Permit - OF TIGARD PLUMBING PERMIT
i DEVELOPMENT SERVICES PERMIT #: PLM2006 -10052
'�I 1 3125 SW Hall Blvd., Tigard, OR 97223 503- 639 -4171 DATE ISSUED: 3/28/2006
PARCEL: 2S 114BA -02000
SITE ADDRESS: 16100 SW GRIMSON CT ZONING: R -4.5
SUBDIVISION: PICKS LANDING NO.2 LOT: 119 JURISDICTION: TIG
Project Description: Kitchen and bath remodel, other fixture: ice maker.
CLASS OF WORK: ALT GARBAGE DISPOSALS: 1 MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: 2 OTHER FIXTURES: 1
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 2 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
JON BALLIN
16100 SW GRIMSON CT Description Date Amount
TIGARD, OR 972234 [PLUMB] Permit Fee 4/6/2006 $116.20
[TAX] 8% State Surcha 4/6/2006 $9.30
Phone : 503- 307 -1435 Total $125.50
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # :
Reg #:
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
7, 4 1g 1L z e_ . _
Issued By: Permittee Signature: dyl ,,Q,11 CA
Call 503 - 6394175 by 7:00 a.m. for an inspection that business day.
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.
. . Building Fixtures
Plumbiil2`iermlt Anp1 IVED I OR OFFICE USL: ONLY
City of Tigard Date/fiy. Received. cm - C 10, 61,5 permit I �Q� _ /pjS
13125 SW Hall Blvd., Tigard, OR 97223 MAR 2 8 200 t , Plan Review -
evie `
Phone: 503.639.4171 Fax: 503.598.1960 4 " L "' 1.: Other Permit No.:
i Date/By.
24- Hour Inspection Line: 503.639.4175 v ;: Date Ready/By.
See Page 2 for
Internet: www.ci.tigard.or.us CITY OF TIGA' " Notified/Method: Supplemental Information
TYP i [tlt• II! ' 4 FEE* SCHEDULE
For special information use checklist
❑ New construction ❑Demolition
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
® I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
rY building ❑ Multi - family SFR (3) bath 399.00
❑ Accesso buildin
❑ Master builder Each additional bath/kitchen 45.00 1
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 14100 G -/ G /v S vn C--Pt Catch basin or area drain 16.60
City /State/ZIP: I t arci 0 2 C7 ZZH Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: (Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site: 0, SCr -Ge. . G rf- CI ) Manholes 16.60
.5 it ,/ /fir ✓ $1)P S i q 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
KNI (4_" 12A-V -o -d I / /34). 1�1 ^ `x 1/'e, &„c, e,..,en r' Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
PROPERTY OWNER I 0 TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: J A
Expansion tank 16.60
Address: I G (0 0 S w G cli ,, so C 1, . Fixture /sewer cap 16.60
City / State/ZIP: ,f 1,, 02 q) 2,7--(4 Floor drain/floor sink/hub 16.60
Phone: (spa ) 3 0 ) _ l ui 3.S Fax: ( ) Garbage disposal I 16.60
Hose bib 7`� 16.60
❑ APPLICANT 0 CONTACT PERSON
Ice maker ( I J 16.60
Business name: Interceptor /grease trap `/ 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City / State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax:: ( ) Sinidbasin/lavatory / D I y 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet j. 16.60
Business name: O V „,.. \e.. ., - Water heater 16.60
Address: Other:
City /State/ZIP:
Subtotal
Phone: ( ) ( ) permit Minimum permit ermit fee: $72.50 `/ (O.
Residential backflow minimum fee: $36.25
CCB Lie.: ,A � P Plumbing Lic. no.:
/ Plan review (25 %ofpermit fee)
lumbi ��TT
Authorized signature: ,✓% lr . eaf/` State surch (8% of permit fee) q_ ,3 )
TOTAL PERMIT FEE 426
Print name: „ ,,, -)..,,, ,, ` 1 6 I (j I Date: 3 /',/, 6 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 \Pennite\PLMF- PermitApp.doc 06/05 440.4616T(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 a 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 $50,000.00.
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Complex Structures
Are you capping, adding or replacing fixtures? If "yes", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria.
accurately report fixtures could result in increased sewer fees *. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building.
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool providing services to human beings.
Car Wash - Each Stall ❑ Plumbing installations, alterations or additions to food service
- Drive Thru facilities where new plumbing fixtures, including interceptors,
Cuspidor/Water Aspirator are being installed for the food service area.
Dishwasher - Commercial ❑ Any new residential building containing three (3) or more
- Domestic dwelling units.
Drinking Fountain
Eye Wash ❑ Any NFPA I 3 multipurpose fire sprinkler system.
Floor Drain /sink 2" Submit 2 sets of plans with any of the above.
-3"
-4"
Car Wash Drain Isometric or Riser Diagram
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
-Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor *Note: If the fixture work under this permit results in an
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: plumbing permit can be issued.
i:\ Building \Pennir9\PLM- PermilApp.doc 07/06/05
Building Division
.,, 1 Request for Permit Action or Refund
City of Tigard EC E R
TO: CITY OF TIGARD MAY ,.: il ;
Permit System Administrator
S�Y�F I�I,L
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov��p DIVISIn►,:
FROM: 21 Owner ❑ Applicant ❑ Contractor ❑ City Staff
(check one)
Name: QH �'n
(Business or Individual) •J dh
V 0 1 D Mailing Address: 16 I 00 St,/ 6 r,.,,, s ,,., e, f'
70 ;' - T6 e9 - //N E City /State /Zip: 1 .e,roi 02 cJ Z L/
Ov /O' Phone No.: So 3- 30 ) -t 4“
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: L.1' 96(Y_p -- /
Site Address or Parcel #: /6 / o o S w Gr,',.s c,t. i ,' 02 7 Z2- ti
Project Name:
Subdivision Name: Lot #:
EXPLANATION: ) /itie_ P. p (.,Mb p.or, Rvr
re.,9Ip�w,,,n,1 o - F Z Tv , t t e-1 a k;`n►� St11k Dt's h wwst.o�
(4- A pc., s.,. 1 4- .c.-e- rv--k <" _L I ../ Q- not c 1c..,. ,A1) & /0 c ,, '/ --)
Signature: g-2"--- a,,,I' ' Date: .S/2.L/ 4 G
Print Name: Tc 60._ 1 1 f r‘
Ge•R%< 72)0ES wo %
Refund Policy 0 " /eC tU /7� , / / of:
I. The B any fee which may was err one the or cd collected. a) a --yJ /1/ /e- ���/
ny e wich oneusly paid or le / C ��
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended
2. Refunds will be returned to the original Payer in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date j .,1y A By Rte to Bldg Admin: Date By
Refund Processed: Date vp 06, By 15EW Invoice Processed: Date By
Permit Canceled: Date 6 / By Parcel Tag Added: Date By
Receipt #� — /%00 Dat OG Method 0.41,4 Amount $ /,2S,5
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