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Permit
I . D• - • ° CITY OF TIGARD SEWER CONNECTION PERMIT DEVELOPMENT SERVICES PERMIT #: SWR2005 -00423 - 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 12/28/2005 PARCEL: 2S103CC -01300 SITE ADDRESS: 11925 SW GAARDE ST ZONING: R - 4.5 SUBDIVISION: COLONIAL VIEW LOT: 008 JURISDICTION: TIG Project Description: Sewer Connection. TENANT NAME: CWS NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 1.0 TYPE OF USE: SF NO. OF BUILDINGS: 1 INSTALL TYPE: LTPSWR IMPERV SURFACE: Owner: FEES JON FRANCE 11925 SW GAARDE ST Description Date Amount TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 12/28/200`. $2,600.00 [SWINSP] Sewer Inspection Fee 12/28/200: $35.00 Phone: 503- 684 -8949 Total $2,635.00 Contractor: Contact #: 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. Issued by: Za , 2d�ti Permittee Signature: - - 7 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. I Building Fixtures 4" cyvi1'hia / Plumb _ 'on FOR OFF ICI use ONLI City of Tigard Received Permit No.�Qa O Q Tai 13125 SW Hall Blvd., Tigard, OR 97223 / /a Date/By: Plan Review Phone: 503.639.4171 Fax: 503.598.1960 ^n .7 all ;f. i \ y . Other Permit No.: Inspection 24- Hour Ins Line: 503.639.4175 -a+ ■i l � Date/By. . p Date Ready/By: *Tuns: ® See Page 2 for Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information TYPE OF WORK FEE* SCHEDULE ' ❑ New construction ❑ Demolition For special information use checklist. 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 (1) bath 249.20 ❑ I - and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 • ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 ❑ Master builder Each additional bath/kitchen 45.00 ❑ Other: Fire sprinkler ( ' sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address:- t key ZS' S W r G tp ' 5 Catch basin or area drain 16.60 City /State /ZIP: 'y-�. G C' / V \t d( `7 .2-2-c Drywell, leach line, or trench drain 16.60 • Suite/bldg. /apt. no.: ` L' 1 Project name: Footing drain (no. linear ft.: ) Page 2 1 �a y Manufactured home utilities 110.00 Cross street /directions to job site: J- Manholes 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 Back flow preventer Page 2 ./ ,,,, ,_ , / LlA-- Backwater valve 16.60 Clothes washer 16.60 • Dishwasher 16.60 ❑ PROPERTY OWNER, ❑ TENANT Drinking fountain 16.60 Ejectors/sump 16.60 ame: C' O \( c Expansion tank 16.60 Address: Fixture /sewer cap 16.60 City /State /ZIP: Floor drain/floor sink/hub 16.60 Phone: (S.)3 ) 6 - �` (4 9' Fax: ( ) Garbage disposal 16.60 • • ❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60 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: 07./ !A _/ 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.: 1 Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (8% of permit fee) Authorized signature: IPPMEI / r I --- TOTAL PERMIT FEE ?A e I Print name: Q- k\t K ` t 1 C e Date: t �F - d5 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. is \ Building \Permits\PLMF - PermitApp.doc 06/05 440-4616T( IO /02/COM/WEB) Plumbing Permit Application - City of Tigard .`., f, • Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total _ Square Footage:. Permit Fee: :_ 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: 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 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 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: 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 fixture s could result in increased sewer fees *. Please check all that apply. Quantity by (Fixture) Work Performed ❑ Any new commercial building. El Fixture Type: Replace 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 El 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 - D 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 El Isometric or riser diagram is required for new buildings Disposal - Commercial three (3) or more stories in height. - Industrial 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 ermit results in an Water Extractor p 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. i:\ Building \Pennits \PLM- PennitApp.doc 07/06/05 r9 • Building Division Request for Permit Action or Refund City of Tigard TO: CITY OF TIGARD Permit System Administrator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 FROM: ❑ Owner ❑ Applicant El Contractor , X City Staff (check one) Name: � �l (L (Business or Individual) A h� /0 Mailing Address: V 0 t D City /State /Zip: /4706 47V Phone No.: ,)(, ill 9 6 � PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): D G, f CANCEL PERMIT APPLICATION. El REFUND PERMIT FEES. l) P ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). V Permit #: SCAliZ, D.005— Site Address or Parcel #: 14-15 5u) a a k. tL4 Project Name: Subdivision Name: Lot #: EXPLANATION: a SLO R".00S- ooN a (1t) �c �R. a.0 D5 z- 4.Z J\- AQ/t.P OA "D 1 Signature: _ � A . , Date: I 4, l v� Print Name: d1?„p 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 BSD By ;_,11 Rte to Bldg Admin: Date /Za B 4 Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date //07 (, By ' arcel Tag Added: Date By Receipt # Date Method Amount $ I: \ Building\Forms\RegPermitAction- Bldg.doc Rev 10/17/05 FROM :HOLLENBACH & HURD Inc FAX NO. :503 848 6832 Jan. 04 2006 05:27PM P1 ALOHA SANITARY SERVICE 8600 SW Hillsboro Hwy., Hillsboro, OR 97123 1 0 3 N4. _ „= 503 -644 -2797. 503 - 648.6254 • 503 -639 -516 0 3 3 1 ADDRESS: / CRY' STATE: Zr: Home: fife I JOB Srre: / ..S7 WORK: CELL: _ _ 7 `, ' �� Pao Br CHARGE �.. • — - CHECK � �, C AaH � —� „ �. _; �._ ._� .,.,.� ._. _ ._�.�. CREDIT CARD D DATA DRIVER OA 741#44 � - f AMOUNT M I © INSPECTION FIF.@ w• En U SERVICE CALL mini LABOR, IIIII Li LOCATING, DIGGING, ®ACIOzILL — THIS IS NOT A SEPTIC SYSTEM INSPECTION R EPORT - - TOTAL t /! TYPE OF TANK: STEEL ] CONCRETE CI PLASTIC U HOMEMADE LI HORIZONTAL LI VERTICAL U RECTANGLE U O OTHER SIZE OF TANK: 350 © 500 CI: 750 U 1000 C1 1350 CI 1500 LI 2000 0 3000 0 LID LOCATION: INLET U OuTL T © !ADDLED TANK CoNornoN: GOOD 0 FAIR LI POOR U ENTIRE Top U FITTINGS: BAFFLES CI CONCRETE CI ._e-A Maws � @W LID? DES © �.... �.1,_� SIZE Fax Transmittal Memo OIot GROUND COVER OVER TANK (� M � d COMMENTS ON CONDITION OF ORAINFI�! ETC. ' �^+ �0' mum � OE CO : dE 1' L C 0 � MA, is *N Phone # t j d• r S Fax 6 4:.912/368 Fax # .* y 8 ea., Amu SIGNED BY — –__. �—• -� Dm/ - — A