Permit 11 1 IsT n CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 00291
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503 718.2439 Date Issued: 10/09/2012
Parcel: 25101 BB00301
Jurisdiction: Tigard
Site address: 11834 SW PACIFIC HWY
Project: Jacksons Subdivision: TIGARD ROAD GARDENS Lot: 1
Project Description: Remove and replace backflow preventer
Contractor: VALLEYSCAPES INC Owner: TEXACO INC
150 NE HOGAN DR TAX DEPT
GRESHAM, OR 97030 PO BOX 7813
UNIVERSAL CITY, CA 91608
PHONE: 503 - 492 -4736 PHONE:
FAX 503 - 492 -4765
' FEES
Quantity Description Date Amount
1 ea Backflow Preventer 10/09/2012 $31 27
Specifics: 1 12% State Surcharge - 10/09/2012 $8 70
Plumbing
Type of Use: COM 41 ea Minimum Fee Adjustment - 10/09/2012 $41.23
Class of Work: OTR
Plumbing
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
i nce, or if wo ' ' 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 b . -fling 503.232.1987 or 1 800.332.2344
Aim Issued By: W40, / i Permittee Sig atur 4 4 aeL
Call 503.639.4175 by 7:00 a.m. for the next available in • - ion 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.
OCT -9 -2012 09:15 FROM: TO:5035981960 P.2'4
Plumbing: Permit Ann lienti ECEIVED
Building Fixtures OCT 0 9 2012
` City of Ti d er io 9 /1 Perm No.. GNo2o t2 -ai e:2? /
13125 SW Hall Blvd., Tigard, OR 9720ITY OF TIGARD �- ew
• Phone: 503.718.2439 Fax: 503.5 G+ 9foN nwemy Omar Permit No.:
1 1 it 1) Inspection Lino: 503.639.4175 Data Ke;ady/Dy. nuns RI See Paget for
Internet. www.rtgard- or.gov RotiftediMaMd: . , ,, corer Information
TYPE OF WORK FEE' SCHEDULE
❑ New consttuction ❑ Demolition For specfal Info»uadon use checklist.
® Addition/alteration/replacement 0 Other De 1 - 2- n ) Qty. � Es. L Total
New 1- 2- family dwdllttta (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
0 1- and 2-family dwelling 0 Commercial/industrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi - family SFR (3) bath 500.32
es
Each additional bathlkitchen 25.02
❑ Master builder Other: Fire
aprinlrlex (___ sq. RJ Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address; 11834 SW Pacific Hwy Catch basin or area drain 18.76
Drywall, leach line, or trench drain 18.76
City/State/ZIP: Tigard, OR 97223
Suite/bldgJapt, no,: 'Project name: Jackson 519 Footing drain home linear ft -: w ) y Page 2
ManulhctureM home utilities 50.. 03
Cross street/directions to job site: Manholes 1 8.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: �....) Page 2
Storm sewer (no. linear ft : ) Page 2
Water service (no. linear l.. ___.) Page 2
Subdivision
- I Lot no.: Fixture or Item:
Tax map/parcel no.: Backflow preventer 1 31.27 31.27
DESCRIPTION OF WORK Backwater valve 12 51
Dios washer 23.02
Back of bldg- remove and replace backflow ` u Cf
-� r����s�w Dishwasher
25.02
- Le4)k.Lr . ?-:(1.CkHI01,6.) -- Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I 0 TENANT Expansion tank 12.51
-
Name: PacWeat Eatery - Jackson Food Fixturc/aowor cap 25.02
Address: 3450 Commercial CL Floor drain/floor sink/hub 25.02
Garbage disposal 25,02
City /State/ZIP: Meridian. ID 83642 Hose bib 25.02
Pe; ( ) Flax: ( ) � Plume; Plume; tee molter _ 12.71
0 APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
r Business name: ValkeyScapes Medics! gas (value: S _ ) Page 2
Primer
Contact name: Jon Clark 12.51
Address: 150 NE Hogan Dr Roof drain (commercial) 12 51
Sink/basin/lavatory 25.02
City/State/ZIP! Gresham, OR 97030 Solar Traits (potable water) 62.54
Phone: (503) 405 -2121 I Fax: : (503) 492 -4765 Tub/shower /shower pan 12.51
E -mail: jonCjvalleyacapes.net Urinal 29.02
CONTRACTOR
Water closet 25.02
• Water heater 37.52
Business name: ValleyScapes Water piping/DWV 5629
Address: 150 NE Hogan Dr Other. 25.02
City /State/ZIP: Gresham, Or 97030 Subtotal 31.27
Phone: (503) 492-4736 lax: (503) 492-4765 Minimum permit fee: $72.50 72.50
CCB Lie.: 8785 LCD I bing Lie, no.:
MoH4larp(tat k Plan review (25% of permit fee)
State surcharge (12% of permit tt>c) 8.70
Authorized signature: '�Y TOTAL PERMIT FEE gcap
Print name: 'Browning Date: 10/8 /2012 This permit application expires It a permit is not obtained within tea days
-- has been accepted to complete-
'Foe - methodology ogy s pt by Tn.Cotaty Building industry service 9mr11
liuUid1nererrn{pW1.M1.1-Na itApp.dee IWUTAro 441.1.401e I uuttwC'UbvwuU)
OCT -8 -2012 10:14 FROM: TO:5035981960 P.3
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total I uare Foota 1 e: Permit Fee:
Fearing drat�n - l 100' 50,03 I 0 to 2 000
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 01 and $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52 Valuation: Permit Fee:
Storm & Ruin Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum The $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 Fee (ea) ' Tot cacti 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 51411.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr
(minimum charge - 1/2 hour) each additional $100.00 or fraction thereof, to
and including $25
Inspections outside of nol business J0 -00/hr . "
hma 525,001.00 to $50,000.00 $379.50 lbr the first $25,000.00 and $1.451br
churn hours (minimum c -2 hams) each additional 5100.00 or fraction thereof, to
Reinspeetion Foss 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up 5742.00 for the first $50,000.00 and $1.20 for
(minimum charge - 1/2 hour) _ each additional $100.00 or fraction thereat:
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? it 'yes „ ,
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees
Quint by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Roam/ Plan review is required any Work Performer: Cupped Added Rdeeem i req red for an of the following.
Dagplistry %Font ^' Please check all that apply.
Rath - 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 Thru - 0 New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR91 S- 790.0040.
Dishwasher - Commercial 0 Medical gas and vacuum systems for health care facilities.
- Domestic 0 Any multipurpose fire sprinkler system.
•
Drinking Fountain _. 0 Any complex structure as defined in 0AR91 8790.0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above,
• 3"
A 4" Wash Drain Isometric or Riser Diagram
Ga - Dtmltuttei non-food 0 Isometric or riser diagram is required for new buildings
Disposal -Domestic related that meet the qualifications above.
-Commercial-Sod related
- Industrial -fund related
Tee Mach. /Refrig. Un ion
Oil Separator (Gas Station) I Comments regarding fixture work:
Rea Vehicle Du p Station
Shower -Gang _ . .
-Stall
-
Sink/Lav Nonfood related . . _ _
-Bradley
- Commercial -food related
- Service _
Swimming Pool Filter * if the fixture work under this
Washer Clothes permit results in an
water Extractor l 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:
http J /www.tigard- or.gov /cityhal l/ departments /cd/docs/PLMF- PamitApedoc
OCT -8 -2012 10:13 FROM: TO:5035981960 P.1'4
PO Box 3461- Gresham, OR 07030
503 492 =4736 of lice Va l leySc a pes
503 492 -4765 fax
FaCK
To City of Ti — Permit Plumbing FrD11 Teni - ValleyScapes
Few 503 598 -1960 Pages: Including cover page 4
Phone: Date October 8, 2012
Ro Permit Application/ CCard Authorzation cc
Please see the following Plumbing Permit Application along with Credit
Card Authorization Form. Should you have any questions please do not
hesitate to contact me.
Thank you
Terri Browning
503 4924736 office
503492 -4765 fax
tetiavallevscapes. net