Permit CITY OF TIGARD PLUMBING PERMIT
gI
S . COMMUNITY DEVELOPMENT Permit #: PLM2012 -00353
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/04/2012
Parcel: 1 S135DB05100
Jurisdiction: Tigard
Site address: 11570 SW GREENBURG RD
Project: Piltz Subdivision: MILLER Lot: 4
Project Description: Installation of bathroom in existing shop. 12/19/12 REPRINT to replace 50' sewer
Contractor: OWNER Owner: PILTZ, KENNETH M
11570 SW GREENBURG RD
TIGARD, OR 97223
PHONE:
PHONE: 503 - 484 -7362
FAX:
FEES
Quantity Description Date Amount
25 If Sewer Service 12/04/2012 $62.54
Specifics: 1 ea Laundry Tray 12/04/2012 $25.02
1 ea Lavatories 12/04/2012 $25.02
Type of Use: SF 1 ea Tub /Shower /Shower Pan 12/04/2012 $12.51
Class of Work: ALT 1 ea Water Closet 12/04/2012 $25.02
Type of Const: 1 ea Water Heater 12/04/2012 $37.52
Occupancy Grp: 1 12% State Surcharge - 12/04/2012 $25.52
Stories: Plumbing
1 ea Hose Bib 12/04/2012 $25.02
Total $238.17
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 • - Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a c• •y of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
/ 46 . Issued By: O11l n ` Permittee Signature: �-� �L ,
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.
u CITY OF TIGARD PLUMBING PERMIT
I II is COMMUNITY DEVELOPMENT Permi #: PLM2012 -00353
T 1G ARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/04/2012
Parcel: 1 S135DB05100
Jurisdiction: Tigard
Site address: 11570 SW GREENBURG RD
Project: Piltz Subdivision: MILLER Lot: 4
Project Description: Installation of bathroom in existing shop.
Contractor: OWNER Owner: PILTZ, KENNETH M
11570 SW GREENBURG RD
TIGARD, OR 97223
PHONE:
PHONE: 503 - 484 -7362
FAX:
FEES
Quantity Description Date Amount
25 If Sewer Service 12/04/2012 $62.54
Specifics: 1 ea Laundry Tray 12/04/2012 $25.02
1 ea Lavatories 12/04/2012 $25.02
Type of Use: SF 1 ea Tub /Shower /Shower Pan 12/04/2012 $12.51
Class of Work: ALT 1 ea Water Closet 12/04/2012 $25.02
Type of Const: 1 ea Water Heater 12/04/2012 $37.52
Occupancy Grp: 1 12% State Surcharge - 12/04/2012 $25.52
Stories: Plumbing
1 ea Hose Bib 12/04/2012 $25.02
Total $238.17
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 ado. by the Oregon
Utility Notifi - •• - - - - Those les are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. Yo may obtai opy of the rules
or direct • estions to OUNC ► ca g 563.232.1987 or 1.800.332.2344.
Issued B : k / /// Permittee Signature: '
1,- • .114,
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.
l
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing per mits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that a II subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I w ill
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
I t c li 4 Pith
Print Name of Permit 7icant
.• t2(b 12
Signature of Permi A fplican Date
Permit #: LN oo � a- 00 35 3
Address: 1/ 570 aftx) (aQEf,J 8uQZ a?J. 7,
--<aet2 02 979'23 !fit
: /00141X0-- fl
Issued Date:
This Copy for Permit Offices
Plumbing Permit ApplicatiRECEIVED
Building Fixtures
City of Tigard DEC 0 4 2012 Received tr z� P er mit No.:
I N III . n 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: �� ao �a-4o 3 S3 Plan
Phone: 503.718.2439 Fax: 503.590ff OF TIGARD Date/By: Review Other Permit No.:
TI G n R D Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard -or.gov �+� Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
la Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
❑ I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
Accessory building ❑ 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: 1 1 5 4.0 .7w. _ r ^ff1/ = RI), Catch basin or area drain 18.76
Q "t 1 Drywell, leach line, or trench drain 18.76
City /State /ZIP: T _,
{ R_ 7 / Q R , ( 7- az-3 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: CdzNER op 5� ��/ Manholes 18.76
4 6ti
Inr+��G(� h`� 43b -f� Q( Rain drain connector 18.76
`� Sanitary sewer (no. linear ft.:Z) Page 2 eea,5
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: 6i 00
Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
''�� 11 � Clothes washer 25.02
LTL/'v I`) Dishwasher 25.02
514e)P hR s Drinking fountain 25.02
Ejectors /sump 25.02
PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: '�'J N . )( (7.77_,
Fixture /sewer cap 25.02
I l y
Floor drain/
floor ?4, * Floor sink/hub 25.02
Address: �
Garbage disposal 25.02
City/State/ZIP: el. 1 oR q?-ZZ Hose bib / 25.02 �,S OZ
Phone: (2 0) 46 . �310Z 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 2. 25.02 01,e,4
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan / 12.51 f.,5
E -mail: Urinal 25.02
CONTRACTOR Water closet ' I 25.02 e ls5;02.
Water heater ' 37.52 37. S ?.
Business name: Water piping/DWV 56.29
Address: OWN/FR Other: 25.02
i
City/State /ZIP: Subtotal p2i ( 9 .
Phone: ( ) Fax: ( )
Minimum permit fee: $72.50 -�
Plan review (25% of permit fee)
CCB Lic.: Piiiiig Lic. no.:
State surcharge (12% of permit fee) (9'5.52.,
Authorized signature: ✓ rippyr. TOTAL PERMIT FEE Ass • J 7
Print name: I «1'V fsj rt- I t i.` 1 Z, Date: i 2. 3 ., Z 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.
I:\ Building \Permits\PLMU- PermiWpp.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 - 1 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:
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 Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
l� 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
Re inspection 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 * . Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
Baptistry /Font ❑ Any new commercial building with water service 2" and
greater, except systems designed and stamped by licensed
Bath: - Tub /Shower
- Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive Stall as defined in OAR918- 780 -0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918 -780 -0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: - 2"
3" Isometric or Riser Diagram
❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the qualifications above.
Garbage - Domestic non -food
Disposal: - Domestic food related
- Commercial food related
- Industrial food related
Ice Mach./Refrig. Drains Comments regarding fixture work:
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower: -Gang
-Stall
Sink: - Lav/Bar non -food related
- Bradley
- Com/Serv/Util food related
- Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs, a sewer permit will be issued and
Washer - Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet - Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Petmits\PLMF- PermitApp.doc 08/04/2011 2
Plumbing Permit Application
Building Fixtures [(Hz ()I 1 1(I I sl. ()NI
City of Tigard
r D ;i ,ed Permit No.: � .3
• 13125 SW Hall Blvd., Tigard,OR 9722 R
0 Phone: 503.718.2439 Fax: 503.598.1960 Ian Review Other Permit No.:
Inspection Line: 503.639.4175 DEC 19 20 pate/By:
I WARD bate Ready/By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov ` tified/Method: Supplemental Information
TYPE OF WORK u� OF TIG FEE* SCHEDULE
❑ New construction ❑ Demo! lLDING DIVISION 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
building SFR (3) bath 500.32
'A Accesso
Accessory 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: 116 0 ai q--1_44,4c.,1 Catch basin or area drain 18.76
/ [ C) � -a D leach line, or trench drain 18.76
City /State /ZIP: i1vv
/ 3
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: cc/A.1y 9V 4i / Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft Page 2 62, S /
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
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
))3p7aCP Al/ Dishwasher 25.02
f Drinking fountain 25.02
Se Ejectors /sump 25.02
PROPERTY OWNER I ❑TENANT Expansion tank 12.51
Name: // AfNA A 6 , 7 - - Fixture /sewer cap 25.02
' Floor drain/floor sink/hub 25.02
Address: (Zsgd qt' V / Garbage disposal 25.02
City /State /ZIP: t Hose bib 25.02
Phone: ( ) 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: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: Water piping/DWV 56.29
Address: Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax ( )
Minimum permit fee: $72.50
CCB Lic.: // 1' lumbinl Lic o.: Plan review (25% of permit fee)
r cv......
State surcharge (12% of permit fee)
Authorized signature 1 TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180 days
Print name: te: after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
I:\ Building \Permits\PLMU- 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 - 1 s` 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
Sewer - 1st 100' /
62.54 3,601 to 7,200 $233.20
&,z. S 7,201 and greater $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 & 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
P 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 * . Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
Baptistry/Font ❑ Any new commercial building with water service 2" and
greater, except systems designed and stamped by licensed
Bath: - Tub /Shower
engineer.
- Jacuzzi/Whirlpool
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive Thru as defined in OAR918- 780 -0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918- 780 -0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: - 2"
3" Isometric or Riser Diagram
❑ Isometric or riser diagram is required for new buildings
- Car Wash Drain
Garbage Domestic non - food that meet the qualifications above.
Disposal: - Domestic food related
- Commercial food related
- Industrial food related
Ice Mach. /Refrig. Drains Comments regarding fixture work:
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower: -Gang
-Stall
Sink: - Lav/Bar non -food related
- Bradley
- Com/Serv/Util food related
- Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs, a sewer permit will be issued and
Washer - Clothes
Water Extractor fees assessed for the sewer increase must be paid before the
Water Closet Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF- PermitApp.doc 08/04/2011 2