Permit a 0 C I
e Building Division
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor [g City Staff
(check one)
REFUND OR Name: /\1/4 INVOICE TO: (Business or Individual)
Mailing Address:
VOID City /State /Zip:
er 0 ' */---
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
►: CANCEL PERMIT APPLICATION.
U REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: 1�-� (9, on7 - Ulan$
Site Address or Parcel #: 1 alp Nt c_ 14-(}L))/
Project Name: (nC')b W ILL / JD 45 r f s
Subdivision Name: ti/ Lot #: /1/4_)//i
-
EXPLANATION: Lo c y s t L ►� 4b Y Arc 0..h I r W /D (A_ ( ,)""b
A LM boo(L bp 5 1
Signature: C — '`�D`�`^��t Date: (94 7 10 7
Print Name: Otis FS ) E. P. Ptb /kM i
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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% o of the land use application fee for issued permits.
c) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) not more than 80:0 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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date ' 27 07 By I Rte to Bld • Admin: Date ..2AV0 7 B .4 •
Refund Processed: Date 6i 7 7 By fe, , Invoice Processed: Date By
. Permit Canceled: Date bt 2,7 0 7 Br D J Parcel Tag Added: Date By
Receipt # 67 — JJ/ Date a /P 7 Method Amount $ 499,
I:\ Building \Forms \RegPermitAction.doc Rev 05/24/06 f�p���� e C TiQ75ALC,VeT'D/t/ ' ME .1s,f}/
v CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2007 -00081
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/27/2007
PARCEL: 2S103DD -01201
SITE ADDRESS: 13920 SW PACIFIC HWY ZONING: C -
SUBDIVISION: GOODWILL INDUSTRIES CENTER LOT: JURISDICTION: TIG
PROJECT: GOODWILL INDUSTRIES
Project Description: 200' of water service.
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: M FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: 200 ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
GOODWILL INDUSTRIES
1943 SE SIXTH AVE Description Date Amount
PORTLAND, OR 97214 [PLUMB] Permit Fee 2/27/2007 $101.40
[TAX] 8% State Surcharl 2/27/2007 $8.11
Phone : 503- 238 -6190 Total $109.51
Contractor:
WILLAMETTE PLUMBING & MECHANICAL
PO BOX 5805
SALEM, OR 97304 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503 -585 -4682
Reg #: LIC 159315 V 0 1 D
PLM 27 -70PB cam V 7 i
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 OU •y calling a .246.6699 or 1.800.332.2344.
Issued By: / ` � /� / ✓ ✓L Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that b siness 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.
Feb 27 07 02:21p _
p. 1
P2/27/2007 13:01 FAX 5UUsuniunu L.111 US 0 •- 10 . .-• • - -
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Plumbing lZLUAikg-r9B r ni c a e ;--2 r c ' g A 7 r in V .
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li 1. w 1 g ‘.,' t: 1_-,_),«-irFICE 1_ SE. CrsaA
City of Tigard Re XV ceived
III - 125 SW Hall Blvd.. Tigard. OR 97223 E 2 7 2007 Date/By: Of D7
Plies Review Pemiii
13 1.1*.: ' Zifigie , 7 -avgi
Phone: 503.639.4171 Pm: 503.590.1960 , Day OtharParmit No.:
T . 1 ,:; i 1. V.1 \I , , ' ., Lupin:don Line: 503.639.4175 el l' y n , ., , , U , ' ) Doe stsalyilly: )ra/ 101 See Pate 2 fer
insenicc www.tigard-orgov I NoticsallMenod: 0 . Soppkwiesta . Ila . fe . naeliao ,
t*PC .: . .., : . ::. .:. ;.::, I :' C .. :.: *. :::',..: ' ';!......!: . --.; •
'f 1 0 Demolition For spedd Weimattan use thecAfix
Description I Qs. 1 Ea I .7otal
1:3 Additionialterationimplacenient. In Other Nen I- 24y dandling, (includes 100 1 for each utility connection) ,
'• - ; :' - - -. '..e::% *.^ 1 : .C.4.,ThcoRy, or coNsnalattort: .-, . .. .• ... ... . • • -..., .. ... SFR (I) bidh 249.20
0 1- mid 2-11coily dwelling . Elannelextiaruglaarisl SFR (2) bath 350.00
SFR th ,
0 Accessory building 0 Mufti-f (3) baaraily 399.00 .
Each additional hathileitcbers 45.00
0 Master badcr 0 Other: Fire sprink/er (____ sq. it) Page 2
.....;,::: ' ....' 01!;:,521M:11 .4 '. : • -:. : -.:. • ' ,-. Ste utilities
Job addn 1 S(.,) 'Pctc I* c 11,i„rA Catch basin mama drain 16.60
City/Stabs/71P: - DI Q ea r 0 R 4 77 z.z- Drywell, leach line, or =eh drain I 6.60
drain (oo. linear ft,: ) Page 2
Suite/bldg./apt. no.: I Praieealatalle; GpodCa..■ ( -riet Footing P 5 Manufactured borne Wanes 110.00
Cross stioat/directions to job Site: Manholes 16.40
5 C, f j IL'1_c_ v IA S.6-4F Rain drain connector 16.60
Sanicary sewer (no. lizeir FL: _J Page 2
Stoma saner (w. lmcar it: ____) Page 2
Watcr service (no. linear Reba) Page 2 1 1 Mt, 1.4 n
sub:h.-160i: Lot no.: y2,0 ;
Fizmre or Rena
Tax map/parcel I10.: "45 I crs 99 Absorption valve 16,60
....' ; '.. .. ,:. '. " %.10 ..• i;:: .'. . : .. :. :: :;: . , ' : ;.:: s Beddow pmens=r Page 2 ,
vp- Cr) IA i tr t i csk u ..• Bedroom valve 16.60
Clothes washer 16.60 -
Dishwasher 16.60
- .. . . ,. Drinking faiintain 16.60
:. '.:::: • -... .: OWN.Bli''.. ...-.. ._,:', ;:. :':::::- ''....:tritI5 :: ,: -. :.-.... •
Electoreinunp 16.0
Name: r,, It -- f_ork.S- i tri f Expansion sank 16.60 r
Addreds: "43 56 S't xii 4vi . • Fixoirelscwer cap 16.60
City/State/ZIP: r ..-ri OR CITZI14 Floor draindloor colic/tub 16.60
disposal Phone: ( A 7:513 - 1 C IO FaX: ( 5.° ) ) 2 3 ci -i 70S disposal 1660
- • • -. Hose bib ' 16.60
0..P01t4eT:
' • • Ica maker 16.60
Business name: el/4 eluw,k.„ c.. inecii.k.,; (A 1 Intaceptorrvane nap ' 16.60
Contact name: e th;lt, 1 Medical gas (valise: S ____) Page 2
,
Address:
'PD • 6 ..,c •< o 5.- Primer 16.60 •
City/State/Z.1P: „ (e a K. Of 7301( • Roarcintim (commercial) 16.60
i Sinktbaciallavatory 16.60 .
Phone: ( S ) r g S - 1 4 6 87_ I Fax: : c s S' F5 - do ;3
Tubishowerishower pm 16.60
E-tnail: • Urinal
1- 16.60
16.60
31 .. . . ..
Business nen= LiAll(imzlf Vint 1-Al ewe( ivi ia, 1 - Warm 16.60
heater
•
Other
Address: ?o tr 1 c 0 3 Ci R S i
I) Stibeond 4) /01
City/State/ZIP: b Minimum pennIt the S72.50
131 (5 ° 1 7 ). c 8 S" - 1 4 b R z Ewe ( c 0 3) Cgc - C 01 Residential baddlow minimum permit fer. $36.25 , W
Plan review (2514. of Tornio fec) , - '.----- . 1 i
CCB Lie.: 15 V 3 is- , Plumbing Lie. no..: a 7 I , .
'.
State surcharge ($IG of permit Tess)
AO°
Authorized signature-,.• TOTAL PERMIT FEE 49 ,
Print name:
The permit appgadion expires if a permit M not obtained ottbirs
1 „ f II III D _. _
_ 4:9
IN days saw it hoe bars accepted aa complete.
'Fee methodology tel by *Di-County Building Industry Service Board.
.51
omeesesivisimmailvadiaasounwm 44amsrommommm1 4 ?*
Feb 27 07 02:22p p.2
02 /27 /'1,uc7 l:r: uL rAA au.ravoivo., V... ... -
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Sitelliiiities -- , . _ .. :.:',':::*!.:.:•?. - Q :: I. S.*. ) :H:: _ T' Square F ootage ` :: Feti nit Feet: _ . . ..
Footing drain - 1`100' ' 55.00 Oto2,000 3115.00
Footing drain - each additional 100' 46.40 2,001 to 3,G00 5160.00
3,601 to 7,200 5220.00
Sesser - 151 100' 55.00 7.201 and greater 5309.00
Sewer -each additional 100' 46.40
WaxerSa'iee - 1st 100' t 55.00 SS -. Medical Gas Systems:
Water Service - catch additional 100' I 46.40 q 6 ,4 0 1 ilti sitiibO: , :.: ..Permit Foie:
":•: ' - :
Storm & Rain Drain - to 100' 55.00 51.00 to $5.000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 55,001.00 to $10, 000.00 $72.50 far the first $5.000.00 and S1.52 for each
additional 5100.00 or fraction (begot to and
Fuiai•+e :or item:. : :. : : :. - . including $10,000.00.
Commercial Barr Flnw Prevention Device 46.40 310,001.00 to $25,000.00 - 3148.50 for the fiat $10,000.00 and $1.54 for
Residential Bacidtow Prevention Device each additional $100.00 crfraction thereof, to
(minimum penult fee 33625) 27.55 and including $25.000.00.
Rain Drain, single family dwelling 6525 325.001.00 to S50. 000.00 1379.50 fur the first 525,000.00 and SIAS for
each additional S100.00 or *action thercoE to
lrrspection prodding plumbing or and including $50,000.00.
specially requested iespecdors- per hour 72,50 _ 350,001.00 and up $742.00 for the first $50,000.00 and 11.20 for
Subtotal: ' each additional $100.00 infraction thereof.
•
Fixture Work:
Are yen capping, adding or replacing fixtures? If "yes", `• igit lteview Plumbitiok It fallatione.' _'. :. `:
please indicate work performed by fixture. Falure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees *. Please check all that. apply.
,, .- :: t - = • •:Olio . by re Wink Q Any new co mmsrcial building with water service 2" and
., a am s
• • �al.m • greater. except systems designed and stamped by licensed
.. .. • . - . • • ..:F.'... _ . Pi i -- - . . .. • ., .. . engineer. • . .. Bapdst r y/Fonr - ❑ New exterior plumbing site utilities for any eomplot structure
Bath Tub/Shower as defined in OAR918- 780 -0040.
dacraoalilVhirliwol ❑ Medical gas and vacuum systems for health we facilities -
Car wall+ - Each Stall ❑ Any multipurpose fire sprinkler system.
-Drive ihru ❑ Any complex Structure as defined in OAR91 &780 -)040.
CuslidonWater Aspirator
Oiahwa,brr -Commercial Submit 2 seta of ptam with any of the above.
-Domestic
Drinking Fountain , • . - '
. ? `Isoiaoemc :her.Riser'Diagragt.
Eye wean ,- �. :. ,: • : � .. .. .
Floor Drain/Sink - 2" ❑ Isometric or riser diagram is required for new buildings
- 3" that meet the qualifications above. ,
-4 "
Car wash Drain
r -Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mech./R&M. Drains
Oil Separator (Gas Seaiio0)
Rec. vehicle Dump Station
Shower -Gang
-Sall
Sink •-Bas/Lavetoty *Notes If the fixture work under this permit results in an
- ma y increase of sewer UM, a sewer permit will be issued and
- Sei'vi erria1
• Service fees assessed for the sewer increase must be paid before the
Swimming Pool Fitter plumbing permit can be issued.
washer - Claus
Water Extractor •
Water Closet- Toilet
t)rinai
Other Flumes:
mann asiiwas uoir iu.rooarApp.dee mama