;.�:` - -' "'' : a `,�,��: =';ur;,�#, "�`�ai .>,.:3 _ - :ter .�,n,a, .rk.: ,..., -.� +'�� °' °:.� . : 7 ',',-fi - ' fiN Backflow preventer Page 2 Backwater valve 16 60 Clothes washer 16.60 Dishwasher 16 60 r - a"', Drinking fountain 16 60 ' � ;<, °: - �„ �'�., ° S:;§,` '�. �- �..,� x a e c ,� Vii?, °, :'% �; g i ' "' ®PI20P ET2:TYK" "O WN E R ` <.: " ;'.:"'? ' - f ; '. ' '''4 4 Ei�I " A' t - '.= " �':: •,. ,�,, _ � , �. :.' } � 1�,” -�g tl`''q. '_� ���::� ..,. :�''�� Ejectors /sump 16 60 Name- • 1 AS)ei� . h 1 fVtiL b )U..6n ct I' r l° Expansion tank 16.60 Address: t 2. ` C 'iL(.) F7 URP ee-‘— Fixture /sewer cap 16 60 Ci /State /ZIP: cp Floor drain /floor sink/hub 16.60 Phone: (503) Co 2 2)4 -- zktp 2-‘ . Fax: ( ) Garbage disposal 16 60 , , F ,, 1 " ,., , , t < F :, , _ , 'tea' ; ,; ; . ,, , , "::., ,., ,�:,,...a'd t " 1 , , ;t , . l' A l'E L AI , „ T ,- -, �. „ " ".. -'> 'CONTACT PERSON ~ - Hose bib 16 60 i ' ""'`< " Ice maker 16 60 Business name: Interceptor /grease trap 16 60 Contact name: Medical gas (value $ ) Page 2 Address: Pnmer 16.60 City/State /ZIP. Roof drain (commercial) 16 60 Phone ( ) Fax:: ( ) Sink/basin /lavatory 16 60 Tub /shower /shower pan 16 60 E -mail: Unnal 16 60 < „�.�,'�� �; -a�i `,�� °. > ,n�. w, .�� a. �x� < -� A �t ` =�� " U , N,. ., Wat close 16 60 Business name: Water heater 16.60 Address: Other Subtotal City/State/ZIP: Minimum permit fee $72 50 Phone: ( ) Fax ( ) Residential backflow minimum permit fee $36.25 CCB Lic . Plumbing Lie. 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 Tn -County Building Industry Service Board I \Buddmg\Pcrmlts\PLM- PermsApp doc 12/03 440- 4616T(10/02/COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: ��; - t,.�°;= s „s; �„ , sW° �, :�� 5 "��r { "_ r, - :,, " , �'�,E = , ,� - • r i -, .; .,.:°,' ,Squ•are�Footage ' . H,�,. ��Per - m>itFee 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: �.n ��.�,.a�- Water Service - each additional 100' 46.40 �, ° .;_ '- _��, �; -' a, _ `Valuation ` ' i .Per t 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 ;� - ., ,,, r _ n, Y i� ` t f :`��ee� ea - .,Total: m, ?; Fixture` o'r ;mein : i fi g. >.,t., Q ; , . () z, M . . ., ��at^ �, :';�.��.� �3�.:�;.. additional $100 00 or fraction thereof, to and - 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 J 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 * . `` ,40, 1WMP. : 'Quantit`y ti ()Iixtgce); Work renf mach 'I Fistur,.t ,,i . ms s , , € Repl3ce ¢. a. - a ® '£ lY,:,� t , l1zaved `, sistin _ 9004 p `i Comments regarding fixture work: Baptistry/Font Bath - Tub /Shower - Jacuzzi/Whirlpool Car Wash -Each Stall .. • -Drive Thru Cuspidor /Water Aspirator - J , . • 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 Ice Mach. /Refng. Drains increase of sewer EDUs, a sewer permit will be issued and 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 \Budding\Pemuts\PLM- PemutApp doc 3/03