Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2014-00333
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/07/2014
Parcel: 2S102AD01900
Jurisdiction: Tigard
Site address: 8935 SW BURNHAM ST
Project: TVF&R Subdivision: TIGARD HIGHWAY TRACTS Lot: 21
Project Description: Site utilities for addition&renovation:(1)catch basin, 100 ft.of footing drain,and(2)rain drain connectors.
Contractor: DON BURKE EXCAVATION&CONSTRUCTION Owner: TUALATIN VALLEY FIRE&RESCUE
15604 SE RUBY DRIVE 11945 SW 70TH AVE
MILWAUKIE, OR 97267 TIGARD,OR 97223
PHONE: 503-652-0175 PHONE: 503-259-1188
FAX:
FEES
Quantity Description Date Amount
1 ea Catch Basin or Area Drain 10/07/2014 $18.76
Specifics: 100 If Footing Drain 10/07/2014 $50.03
2 ea Rain Drain Connector 10/07/2014 $37.52
Type of Use: COM 1 12%State Surcharge- 10/07/2014 $12.76
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $119.07
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 rule adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. Y -ma obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or
Issued By: -• mittee Signature:
:��/�
Cal 13.• 75 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.
Plumbing Permit Application
Site Utilities I t)I{ t.1 I 1( 1 l ,l t 1.1 l
Received
City of Tigard r� 14 Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 j 1 2� DateBy: 1017�I7 ITT- /> ? 017 rK-c�h 33
� Plan Review
Phone: 503.718.2439 Fax: 503.598.19600 AUv patcBy: other Permit No.: ppatti�,�zQ
Inspection Line: 503.639.4175 '` AVt; l� f/ /
1 I G n K D ��V� ■Orate ReadyBy: ]uris: fa See Page 2 for
Internet: www.tigard-or.gov Ctt DIN IS` ttified/Method: ---r.--C. Supplemental Information
TYPE OF WORKWI V-- FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist
Description I Qty. 1 Ea. 1 Total
Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
❑ 1-and 2-family dwelling Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑ ulti-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler(sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION r Site utilities:
Job site address: 3.93 I �J tJ /3i�rti 4h �.1 t. Catch basin or area drain 18.76 !� )(p
City/State/ZIP: Drywell,leach line,or trench drain 18.76
TT-9C£ ) nR �7 Footing drain(no.linear ft.:/00) / Page 2 f0,03
Suite/bldg./apt.no.: I Project name: TfFd 1Z 5/iS,3•. 5 1 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector "Z 18.76 3 7..5
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 map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
T _1 (� j� Clothes washer 25.02
- --� rr let�� /'Rq/� a AR/"./ d' Dv""� Dishwasher 25.02
ro. A.L� d/7i0._. / p 6A.14- Drinking fountain 25.02
i"CA- 00a16:01 eq.let �7f l � Lt., Ejectors/sump 25.02
❑ ROPERTY OWNER I ❑ 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 NE1/CONTACT PERSON Interceptor/grease trap 25.02
Business name: Doi.. .�I(e CNt:rvc11Jp.- I- /4,.S/, Medical gas(value:$ ) Page 2
Contact name: U �-sc� Primer 12.51
Roof drain(commercial) 12.51
Address: /$ O� Jr J S D r. Sink/basin/lavatory 25.02
City/State/ZIP: 44,1/ 4.tik L, ( I? el 726 7 Solar units(potable water) 62.54
J
Phone:(V03 ) rI/') - 77e�' Fax::( ) Tub/shower/shower pan 12.51
E-mail: Dot/ Lie W e 64"
,,; be6 G, cO' Urinal 25.02
CONTRACTOR Water closet 25.02
�+ 1 Water heater 37.52
Business name: /)dh BvikQ- p..ti� t `dr.,S 1 - Water piping/DWV 56.29
Address: /5-649q SE gL en.. Other: 25.02
City/State/ZIP: 44 z/i./,o✓4-Q., )R 1 7 Z,( 7 Subtotal i()&•,j f
V / Minimum permit fee: $72.50
Phone:(TO3) e S Z on S Fax:(S03) 573. 6 Z t y
H Plan review (25%of permit fee)
CCB Lic.: /cO 96/ ( Plumbing Lic.no.: P/3 w
State surcharge(12%of permit fee) t) .7(p
Authorized signature/ TOTAL PERMIT FEEir )/1.U7
Print name: Date: (/ This permit application expires if a permit is not obtained within 180 days
�4LiS (} s 70 -7 / 7- after it has been accepted as complete.
✓ "Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
Plumbin)? 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-l'100' j 50.03 0-„3 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 Qty. 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$25,000.00.
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/ any review is required for of the following.Performed: Capped Added Relocate 9 y g
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 ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water 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.
Eye Wash
Floor Drain/sink -2" Submit 2 sets of plans with any of the above.
Isometric or Riser Diagram
Car Wash Drain
El Isometric diagram is required for new buildings
Garbage -Domestic-non-food c or r g ram re q g
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/Lav -Non-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:
1:\Building\Permits\PLMU_PermitApp.doc 2
Location:
Record Type:
Inspection Type:
Result:
Comments:
Inspection Date:
Record ID:
Inspector:
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
8935 SW BURNHAM ST, TIGARD, OR, 97223
Commercial - Plumbing
399 Plumbing final
PASS - No C of O
PLM2014-00333
George Heimos
Violation Summary:
Inspector Contractor
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
-. Request for Permit Action
T 1 G A R D 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov
1 0: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@ • -or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) /fielN' /r2�Gv E/f 1 S//eF
" i rivC.
Mailing Address: `t 5 6 1 1 (.4 by V r- ife--
City/State/Zip: / ICf'G 1 <1� 970UCo 7
Phone No.: Csz3S 6542-1)T7 S"
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
- VOID PERMIT APPLICATION.
L' REFUND P 'MIT FEES (attach copy of original receipt and provide explanation below).
" - OR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: Ail?AO 111 063-3 3
Site Address or Parcel#: 3 s ryv ke4i
Project Name: 'f V�--d-
Subdivision Name: r- Lot#:
EXPLANATION: 6) eAdadi 7S Via,,/ , 7LC t$�,� �✓aJ
-tce- /2 ,zs- e-AA/4 71,4_ -1-e, fa_S p i i I !'y 75, LA t�+•d✓-
rcJr� 74, 77%, Le ca<
Signature: Date: w
Print Name: 6,24,x,., 0d
a
Refund Policy,
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check is I'ti postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to S s Admin: Date a B p ii Route to Records: Date, fS AaMI B 1_1M1
Refund Processed: Date /0 ./Y B '"' Invoice Processed: Date By
Permit Canceled: Date /✓ ' By./ Parcel Tag Added: Date By
I:\Building\Forms\Rey PermitAction_( 314.doc
Er
TIGARD
City of Tigard
October 30, 2014
Don Burke Excavation Inc
Attn: Tracy Ellis
15604 SE Ruby Dr
Milwaukie, OR 97267
Re: Permit No. PLM2014-00333
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 8935 SW Burnham St.
Project Name: TVF&R
Job No.: N/A
Refund: ® Check#215397 in the amount of$2.25.
❑ Credit card "return" receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Refund overpayment of state surcharge.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
1:\Building\Refunds1,11ZsSaWn�Lat4gf iydlerpa 91b6Pregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
" City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Don Burke Excavation Inc. DATE: 10/23/2014
Attn: Tracy Ellis
15604 SE Ruby Dr REQUESTED BY: Dianna Howse
Milwaukie, OR 97267 BT
TRANSACTION INFORMATION:
Receipt#: 197915 Case#: PLM2014-00333
Date: 10/08/2014 Address/Parcel: 8935 SW Burnham St
Pay Method: CreditCard Project Name: TVF&R
EXPLANATION: Refund overpayment of state surcharge.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
12% State Surcharge 100-0000-24001 $2.25
TOTAL REFUND: $2.25
APPROVALS: SIGNAT 'FS/DATE:
If under$5,000 Professional Staff / , 74,2—
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: 1 /T/33// Y By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010