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Permit
•.t - CITY TIGARD SEWER CONNECTION PERMIT DEVELOPMENT SERVICES PERMIT #. SWR2005 - 00292 A 13125 SW Hall Blvd., Tigard, OR 97223 503- 639 -4171 DATE ISSUED: 9!16/2005 PARCEL: 2S 103AD -00400 SITE ADDRESS: 10980 SW ERROL ST ZONING. R -4 5 SUBDIVISION: LOT: 012 JURISDICTION. TIC Project Description: Sewer connection for existing residence TENANT NAME: CWS NO: FIXTURE UNITS• CLASS OF WORK: NEW DWELLING UNITS: 1 0 TYPE OF USE: SF NO. OF BUILDINGS: 1 INSTALL TYPE: LTP IMPERV SURFACE: Owner• FEES NUKE, STEVEN C + .1=1 Description Date Amount CHRISTON, BA F� J 10980 SW W ERROL ST ((��I1 [SWUSA] Sewer Connection Fee 9/16/2005 $2,600 00 TIGARD, OR 97223 a [SWINSP] Sewer Inspection Fee 9/16/2005 $35 00 Phone. 503 -598 -4587 aZ Total $2,635.00 f? C Contractor: 4 V H g a a V REQUIRED ITEMS AND REPORTS Phone• Q H C Reg #: Z W a CID Pk CD .< 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:" 7..e./&04 Permittee Signature: Ac/ � l .. Apt _ La — f Call 503 - 639 -4175 by 7:00 a.m for an inspection that bu- ess 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. BI i -QL) 4( 1 t PI mbing_Permt plication FOR OF);ICE USE ONLY • City of Tigard Received vvWWWWWW 3 9 4171 Fax 503 598 1960 krni a ' q Date/By Review p ,f4i Other Permit No Phone 503 6 24- Hour Inspection Line 503 639 4175 i I I Date Internet www et ngard or us Notified/Method � S pplemental Information TYPE OF WORK FEE* SCHEDULE For special information use checklist. ❑ New construction ❑Demolition Description I Qty I Ea I Total ❑ Addition /alteration /replacement ❑ Other New 1 - 2 - family dwellings (includes 100 ft for each utility connection) CATEGORY OF CONSTRUCTION SFR (I) bath 249 20 ❑ I- and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350 00 ❑ Accessory building ❑ Multi -family SFR (3) bath 399 UO Each additional bath/kitchen 45 00 ❑ Master builder ❑ Other Fire sprinkler (_ sq ft ) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address f )' , 9 SO s Ad, Eat z_ sr Catch basin or area drain 1660 City/State/ZIP 7- (a A2 Op. q 7 22 3 Drywell, leach line, or trench drain 16 60 Sutte/bldg /apt no Project name Footing drain (no linear ft ) Page 2 Cross street/directions to job site Manufactured home utilities 1 10 00 Manholes 16 60 Rain drain connector 16 60 Sanitary sewer (no linear It ) 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 Back flow preven[er Paget Backwater valve 16 60 Clothes washer 16 60 Dishwasher 16 60 72QROPERTY OWNER I ❑ TENANT Drinking fountain 1660 ,L Ejectors/ sump 1660 Name 13 J Ctf21Sempnr{echs) fi cpr —'Jvg- t hAie. Expansion tank 1660 Address 1 09 t c fn) eta-O,. Cr. Fixture /sewer cap 16 60 City /State /ZIP --T-1 (a Aem i Oa_ 9 - - Floor drain/floor sink/hub 16 60 Phone (503) 54 t—cc5 -9-9 Fax ( ) Garbage disposal 1660 ❑ APPLICANT ❑ CONTACT PERSON lose bib 1660 Ice maker 16 60 Business name Interceptor /grease trap 16 60 Contact name Medical gas (value $ ) Page 2 Address Primer 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 Urinal 16 60 CONTRACTOR Water closet 16 60 Business name Water heater 16 60 Address Other City /State /ZIP Subtotal Minimum permit fee $72 50 Phone ( ) Fax ( ) Residential backflow minimum permit fee $36 25 CCB Lic Plumbing Lic no Plan review (25% of permit fee) Stale surcharge (8% of permit fee) Authorized signature TOTAL PERMIT FEE Print name • Ca. .470 r Air /S..• Date 0 art This permit application expires if a permit is not obtained within 180 days after it has been auepted as complete. *Fee methodology set by Tn- County Building Industry Service Board i \Buildina'Pemms\PLMF- Pcrmivlpp doe 06/05 44e-4616T(10/02/COM/WEa) a(o �c e-c Plumbing Permit Application - City of Tigard • W. Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: Footing drain - l 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 - Ist 100' 55 00 Medical Gas Systems: Water Service - each additional 100' 4640 Valuation: Permit Fee: Storm St 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 $ 152 for each Fixture or Item Qty. Fee (ea) Total 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 Back flow 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 $ t 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 $50,001 00 and up $742 00 for the first $50,000 00 and $1 20 for Subtotal: 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 ❑ My 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 - Jacuzai/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 ❑ My new residential building containing three (3) or more - Domestic dwelling units Drinking Fountain Eye Wash ❑ Any NFPA I 3-D multipurpose fire sprinkler system Floor Drain/sink - 2" Submit 2 sets of plans with any of the above. -4 „ Car Wash Drain Isometric or Riser Diagram Garbage - Domestic ❑ Isometric or nser diagram is required for new buildings Disposal - Commercial three (3) or more stories in height - Industnal Ice Mach /Refrig 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 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. 1 \Budding \Peimiu\PLM- PennitApp doe 07/06/05 SPEEDY SEPTIC & ROOTER SERVICE PO BOX 1260 BORING, OREGON 97009 Phone: (503) 663 -2807 Fax: (503) 663 -2840 www speedyseptic net 8 0 11 DATE 9'30105 CustomerlJob Name: e ' ' (�� ^L if Site Address: O - iU .1k-'. = �_--_ __ 1 x✓? ©L Customer Phone #: 505-Y7.5 Alternate #. Mailing Address: Description of Work Amount " /6'00 e Tic T✓�'C S 7174 iiw, t :SS C 2 A 1y I Next Pumping To Be Done In ( 3 L C 1 1 2 3 4 5 6 7 8 9 10 YEARS (Total T? . Payment ❑ Check # c Visa /MC # Exp Date Customer Signature: Thank you We Appreciate your business I hereby acknowledge the completion of the above work I do not hold Speedy Septic & Rooter Service liable for any /and all pre - existing conditions or damage to landscape due to the above described work