Permit IA - +w
C ITY OF TIGARD PLUMBING PERMIT
� 'I" DEVELOPMENT SERVICES PERMIT #: PLM2003 -00277
��I II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/19/03
SITE ADDRESS: 13500 SW PACIFIC HY 17 OLD CNTRY PARCEL: 2S102CC -00500
W
SUBDIVISION: BUF ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: FLOOR DRAINS; 2 TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 100 ft
WATER CLOSETS: WATER LINE: 100 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Plumbing work associated with remodel of dining & buffet area. Install 100ft sewer and water lines, 1 sink, add
2 floor drains and cap 3. NO SEWER TALLY INCREASE..
FEES
Owner:
Description Date Amount
OCB RESTAURANT CO.
1460 BUFFET WAY [PLUMB] Permit Fee 8/19/03 $209.60
EAGAN, MN 55121 [TAX] 8% State Tax 8/19/03 $16.77
[PLMPLN] Plan Review 8/19/03 $52.40
Phone : 651 365 - 2142 Total $278.77
Contractor:
KSM PLUMBING INC
DBA SUNSET PLUMBING
PO BOX 23263 REQUIRED INSPECTIONS
TIGARD, OR 97281
Phone : 503 Top -out Insp
Final Inspection
Reg #: LIC 141154
PLM 34 -366PB
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
/�
�, ��r ' 1 L . J..' r :I y: L _, Permittee Signature: ,� 01'17 �
Call (5.. 639 -4175 by 7:00 P.M. for an inspection neede. th � r— day
06/26/2003 10:27 FAX lj002
r.
' w12.-c)O 0 3 -Gd
Al Plumbing Permit Application City of Tigard
OFFICE USE ONLY .
Date received: , - , - / Permit no.: d as %/ - a)a),..-73 =1' -,- J I Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
, Fax: (503) 598 - 1960 Date issued: By: Receipt no.:
L and use approval:
Case file no.: Payment type:
TYPE OF PER5IIT
O 1 & 2 family dwelling or accessory ❑ ommercial/industrial ❑ Multi- family ❑ Tenant improvement
O New construction ■ 4 . ddition/alteration/replacement 0 Food service ❑Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
i x F -
- — • . Description:— - --- .... F•
=' "" 7ob 'adtiress' - — -- t:e e a, Total �
1,3 '. - Gtr: - �ff �f1� - � - � ''�.
Bldg. no.: Suite no.: New l - and 2- family dwellings only: '—
L � y'
Tax map /tax lot/account no.: `,,,:or..." A+),f rb) (includes 100 at R for each utility connection)
(1) bath
Lot: Block: Subdivision: SFR (2) bath 7
Project name ^/ kart +✓T SFR (3) bath
F ° W
City/county:'r /� /y/r : 97 a;a .. Each additional bath/kitchen
i l-
Description and location of work on premises: f fY E7_ Siteutilities:
OF ''NE/1/ t .tom 7 • J¢ Catch basin/area drain
Est date of completion/inspection: Drywalls/ leach line/trench drain
PI UlMBING CONTRACTOR Footing drain (no. lin. ft)
Manufactured home utilities ,______ F---
Business name:
no e, e S-1- ON • lit - CA ( Manholes
Address: 0.13 o N el ��i Al 0 . 5 S 1= Z7 Rain drain connector
City: 14'l 1 o ' ■ I • : b A,ZW: c -7, L`l Sanitary sewer (no. lin. ft.)
Storm sewer (no. lin. ft.
Phone: S�cFy :.- � I Fax:B' �SZq I E -mail: ( ft.) j 55.00
CCB no.: • lumb. bus. reg. no: Water service (no. lin. ft.)
City/me • o lic. no.: I ' Z g Fixture or item:
t
Contractor's representative signature: Absorption valve
Back flow preventer .
Print name: Date: Backwater valve
CONTACT PERSON Basins/lavatory
Name: k_ , �� ` Clothes washer
j�'riri Dishwas er
Address:/ L_ � W ;��t� ZIP: Drinkingfountain(s) p
City: ...11.,:i a. -...11.,:i 1 _ C 7lfuYA 55 _ Ejectors/sump
Phon. , .S E- mail®, .ii.;_,. • •y Expansion tank
OWNER Fixture /sewer c
Name (print): iI A tifT 'GO Floor dra' s/floor s' ub ,�i
Garbage disp
Mailing address: 174((7 (v/ Hose bibb
City:E / /V yak State/MA/ ZIP: .5.57.z./ Ice maker
Phone'4 5 a /[/?j Fax/'J I E -mail j t be,r Interceptor /grease trap
Owner installation/residential maintenanab only: The actual installation Primer(s)
will be made by _ : i e , aintenance and repair made by my regular Roof drain (commercial)
..
employee on the : rty / 'wn as-per RS heater 447. Sink(s), basin(s), s
X 4 / 7 10 3 Sump O, lays / /6,4,11 /6,4,11 Owner's sigrlaN ; '
ENGINEER Tubs/shower /shower pan
�� • Urinal
Name• "Icts_sochores - #3 h
Water lose
Address /9 P� " Water heater
City: `, State %n/V ZIP: 5// f - _ /i . Other , .- - - 1/9-KO
Phone, J' 7 / —OZ8 1J��7 e n. a ne,' Total
Not all jurisdictions accept uedit cards, please call jurisdiction for more inrormatioo.
O Visa O MasterCard Minimi.,n ree $ .1 . ' (ve)
Notice: This permit application P lan review (at _ %) $ s'c .4in
( )
expires if a permit is not obtained /dr7 .,'
Credit card number. / / within 180 days after it has been State surcharge (8 %) $
Expires TOTAL $ A7 R'• 11
Name or cardholder as sdrown on credit card accepted as complete •
S
Cardholder signature Amount 440-4616 (6/00/COM)
o8,olAug•12. 2003F 7 :12AM981960 CITY OF TIGARD No.1058 P. 2/5
' �:, •
Plumb gPe1m1t Carlo OFFICE USE ONLA .
Alk � F ate t�ehtMt ' , - • _ , i41 ° 77 •
,,Tr � Cit o Tigard ��V �'
Building permit no-:
- Address: 1 SW F a Bl vd , T 7223 •
wry olf$ard , Phone: (503) 639 . �rJ '1003 Eapa+° dace .
Fax: (503) 598 -1960 0 D•_ ,6 I o�
:State EMMEN eQ Land use, approval: - a 1' -
-p
. .: r. OF 1'ElMl - l' I O.
O 1 & 2 &mily dwelling of ace sssoay CI ConurtereiaWiitdustrial CI Multi-family O Tenant improvement C `\
0 New construction • d ddidantaltantiodrepl9Cement 0 Food service 0 Other. �
x -1:' .1011 Sill 1 \i01111 1X1ON FLESCLILULLE( jor. pcti .3linl'OrnlatilmIuscchq.CtLlia) '' _,.
ovaddegss3. .. _ _ - - • . ; , ' — Qtr, 1 .�. 4'1/4 _. �, L ,. V i a,.1- and 2 -laTally dwelling ouir
Bldg. no.: S p i t e no.: lee ft, for each utility eonneeti0d) •
o.• �, _ II �
'radaE ie►ep/we (otJscoo>ant� �� � ' �,.- tee_ SFA (1) bath
Lot Block Subdivision: SFR
,.. ha • ,, s • •, (3 � �
ntr.lAT iki ii �� a SFR Each ..rt �•a1ea•� • hen � �� C
Description and kcax,, o worts -o '- Site u6.ht,
Dom �N1 oet m1 _ Catch basic/area drain
I each 1itrench drain
EEL date of constpltxiotnlfat eotloa: • 'Footing drain (no, lta R M •
PLUMIUNG CU\TIt,NCWit i7 ' ediwmeaolr0es
Business fans"' 5 /n u� 6i `i Y (5d/1)k-7) • ley VAIN Mini
• co for •
cd - o -Z . 77R- __
Storm sewer no. tin. it) / )
Pbmtej3..(�57 �calo F� WNW 6esvies DO. lira. R.�
Cal rq= C //5 t{ " bus. rya own ��
City/metro _ Ream Ream oriturine's: -
ao ila no,: Abs • on valve
rer ✓.. ��
' Centripetal: re °• --- Back fiowpeeV�cttG:r
pant. •• - __ _ Hetckwattrreltti
CO \ t .%(.1 11115 v:: Basins/lavatory _ r— '
- ales 'tuba • _
Name: ; ` ■ �Ali_Lk�1 D a
Addaesa:/ �� i1��l! • , ., : foot►• a • _11111M
!11E, ton _ � —
_ :.��'l�g a . OD tank
O \\ \ER _��
: : ��
.t
EFE11%,- FA� r
Meiling addread: Rue 6ibb
C ' ��- State/!? ZIF: /7 tinker aker ,
PhDn • ,r L I TetTaLG: r Erman _.. _ .. '' tare • for _ e • • w
Owner iroranationlosidentiel • . • • only_ The actual installation Pnmer(s)
will ben made by • .. , s , .: ce: sod repair mod m
Mlle by my regular Roof drain eonerobt , . ME - . .
' " '- • PS 447. Si nk(s , • . s . ova s / •Ld
•
employee nn 6, a ll, tun sir r• rte . L / �O•7 Sump
� .i � � L
t'!NCINGER 1Wrs/shower7ahoora pan ., =�
Urinal !� ;iI _ Water Closet ��yy
Amu= City: . 1. • , J / -.,4, . Oth-. , : .
nom* 77/-0870 .., i';1'i• iY1�t�- I'ATL— 1u "♦• ' 40e)
Mitniut n n toe .. 3 - •
Na.n;vr;•a +• arenmm, skim l aiai,m06.. rd 11.°' mramrtm Notice nil peami< a aiiraeoa Pion review (at 34) 3
0 v\e• 0 M.rueAre ' implicit d a pew is o btone d Stair ...h (5%) S _ �'
d.d>t - L - within 180 days it has been TOTAL ._....... - S d'C9 sr. 7?
° =septa as aDejptete
)l jac a(n�nldsV a flrwa a. cialtmrd, Z
4 ...“&16 t610o�1.q
1Srd6alds� a��stmv
06/26/2003 10:28 FAX e1003
- • '
PLUMBING PERMIT FEES:
k r 1 . ' ;';‘, ,e '',•,•' r. • :' e ,� o Il ... k E? i_ / " v � i 4 I i ��f l W4. . ' '
�r, ^� }' � t Y 7l2�- � �' . v � ' ,� � �+•C ?, �• t�s, ` � 1C T '� ""�e '�„ x= � • s R 'y 11J:L1JF. s o h ; •ppsa '�"5 a n1 " r i . r - ,i, r i;� N'1�tr .,ti.1 _ . . . , + a l;'
Sink 16.60 u .- 1 �, o �
LC 4 ,.J� ` iY (C,�e�l. i .4 IF�A -1� t. '� , , c� 1 4, t e� l 1i r �� 1 E 7 v 1 �{
'.Sf� :.l3.i l:.�a:AIL1�::K:.Ll l.1 l-r - li?": 9' -'?j r old.. .: o ff:.,v....
Lavatory 16.60 One 1 bath $249.20 -
Tub or Tub/Shower Comb. 16.60 Two 2 bath $350.00
Shower Only 16.60 Three 3 bath . _ $399.00 -_
Water Closet 16.60 SUBTOTAL ;•? _
Urinal 16.60 8% STATE SURCHARGE f.`bt] 't a Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL G'r ¢ -:54[ uW"` ` ;
Garbage Disposal 16.60
TOTAL r Jr " ii M
Laundry Tray 16.60 _. - •_�.•v_... -� :.
18:60• - "__� r... �... y.
- M achbte -- _ ..._.
Floor Drain/Floor Sink 2' . 16.60 '
3' e 16.60 yy, b0 PLEASE COMPLETE:
4' 16.60
Water Heater 0 conversion 0 like kind 16.60 rk i3-. a ,� +' " �� ' -tom { fl,.�'�i Z sF.x�wU� 07'11
Gas piping requires a separate mechanical ' •�f 7 -. s { ,.; , +5 � s t F � c : t . .. t �
permit s_ =, t t. _ '? ea:A L.� t_ .'.?z x ' .tgi.'fi ?,K1 x .,1 5 .. -s 1�3
MFG Home New Water Service 46.40 Sink Si
MFG Home New San/Storm Sewer 46.40 r "'' - - --
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower • -' --
Drinking Fountain 1 16.60 Water Closet - - --
Other Fixtures (Specify) 16.60 Urinal - --
Dishwasher - - --
alb • , ' ' • �.:J♦ � - --
Leund Room Tra
Washi • Machine -
`C Floor Drain/Sink; 2'
Sewer - 1st 100' 55.00
.7 • pp 3' �� - -1111Lr
Sewer - each additional 100' 46.40 4'
Water Service - 1st tar
[ 1 55.00 55-. 55-. p6r .FHbd�ilfes
W Service - each additional 200' 46.40
Storm S Rain Drain - 1st 100' 55.00 _ - --
Storm & Rain Drain - each additional 100' h 46.40 - _ -_ -_ -_
Commerdal Badc Flow Prevention Device - 46.40 - --
Residential Badcflow Prevention Device" 27.55 - - --
Catch Basin 16.60 IFNI 0 p MK MINN
inspection of Erasing Plumbing or Specially r 62.50
Requested inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25 '
Grease Traps 16.60
QUANTITY TOTAL: •, m ;,
'
Isometric or riser diagram Is required If ;:s: ; + w i R A
S 'r' e. -4,
, Quantity Total Is > 9 � a • ' �t),
'SUBTOTAL: a s1?tA : ,,. •
l.• T1 ,1'00
8% STATE SURCHARGE: �� t';
nr ;' "'V? :s.9 r � ; ) l0 I I 1
rt .,
"PLAN REVIEW 25% OF 't y 1 R - 1.,�` 'MI > ' k ; t '
Required only if fixture qty. local is > 9
TOTAL PERMIT FEE: F tV 779.1-7
* Minimum permit fee Is 172.50 + 8% slate surcharge, except Residential Beddow •• •
Prevention Device, which Is 198.25 + 8% state surcharge.
"Ail New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
i :Was \forms\plm- fees.doc 02/05/02
Accumulative Sewer Tally
Tenant Nam HomeTown Buffet (Old Country Buffet) This SWRA Not required
Site Address: 13500 SW Pacific Hwy. This PLM# 2003 -00277 _ ..
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 _ 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 3 15 2 10 -1 -5
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 _ 0 0 0 0 0
Garbage Disposal _ .
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 48 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 , 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 • 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 1 3 1 3
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 10 160 160
Capped EDU Credit 0
TOTALS 0 160 3 15 3 13 0 158
Current Fixture Value 158 divided by 16 = 9.9 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 160 divided by 16 = 10.0 Previous EDU
Change -2 divided by 16 = -0.1 over (under) $ (240.00)
Enter EDU Change Here -0.1
HISTORY
EDU ct. from Ali. Fixture value PLM# EDU# SWR#
reduced by 2= .1 credit. PLM# EDU# SWR#
PLM# DU# SWR#
Name: z
6 Date: 7-/2--e2 3
Signature of person that calculated this tally sheet and date perfromed is required
rte,
CITY OF TIGARD <,. 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 - 4171 MST
BUP g - 60376
Received Date Requ eted '"l AM PM BUP
Location 3 • ♦ = _ % _ Suite MEC
Contact Person Ph ( ) 5 - s ( 7 (. PLM 3 - 06 7 7
Contractor / Ph ( - ) SWR
BUILDING Tenant/Owner / �'7z o_ - TardZei_401.4 ELC
Footing
Foundation Access: ELC
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
L0QMBII
eam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
PART FAIL
ANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
•
Fire Alarm
Final ❑ Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinsp - tion RE: Unable to inspect — no access
Fire Supply Line
ADA "T"°-1/11
Approach/Sidewalk Date Inspector Ext
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL