Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2011 -00383
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/15(2012
Parcel: 1 S136DCO2504
Jurisdiction: Tigard
Site address: 7275 SW DARTMOUTH ST 180
Project: Tigard Triangle Smiles Subdivision: HUNTER POLLOCK NO.2 Lot: G
Project Description: Interior plumbing.
Contractor: PMSI LLC Owner: AMERICAN INDUSTRIES INC
21195 NW EVERGREEN PKWY #204 1750 NW FRONT AVE STE #106
HILLSBORO, OR 97124 PORTLAND, OR 97209
PHONE: 503 -466 -2222 PHONE:
FAX: 503- 466 -2211
FEES
Quantity Description Date Amount
2 ea Backflow Preventer 03/23/2012 $62.54
Specifics: 1 ea Backwater Valve 03/23/2012 $12.51
1 ea Clothes Washer 03/23/2012 $25.02
Type of Use: COM 1 ea Expansion Tank 03/23/2012 $12.51
Class of Work: ALT 4 ea Fixture /Sewer Cap 03/23/2012 $100.08
Type of Const: 1 ea Floor Drain/Floor Sink/Hub 03/23/2012 $25.02
Occupancy Grp: 6 ea Sink 03/23/2012 $150.12
Stories: 1 ea Water Piping /DWV 03/23/2012 $56.29
2 ea Water Closet 03/23/2012 $50.04
1 ea Water Heater 03/23/2012 $37.52
25 Misc Other Fee 03/23/2012 $25.02
ea Medical Gas 03/23/2012 $72.50
1 Plan Review 03/23/2012 $157.29
1 12% State Surcharge - 03/23/2012 $75.50
Plumbing
Total $861.96
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 • Ica ion - • • er. •ose rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You ma •btain a co• of the rules
or • ect questions to OU • •y c• • 503.232.1987 or 1.800.332.2344.
I sued By: 4 i Y Permlttee Signature:
A III I P O PP?"
Call 503.639.4175 by 7:00 a.m. for the next available inspectio • ate.
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.
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Plumbing Permit Application 27) / _
B uilding Fixtures • ,,; \ " ..
Received
City of Tigard of'
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Date/By: l� ll' - tl Permit No.:P1W]UO I 1-0o3.81 3_
V 13125 SW Hall Blvd., Tigard, OR 97 )t . 3 � - p
Nora/U(3 �
Plan Review
• C Phone: 503.718.2439 Fax: 503.5 fir. ,;t'. 0 . Q /B
Date/By: a _ Cher Permit No�� /[ 00: a 7
Inspection Line: 503.639.4175 .. R e 2 for
TIGARD Internet: Internet: www.ti and -or. ov �� ♦ ,; Read y:. r is: to See Page
g g � rN Notified/Methi.., J/ Supplemental Information '
� �
TYPE OF WORK „� 1 FEE* SCHEDULE •
❑ New construction ❑ Demol For special information use checklist
N Description I Qty. I Ea. Total
❑ Addition /alteration/replacement ® Other: T New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70 .
❑ I - and 2- family dwelling 0 Commercial/industrial SFR (2) bath 437.78 ,
SFR (3) bath 500.32 •
❑ Accessory building ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities: •
Job site address: 7275 SW DARTMOUTH AVE Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City /State /ZIP: TIGARD, OR 97223 Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: 180 I Project name: TIGARD TRIANGLE SMILES Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
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Rain drain connector 18.76 •
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Sanitary sewer (no. linear ft.: _) Page 2 •
Storm sewer (no. linear ft.: _) Page 2
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Water service (no. linear ft.: ) Page 2 •
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Subdivision: l Lot no.: . Fixture or item: •
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Tax map /parcel no.: Backflow preventer 2 31.27 . 62 .5
DESCRIPTION OF WORK Backwater valve I / 12.51 /2 -j
Clothes washer 1 ✓ 25.02 9.5'.64
VACCUM /AIR/WATER TO DENTAL CHAIRS, PLUMBING DISTRIBUITON, Dishwasher 25.02
TWO TOILETS, SINKS, WASHER/DRYER, Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER I ® TENANT Expansion tank I 12.51 / ,5-/
Name: PACIFIC DENTAL SERVICES Fixture /sewer cap %i 25.02 [ co Og
Floor drain /floor sink/hub I ✓ 25.02 ads n1
Address: 2860 MICHELLE DRIVE, 2 FLOOR
Garbage disposal 25.02
City /State /ZIP: IRVINE, CA 92606 Hose bib 25.02 ,
Phone: (714)508 -3600 Fax: (714)388 -3951 Ice maker 12.51
® APPLICANT ® CONTACT PERSON Interceptor /grease trap 25.02 7d
Business name: PACIFIC DENTAL SERVICES Medical gas (value: $ 1526.) Page 2
Primer 12.51 •
Contact name: JULIE MARGETICH
Roof drain (commercial) 12.51
Address: 2044 CALIFORNIA AVE. Sink/basin/lavatory 6 7 25.02 /50. /
City /State /ZIP: CORONA CA 92881 Solar units (potable water) 62.54
Phone: (951) 582 -5745 Fax: : (714) 388 -3951 Tub /shower /shower pan 12.51
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E -mail: MARGETICHJ @PACDEN.COM Urinal 25.02
Water closet 2 / 25.02 5
CONTRACTOR Water heater I 37.52 37. 52
Business na70/751 re. / l #4, 4C.f v � yS7 .?Y '
?s AN C. Water piping/DWV 1 56.29 54
Address: a / / A/aJ ,4 4 ff. Ze �/ Other: PLASTER TRAP 1 25.02 ,5
City /State /ZIP: tii 44,0449 P) e 1 7/.27- f Subtotal : 6,171.11
!�4 f 2 ' 2
Phone: -2 �Q) r o Fax: ( )
p ry � Plan review (25% of permit fee) 75 . �A
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CCB Lic.: GG 6 m Lic. no.:
State surcharge (12% of permit fee) 15.
Authorized signature: 40, TOTAL PERMIT FEE Y _[(,
Print name: Date: 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\PI.M1J- Permit App ,doc 10/01/09 440.4616T(10/02/COM/WEB)
Pp•mb,ing 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 - l'' 100' 50.03 0 to 2,000 $121.90 •
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54 •
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems: •
Water Service - each additional 1 00' 37.52 Valuation: Permit Fee: .
Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50 •
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
P and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to •
(minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge - 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ",
please indicate work performed by fixture. Failure to , •
accurately report fixtures could result in increased sewer fees * .
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Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace/ Plan review is required for any of the following.
Work Performed: Capped Added Relocate please check all that apply.
y
Baptistry/Font
Bath Tub /Shower ❑ Any new commercial building with water service 2" and
Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918- 780 -0040.
Dishwasher - Commercial ® Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ Any complex structure as defined in OAR9I8- 780 -0040.
Eye Wash
Floor Drain /sink - 2" I Submit 2 sets of plans with any of the above.
4,. Isometric or Riser Diagram
Car Wash Drain ❑ Isometric or riser diagram is required for new buildin s
Garbage - Domestic - non - food g q g
Disposal - Domestic - food related that meet the qualifications above. .
- Commercial -food related .
- Industrial -food related
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Ice Mach. /Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang .
-Stall
Sink/Lav - Non -food related 2 6
-Bradley
- Commercial -food related
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- Service
Swimming Pool Filter -
Washer - Clothes 1 *Note: If the fixture work under this permit results in an
Water Extractor increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet 2 2 fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued. .
Other Fixtures:
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