Permit CITY OF TIGARD PLUMBING PERMIT
2 COMMUNITY DEVELOPMENT Permit #: PLM2013 00178
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06!19/2013
Parcel: 1 S 135BC00202
Jurisdiction: Tigard
Site address: 10763 SW GREENBURG RD 110
Project: Mattress Closeouts Subdivision: HILLSBORO Lot: PTS 1 -2
Project Description: Install (1) water closet, (1) lay and (1) water heater.
Contractor: K & C PLUMBING INC Owner: BELANICH, ROGER M
PO BOX 2124 22020 17TH AVE SE #200
OREGON CITY, OR 97045 BOTHELL, WA 98021
PHONE: 503 - 518 -0234 PHONE:
FAX: 503 - 518 -1100
FEES
Quantity Description Date Amount
1 ea Lavatories 06/06/2013 $25.02
Specifics: 1 ea Water Closet 06/06/2013 $25.02
1 ea Water Heater 06/06/2013 $37.52
Type of Use: COM 1 12% State Surcharge - 06/06/2013 $10.51
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $98.07
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 by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or direct qu ons to to • k C by calling 503.232.1987 or 1.800.332.2344.
Issued y: / Permittee Signat • re: , „ • ✓
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.
05 Jun 13 11:21a Russ 503 -518 -1100 p.1
Plumbing Permit Applicatio_ _ ,
Building Fixtures FOR OFFICE t tit, ONLY
JUN 0 5 2313 City of Tigard RDaeceioBy: ved , D _ , Permit No.: It�2,C /3-ea: n¢
11 61
13125 SW Hall Blvd, Tigard, OR 9..'� TIGARD Review
('
i OF Plan Rev
OFTIGARD Y t'111Y
e . Phone: 503.718.2439 Fax: 503 i �T m Other Permit NO. p(Zo�U1 3�42 G.1
TIC A R D Inspection Line: 503.639.4175 1 ING DNISION Date Ready/Br lmie GB 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 theckiisi - F
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 312.70 O
ID 1- and 2- family dwelling Commercial/industrial SFR (2) bath 437.78
ID Accessory building SFR (3) bath 500.32
❑ 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 0 -7 (o 3 G r lit,, r, Catch basin or area drain 18.76 ,.
CitylStatelL�:'rI �, (�r � 0 R ✓ Dtywell, leach line, or trench drain
18.76
Footing drain (no. linear fl.: ) Page 2 0Q., ✓7
Suite/bldg. /apt. no.: 1 I n ( name: Harm 0/05,26a L f` Manufactured home utilities 50.03
Cross street /directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. Linear ft.: } Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: `) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax mapiparcel no.: r S / 3 5) (y �,P.-.. Baekflow preventer 3127
DESCRIPTION OF WORK Backwater valve 12.51
.J r - rn I Lo � C ` Q6 - / 1 t Clothes washer 25.02
_r Xa[. I L _ .- ( l �h � ` Dishwasher 25.02
G't.l lr U 1 L)4.i '�-� ,/tfL t J_ 2y Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER 1 ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City /State /ZIP: 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 2, s, el
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) 1 Fax: : ( ) Tub /shower /shower pan 12.51
E -mail; Urinal 25.02
Water closet 25.02 2-57 e2-
CONTRACTOR Water heater i_ 37.52 37.5
Business name: K ' C p, v b / j�t Water piping/DW`J 56.29
Address: K �r Z ( Other: 25.02
City /State/ZIP: �� c L`T, _ o q) t'7 - Subtotal e7. S�
Phone:S �'-2 3 Q' Fax: SC) ) 7 g...4 / O Minimum pennit fee: $72.50
CCB Lic. :1 &,/, Plumbing Lic. no.: p 0 J . Plan review (25% of permit fee)
State surcharge (12% of permit fee) I p, &/
Authorized sign , c • TOTAL PERMIT FEE 9 $, 8 7
_et, This permit application expires if a permit is not obtained within 180 days
Print name:
t lids t I Date: - 5- ' / 3 after it has been accepted as remplete.
'Fee methodology set by Tri -County Building Industry Service Board.
05 Jun 13 11:21a Russ 503 - 518 -1100 p.2
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' 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 Q Fee (ea) Total each additional $100.00 or fraction thereof, to
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 525.000.00.
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 0 New exterior plumbing site utilities for any complex structure
Cuspidor/Watcr 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.
Eve Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above.
- 3"
Isometric or Riser Diagram
Car Wash Drain
Garbage - Domestic non - food ❑ isometric or riser diagram is required for new buildings
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/Lay - Nan -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
WaterCloset - Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
Accumulative Sewer Tally
II v Tenant Name: Mattress Closeouts ** *CREDITS * ** S \WR # N/A
TIGnRU Site Address: 10763 SW Greenburg Rd #110 P1,M # 2013 -00178
Parcel #:,1S135B000202
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Baptisery /Font 4 0 0 0 0 0
Bath: - Tub /Shower 4 0 0 0 0 0
- Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher: - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 • 0 0 0 0
Eve Wash 1 0 0 0 0 0
Floor Drain /Sink: - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash 6 0 0 0 0 0
Garbage Disposal:
- Domestic (to 3/4 I -IP) 16 0 0 0 0 0 •
- Commercial (to 5 1 -IP) 32 0 0 0 0 0
- Industrial (over 5 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower: - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink:
- Lay/Bar - Non -Food Related 2 0 0 1 2 1 2
- Bradley 5 0 0 0 0 0
- Com /Serv/Util - Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 1 6 1 6
Urinal 6 0 0 0 0 0
•
Previous El)U Count 0 0
Capped EDU Credit 1.88 30.08
TOTALS ALS 0 0 0 0 2 8 2 -22.08
Current Fixture Value -22.08 divided by 16 = -1.380 Current El)U 1 EDU = $4,665.00
Previous I:ixture Value 0 divided by 16 = 0.000 Previous EDU
Change -22.08 divided by 16 = -1.380 over (under) S (6,437.70)
Enter EDU Change Here , -1.380
Notes: ** *CREDITS * ** Credits from PLM2013 -00193 applied to this permit.
Authorized Name /Signature: •Debbie Adamski Date:', 6/6/2013
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of "Tigard Building Division to redeem credits towards future system development charges.
I : \Building \Sewer "Tally \ Sew er I'allvSheet- 4665.xls 07/01/12