Permit C ITY OF TIGARD PLUMBING PERMIT
, DEVELOPMENT SERVICES PERMIT #: PLM2003 - 00632
����1, 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 12/19/03
SITE ADDRESS: 11500 SW FONNER ST PARCEL: 2S103AC - 02400
SUBDIVISION: ZONING: R - 4.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 50 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: 50' of sewer. Owner will be trenching from house - out 5 feet
FEES
Owner:
Description Date Amount
FILLER, DAVID E + MARY C
11500 SW FONNER ST [PLUMB] Permit Fee 12/19/03 $72.50
PORTLAND, OR 97223 [TAX] 8% State Surchan 12/19/03 $5.80
Total $78.30
Phone : 503- 620 -1912
Contractor:
BRIAN CLOPTON EXCAVATING INC
PO BOX 509
REQUIRED INSPECTIONS
Phone : 503- 682 -0420 Sewer Inspection
Reg #:
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Issued By: / L. , g44 , Permittee Signature:
Call ( 03) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures 503 -a0 1 7 1 0a_.
�lun7�l)1<n Per mit Application F OR OF U SE O < , _ ,. ;
Received �yM� Plumbing
Date/By C 7/ I l 1 2 119 (c•3 Permit No.. fL/Yf ;2(03 d 0 t° 3� .
City of Tigard Planning Approval Sewer
Date/By Permit No
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date /By Permit No..
Phone: 503- 639 -4171 Fax: 503-598-1960 Po - Re Land Use
Internet: www.ci.ti a rdor us Date By Case No
g filL.I�: Contact Juris.• ® See Page 2 for
24 - hour Inspection Request: 503 639 - 4175 Name /Method Supplemental Information.
�' N': • • . : ;', '' TYPE 'OF WORK' `r: ; • �, .• r FEE S HED
� ' `� � � j `� "� ��_ f '� k' r = `s'•= , �.�•a�£ :�; C UtiE(fo "r -' special ,infor`mation�usechecklst ��`�.�"�
New construction 0 Demolition Description I Qty. I Fee(ea.) I Total
❑ Addition/alteration/re lacem "s'" ,., '�r > „= « y'i 'New..i� = &�2 family =dw li" i: ;_ r .��.�,
r;"��'
Addition/alteration/replacement en ❑Other: � _ ; ��, r el ug "s :�3�� . �,_ ��;��:.:
> r.`. , ' � .,� icIt .�,trc• r, ,..'$s i � i t'. a eon E eitro -;,� , ±� " -`
" •''i 4'•` CATEGORY;OE,CONSTRUCTION• : F",f. u . ,,:Y (i nicludes':100,ft: for'', each utilitydconnection).� ° _
1 & 2-Family dwelling SFR (1) bath 249.20
El y g ❑ Commercial/Industrial SFR (2) bath 350.00
❑Accessory Building El Multi-Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
e;i ; ;=JOB;SITE INFORMATION,andtiLOCATION • ,"" Fire sprinkler - sq. ft.• Page 2
Job site address: // a a S-,.. LO4.4J£,2 57 ,, ' : -. :t Hsu ' `t' ::03t.. a sa �,
-+ K� .Site "Utitities�, ..,�;• ,���� - ,,��. "� °' °�
Suite #: Bldg. /Apt. #: Catch basin/area drain 16 60
Project Name: Drywell /leach line /trench drain 16 60
Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110 00
,.G "i/rJ M S j cL,f' G Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.) J TO / Page 2 550="C.)
Subdivision: Lot #: Storm sewer (no. linear ft.) Page 2
Tax map /parcel #. Water service (no. linear ft.) Page 2
,
nr� ;;i „:.;„;V''. 41 s�.3 tUCe,OG'Itenl,. i tii - ;-:t
' O O _ORK ' ... , , _ y ,' '„ • ` �. „ *r" 'r r4`" .k,. i'7,
_ . �'� �. �,- - � DESCRIP�TI , N Li� '" � : ,. - =��a� �� r _ ,�t� `. B,<�.�F• _.� _>
-73? £� Absorption valve 16.60
C»'.,t 6. � , .-' " L��f zn ,Ci2Q, , Backflow preventer Page 2
.//a ig �., -,0 Lit/ J Backwater valve 16.60
.C'/Lz fF ,, e. 7b...2., Clothes washer 16.60
/� Dishwasher 16.60
Drinking fountain 16.60
®;PROPERTY °,OWN'ER ,:`';v ,? ®T ENANT°:: ; ,.'' _ ,t.^`i`' ,.,:'
� - Ejectors/sump 16.60
Name: --7 f G /G- f,, Expansion tank 16.60
Address: /7,7- c4 ,E;;ti.[Ji .$1 Fixture /sewer cap 16.60
City /State /Zip: Td ,v ,e,› Floor drain /floor sink/hub 16.60
Phone:�a 7 6Za . Fax: Garbage disposal 16.60
Hose bib 16.60
E- APPLICANT . x• '.` , ;t - ';;,• :1 El;' ONTAC•T P,ERSON,; F., Ice maker 16.60
Name: Interceptor /grease trap 16.60
Address: Medical gas - value: $ Page 2
City /State /Zip: Primer 16.60
Roof drain (commercial) 16 60
Phone: Fax: Sink/basin/lavatory 16.60
E -mail: Tub /shower /shower pan 16.60
- ` ` " ; . • -°` `CONTRACTOR ` `. _. Urinal
- -� � 16.60
Business Name: i ?,e, ,,. G 40 " a ff Water closet 16.60
C' �' Go Water heater 16.60
Address: 7 0ox- ,,'o7 Other
City/State/Zip: � ,,,,LC f Other
Phone:, -- o :6�r,z d4-4 e Fax, a.� GS-; o d 7 " , .Pa` r . ' {, ; -'r Plu'm6ingePermit`Fee *' ' `; :: '
CCB Lic. #: 5 2 3 7 Plumb. Lic. #: mum rm it Fee
-Subtotal_ $
$72 SQ $
Authorized y Minimum Pe 5---C., Signature c ✓`t�/ ,, __ Date. /. / /. Residential Backflow Fee $36.25 �a
Plan Review (25% of Permit Fee) $
`4 v f. ,C L L i iZ State Surcharge (8% of Permit Fee) $ .5 • CO
(Please print name) TOTAL PERMIT FEE $ 7 . Sc..)
Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans with isometric or
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri -County Building industry Service Board.
i \Dsts \Permit Forms \P1mPermitApp doc O1/03
s7 3, 3 cv
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Square Footage: 9 Permit Fee:
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
F
Fee'(ea).°" Total`4
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.
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*.
' ,cq ''_;,r,i M 4 QuintiTby :(Fizture)rwockI!erforined , Comments regarding fixture work:
Axtur.e;T e M; F - +° Re la c
' ,,, �,, ✓5 " ., e '. = - e� a i4
:��i�New�,' �111oved'.:,„� a„Capped` - -`_
Baptistry/Font
Bath - Tub /Shower •
- Jacuzzi /Whirlpool
Car Wash -Each Stall
-Dove Thru
Cuspidor /Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
-3"
-4"
Car Wash Drain *Note: If the fixture work under this permit results in an
Garbage - Domestic p
Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and
• - industrial fees assessed for the sewer increase must be paid before the
Ice Mach. /Refrig Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures
i. \Dsts \Permit Forms \PlmPermitAppPg2 doc 01/03