Permit 3/2 q//_5. d%,.
Plumbing Permit Applicati 0 t i
Building Fixtures i FOR OFFICE USE ONLI
City of Tigard �j v Received Permit No.: ) ` ,r�
• 13125 SW Hall Blvd.,Tigard,OR G ` Date/By: - /0 /6j ) a' LA/�, J-��76
;� I 05 Plan Review
Phone: 503.718.2439 Fax: 503. 0 + 0 DateBy: Other Permit No.:
TI G n R D Inspection Line: 503.639.4175 ‘NO'''
�P� i PQ�Q pate Ready/By: Juris 61 See Page 2 for
Internet: www.tigard-or.gov �V` Oc ���`CJ�� Notified/Method: Supplemental Information
TYPE OF WORK G\-f\( \_`G�\ FEE* SCHEDULE
❑New construction ❑ 9.:Mtibbn For special information use checklist.
Description I Qty. I Ea. I Total
Addition/alteration/replacement ❑ I er: New 1-2-family dwellings(includes 100 ft.for each utility connection)_
g 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 ❑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: �'` -7 Catch basin or area drain 18.76
/6,3 s40 es - f}z� � ,f
City/State/ZIP: n �/ Drywell,leach line,or trench drain 18.76
`"� `t(/ Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: K/S V` Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
C2 '.in drain connector 18.76
Mi1 r
r V • Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
` i IMF;• Water service(no.linear ft.: ) Page 2
Subdivision: • Lo a. Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
J Clothes washer 25.02
Coo 5>t r„c t ct// 1I ry®✓e/ 5 h��I ti M I" "5 /�'! -f ce-1 Dishwasher 25.02
aryl odor- 1 /0 C /I r r St r,41A.,✓e Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name: C/0,r 144 J-tr Sr r✓ t fS
Floor drain/floor sink/hub 25.02
Address: ) (, D6 O -S441 g-C 1.e- Garbage disposal 25.02
City/State/ZIP: -r,, t r,i, O 9 7 2-2 L, Hose bib 25.02
Phone:(,Se3) SA 7_ 42 75 Fax:( ) Ice maker 12.51
❑ APPLICANT 5x CONTACT PERSON Interceptor/grease trap 25.02
Medical gas(value:$ ) Page 2
Business name: C 1 e 4 h Wq i--e r Se r,, c r S
� / Primer 12.51
Contact name: J t( 40 rc h r-s
Ave oof drain(commercial) 12.51
Address: ) Co 6 0 S W S S• - /Y
Sink/basin/lavatory 25.02 I
City/State/Z1P: 77s 4 re/ O n 9 7.2 4 Solar units(potable water) 62.54
Phone:(573 ) .S.-11 7- 8 1 .7 7 Fax::( ) Tub/shower/shower pan 12.51
E-mail: b 0r6Atr.S . 0 C 1e0,, Wq'frrS er✓�1c FS', 0 I-r Urinal 25.02
.1 ,� Water closet 25.02
CONTRACTOR
• Water heater 37.52
Business name: oC 1 6 C o y t r ri.c tors, Th ` Water piping/DWV 56.29
Address: 1 9 1 7 N E 18 5 6 Other: 25.02
City/State/ZIP: PQ r t 6 ..,J 0 '\ `17 a 3 o Subtotal
t Minimum permit fee: $72.50
Phone:
(S-a3 ) 4 81- 2.c. X7 Fax:( ) - //i/7
Plan review (25%of permit fee)
CCB Lie.: g 0 ' Plumbing Lic.no.: 3--5"-70 PD J
State surcharge(12%of permit fee)
Authorized signature: C, g--6v? _jtD/2/d._ TOTAL PERMIT FEE
Print name: \ro e 1 C, Q o rC A ter S Date: .3// ,"2 0/Lc This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:I Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
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-I"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 Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
P 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*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
Baptistry/Font
CI Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower engineer.
-Jacuzzi/Whirlpool
Car Wash: Each Stall CI New exterior plumbing site utilities for any complex structure
Drive Stall as defined in OAR918-780-0040.
I=1 Cuspidor/Water Aspirator Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial CI Any multipurpose fire sprinkler system.
Domestic CI Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2"
3" Isometric or Riser Diagram
❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -LavBar non-food related
-Bradley
-Com/Serv/Util food related
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
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