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Permit l• CITY TIGARD SEWER CONNECTION PERMIT COMMUNITY DEVELOPMENT PERMIT #: SWR2007 - 00118 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 5/21/2007 PARCEL: 2S 103 DA - 03201 SITE ADDRESS: 10625 SW PARK ST ZONING: R -3.5 SUBDIVISION: DERRY DELL PLAT 2 LOT: 034 JURISDICTION: TIG PROJECT: WINTERS Project Description: Sewer connection. TENANT NAME: CWS NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 1.0 TYPE OF USE: SF NO. OF BUILDINGS: INSTALL TYPE: LTPSWR IMPERV SURFACE: Owner: WINTERS, GERRY L FEES 10625 SW PARK ST Description Date Amount TIGARD, OR 97223 • [SWUSA] Sewer Connection Fee 5/21/2007 $2,700.00 [SWINSP] Sewer Inspection Fee 5/21/2007 $35.00 Phone: • d; Total $2,735.00 p"' M o Contractor: Contact #: W V REQUIRED ITEMS AND REPORTS . tea Reg #: ' 4, Owl g ee � ao git This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow 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 copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued by: Permittee Signature: • A.11.- 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. . . . ■%1)i Ji / . ,-.QA FOR OFFICE USE ONLY City of Tigard { : ' Permit o. o p - 2 a 13125 SW Hall Blvd., Tigard, OR 97223 ■ i ce: Review C Phone: 503.639.4171 Fax: 503.598.1960 REC iT Date/By: Other Permit No,:. • TI G A R D Inspection Line: 503.639 Read orris: El See Page 2 for Internet: www.tigard or.gov MAY 2 1 20 Nori fie Supplemental Information TYPE OF WORK CITY OF F IGARD FEE* SCHEDULE ❑ New construction ❑ DemoaddILDING DIVIS1UN For spedal information use checklist Description I Qty. I Ea. I Total ❑ Addit ion /alteration/replacement ,Other: New I- 2- family dwellings (includes 100 ft. for each utility connection) • CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 MI- and 2- family dwelling ❑ Commercial/industrial - SFR (2) bath 350.00 Accessory building ❑ Multi - family • SFR (3) bath 399.00 ❑ Master builder Each additional.bath/kitchen 45.00 ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities . Job site address: `O S Ss ( .., 0 ..,_ c'"� , Catch basin or area drain '16.60 City/State /ZIP: (g�� ,r P ,. �''t223 Drywell, leach line, or trench drain 16.60 • Suite bldg. /apt. no.: I Project name: 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.: ) Page 2 Storm sewer (no. linear,ft.: ) Page 2 Subdivision: 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 ''._ \.1.3-...: kNc:23 cZ)' �\--4) Backwater valve 16.60 Clothes washer 16.60 . Dishwasher 16.60 ❑ PROPERTY OWNER I 0 TENANT Drinking fountain • 16.60 Ejectors/sump • . 16.60 Name' �p C' V3 `\---._ Expansion tank 16.60 Address: ` %_� 'J \� Fixture /sewer cap 16.60 City/State /ZIP:' ), -. v (k sza '1 `/ • Floor drain/floor sink/hub 16.60 Phone: ( 3 ow b _© 7 -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. Sink/basin/lavatory 16.60 Phone: ( ) Fax:: ( ) Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 ' CONTRACTOR Water closet • 16.60 Business name: Water heater 16.60 Address: Other: Subtotal City/State/ZIP: • Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 CCB Lic.: Plumbing Lic. no.:' Plan review (25% of permit fee) • \ State surcharge (8% of permit fee) Authorized signature: `�) TOTAL PERMIT FEE /5 Print name C''�� ` `.. . Date 2 ` ^� 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. • 1: \ Building \Permits\PLM- PermitApp.doc 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 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 Q ty. Fee (ea) Total additional $100.00 or fraction thereof, to and Fixture or Item 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 Inspection of existing plumbing or each additional $100.00 or fraction thereof, to 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. • Fixture Work: Are you capping, adding or replacing fixtures? If "yes", Plan Review for Plumbing Installations please indicate work performed by fixture. Failure to Plan review is required for any of the following. accurately report fixtures could result in increased sewer fees * . Please check all that apply. • Quantity, by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and Fixture Type: Replace greater, except systems designed and stamped by licensed Previous Capped Added Existing engineer. Baptistry/Font Tub /Sr ❑ New exterior plumbing site utilities for any complex structure Bath - hower Tub/S i/ erlpool as defined in OAR918- 780 -0040. Car Wash - Each Stall •❑ Medical gas and vacuum systems for health care facilities. Drive Stall ❑ Any multipurpose fire sprinkler system. CI Cuspidor/Water Aspirator Any complex structure as defined in OAR918 780 - 0040. Dishwasher - Commercial Domestic Submit 2 sets of plans with any of the above. Drinking Fountain • Eye Wash Isometric or Riser Diagram Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings - 3 that meet the qualifications above: - 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 *Note: If the fixture work under this permit results in an - Bradley - 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:\Building\Permits\PLM- PermitApp.doc 12/27/06 CITY OF TIGARD BUILDING DIVISION PERMIT #: 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: Phone: (503) 639 -4171 , � I � � Inspection Requests (24 Hrs.): (503) 639 -4175 �`:_.. INSPECTION WORKSHEET FOR DATE: c/ - 2,S7 V - 7 TIME: PAGE: SITE ADDRESS: I(1) (.e2 Q L 1t— CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: DESCRIPTION: OWNER: PHONE #: CONTRACTOR: PHONE #: Inspection Request Scheduled For: Date: Pour Time: Code # Inspection Description Confirm # Contact # Message C )'(' C 'YkA)9211C. ,,.- J Corrections /Comments /Instructions: 47(........--- T C---0 rem , l I Vic -4 7 0 2 ______\_. ` R f ir ii i l fj,.j I / ❑ PAS ❑ 'ART, .L APP - OVAL ❑ ANC ❑ NO A:. SS 11 F A CALL ' O' NSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: `/ v ` c v ✓ Date: 5 7 1 / 6 1 Phone #: (503) 718- 2 4 1-1