Permit a CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00197
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/30/2012
Parcel: 2511 5 BA02600
Jurisdiction: Tigard
Site address: 16230 SW PACIFIC HWY 140
Project: House of Bread Subdivision: 2004 -015 PARTITION PLAT Lot: 2
Project Description: Installation of all new fixtures for new tenant.
Contractor: G & B PLUMBING & SONS INC Owner: SN PROPERTIES PARTNERSHIP
PO BOX 92 1121 SW SALMON ST
ST PAUL, OR 97137 PORTLAND, OR 97205
PHONE: 971 -563 -3268 PHONE:
FAX: 503 - 633 -8378
FEES
Quantity Description Date Amount
6 ea Floor Drain/Floor Sink/Hub 07/30/2012 $150.12
Specifics: 4 ea Sink 07/30/2012 $100.08
1 12% State Surcharge - 07/30/2012 $30.02
Type of Use: COM Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $280.22
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 - copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. � ' I III 11
Issued B Permittee Signature: k / /�' V II , A
Call 503.639.4175 by 7:00 a.m. for the next available Inspection d e.
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
Site Utilities RECEIVED FOR OFFICE USE ONLY
City of Tigard RECEIVED �L Received n
Date/By: ( l7 r Permit No.: p �1 �..0D/9'7'
V 13125 SW Hall Blvd., Tigard, OR 972
2 /lY/,
C � Date/By: Review _ _ r,�r -61
Phone: 503.718.2439 Fax: 503.598. 0 1 2 2 Date/By: Other Permit No.:
"I� I G A It D Inspection Line: 503.639 Date Ready/By: Juris: El See Page 2 for
Internet: www.tigard - or.gov CITY OFTIGARD Notified/Method: Supplemental Information
TYPE OF MIMING 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
❑ Accesso buildin SFR (3) bath 500.32 C
ry g ❑Multi - family
4
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: 16230 SW PACIFIC HY #140 Catch basin or area drain 18.76 \
W
City/State /ZIP: TIGARD OR 97224 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: 140 I Project name: HOUSE OF BREAD Manufactured home utilities 50.03
Cross street/directions to job site: 99W AND DURHAM Manholes 18.76
OUT BUILDING NEXT TO BISCUITS CAFE Rain drain connector 18.76
Sanitary sewer (no. linear ft.: Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
nn
Tax map /parcel no.: o . S I / S hft 6?-600 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
1 TENANT PLUMBING FIXTURES EXCLUDING RESTROOMS, WATER Dishwasher 25.02
SERVICE AND HOT WATER HEATER WHICH WERE INSTALLED PRIOR Drinking fountain 25.02
BY LANDLORD Ejectors /sump \ 25.02
❑ PROPERTY OWNER ® TENANT Expansion tank •2.51
Fixture /sewer cap 25.02
Name: HOUSE OF BREAD 61:00%
Floor drain/floor sink/hub ( ,r 25.02 1Jbtsr
Address: 14930 SW BROOKLET PL.
Garbage disposal 25.02
City /State /ZIP: TIGARD, OR 97224 Hose bib 25.02
Phone: (503)475 -9702 Fax: ( ) Ice maker 12.51
0 APPLICANT ® CONTACT PERSON Interceptor /grease trap 25.02
Business name: BLACK DIAMOND HOMES, INC. Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: JEFF BETTINELLI
Roof drain (commercial) 12.51
Address: 15685 SW 116 AVE. SUITE 290 Sink/basin/lavatory 4 25.02 100.08
City/State /ZIP: TIGARD OR 97224 Solar units (potable water) 62.54
Phone: (503) 201 -6304 Fax: : (503) 579 -3990 Tub /shower /shower pan 12.51
E -mail: BLACKDIAMONDHOMES @COMCAST.NET Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: G &B PLUMBING INC. Water piping/DWV 56.29
Address: 20591 SECOND STREET Other: 25.02 Pt
City /State /ZIP: ST. PAUL, OR 97137 Subtotal 275122' off&
Phone: (791) 563 -3268 Fax: ( ) Minimum permit fee: $72.50
CCB Lic.: 184372 Plumbing Lic. no.: PB634 Plan review (25% of permit fee) 68 .1.
_Ar ' ��! '/ / State surcharge (12% of permit fee) 33.63-• •
Authorized signature: J��� • limo,.` This permit application TOTAL PERMIT FEE 3 7 9t1'•
ILO' �� Thiit lication expires if a permit is not obtained within 180 days ILO' name:
. ra Da[e�r after it has been accepted as complete. QQ•
*Fee methodology set by Tri -County Building Industry Service Board. v
1:\ BuildingWennits \PLMLI- PermitApp.doc 10 /01/09 440- 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 - 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 - 1st 100' 62.54 Medical Gas Systems:
Watcr 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 Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
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/ Plan review is required for an y of the following.
Work Performed: Capped Added Relocate
Please check all that apply.
Baptistry/Font
Bath Tub /Shower ❑ 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" f q Submit 2 sets of plans with any of the above.
Isometric or Riser Diagram
• Car Wash Drain ❑ Isometric or riser diagram is required for new buildings
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 2 •
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav - Non -food related 2
- Bradley
- Commercial- food related 1
- Service 1
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer - Clothes
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:
C: \Users\Jeff Bettinel li\Downloads\PLMU - PermitApp.doc 2
Accumulative Sewer Tally
1 4
p
Tenant Name: House of Bread SWR # 2012 -00161
TIGARD Site Address: 16230 SW Pacific Hwy #140 PIN # 2012 -00197
Parcel #: 2S 115BA02600
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #5 value count added # added value total #s total values
Baptistry/Font 4 0 0 0 0 0
Bath: - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool - 4 0 0 0 0 0
Car Wash: - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher: - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink: - 2 inch 2 0 0 2 4 2 4
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash 6 0 0 0 0 0
Garbage Disposal:
- Domestic (to 3/4 I-IP) 16 0 0 0 0 0
- Commercial (to 5 I-IP) 32 0 0 0 0 0
- Industrial (over 5 1 -IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 2 2 2 2
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower: - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink:
- I.av /Bar - Non -Food Related 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Com /Serv/Util - Food Related 3 0 0 4 12 4 12
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
. Capped EDU Credit 0
TOTALS 0 0 0 0 8 18 8 18
Current Fixture Value 18 divided by 16 = 1.125 Current EDU 1 EDU = $4,665.00
Previous Fixture Value 0 divided by 16 = 0.000 Previous I'.DU
Change 18 divided by 16 = 1.125 over (under) S 5,271.45 '
Enter EDU Change Here 1.130
Notes:2 of the food prep sinks indirect drain to floor sinks, so only the food prep sinks are calculated (did not include 2 floor sinks in the calculation).
Authorized Name /Signature: Debbie Adamski Date: 7/17/2012
Building Division
su ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
bmitted to the City of "Tigard Building Division to redeem credits towards future system development charges.
I: \Building \ Sewer Tally \Sewer TallyShcct- 4665.xls 07/01/12