Permit 1r w
C ITY OF TIGARD SEWER CONNECTION PERMIT
� DEVELOPMENT SERVICES PERMIT #: SWR2004 -00192
s ` Ail 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/29/2004
SITE ADDRESS; 10630 SW PARK ST PARCEL: 2S103DA -04400
SUBDIVISION: FANTASY HILL ZONING: R -3.5
BLOCK: LOT: 003 JURISDICTION: TIG
TENANT NAME:
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.
Owner: FEES
NOLES, DAVID R AND Description Date Amount
MARGARET L
10630 SW PARK ST [SWUSA] Swr Connectic 6/29/2004 $2,400.00
TIGARD, OR 97223 [SWUSA] Swr Connectic 6/29/2004 $0.00
Phone: [SWINSP] Sewer Inspect 6/29/2004 $35.00
[SWINSP] Sewer Inspect 6/29/2004 $0.00
Contractor:
Total $2,435.00
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
may obtain copies of these rules or direct questions to OUNC by calling (503) 246 - 6699.
Y Permittee Si g e��' 1' (
Issued b natur �� . ` - , � 4
� Gl/1X,� I7
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next tjiness day
B eZi.) D N(
" ` A . ' � f FOR , O p F � FICE USE ONLY
City of Tigard Date/By: �Q Permit No. & 4-09/R�
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie
Phone: 503.639.4171 Fax: 503.598.1960 /�nt , t f l h i \ Other Permit No.:
24- Hour Inspection Line: 503.639.4175 ■ j D ate By:
p - a - �i' �� Date Ready/By: f °� El See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: 'CA
� Supplemental Information
TYPE OF WORK . • - • FEE* SCHEDULE :
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION '. SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: /063#) 51 Raik 5'/ Catch basin or area drain 16.60
City/State/ZIP: / `9Q r Ore Q 7 l) 3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: c.J Project name: t) /es Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 1 10.00
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
DC O F Qpij Backflow preventer Page 2
Backwater valve 16.60
( /J) . (2-- f-f-/ Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
❑` PROPERTY OWNER I ❑ TENANT
Ejectors /sump 16.60
Name: Dew id )l r g f No %s Expansion tank 16.60
Address: /O /off c ` ' "v, r k SA. Fixture/sewer cap 16.60
City/State/ZIP: / l avd tr q 7) 3 Floor drain/floor sink/hub 16.60
Phone: 3) / '7i 3 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) 16.60
Phone: ( ) I F yx:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: Bug A/SrZ Water heater 16.60
Address: Other:
City/State/ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: P umbing Lic. no.: Plan review (25% of permit fee)
_
Authorized si lure: / , r � , State surcharge (8% of permit fee)
,�. /,J . /, / / 0 ``� -/ .1 _ TOTAL PERMIT FEE 1135
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.
is\ Building \ Permits \PLMF- PemutApp.doc 12/03 440- 4616T(10/02/COM/WEB) -
Plumbing Permit Application - City of Tigard • . a ,.,
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities ' Qty. Fee (ea) Total Square Footage:' ' _Permit F •,: -
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
$309.00
r Sewer - 1st 100' 55.00 7,201 and greater
1 Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40 - M , - -
Storm & Rain Drain - 1st 100' 55.00 Valuation: :... - Permit Fee::
$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 Mach./Refrig. 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:
is\ Building \Pcrmits\PLM- PermitApp.doc 3 /03