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Permit
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT I N " Request Permit Action !� q /a s� I ....!,..... T I c, A It r) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- .g v TO: CITY OF TIGARD Building Division Services Supervisor 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor Ei City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State /Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( CANCEL /VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: kti AO (► — 00310 Site Address or Parcel #: I 1565 0 P AC t 0 e_ 1 Project Name: f i .i M tyvz. Subdivision Name: 6)//1- Lot #: /VR EXPLANATION: (,,Dp(2, Dt_Q. M i i t - 4 01) l .5 t 'r 13 E_ - Pun aota -oo(3) . Signature: 6 ( 01-- vtA- e-tU Date: it / /12_ Print Name: ^ fit Mi € ' . A A)•-t 5 kt Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds. FOR OFFICE USE ONLY Rte to S s Admin: Date (( PMEIONIM Rte to Bld: Admin: Date / ©m MS' Refund Processed: Date A/IBM B :4/- Invoice Processed: Date B Permit Canceled: Date AZIOMMI B f ■F Parcel Tag Added: Date By Receipt # Date Method Amount $ I: \Buil ding \Forms \RegPemntAction.doc Rev 05/25/2012 V 0 1 0 - i //--.000 13 m i , ' ermit A 1 I lie *,,LI, Site Utilities EIVED FOR OFFICE USE ONLY 2 2011 Received - t of Tigard (�F(� Date/By: f A / , / Permit No.: z jav /�o3 N.. a 13125 SW Hall Blvd., Tigard, OR '97223 Plan Review Phone: 503.718.2439. Fax: 5( ,5 iD Date/By: Other Permit No.: T I G A R D Inspection Line: 503.639.4175 I I T (Jr Date Ready/By: Q L �� Juris: la See Page 2 for Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: o� � /' , � J Supplemental Information TYPE OF WORK FEE* SCHEDULE ❑ New construction ❑ Demolition For special information use checklist Description I Qty. I Ea. I Total Z 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 ❑ 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: 11565 SW Pacific Highway Catch basin or area drain I 18.76 /1:747 City /State /ZIP: Tigard, OR, 97223 Drywell, leach line, or trench drain 18.76 Footing drain (no. linear ft.: 170) Page 2 Suite/bldg. /apt. no.: I Project name: FM #375 Tigard Manufactured home utilities 50.03 Cross street/directions to job site: SW 71st Ave Manholes 2 18.76 37.52 Rain drain connector I 18.76 fig, 74 Sanitary sewer (no. linear ft.: 240) Page 2 /57.5f Storm sewer (no. linear ft.: 370) Page 2 / 75 Water service (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map /parcel no.: 1S136DB, Tax Lot 201 Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Clothes washer 25.02 Addition to existing retail building. New grease trap. ,r PgQjt Lo- Dishwasher 25.02 New storm water quality vault, and side sewer connection, one new roof drain. Drinking fountain 25.02 Ejectors /sump 25.02 ® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 Name: Fred Meyer Stores Fixture /sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: 3800 SE 22nd Ave Garbage disposal 25.02 City /State /ZIP: Portland, OR, 97202 Hose bib 25.02 Phone: (503)232 -8844 Fax: (503)797 -3509 Ice maker 12.51 ❑ APPLICANT ® CONTACT PERSON Interceptor /grease trap 1 25.02 AT Business name: Mulvanny G2 Architecture Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: Amy Scheckla -Cox Roof drain (commercial) 1 12.51 fa.67 Address: 601 SW Second Ave Sink/basin/lavatory ' 25.02 City /State /ZIP: Portland Or, 97202 Solar units (potable water) 62.54 Phone: (971) 998 -1443 Fax: : (503) 223 -8381 Tub /shower /shower pan 12.51 E -mail: amy.scheckla- cox @mulvannyg2.com Urinal 25.02 CONTRACTOR Water closet 25.02 Water heater 37.52 Business name: TBD Water piping/DWV 56.29 Address: Other: 25.02 '/ City /State /ZIP: Subtotal 4 7 A5.,0, 5 Phone: ( ) Fax: ( ) Minimum permit fee: $72.50 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (12% of permit fee) 51.03 Authorized signature: //`-- �� TOTAL PERMIT FEE �7(,.:Za Print name: `, I / Date: This permit application expires if a permit is not obtained within 180 days "^ ��, ...--a x N • ,...,A.../.-...._ ,...,A.../.-.,...,A.../.-...._ � ( 3� - r I after it has been accepted as complete. *Fee methodology set by Tri- County Building Industry Service Board. 1:\ Building \Permits\PLMU- PermitApp.doc 10/01/09 440-4616T( 1 0/02/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' 100' 1 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' I 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer - 1st 100' I 62.54 7,201 and greater $327.54 Sewer - each additional 100' 2 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' 1 62.54 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 3 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/ Work Performed: Capped Added Relocate Plan review is required for any of the following. Baptistry/Font Please check all that apply. 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 Thru ❑ 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 >, -4" 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 *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: P:\Fred Meyer \l 1\11-0029-01 - FM Tigard \02Corresp\204Jurisdiction \Buying \PLMU - PermitApp.doc • I P Site Utilities — Plumbing Permit Application Plan Submittal Requirements TIGARD A plumbing permit for site utility plumbing work is required for sanitary sewer, storm sewer and potable water systems on private property. 1. SITE PLAN and vicinity map showing the geographic location (fully dimensional, drawn to scale) labeled with: A. ® map & tax lot # ® project name ® site address ❑ suite number ❑ zoning ® applicant name ® phone number B. North arrow. C. Scale (architectural or engineering only). D. Street names. E. Building pads with project location. 2. PLUMBING PLANS - Two (2) complete sets, civil only. All details listed below shall be incorporated into the plumbing plans: A. Storm drainage plan showing: 1) Finish elevations throughout the developed site. 2) Grade breaks determining area serving each catch basin. 3) Location of catch basins. 4) Pipe size. 5) Type of material. 6) Slope of piping. 7) Manholes and field drains. 8) Cleanouts provided for each 100 feet or fraction thereof. 9) Roof drain laterals specifying cleanouts at each upper terminal. 10) Location of existing or proposed connection to a public sewer line. B. Utilities plan showing: 1) Sanitary sewer line location, pipe size, type of material, slope of piping, manholes and cleanouts provided as required for storm. 2) Size and location of domestic water piping and drainage. 3) Proposed location of connection to a public water or sanitary sewer line. 1:\ Building \Permits \PLMF - PermitApp.doc 12/30/05