Permit •
CITY OF TIGARD PLUMBING PERMIT
PERMIT #: PLM2002 -00193
DEVE H BMEN9 rd, S 2CES 639 -4171 DATE ISSUED: 10/22/03 all
SITE ADDRESS: 16875 SW PACIFIC HY PARCEL: 2S115BD -02600
W
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION: KIN
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 3
OCCUPANCY GRP: M FLOOR DRAINS: 5 TRAPS:
STORIES: 1 WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 4 URINALS: GREASE TRAPS: 1
LAVATORIES: 1 OTHER FIXTURES: 17
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 1 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: New 4,243 sq.ft. gas station /convenience store with future TI space. Other fixtures are (3) hose bibs, (12) roof
drains, (1) air /water, (1) ice maker. Sewer connection permit is to obtained from Clean Water Services.
FEES
Owner:
Description Date Amount
SPACE AGE FUEL INC
PO BOX 607 [PLUMB] Permit Fee 10/22/03 $637.20
GRESHAM, OR 97030 [PLMPLN] Plan Review 10/22/03 $159.30
[TAX] 8% State Tax 10/22/03 $50.98
Phone : 503 - 665 - 5693
Total $847.48
Contractor:
EAGLE PLUMBING
13801 S FORSYTHE RD
OREGON CITY, OR 97008 REQUIRED INSPECTIONS
Phone : 503 - 650 - 8703 Water Service Insp
Rough -in Insp
Reg #: LIC 47914 Underfloor /Underslab
PLM 3 -154PB Top -out Insp
Rain Drain Insp
Gas Line
RP /Backflow Preventer
RP /Backflow Preventer
RP /Backflow Preventer
Final Inspection
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
--
Issued B `� � �� ��_ Permittee Signature: Zjeti
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
•
Plumbing Permit Application
Date received:-.3 /..00 Permit no .61 -001q.
�, i ; ' Cit of Ti
AU - I, Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223 1
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 - 1960 r,� - , p, Date issued: B} li I Receiptno.:
Land use approval: 1 5 71 Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory CdniiiiircisUiridus[rial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: 161n5 51/ f il- 4 ,111 4144 erri Description Qty. Fee(ea.) Total
New 1- and 2- family dwellings only:
Bldg. no.: 1 Suite no.: (includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: Z Cj f ep/ rj 2 ., SFR (1) bath
Lot: Block: 'Subdivision: SFR (2) bath
Project name: ziL� A SFR (3) bath
City /county: 77 (t 9 ZIP: dj7ZZl� Each additional bath/kitchen
Description and locatiofi of work on premises: 4z43 '. p Site utilities:
6.4.1Vcalieal[c S 7zf sr - T1 SPA 4, Catch basin/area drain .
•
Est. date of completion/inspection: Drywells/leach line/trench drain
Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR
Manufactured home utilities
Business name:
6R6� 4 £ l6ri�1a • Manholes
Address: /)/ 4 fo g-yrif 6 / 21- Rain drain connector
City:00460,J der)/ I State /L 'ZIP: 97aeg Sanitary sewer (no. lin. ft.)
Phone: 650- Vo5 I Fax:&93 -$ E -mail: Storm sewer (no. lin. ft.) .
CCB no.: 4/79 'Plumb. bus. reg. no: 3 -- /,5-c W ater service (no. lin. ft.)
•
City /metro lie. no.: 1 3
Fixture or Item:
"C Contractor's representative signature: - Absorption valve
Back flow preventer
Print name:
Ik y - ) Date:10 6 Backwater valve
CONTACT PERSON Basins/lavatory
Clothes washer •
Name: L,et,L f f e �-Q Dishwasher •
Address: fp E3 60-7 Drinking fountain(s)
City: t i41 , q I Stater 'ZIP: '3'7c 0 Ejectors/sump
Phone:,- Fax:465- f : E -mail: Expansion tank
OWNER Fixture/sewer cap -
Name (print): -L WC. Garbage drains/floor sinks/hub
Mailing address F 8,6)e 601 Hose disposal
Hose bibb
City: --</tic I State• 'ZIP: 37030 Ice maker
Phone: e 56e )s I Fax:61,,547 E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name: i ts Et &tl Water closet
Address: e u ,2�i - s7: Water heater
City: .- State 'ZIP: $ 3 ZO I Other.
Phone:? - t �p 478 -46(31 Fax: OS- 7e) 1 r "'60 Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information Minimum fee $
Not This permit application
❑ Visa ❑ MasterCard Plan review (at %) $
Credit card number: / / expires if a permit is not obtained State surcharge (8 %) .... $
Expires within 180 days after it has been
Name of cardholder as shown on credit card accepted as complete. TOTAL $
$
Cardholder signature Amount 440-4616 (6I00/COM)
' PLUMBING PERMIT FEES: " .. .
•• PRICE TOTAL New.1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures In PRICE TOTAL
Sink -5 16.60 80 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 4.4.�� for each utility connection)
je: • 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 ✓• I 16.60 1& .&o SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray • 16.60
Washing Machine 16.60 16.60 Floor Drain/Floor Sink 3" 1 16.60 II6'20 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind J 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New - Moved Replaced Removed/
permit
I ,(� Capped
MFG Home New Water Service 46.40 Sink 5
MFG Home New San/Storm Sewer 46.40 Lavatory (
16.60 Tub or Tub /Shower •
Hose Bibs J
33G'7 Combination
Roof Drains /0 16.60 1 .er. Shower Only
Drinking Fountain 16.60 Water Closet i
Other Fixtures (Specify) 16.60 Urinal
Dishwasher
Ale/u/4 Tke goy- I (6.4,O 16.60 Garbage Disposal
leg Mde fit> I • 16-CO i t .6a Laundry Room Tray
Washing Machine •
Sewer - 1st 100' I 55.00 Zit' Floor Drain /Sink: 3" Sewer -each additional 100' f! 46.40 4"
Water Service - 1st 1 ' ,. V I_ 55.00 .Z; Water Heater I
eA l Other Fixtures
Water sdc� - vac d dl�d � n 200' �/ 2 r epo g Z. f3o (Specify)
Storm &Wa1 / - ain 1st ' 10 W 0' r/ 55.00 a00 ICC 11A m
Storm &cRa n Drain - each `dit 100' 46.40 i �O za A)e ./Lt gyp_- )
Commercial Back Flowp(evention Device /I 46.40 e,2,Sl_2 .
Residential Backflov).,Prevention Device *// 27.55
Catch Basin/ / 16.60 .
Inspection of Existing Plumbing or dally 72.50 •
Requested Inspections / , per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwell g% 65.25
Grease Traps ( a I 16.60 14,60
QUANTITY TOTAL
Isometric or riser diagram is required if 3,
Quantity Total is > 9
'SUBTOTAL 1C1
8% STATE SURCHARGE Q ^ 6'j
CJ�
"PLAN REVIEW 25% OF SUBTOTAL Z 5Ca.
Required only if fixture qty. total Is > 9 •
TOTAL . $133/35
Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $38.25 + 8% state surcharge.
"All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
i:\dsts \forms\plm- fees.doc 10/10/00
•
OCT -20 -2003 10 10 PARSONS BRINKERHOFF 5032741412 P.02/02
FN.UM : M NLI- 11t{NN -iN I ., . .... _ - - - .
- - Permit # : 03 - 500915 - 00 - PE
C1ea i Water Services
c I n s pection Request Line: X03- 846 -8444
(SS N. First Avenue Suite 270 24 hour notice required for all inspections
Hillsboro. OR 97113 �1
Ph: (503) 846-8621 � ���
Project Name: SPACE AGE r1 TNG o
Project Address: 16875 SW PACIFIC H4 O -(Ve e Issued By: Nlchoie Vanderzanden
$lb
Typo; Sani/SWM Connection . Issued: Oct 02, 2003
Commercial � MIt'w Expires: Mar 30, 2004
Project Doscription:
_...
Owner Applicant Contractor
NONE SPACE AGE FUEL NONE
PO BOX 607
GRESHAM. OR 97030 -
Number of Equivalent Fixture Unita (PU)' 38 Number oCSq Ft 69459
Treatment Plant Rock Creck Water District Tualatin Valley
Permit Fixtures
r DescriptIoii :.. ` . ,1Q n ' [ D cription . JQuantityj Description j - Quanti t 1: i
Dr (
(Flonr Drain - 2 inch FS - ear I 1 (link - Commcrci
- ��9:. .•A -_��� ._�� fir .� �• 1'4 :.. ... .. � ^;p.r :fi'•• .
� I I water Closet — ]r 1
Sink • Service 3 I Washer. Clothes JL
Fee Descriotion Amount
Erosion Control Inspection Fee 88.00 •
Erosion Control Plan Check Fee 57.20
Sanitary SDC Fee (Connection) 5,700.00
Water Quality SDC 0.00
Water Quantity SDC 0.00 •
Sub Total 5,845.20
• TOTAL 5,845.20
•
•
•
I HEREBY CERTIFY AT THE BOV - ;' •OORR A IS CORRECT.
SIGNATUR) : Date: / Ct ^ Z 0-3
SPACR AGE FUEL
TOTAL P.
Accumulative Sewer Tally
Tenant Name: cp Ace, GT e, This SWR#
Address: / to 5 7S Sw au_ 'Fs'c P-wj• This PLM #: Q06 2 - op f 61
Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New
# Value Capped off value added # added #s total
Count off #s count value values
Baptistry/Font 4
Bath - Tub /Shower 4
- Jacuzzi/Whirlpool 4
Car Wash - Each Stall 6
- Drive Through 16
Cuspidor/Water Aspirator 1
Dishwasher - Commercial 4
- Domestic 2
Drinking Fountain 1
Eye Wash 1
Floor Drain /sink - 2 inch 2 5 •
- 3 inch 5 /
- 4 inch 6
C - - Car Wash Drn 6
I _ S ,...v
Garbage Disposal 16
- Domestic (to 3/4 HP)
- Commercial (to 5 HP) 32
- Industrial (over 5 HP) 42
Ice Machine /Refrigerator Drains 1
Oil Sep (Gas Station) 6 /
Rec. Vehicle Dump Station 16
Shower - Gang (Per Head) 1
- Stall 2
Sink - Bar /Lavatory 2 /
- Bradley 5
- Commercial 3 3
- Service 3 1
Swimming Pool Filter 1
Washer - Clothes 6 ,
Water Extractor 6
Water Closet - Toilet 6 1
Urinal 6
TOTALS
Total fixture values: divided by 16 = EDU
HISTORY
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
i:.dsts\swrtaly.doc
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
J /a AM PM BUP
Received / ` °-( t!
2 - �'` Date Requested BUP
Location G6'eSP 7 5
Suite MEC
Contact Person Ph ( ) LM --- 9
Contractor ( AeP-14/1 Ph ( Sd ? <0 'l Z3 4t SW
BUILDING Tenant/Owner 9a,e-0 � ` =Z ELC
Footing
Foundation ELC
Access:
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 / , / / ✓� Lf i //_
Other:
Final /
PASS PART FAIL
PLUMBING i
Post Beam / � `
Undnder r Slab '�/
-
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Fin.. ..`
PART FAIL /
n� - ' 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 0 Please call for reinspection RE: El Unable to inspect - no access
Fire Supply Line
ADA )3/J
Approach/Sidewalk Date Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL