Permit CITY OF TIGARD PLUMBING PERMIT
11111 • COMMUNITY DEVELOPMENT Permit#: PLM2015-00025
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 er4 Date Issued: 02/03/2015
Parcel: 2S102AC00500
Jurisdiction: Tigard
Site address: 12492 SW MAIN ST
Project: Tigard Beer&Wine Deli Subdivision: BURNHAM TRACT Lot: 1
Project Description: Adding(1)2"floor sink,(1)3-compartment sink,(1)grease trap and(1)backflow preventer. Replace(2)food
related sinks.10/28/15.oer owner,these fixtures are rough-in only setting of fixtures are to be under separate
permit.Sewer SDC fees already collected from previous credits for these fixtures.
Contractor: WESTERN PLUMBING Owner: WOODARD LIVING TRUST
9460 SW TIGARD AVE SUITE 101 PO BOX 23303
TIGARD, OR 97223 TIGARD, OR 97281
PHONE: 503-639-5296 PHONE:
FAX: 503-684-9015
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 01/30/2015 $31.27
Specifics: 1 ea Floor Drain/Floor Sink/Hub 01/30/2015 $25.02
1 ea Interceptor/Grease Trap 01/30/2015 $25.02
Type of Use: COM 3 ea Sink 01/30/2015 $75.06
Class of Work: ALT 1 12%State Surcharge- 01/30/2015 $18.76
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $175.13
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 estions to . NC b - ling 503.232.1987 or 1.800.332.2344.
Iss d By: / � Permittee Sienature:
Call 503.639.4175 by 7:00 a.m.for the next available ins.•ction 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.
CITY OF TIGARD PLUMBING PERMIT
•
" COMMUNITY DEVELOPMENT Permit#: PLM2015-00025
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/03/2015
Parcel: 2S102AC00500
Jurisdiction: Tigard
Site address: 12492 SW MAIN ST
Project: Tigard Beer&Wine Deli Subdivision: BURNHAM TRACT Lot: 1
Project Description: Adding(1)2"floor sink,(1)3-compartment sink,(1)grease trap and(1)backflow preventer. Replace(2)food
related sinks.
Contractor: WESTERN PLUMBING Owner: WOODARD LIVING TRUST
9460 SW TIGARD AVE SUITE 101 PO BOX 23303
TIGARD,OR 97223 TIGARD, OR 97281
PHONE: 503-639-5296 PHONE:
FAX: 503-684-9015
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 01/30/2015 $31.27
Specifics: 1 ea Floor Drain/Floor Sink/Hub 01/30/2015 $25.02
1 ea Interceptor/Grease Trap 01/30/2015 $25.02
Type of Use: COM 3 ea Sink 01/30/2015 $75.06
Class of Work: ALT 1 12%State Surcharge- 01/30/2015 $18.76
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $175.13
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 Notifica ion enter. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direc estions to O C b fling 503.232.1987 or 1.800.332.2344.
Iss ed By: I( �� Permittee Signature: )
Call 503.639.4175 by 7:00 a.m.for the next availabl• • spection 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 ��
Building Fixtures tIt Cii
City of Tigard Received � 6191!6 ) Permit No.. pa-44c/ -u�b�ir
11 13125 SW Hall Blvd.,Tigard,OR 97223 l., 2 �p15 Plan Review
g Phone: 503.718.2439 Fax: 503.598.1404N Other Permit No.:
Inspection Line: 503.639.4175 .A Date Ready/By: �T/�� (l,, Juris: B See Page 2 for"/a�U ✓C•''j 17,)
T I L A K D Internet: www.tigard-or.gov .' ' f il� Notified/Method /107 a�,.<' f'J Supplemental Information•
TYPE OF W ara1"` ��a.� , _ , .� r_- FEE* SCIIEDLrLE
❑New construction • Demolition For special information use checklist
Description I Qty. I Ea. Total
ts1,1 Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
❑ I-and 2-family dwelling CommerciaLindustrial
SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
s Catch basin or area drain 18.76
Job site address:`g AQ 0 rnckAY\ ��r;ok 1
Drywell,leach line,or trench drain 18.76
City/State/ZIP 1 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.:° 6 Project name: 1(� -6 x-q u3 1�Q, 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: Lot no.: Fixture or item:
Tax map/parcel no.: j.'3 r d 4 pc e....00 500 Backflow preventer 1 ` 31.27 ` ,a-A
Backwater valve 12.51
DESCRIPTION OF WORK
Clothes washer 25.02
\\'C'KJt\y t`- 1\ \)\,h,∎ 1't A,AI\(,b Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
( i PROPERTY;OWNER ❑ TENANT Expansion tank 12.51
�I- ,�,� n .r Fixture/sewer cap 25.02
Name: \
, ski C >L.4AJY CA 25.02 1� n
U. Floor drain/floor sink/hub \ ,.., ,0
Address: ,c)( \$ 11.xC\ l_ Garbage disposal 25.02
City/State/ZIP: ck (5 Q \- Hose bib 25.02
Phone: )LG\ ��,) Fax:( ) _
Ice maker 12.51
❑ APPLIC y ❑ CONTACT PERSON Interceptor/grease trap k 25.02
Medical gas(value:$ ) Page 2
Business name: 12.51
Primer
Contact name: • Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 11\ 25.02 .)t0,4,
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
Urinal 25.02
E-mail: 25.02
Water closet
CONTRACTOR �,?' N 37.52
- Water heater
Business name:Western Plumbing,Inc. Water piping/DWV 56.29
Address:9460 SW Tigard Street,Suite 101
Other: 25.02
City/State/ZIP:Tigard,OR 97223 Subtotal IC310 S.
( )
Phone:(503) Fax: 503 684-9015 Minimum permit fee: $72.50
_
Plan review (25%of permit fee) kql15144C1...._
CCB Lic.:2439 Plumbing Lic.no.:3429PB State surcharge(12%of permit fee) •
Authorized signature: I1 TOTAL PERMIT FEE '
"'ice n�This permit application expires if a permit is not obtained within 180 days
Print name 111, �� Date: (,� , after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board. ;
1:16uilding�Permits�PLMU-PermitApp.dat 10/01/09 440-4616T(10/02/COMAVEB) =4 - 0/75
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- U 100 50.03 0 to 2,000 $121.90
-
37.52 2,001 to 3,600 $169.69
Footing drain-each additional 100' 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 V VA" T .A5 ' A�
+.z f
Storm&Rain Drain-1st 100' 62.54
.00 to$5, .
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
Fee(ea) Total each additional$100.00 or fraction thereof,to
Other Inspections or Fees Qty" 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
each additional$100.00 or fraction thereof.
(minimum charge-1/2 hour)
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/ plan review is required for any of the following.
Work Performed: Capped Added Relocate Plan
check all that apply.
PP y
Baptistry/Font ❑ Any new commercial building with water service 2"and
Bath -Tub/Shower greater,except systems designed and stamped by licensed
-Jacuzzi/Whirlpool
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.
Di shwsher -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.
-3,'
a" Isometric or Riser Diagram
_ Car Wash Drain ❑ Isometric or riser diagram is required for new buildings
Garbage -Domestic-non-food
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 \ 7-",
-Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer-Clothes increase of sewer EDUs,a sewer permit will be issued and
Water Extractor fees assessed for the sewer increase must be paid before the
Water Closet Toilet
Urinal plumbing permit can be issued.
Other Fixtures.
http a/www.tigard-or.gov/city_hal l/departments/cd/docs/PLMF-PermitApp2doc
Accumulative Sewer Tally
Tenant Name: 'Tigard Beer&Wine Deli ***CRI?DTI'S*** SWR#
Site Address: 12492 SW Main St P1.M# 2015-00025
Parcel#: 2S102AC00500
Fixture Value Previous Previous Credits Capped Fixture Fixture New \,\■
# value count nipped#s ,sluecount added# added value total#s t, 1.11 \.1l1i,
Baptisery/Font 4 0 0 0 0 O
Bath: -Tub/Shower 4 0 0 0 0 (I
-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 II
Dishwasher: -Commercial 4 0 0 0 0 0
Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye 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 HP) 16 0 0 0 0 0
-Commercial(to 5 HP) 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
Living Unit 16 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:
-Lav/Bar-Non-Food Related 2 0 I i 0 0 0
-Bradley 3 0 0 0 0 O
-Com/Serv/Util-Food Related 3 0 0 1 3 1 3
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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0.56 8.96
TOTALS 0 0 0 0 1 3 1 -5.96
Current Fixture Value -5.96 divided by 16= -0.373 Current El)1 1 EDU= $4,900.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -5.96 divided by 16= -0.373 over (under) $ (1,813.00)
Enter EDU Change Here -0.370
Notes: Per CWS when food prep sink drains into floor sink,only charge for the higher valued fixture. Credits from PLM2014-00215
applied to this permit. ***CREDITS STILL REMAINING***
Authorized Name/Signature: Debbie.\damski Date: 1/26/2015
Building Division
rote: 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\Sewer CallySheet_4900._070114.xlsx
gi Accumulative Sewer Tal
Tenant Name: Spec Space ***CRI DITS*** l
SWR# N/A
Site Address: 12492 SW Main Sr Pl.hl# 2014-00215
Parcel#: 2S102AC00500
Fixture Value Irevious Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s t"ital 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
Eye Wash I 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 ( 2 1 2
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 0 0 (I
-Car Wash 6 0 I) 0 0 0
Garbage Disposal:
-Domestic(to 3/4 HI') 16 0 0 0 0 0
-Commercial(to 5 HP) 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
Living Unit 16 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:
-Lav/Bar-Non-Food Related 2 0 1 2 0 -1 -2
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 1 .3 1 3
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 (1 0 0 0
Water Closet-Toilet 6 0 1 6 0 -1 -6
Urinal 6 0 1 6 0 -1 -6
Previous EDU Count (1 0
Capped EDU Credit 0
TOTALS _ 0 0 3 14 2 5 _ -1 -9
Current Fixture Value -9 divided by 16= -0.563 Current EDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -9 divided by 16= -0.563 over (under) $ (2,688.00)
Enter EDU Change Here -0.560
Notes: ***CREDITS*** 1/26/15,credits applied to PLM2015-00025.
Authorized Name/Signature: Debbie Adamski Date: 6/30/2014
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\Sewer I'allySheet_48(K)._070113.xlsx