Permit CITY OF TIGARD PLUMBING PERMIT
' '' COMMUNITY DEVELOPMENT Permit #: PLM2009 -00088
TI G.ARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/14/2009
Parcel: 2S101CB00500
Jurisdiction: TIGARD
Site address: 12670 SW Hall BLVD
Subdivision: Lot: 0
Project:
Project Description: Install water sub meter to irrigation line.
Owner: FEES
TCTPI LLC Quantity Description Date Amount
25977 SW CANYON CREEK RD #J 17 da Misc Other Fee 04/14/2009 $16.60
WILSONVILLE, OR 97070 1 12% State Surcharge - 04/14/2009 $8.70
PHONE:
Plumbing
56 ea Minimum Fee Adjustment 04/14/2009 $55.90
Contractor: - Plumbing
GILLESPIE PLUMBING LLP
PO BOX 1474
BORING, OR 97009
PHONE: 503 - 750 -3449
FAX:
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 • • • :rk_ suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Util• Notification Center. T •se r les are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
ssued By: (1, � �� / Permittee Signature
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.
Plumbing Permit Application
x Building Fixtures FOR OFFICE USE ONLY : - -
City of Tigard Date/By: Received / / Permit No.:fi 9 -.(0080
III a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
_ Phone: 503.639.4171 Fax: 503.598.1960
Date By: Other Permit No.:
T I GA RD Inspection Line: 503.639.4175 Date Ready /By: lur" . See Page 2 for
Internet: www.tigard- or.gov Notified /Method: i �p Supplemental Information
' , , T YPE OF WORK. FEE* SCHEDULE `
❑ 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)
. . . 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: \ -- )0 S.,hr, \VA\ Q\ ,,dt. Catch basin or area drain 16.60
City /State /ZIP: GR-c, 0 cr\'] .3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: '1�k �Ro Vtx Footing drain (no. linear ft.: ) Page 2
Y` Manufactured home utilities 110.00
Cross street/directions to job site: 7 - '-f ./ 4 -L-C_ 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 preventer Page 2
Backwater valve 16.60
�� \ \:v.c� U sl\Qw 'M�\-Q,� d^(. v`�c �ZSo,\ -Zor
S■IS tr\ Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
❑,,.PROPERTY' OWNER.-'' s.. - ❑ TENANT'
Ejectors /sump 16.60
Name: N:AkS v`,t.4 S`k`t'Q'i,1
Expansion tank 16.60
Address: • 3 .,w A ���; SdNN Sv U Fixture /sewer cap 16.60
City /State /ZIP: i lvt� \ay.�\ CJ ° V S Floor drain/floor sink/hub 16.60
(T )' 2 - 3 \ - 71
Phone: Fax: ( ) Garbage disposal 16.60
❑, APPLICANT . , Hose bib 16.60
0' PERSON
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: .1N, \ph. 4 \V, )r•-1..-- 4' Water heater 16.60
Address: \.140,..4
Other: (Vk,,,, 'C��R;'c
� ��� \\A-7V\ Subtotal
City /State /ZIP: * scs, Q C)\ -
Minimum permit fee: $72.50 '
Phone: (SO) )-)5a - ? :l\v\ Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lie.: \`7 \- \'\ ,j7/)--/ / I Plumbing Lic. no.: i,t \ 71i It( Plan review (25% of permit fee) -®-
State surcharge (12% of permit fee) g'- V
Authorized signature.
TOTAL PERMIT FEE ?/ .
Print name: \\\/■. \< \\9.5Q,k.„ Date: N) \\NJ 60\ 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.
I.\ Building \Permits\PLMF- PermitApp doe 12/27/06 440- 4616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site• Utila ti'es' A", Qty ° Fee (e i) Total : Square Footage: Permit Fee: ` ak :
Footing drain - 1S 100' b 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:� _ ; Peirnait; ",
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
FiXtl1I1Q' O)r� : ' Qty.a . '.Fee (ea)t 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
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.
Commercial Fixture Work: - Pla Review for Plumbing Installations :' " u
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 ❑ Any new commercial building with water service 2" and
QuantitYby (Fixtdre):WorkPerformed greater, except systems designed and stamped by licensed
• ' engineer.
AiatureFType: 'Replace
° Previous Capped' 'Added - Eiisting . ❑ 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 Risser•,Diagrall)l.
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:
\Building\Permits\PLM- PermitApp doc 12/27/06
1
RECEIVED
Community Development = Y 1� APR 2 8 2009
TIGARD CITY for Permit Action
CITY OF TIGARD
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) G N IZ 5 r t ,� P/0,-1 b r Q
Mailing Address: PC Q v x ) - 2 1 1
City /State /Zip: g y 0 970� 9
Phone No.: - 7S0-39` 1 `I
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL PERMIT APPLICATION.
• REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: P Z 00 ` — OO 0 .s 2
Site Address or Parcel #: ) 2 670 S 'v/ }-4 (31
Project Name:
Subdivision Name: I Lot #:
EXPLANATION: NO I o' e ( /V e.J of \ tQ r »i t
Signature: Date: W 2Q - 0 1
Print Name: , €w�yp� G
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date nos /e) rj 1j,K W'' Rte to Bldg Admin: Date x ,27 0? B
Refund Processed: Date / 4,t cJ By 4z/ Invoice Processed: Date By
Permit Canceled: Date �% r9 By ._Parcel Tag Added: Date By
Receipt # Date / //'' Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07 ,V0 /NS/°(C77O/✓S
Caty of Tigard, Oregon 0 13125 SW Hall Blvd. ° Tigard, OR 97223
VP!
August 27, 2009 . _ _.. _
Gillespie Plumbing
P.O. Box 1474
Boring, OR 97009
. Attn: Jefferson Gillespie
Re: Permit No. PLM2009 -00088
Dear Mr. Gillespie:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12670 SW Hall Blvd.
Project Name:
Job No.: •
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $64.96.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
- -
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds \Administrat ion \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 . o www.tigard - or.gov • TTY Relay: 503.684.2772
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Gillespie Plumbing DATE: 8/20/09
P.O. Box 1474
Boring, OR 97009 REQUESTED BY: Dianna Howse
Attn: Jefferson Gillespie
TRANSACTION INFORMATION:
Receipt #: 173184 Case #: PLM2009 -00088
Date: 4/14/09 Address /Parcel: 12670 SW Hall Blvd
Pay Method: CreditCard Project Name:
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORMATION: •
Fee Description From Receipt Revenue Account No. Refund
Example:: [BULLD1 Permit. Fee Example: 245- 0000 - 432000 • • . $ Amount
Plumbing Permit 245- 0000 - 431000 $58.00
12% State Surcharge 100- 0000 - 207020 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager 11 0,40~K,__
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY -,
Refund Request Reviewed: Date: r�:i -� �� By: `
Case Refund Processed: - Date:..`' ,. z By: .
1: \Building \Refunds \RefundRequest.doc 04/13/09
CITY OF TIGARD RECEIPT
C 13125 SW HaII Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 175011 - 08/27/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 -00088 $ -64.96
Total: $ -64.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 014376 DHOWSE 08/27/2009 $ -64.96
Payor: Gillespie Plumbing
Total Payments: $ -64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD RECEIPT
S : 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171 •
TIGARD
Receipt Number: 173184 - 04/14/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 -00088 Misc Other Fee 245- 0000 - 431000 $16.60
PLM2009 -00088 12% State Surcharge - Plumbing 100- 0000 - 207020 $8.70
PLM2009 -00088 Minimum Fee Adjustment - Plumbing 245 - 0000 - 431000 $55.90
Total: $81.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 014376 DADAMSKI 04/14/2009 $81.20
Payor: Gillespie Plumbing
•
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1