Permit II
EXPIRED RECEIVED
i . ..
/'a �� Community Development
Request for Permit Action OCT 0 7 2011
TIGARD
CITY OF TIGARD
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner n Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) f\i/t+
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION. CX P f/Z'c�' Y /,i(T (Q_ "
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 #: t.t-f 00 g Ub0 9 a
Site Address or Parcel #: t.2. 2,.--7 3 5(....0 +J(-4-C.L )`rl rN ` N:::.
Project Name: /4-r 6//-6 4-/J7) /-!i!-5 E57-6-r16
Subdivision Name: Lot #: �/09-
EXPLANATION: x I0,00 L PE _H/T.' / hi'L I`li/4 lc3l4-i re. AA-NS f_
GFr4rJbC7> 4N„ cif/5 k�o/2.44, 6045 No tox.)(;tx_. Qe.Qui,eg-D.
Signature: ■ L • . i,iLa-..,...[ • Date: /o�74
Print Name: l--- M/t L 47).�J-/-/rj/G/
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 1-2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date Jo IfMrretlit, Rtc to Bid; Admin: Date // isA' B aja
Refund Processed: Date A//9" By I;7411 Invoice Processed: Date By
Permit Geaeeled:)C. Date /�/0/ By vh. Parcel Tag Added: Date By
Receipt# Date // Method Amount$
L\Building\Forms\RegPermitAction.doc Rev 07/26/07
., ,. 1,3933 H Irv- Ex//a ,i ,�
Plumbing Permit Application X& hod 7..A '3 P(R
Building Fixtures RECEIVED MI( 014 1( I. t AI.. 0\I.1
City of Tigard AR 3 Received 2 p
g AR 3 LUU� Date/By: I 40 Permit No.: e ��. �i .ter
• 13125 SW Hall Blvd.,Tigard,OR 972 Plan Review
_ Phone: 503.639.4171 Fax: 503.59��=t�OF r1�Q,flD Other Permit No.:
DateBy:
Inspection Line: 503.639.4175
T I G A R D BU ILDeMVI5
1O Date Jut :' See Page 2 for
Internet: www.tigard-or.gov Nof eod:
i 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(1)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:Site Work
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 13273 SW Bull Mountain Rd Catch basin or area drain 1 16.60 16.60
City/State/ZIP:Tigard'OR 97224 Drywell,leach line,or trench drain 16.60
Suite/bldg./apt.no.: I Project name:Highland Hills Footing drain(no.linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job ste:Between SW Hoodvista on the east and SW
Manholes 4 16.60 66.40
Alpine Crest Way on the West. Rain drain connector 16.60
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.:1) 1 Page 2 101.40
Subdivision: I Lot no.: Water service(no.linear ft.: ) Page 2
Fixture or item
Tax map/parcel no.:2S1 09AB 00300 Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Install private storm system with area drain and cleanouts for roof and Backwater valve 16.60
foundation drains for future Lots 2-8 of Highland Hills Clothes washer 16.60
Dishwasher 16.60
® PROPERTY OWNER f ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name:Shadypeak Development LLC
Expansion tank 16.60
Address:2675 NW Thurman St Fixture/sewer cap 16.60
City/State/ZIP:Portland OR 97210 Floor drain/floor sink/hub 16.60
Phone:(503)295-0200 Fax:( ) Garbage disposal 16.60
❑ APPLICANT ® CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:LanPacific Inc.
Interceptor/grease trap 16.60
Contact name:Scott Emmens Medical gas(value:$ ) Page 2
Address:5125 SW Macadam Ave Suite 140 Primer 16.60
City/State/ZIP:Portland OR 97239 Roof drain(commercial) 16.60
Phone:(503)238-2097 Fax::(503)238-2447
Sink/basin/lavatory 16.60
Tub/shower/shower pan 16.60
E-mail:jse @lanpacific.com Urinal 16.60
CONTRACTOR Water closet 16.60
Business name:TO BE DETERMINED Water heater 16.60
Address: Other:
Subtotal 184.40
City/State/ZIP: Minimum permit fee: $72.50
Phone:( ) Fax:( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic.no.:
Plan review (25%of permit fee) -4111
State surcharge(12%of permit fee)
Authorized signature: 40 ��2-� TOTAL PERMIT FEE
Print name: � l0 -- A I C,J Date �3 This permit application expires if a permit is not obtained ithin
Y 180 days after it has been accepted as complete.
L, P4-0.A G1 C� *Fee methodology set by Tri-County Building Industry Servi Board.
/ / n n
t:�Building�PermitsWLDIF-PermitApp.doc 12/27/06 440-4616T(10/02/COM/WEB) *An . J
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-1st 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
Storm&Rain Drain-1st 100' 1 55.00 55.00 Valuation: Permit Fee:
$1.00 to$5,000.00 Slinimum fee$72.50
Storm&Rain Drain-each additional 100' 1 46.40 46.40 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for each
t additional$100.00 or fraction thereof,to and
'I' 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 • rmit 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
and including$50,000.00.
s•eciall re.uested ins sections- .er hour 72.50
Subtotal: l 01.40 $50,001.00 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 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.
-3"
-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'Permits\PLM-PermitApp.doc 12/27/06