Permit Building hermit Application EXPIRED 0 // i0 ii'
Residential OCBDI t� FOR OFFICE USE ONLY
ii i i / i
City of Tigard Received
Q Datan e /BB� Re� ieN Y���� f - Permit No ► 4-X.3
° 13125 SW Hall Blvd , Tigard, OR 97223 9
no Date
C .: Phone. 503 639 4171 Fax 503 598 1960 p�G 2 , Z9 �` Other Permit -
T I G n R D Inspection Line 503.639.4175 CMG • ' , D to Ready /By _Tuns El See Page 2 for
Internet www.tigard -or gov G t .[N Or II
D . .,,C % ` 726 Supplemental Information
TYPE OF WORK J REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
i e] Addition/alteration/replacement ❑ Other: equipment, materials. labor. overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
J] I- and 2-family dwelling Valuation: $ •
� g ❑ Commercial /industrial
❑ Accessory building ❑ Multi- family Number of bedrooms: * 4 . . ) 9 10 .--72._
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: i 1 (o -1g S 0 , ■ b y , • New dwelling area: square feet
City /State /ZIP: 1 k ( 4.4 0-� Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: t 1't.(,) 5i f C0 p1^ 4 71 - 0 OVA Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.. Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
661-3 V ___ E.,ut STI`,v C . o 1J i'1 Iv t S F12 L":1- Valuation: $
o so 0 use -to (3 D ri d0 tarn•• 9 Existing building arca: square feet
S --( a 4 C S n A t-e--- , 'I5� —� New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: p 1 a J t9 . p (7 O Z,■ Type of construction:
Address: ( '
S vu -e _ rJ (_(D i Occupancy groups:
City /State /ZIP: `- ( i .9 0.2- Existing:
Phone: ( ) Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name: A' - .Z (L, (<A All contractors and subcontractors are required to be
Contact name: J z (ems licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: I'Z_ '7 7 5 S W . c i J S i jurisdiction in which work is being performed. If the
City /State / /_IP: c �J ��� ` applicant is exempt from licensing, the following reasons
apply:
Phone: (50 3) 3 v O ` C.(7 S Fa x:: (SO 3) Z 3 5 " .Z
E -mail: Z VA i L_ i (. ii•-3 //
e_ V Irv\ 4 l.. ' -'- "A
CONTRACTOR
•
Business name: e'1 L . 7 e C_ CA BUILDING PERMIT FEES*
Address: c �tnA� A'S. �/1) 0-1 (Please refer to fee schedule)
City /State /ZIP: Structural plan review fee (or deposit): )-3, 711
FLS plan review fee (if applicable): —
Phone: ( ) Fax:( ) �
CCB lie.: j („ �' total fees due upon application: x35r ^ !'j
`�' & Amount received:
Authorized signature: r ,. v ..3 I¢ I L....C.C.Ac This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Date: s( 7 J d * Fee methodology set by Tri- County Building Industry
��(( ` Service Board.
I \Building \Permits\ ' P -RE PermtA p d'c 1 1/6/07 440- 4613T(1 I /02 /COM /WEB)
Building Permit Application Checklist
One- and Two- Family Dwelling FOR OFFICE USE ONLY
City of Tigard Received Permit No.
q 13125 SW W Hall Blvd , Tigard, OR 97223 Date/By
: r 0 Phone 503.639.4171 Fax 503 598 1960 Associated permits.
TIGARD
24- Hour Inspection Line 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical
Internet www tigard -or.gov , ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW I Yes I No I N/A
I Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑
2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑
3 Verification of approved plat/lot. ❑ ❑ ❑
4 Fire district approval required. Name of district: . ❑ ❑ ❑
5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ ❑
6 Sewer permit. ❑ ❑ ❑
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑
basin protection, etc.
10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.
11 Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ ❑
there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements
and driveway; footprint of structure (including decks); location of wells /septic systems; utility locations; direction
indicator; lot area; building coverage area; percentage of coverage; impervious area; existing structures on site; and
surface drainage.
12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑
and location.
13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑
furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc.
14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑
floor, wall construction, roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings
and foundation, stairs, fireplace construction, thermal insulation, etc.
15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. ❑ ❑ ❑
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full -size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing (prescriptive path) and /or lateral analysis plans. Must indicate details and locations; for non ❑ ❑ ❑
prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor /roof framing. Provide plans for all floors /roof assemblies, indicating member sizing, spacing, and bearing ❑ ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑
systems, see item 22, "Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑
over 10 feet long and /or any beam/joist carrying a non - uniform load.
20 Manufactured floor /roof truss design details. ❑ ❑ ❑
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑
for four or more appliances.
22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or ❑ ❑ ❑
architect licensed in Oregon and shall be shown to be applicable to the •roject under review.
JURISDICTIONAL SPECIFICS
23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ❑ ❑ ❑
24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ ❑ ❑
25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. ❑ ❑ ❑
26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document. ❑ ❑ ❑
27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑
28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
I \BuddmgtPermus\BUP- RES- PermnApp doc 03/21/06 440- 4613T(I 1 /02/COM/WEB)
Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard EXPIRED Received
Deceiv
y g U " Permit No .77) , 13
• 13125 SW Hall Blvd , Tigard, OR 97223 Plan Review
C Phone 503.639 4171 Fax 503 598 1960 Date /By Other Permit•
TI • G A It D inspection Ltne 503 639 4175 Datc Ready /By liens 0 See Page 2 for
w
Internet ww tigard - gov 0C Q Notified/Method Supplemental Information
TYPE OF WO �� 600U COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
❑ New construction ❑Addition /alteraUOn /re `5� Mechanical pemut fees` are based on the value of the work
performed Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: CSts1 \ Cs� mechanical materials, equipment, labor, overhead, and profit
CATEGORY OF CO N TTION Value $
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building
For special information use checklist
❑ Multi- family ❑ Master builder ❑ Other: Description I Qty I Ea I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
/ S . ` W 1 Air conditioning or heat pump
Job sift address:
3 6 1 J � {� I O �^ (requires site plan showing placement) 14 00
City /State /ZIP: 1(L eve.• 9 0" Furnace 100.000 BTU (ducts/vents) 14 00
�/' Q0, Furnace 100,000+ BTU (ducts /vents) 17 90
Suite/bldg. /apt. no.: Project name: /Of 1,6 Bk 400M/ 5 k( T Y'l Gas heat pump 14 00
Cross street/directions to job site: Duct work 10 00
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14 00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc 14 00
Subdivision: Lot no.: Flue /vent for any of above 6 80
Other 10 00
Tax map /parcel no.: Other fuel appliances )
DESCRIPTION OF WORK Water heater ( 10.00 /J, w
Gas fireplace 10 00
ae j./.(J : )( / c- w 6 U N t iu i5 k+ fl Flue vent for water heater or gas
/1 W.-0 Kq'Ovvv ` 13-((-4-4-f fireplace 1000
Log lighter (gas) 10 00
Wood/pellet stove 10 00
Wood fireplace /insert 10 00
❑ PROPERTY OWNER I ❑ TENANT Chimney /liner /flue /vent 10 00
Other 10.00
Name: 04.0 t.\) S l o oz +J rtivZ_ Environmental exhaust and ventilation
r q /4 Range hood/other kitchen
Address:
` 36 7 l 5 W {'t 5 -1� C l equipment 10 00
City /State /ZIP: T ( L q--e_-t0 6 Clothes dryer exhaust 10 00
Single -duct exhaust (bathrooms,
Phone: ( ) Fax: ( ) toilet compartments, utility rooms) 6 80
® APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 10.00
L Other 10 00 A ,
Business name: ( Lt '!� Fuel piping
Contact name: J0 tt.3 2 ( t (L $5.40 for first four; $1.00 for each additional
Address: f z - 7 7 S S 51 - Furnace, etc
Gas heat pump
City /State /ZIP: f)F 42/1(A-44 O2 Wall /suspended/unit heater
Phone: (9v3) 7...4=> — 776 7 Fax: : ( )
Water heater
Fireplace
E -mail: Ranee
CONTRACTOR Barbecue
Clothes dryer (gas)
Business name:
4
.. • - NA rn A et Cr.e \ l In I • Other
Add ;::).444 e5 713 SE [ 6*- MECHANICAL PERMIT FEES*
City /State /ZIP: (1(\i uocuk Q oof__ Qq--? zZ 7 Subtotal
1 Fax: ( ) Minimum permit fee ($72 50) - 12, ~JCS
Phone: ( Bca ,..2.7. 31'T4 Plan review (25% of permit fee)
CCB lie.: -I 2.G -7 State surcharge (12% of permit fee) 8,"10
TOTAL PERMIT FEE fj . 20
Authorized signature: I This permit application expires if a permit is not obtaineawithin 180
days after it has been accepted as complete.
Print name: .„1"E> NS Ake, ttt "Z_ ( 4 Date: g /0 t c a • Fee methodology set by Trh- Comity Building Industry Service Board
1\Budding\Permns \MEC- PermiiApp doe 01/19/07 440.4617T (I 1 /02 /COMAVEB)
•
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial Fee Schedule:
Total Valuation: Permit Fee:
$1.00 to $2,000.00 Minimum fee $72.50
$2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30
for each additional $100.00 or fraction
thereof, to and including $5,000.00.
$5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and
$1.80 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and
$1.35 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and
$1.25 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $1,396.50 for the first $100,000.00 and
$1.10 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
I \ Building \ Permits \MEC- PermitApp.doc 01/19/07 2
Electrical Permit Application EXPIRED FOR OFFICE USE ONLY
Cl of Ti and �� Received Permit No .
•J g 1�1 m� Date /Bv t/ �o�a
' y
q 13125 SW Hall Blvd , Tigard, • ' Plan Review
C Phone 503 639 4171 Fax 50 . *1: 0 Date/By Other Permit.
TI G A R D Inspection Line' 503 639.4175 9 �Q� Date Ready /By ions ® See Page 2 for
Internet www tigard - gov 0 I O Notified/Method 776 Supplemental Information
TYPE OF WO ��` -5i - PLAN REVIEW
0 New construction ❑Addition /alteka ' OCINtnent
Please check all that apply (submit 2 sets of plans w /items checked below).
❑ Service or feeder 400 amps or more ❑Building over three stories.
❑ Demolition ❑ Other: V where the available fault current ❑ Marinas and boatyards
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other Installations buildings
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "I -3 ",
Job no.: I Job site address: 13 6 7 9 54./ 4 5 f /J Lt O / \ 100HP or more. occupancy.
❑ Six or more residential units ❑ Recreational vehicle parks.
City /State /ZIP: 7' t (, Ave (2 0-(/— ❑ Health -cart facilities ❑ Supply voltage for more than
❑ Hazardous locations 600 volts nominal
Suite/bldg. /apt. no.: Project name: ,.. ' ' : '.,,,, ! Y / , Service or feeder 600 amps or more
FEE SCHEDULE
Cross street/directions to job site: 5AX y\ ' Description I Qty. I Fee. I Total I •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft or less 145.15 4
Ea add'I 500 sq ft or portion 33.40 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq ) 75.00 2
ft
Limited energy, multi - family 75 00 2
(kriiY 11'' ) &5- 1 1-1-1-- , (,,, ( )/'J 4, r f S tit Cti/ . 1 residential (with above sq ft )
J Services or feeders installation, alteration, and/or relocation
T f` €l4/ - O LI 'V "en P s �( �+� __ 200 amps or less 80 30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: PAL) [ 0 S (JO a n.} RA& 401 amps to 600 amps 160 60 2
601 amps to 1,000 amps 240.60 2
Address: ( '3 6 ? q 5 o u 4_ L, -i"V C- t D -r' Over 1,000 amps or volts 454.65 2
City/State /ZIP: -1-7 �� �� Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) I Fax: ( ) 200 amps or less 66 85 I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133 75 2
Branch circuits - new, alteration, or extension, er panel
Owner signature: Date: A Fee for branch circuits with
APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 6 65 2
each branch circuit
Business name: A , ( -, - 1 ._,4 ( 4 ,, _ ,- B. Fee for branch circuits
Contact name: L � without service or feeder fee, ( 46 85 2
J C 73 Z kA first branch circuit
Address: f Z '7`7 S S (.i 6 S (. Each add'I branch circuit [ 6 65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: I ,MO ?.(/C - t - t✓\.. 6— Each manufactured or modular 90.90 2
dwelling, service and/or feeder
Phone: (93) 'Zdq 7 '7G ( Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53 40 2
f �� L G Signal circuit(s) or limited-
Business name: . tJ fr 1 9s6 C .Q C I
l l , . j ., 1 v uergy panel, alteration, or
extension Describe' Page 2 2
Address: '
P.o- a h,c -,c, Co
City /State /ZIP: ` 1 ` ` ., "� '" c-{� 1 2 9 7 O Each additional inspection over allowable in any of the above
1 r �
T ' Per inspection 62 50
Phone: (563) C M ) 1 , LI ( 40 Fax: (So3) C 8 I - (043 Investigation per hour (I hr min) 62 50
CCB Lie.: 162. 10S Electrical Lie.: CZ I J(0 Suprv. Lie.: (02 S Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal 4" ,j1 _50
Print name: Date: Plan review (25% of permit fee)
State surcharge (12% of permit fee). 4p, 2 }2--
Authorized signature: - TOTAL PERMIT FEE. 5 1' , Z
Print name: j o Date: O This permit application expires if a permit is not obtained within 180
�� L- IAA p /� q dg
days after it has been accepted as complete.
• Number of inspections allowed per permit
I \Bui :ding\Permits\ELC- PermitApp doc 05/23/06 440-4615T(I I /05 /COWWEB
Electrical Permit Application - City of Tigard •
Page 2 - Supplemental Information •
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls •
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I \Building'Permtts'ELC- PermitApp doc 03/23/06
Plumbing Permit Application EXP ' ED
Building Fixtures FOR OFFICE USE ONLY
City of Tigard DateiBed � 2� � �, l_,1
Date /By. Permit No /��
V 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503 639.4171 Fax 503.598.1960 Date/By. Other Permit No.:
TI G A R D Inspection Line 503 639.4175 Date Ready /By: Juns SI 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
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350 00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler (_ sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 16 L '7 S " ∎ 0-- • Catch basin or area drain 16 60
City /State/ZIP: A- \ - , a , oR Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: l Project name: GO NEC. Footing drain (no. linear ft.. ) Page 2
Manufactured home utilities 110 00
Cross street/directions to job site:
Manholes 16 60
Rain drain connector 16 60
Sanitary sewer (no linear ft ) Page 2
Storm sewer (no. linear ft ) Page 2
Subdivision: I Lot no.: Water service (no linear ft.. _) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16 60
DESCRIPTION OF WORK Backflow preventer Page 2
.A1 i ,l3 ` 5I roc, M Zy6n1r4 c2i Backwater valve 16 60
Clothes washer 16 60
Dishwasher 16 60
�' PROPERTY OWNER ❑ TENANT Drinking fountain 16 60
Ejectors /sump 16.60
Name: r" V ` r. Expansion tank 16 60
Address: R Lo -7 CL ,1 e, z ( D ,,. 1 CW , Fixture /sewer cap 16 60
City /State /ZIP: ( 1 f Or\) O 0 1-, Floor drain/floor sink/hub 16.60
—
Phone: ( ) Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16 60
Ice maker 16 60
Business name: R • L. 2 t l ! C` Interceptor /grease trap 16.60
Contact name: ^t1 e••\ -2 ' C ` K-r- Medical gas (value: $ ) Page 2
Address: I'2 '7 '7 5 Su., ( 41 8lt • - Primer 16.60
-
City /State /ZIP: Vy ak v.Q�4. oY'' d 2 Roof drain (commercial) 16 60
1 Sink/basin/lavatory 16 60
Phone: (eQ3 20q - 7 Go - Fax: : ( ) -
Tub /shower /shower pan 16 60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16 60
Business name: n I A a 1 t t( -0 A t GPk , "t""�"�„�),,ry _Water heater 16.60
Address: { q l ( t7 g X � Ci r C(r ` " - Other
Subtotal
City /State /ZIP: I QS,F L_4 n In OIL Q 7CM(0
"t_/ ) 8 Minimum permit fee $72 50
Phone: e )8 R A - 61. 3 l Fax: ( ) Residential backflow minimum permit fee: $36 25 7 .)
CCB Lic.: ILO.. ( (.06 Plumbing Lic. no.: 34.3-74-v Plan review (25% of permit fee)
State surcharge (12% of permit fee) e ,
Authorized signature: TOTAL PERMIT FEE 0 . ZO
Print name: Date: 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.
1•\ Building \Permits\PLMF- PermitApp doe 12/27/06 440- 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 - I 100' 55 00 0 to 2,000 $115 00
Footing drain - each additional 100' 46 40 2,001 to 3.600 $160 00
3,601 to 7,200 $220 00
Sewer - 1st 100' 55 00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55 00 Medical Gas Systems:
Water Service - each additional 100' 46 40
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 55.00 $1 00 to $5,000 00 Minimum fee $72 50
Storm & Rain Drain - each additional 100' 46.40 $5,001 00 to $10,000 00 $72 50 for the first $5,000.00 and $1 52 for each
Fixture or Item Qty. Fee (ea) Total additional $100 00 or fraction thereof, to and
including $10,000 00
Commercial Back Flow Prevention Device 46.40 $10,001 00 to $25,000.00 $148 50 for the first $10,000.00 and $1 54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27 55 and including $25,000 00
Rain Drain, single family dwelling 65.25 $25,001 00 to $50,000 00 $379.50 for the first $25,000.00 and $1 45 for
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
specially requested inspections - per hour 72 50 and including first 0 00
Subtotal: $50 and up $742 00 for the e first $50,000 00 and $1 20 for
each additional $100 00 or fraction thereof
Commercial Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory'
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures
I'Building\Permus\PLM- PermnApp doc 12/27/06