Permit CITY OF TIGARD PLUMBING PERMIT
IN COMMUNITY DEVELOPMENT
Permit #: PLM2012 -00168
T t (;AR D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/11/2012
Parcel: 2S103BD02900
Jurisdiction: Tigard
Site address: 12020 SW CARMEN ST
Project: Horak Subdivision: CARMEN PARK Lot: 2
Project Description: fresh water replumbing
Contractor: OWNER E ED Owner: HORAK, TRAVIS
/— e? /o9— I 12020 SW CARMEN ST
K' TIGARD, OR 97223
PHONE
PHONE: 541- 231 -8161
FAX:
FEES
Quantity Description Date Amount
100 If Water Service 06/11/2012 $62.54
Specifics: 1 ea Water Piping /DWV 06/11/2012 $56.29
1 ea Water Heater 06/11/2012 $37.52
Type of Use: SF 1 12% State Surcharge 06/11/2012 $18.76
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $175.11
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 -0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature: n t /1 P P/ , �+ T - ra I
Call 503.639.4175 by 7:00 a.m. for the next available inspection date. `J `.-r t /�,
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.
CITY OF TIGARD PLUMBING PERMIT
8 .. COMMUNITY DEVELOPMENT Permit #: PLM2012 -00168
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/11/2012
Parcel: 2S103BD02900
Jurisdiction: Tigard
Site address: 12020 SW CARMEN ST
Project: Horak Subdivision: CARMEN PARK Lot: 2
Project Description: fresh water replumbing
Contractor: Owner: HORAK, TRAVIS
12020 SW CARMEN ST
TIGARD, OR 97223
PHONE
PHONE: 541 - 231 -8161
FAX:
FEES
Quantity Description Date Amount
100 If Water Service 06/11/2012 $62.54
Specifics: i ea Water Piping /DWV 06/11/2012 $56.29
1 ea Water Heater 06/11/2012 $37.52
Type of Use: SF 1 12% State Surcharge - 06/11/2012 $18.76
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
•
Total $175.11
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 -0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Pennittee Signature: , ki( nra j c...,
__
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
Plumbing Permit Application
Building Fixtures RECENED Received FOR OFFICE USE ONLY
City of Tigard Permit U(,( 1��
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, ( ( ie
e 13125 SW Hall Blvd., Tigard, OR 9722361 U N 1 1 2012 Pla Plan ev � � ( I S �
Plan R Review
Phone: 503.718.2439 Fax: 503.598.19 Date/By: Other Permit No.:
T I G n K D Inspection Line: 503.639.4175 CITY OF TIGARD a ReadyBy: yr / See P age 2 for
Internet: www.tigard- or.gov I Notified/Method: 1 r cc.) Supplem Information
TYPE OF WOIIJILDING DIVISION 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 312.70
® 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
❑ Accessory building SFR (3) bath 500.32
ry g ❑Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 12020 SW Carmen Street Catch basin or area drain 18.76
City/ State/ZIP: Tigard, OR 97223 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: t - L Ctetfuy1 rajvifyitoakk Manufactured home utilities 50.03
Cross street/directions to job site: 121st Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: /00) 1 Page 2 62.54
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Fresh Water Replumbing
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump ,, 25.02
® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Travis Horak FixtureJsewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 12020 SW Carmen Street
Garbage disposal 25.02
City/State/ZIP: Tigard, OR 97223 Hose bib 25.02
Phone: (541)231 -8161 Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/ State/ZIP: Solar units (potable water) 62.54
Phone: ( ) I Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 1 37.52 37.52
Business name:
Water piping/DWV 1 56.29 56.29
Address: Other: 25.02
City /State/ZIP: Subtotal 156.35
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee) 18.76
�( Authorized signature: �� % � / - TOTAL PERMIT FEE 175.11
Print name: Travis Horak I Date: 5/228012
This permit application expires if a permit is not obtained within ISO days
after it has been accepted as complete.
Fee methodology set by Tri -County Building Industry Service Board.
I :\ Building \Permits\PLMU- PeimitApp.doc 10 /01/09 440- 46I6T(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 - l 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - Ist 100' 1 62.54 6254 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other ec
Ins tions or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
Inspections and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr _ and including $50,000.00.
Additional plan review for revisions 90.00/hr • $50;001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge - 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace) Pl review is required for any of the following.
Performed: Capped Added Relocate �l Y g•
Baptistry/Font Please check all that apply.
Bath Tub /Shower El Any new commercial building with water service 2" and
- Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thm ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918 -780 -0040.
Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ Any complex structure as defined in OAR918- 780 -0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above.
-3"
Isometric or Riser Diagram
Car Wash Drain ❑ Isometric or riser diagram buildings
is required for new buildin
Garbage - Domestic - non - food
q g
Disposal - Domestic - food related that meet the qualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav - Non -food related
- Bradley
- Commercial -food related
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
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