Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009 -00132
T IGARD 13125 SW Hall Blvd , Tigard OR 97223 503 639 4171 Date Issued: 06/01/2009
Parcel: 2S103DD00409
Jurisdiction: Tigard
Site address: 0965 SW FAIRHAVEN_ST
Subdivision: Lot: 0
Project: Hansen
Project Description: Connect existing house to sewer service, approximately 160' Septic tank is to be pumped and
filled. Reimbursement District #38 fee paid
Owner: FEES
HANSEN, LAURENCE LEE Quantity Description Date Amount
10965 SW FAIRHAVEN ST 160 If Sewer Service 06/01/2009 $101 40
TIGARD, OR 97223 1 12% State Surcharge - 06/01/2009 $12 17
PHONE Plumbing
Contractor: kot) o Nan Cb
Po 30•4 g
Po&r�rrrS , .O2 977$
PHONE " 0' 1 88 -/ 2 jO
FAX.
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $113.57
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR Specialty Codes and all other
applicable law 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 the 180 days ATTENTION Oregon law requires you to follow the 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 a copy of the rules
or direct • - stions to gUNC by calling 503 246.6699 or 1 800 332 2344
Issued ;y: Permittee Signature: p / ,
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.
A
4
Plumbing Permit Application
Building Fixtures FOR .OFFICE USE..YONLY
F .
III City of Tigard Date /B l( 1 09 �le�4�o /�2
Y Permit No
1 3125 SW Hall Blvd , Tigard, OR 97223 Plan Review
C 7' Phone 503 639 4171 Fax 503 598 1960 Date /By Othet Permit No < Di!r
Inspection Line 503 639 4175 Date Ready/By J
TI,GARD ^ ®See Page 2 for
Internet www tigard - gov Notified/Method i t t Supplemental Inform
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description Qty Ea 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
❑ 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
Fire sprinkler ( sq ft ) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: • ( k ..n rA 1'-C lT AN 57: Catch basin or area dram 16 60
City /State /ZIP / ( /C4 o ? /-7 �� Drvwell, leach line, or trench drain 16 60
Suite/bldg. /apt. no.. ( Project name. / 40 4- / ( i � Al 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
Sanitary sewer (no linear ft /4- / Page 2 /61/. 4Q
Storm sewer (no linear ft ) Page 2
Subdivision: 1 Lot no . Water service (no linear ft ) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16 60
DESCRIPTION OF WORK Backflow preventer Page 2
O /J,t/ �6 / �5'/ (/ � - 76 J C �) E7 Backwater valve 16 60
Clothes washer 16 60
Dishwasher 16 60
® PROPERTY OWNER I ❑ TENANT Drinking fountain 16 60
Ejectors/sump 16 60
Name 44 0 6 J L C -4-447E iU Expansion tank 16 60
Address: /- F L i�l Az� v6 g ( , Fixture /sewer cap 16 60
City/State/ZIP. ? ( (d Q ? 2 2_-2_-_3 Floor drain/floor sink/hub i 16 60
Phone �'6, 6 o9 r, „.?02_6 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 J� Water closet 16 60
Business name. ` - --r( ( t; "r-4-V j ' 1 /�eitt GO — Water heater 16 60
Address. ? 11 , Fo ,-. Other
Subtotal
� `-
City/State /ZIP: , �� ' z /1 g 7
Minimum permit fee $72 50 e /
Phone' ( ) c ( 6, v G Fax: (5 ` 3 . �6'�_ (& s O Residential backflow minimum permit fee $36 25 /Q /. `
s.; Plan review (25% of permit fee) --e9--- CCB Lic.: Plumbing LA
Authorized signature: , State surcharge (8% of permit fee) /A. / 7
�� ‘ Li TOTAL PERMIT FEE ff 57
Print name. 1 r�G�./C� '+i Date: 6 t 07 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\Permns\PLMF- PermnApp doc 12/27/06 440- 4616T(i 0 /02 /COM /WEB)
Plumbing Permit Application - City of Tigard
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
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 Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees ❑ Y new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater except systems designed and stamped by licensed
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040
- Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach /Refrig Drains
Oil Separator (Gas Station)
Rec Vehicle Dump Station
Shower -Gang
-Stall
Sink -Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures
I it 3wldmgWermrts\PLM- PermrtApp doc 12/27106