Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009 -00128
T I GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 05/27/2009
Parcel: 2S 111 ACO2500
Jurisdiction: Tigard
Site address: 9110 SW PINEBROOK ST
q
Subdivision: Lot: 0
Project: Mayer
Project Description: Replace up to 100 feet sanitary sewer.
Owner: FEES
MAYER, JAMES C & E J Quantity Description Date Amount
9110 SW PINEBROOK ST 100 If Sewer Service 05/26/2009 $55.00
TIGARD, OR 97224 1 12% State Surcharge - 05/26/2009 $8.70
PHONE: • Plumbing
18 ea Minimum Fee Adjustment 05/26/2009 $17.50
Contractor: - Plumbing
AMERICAN RESIDENTIAL SERVICES LLC
P.O. BOX 2830
CLACKAMAS, OR 97015
PHONE: 503 - 235 -8784
FAX: 503 - 491 -2932
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Issued By: d eslatng. Permittee Signature: �' , f, k
r Call 503.639.4175 by 7:00 a.m. for an inspection that business day. ` \ 0 1 l
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.
OCT -23 -2004 17:45 P.001
Plumbine Permit Application RECEIVE r
Building Fixtures FOR OFFICE (I,SE ONLY
City of Tigard MAY 2 2 2009 Received
at�By.
SW l ,� Pamut No.'QLm'� � . '� N
q 13125 W Halt B a
lt,d.. Tigard. OR 97223 Dft B c.in%, - J - ,e
C Phone: 503.639.4171 Fav: Sol .s98 1 I t r OF TIGARD e e> Other Permit NC .
TI GARD Inspection Line: 503.639.417 BUILDING DIVISION o-�e Read Bl wns ® See Page lfor
Internet: wtitw,tlgard-ic6m SION Nn�ufiertt od Su .lemental tnformetioe
TYPE OF WORK FEE* SC EDULE
El New constitution ❑ Demolition For specia 1 it ormallon use checklist.
Descn NM Ea. Iout
\t' • ddition /altcration/replacemenl ❑ Other New I. 2-family dssellings (includes 100 It for each utility connectio
CATEGORY OF CONSTRUCTION SFR ( 1 1 bath 249.20
W I- and 2- family dwelling ❑ Commercial /industrial SFR t2i bath
❑ Accessory building ❑ Multi- fanhil SFR 131 bath 399.00
Q Master builder ❑ Other Each additional bath/kitchen a5.00 Mill
Fire sprinkler ( sq, hi Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: // • / /^ ,P;
Catch basin or area drain MEM
f / JRa Drywell, leach line, or trench drain 16.60 ME
Suite/bldg, /apt no.: Project name: / - Footing drain tno. linear 11: i �
Cross strcct/ditections to job site; Manufactured home utilities 110.00
Manholes 16.60
Rain drain connecter 16.60
. Sanitary sewer (no. linear R.: f
Storm sewer (no. linear ft.: _ ` _ I
Subdivision: Lot no.: Water service (no. linear 0.: � 1 Page 2 MN
Tax map /parcel no.: Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK tlaekflow preventer —.
r47 7�f Backwater valve 16.60 W
e�C Clothes washer
16,60 MN
ki
i
D
[] TENANT Drinking fountain
g PROPERTY OWNER g 16.60 MO
• Ejectors/sump 1660
1V:imc: . P 4
. Expansion tank 16.60 MIE
Address:
MA���t /,�21 Fixture/sewer cap I6.60
City /State/ZIP: ' / Fl oor drain/floor sink /hub
I / � 16.60�
Phone: ( 65 + ) Garbage disposal
A APPLICANT • 0 CONTACT PERSON
Ice I bib LIM
ce maker 16.60
Business name: ARS dba JACK HO1Yti iReacute Rooter -
--
Interceptor/grease trap 16.60
M
Contact name: JOYCE DENNIS Medidicaijal l gas as (value: e: $ ) • Page 2
Address: P.O. BOX 21130 Primer 1111111 16.60 r
City /State /ZIP: CLACKAMAS. OR 97015 Roof drain (commercial) 16.60
Phone: .1.0 0 ?ID li Fax: : (5031 491-2932 Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60 -
E-mail: JOYCE@JACK1- OWh .COM Urinal
16.60
CONTRACTOR Water closet 16.60
Business name: ARS dba JACK IIOR'K /Rescue ooter R Water heater 16.60 —
Address: P.O. BOX 2830 Other. =
City/State/VP: CLACKAMAS, OR 97015 Subtotal '�
Minimum permit fee: 172.50
Phone: /5 . 44. Fax: (503) 491 -2932 Residential backtlow minimum permit fee: $3625 '115
CCB Lic.: 127325 _ Plumb' g Lie. no.: 34 -168 P Plan review (25% of permit fee) MIN
Authorized signature: ` . ; State surcharge (12% of permit fee) MOP ,
j
Print name: yr/ �e /MT Date: 6157,-,0 � '? T IM perm application expires If a permit Is nut o , . in ► ht ,
180 days after It has been accepted as corn . .
*Fcc methodology set by Tri -County Building Industry Service Board,
t:1BulldinyTermiu\PL,MP.P. Please FAX BACK to003- 491 -2932 •
OCT -23 -2004 17:45 P.002
5',f'■• v
Plumbing Pe Application - City of Tigard
Page 2 - Supplemental Information
- , Fee Schedule: Residential Fire Su I i ression S - stems:
Site Utilities Qty. Fee feet Total S t uare Foots: e: Permit Fee:
- Footing drain -9" 100' 55 00 IMIMI 0 to 2.000 $115.00
• Footing drain'• each additional 100' 46,40 MI 2.001 to 3,600 $160.00
Server • I cu 100' - �f� 55 9U 3.601 In 7,2f10 $220.00 1
7.101 and "mater $300 00
Sewer - each 'additional 100 46.40
Water Service • 1st Int) 55.00 Medical Gas Systems:
Water yen ire - each additional 101)' 46.40 _
Valuation: Permit Fee: 7
Storm &Ram Drain • • 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee 572,50
"-
Storm & Rain Dram - each additional 100' 46.40 55.001.00 to $ 10.000.00 572:50 for the hest $5.000.00 and $ I.52 fir each i
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraciinn thereof. to and
including $ I0,600,00.
Commercial Back Flow Prevention Device 46.411 $10. lo $ ' $148.50 for the first $10.1)00.00 and $1.54 fur
Residential Backflow Prevention Device each additional $100.00 or fraction thereof. to
(minimum .ermit fee 536 25) 27.55 and including $25,000.00.
Rain Drain. single family dwelling 65.25 _ 525 001.00 to $50.000.00 $379.50 for the first $25.000.00 and $1 45 for
Inspection ofe tisimg plumbing or each Additional $100.00 or fraction thereof, to
s.eciallv re. uestedin .aliens - .erhour 7250 and including $50.000.00.
Subtotal: $50,001.00 and up 5742100 for the titst $50,000.00.and $1.20 fur
teach additional 5100.00 or fraction thereof. J •
Commercial Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased.sewer fees*, El Any new commercial building with water service 2' and
poanti by.(Fixture) Work Performed greater. except systems designed and stamped by licensed
Fixture Type: Replace engineer.
Preview* capped Added Editing ❑ New• exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918 780 -0010.
Bath -Tub /Shower ❑ Medical gas and vacuum systems for health cart facilities.
-Jacuzzi/Whirlpool ❑ Any multipurpose'firc sprinkler system.
Car Wash -Bach Stall 0. Any complex structure as defined in QAR918- 780 -0040.
-Drive Thru _ _ -
Cuspidor/Water Aspirator ' Submit 2 sets of plans with any of the above.
Dishwasher - Commercial '
-Domestic .
Drinking Fountain Isometric or Riser Diagram
Eye Wash • ❑ Isometric or.riser diagram is required for new buildings . ..
Floor Drain/sink - 2" that meet the qualifications above.
•3 „
-4^
Car Wash Drain I -
- - Garbage" - - -- Domestic— Comments regarding fixture work:
Disposal - Commercial
- Industrial —
Ice Mach JRefrig. Drains
Oil Separator (Otis Station)
Rec. Vehicle Dump Station
Shower -Gang - .—
-Stall
Stn: - Bar/Lavatory
- Bradley "Note; If the work under this permit results in an
- Commercial -- increase of sewer EDUs, a sewer permit will he 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 Plodding' -pcona o.da: 1at27/o6
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