Permit . pcfri a oo Li- 00 37 q
C ITY OF TIGARD SEWER CONNECTION PERMIT
2111 DEVELOPMENT SERVICES PERMIT #: SWR2004 -00226
..� II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/20/2004
SITE ADDRESS; 10735 SW PARK ST PARCEL: 2S103DA -03400
SUBDIVISION: DERRY DELL PLAT 2 ZONING: R - 3.5
BLOCK: - LOT: 037 JURISDICTION: TIG
TENANT NAME: MCGRIFF
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection for existing house to newly installed sewer lateral. Reimbursement District #29
deferral fee paid this date.
Owner:
FEES
MCGRIFF, JAMES E /SHEILA M
10735 SW PARK ST Description Date Amount
TIGARD, OR 97223 [SWUSA] Swr Connectic 8/20/2004 $2,500.00
[SWUSA] Swr Connectic 8/20/2004 $0.00
Phone: [SWINSP] Sewer Inspeci 8/20/2004 $35.00
[SWINSP] Sewer Inspeci 8/20/2004 $0.00
Contractor:
Total $2,535.00
Phone:
Reg #:
Required Inspections
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
ma tain cop' of these rules or direct questions to OUNC by calling (503) 246 -6699.
f r G Is ed by: , i � . !r l jJ� Permittee Signature: .9 ` e l
Call (503) .39-4175 by 7:00 P.M. for an inspection needed th ext business day
Building Fixtures
ro
Plumbing Permit Application FOR OFFICE USE ONLY
City of Tigard Received ,-f
13125 SW Hall Blvd., Tigard, OR 97223 Date/By: • ' 0 - i •W - I�. =50
Plan Review Other Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 / /y�ak�a) €� Other
24- Hour Inspection Line: 503.639.4175 ■ �. cr' I Date Ready/By: ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: / l Supplemental Information
• . TYPE OF WORK , :-',FEE* SCHEDULE - - : -:::' '
❑ New construction ❑ Demolition For special information use checklist
Descrip on I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1 2 amily dwellings (includes 100 ft. for each utili connection)
CATEGORY OF CONSTRUCTION ` .4 ` ° ; -∎' .: , SFR (1) ba •, 249.20
❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.
❑ Accessory building ❑ Multi- family SFR (3) bath 39 .00
• Each additional •ath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
• JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: Catch basin or area . in 16.60 °
City/State/ZIP: 17 j t. Nk� t A t�p.J Drywell, leach line, or , ench drain 16.60
Suite/bldg. /apt. no.: Project name: ,-% i 7.9-2-5/ Footing drain (no. Linea ) 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: I 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
Backwater valve / 16.60
Clothes washer / 16.60
Dishwasher / 16.60
❑' PROPERTY OWNER - , I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: - t, -if,ts CI. A.1.. t � 1 2. p� 1L
l �p P‘vrj Expansion tank 16.60
Address: (0 ? 5s ' W A. hot Fixture/sewer cap / 16.60
City/State/ZIP:-- q- Q1 dP- G 7' -2.5 Floor drain/floor sin b 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
• - ❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease ap 6.60
Contact name: Medical gas (valu : $ ) Pa e 2
Address: Primer 16. 0
City/State/ZIP: Roof drain (co ercial) 16.
Phone: ( ) Fax:: ( ) Sink/basin/lava ry 16.6
Tub /shower /sh wer 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: ( ) ax ( ) Resi tial backflow minimum permit fee: $36.25
CCB Lic.: PI bing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature:
TOTAL PERMIT FEE
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\Pemtits\PLMF PermitApp.doc 12/03 440- 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
Fixture or Item Qty. Fee (ea) 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
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, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by (Fixture) Work Performed
Fixture Type: Replace
New Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
-3"
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice MachiRefrig. Drains
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory _ Quantity Total
- Bradley Isometric or riser diagram is required if fixture quantity
- Commercial _
Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
i:\ BuildinglPennits \PLM- PemtitApp.doc 3/03