Permit CITY OF TIGARD PLUMBING PERMIT
11111 _ ' COMMUNITY DEVELOPMENT Permit#: PLM2015-00208
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/02/2015
Parcel: 1 S134BC00200
Jurisdiction: Tigard
Site address: 12196 SW SCHOLLS FERRY RD
Project: Mod Pizza Subdivision: GREENWOOD TERRACE CONDO Lot: 17
Project Description: Landlord work to prepare space for new tenant. Cap(2)lays&(1)water closet. Install(1)grease interceptor.
Contractor: PMSI LLC Owner: ATLAS GREENWAY LLC
21195 NW EVERGREEN PKWY#204 333 NW NINTH AVE, STE 1009
HILLSBORO, OR 97124 PORTLAND,OR 97209
PHONE: 503-466-2222
PHONE:
FAX: 503-466-2211
FEES
Quantity Description Date Amount
3 ea Fixture/Sewer Cap 07/02/2015 $75.06
Specifics: 1 ea Interceptor/Grease Trap 07/02/2015 $25.02
1 12%State Surcharge- 07/02/2015 $12.01
Type of Use: COM Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $112.09
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 s NC by calling 503.232.1987 or 1.800.332,2344.
Issued y: �/j / Permittee Signature:
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.
From: 07/01/2015 20:22 *348 P.001/002
Plumbing Permit Applii CEIVED
Building Fixtures C FOR OFFICE USE ONLY
City of Tigard JUL 1 2015 Received
pa y: 7 Cj\,rt"9 Permit No.. ( 9.b 15-C!�dZC
111
• 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Q�lS 7
R Phone: 503.718.2439 tCARD Date/By Other Permit No.: I' l
TWGARD Inspection Line: 503.b39��{I t xtNO ru iio ON Date Ready'By: lure: RI See Page 2 for
Internet: www.tigard-or.gov !�U L•� Notified/Mediud: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist.
Description I Qty. 1 Ea. { Total
®Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 1 312.70
❑ 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: 12196 SW Scholls Ferry Rd Catch basin or area drain 1 8.76
- - Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,OR 97223
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: Project name:MOD Pizza Landlord work 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 fl.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: Lot no.: i Fixture or Item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION or WORIZ'" Backwater valve 12.51 i
Clothes washer 25.02
Install grease interceptor,cap fixtures Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
❑.PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Nance: Fixturcisewercap 3 25.02 75.06
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: _ Hose bib 25.02
Phone:( ) Fax:1 ) Ice maker 12.51
❑ APPLICANT CI CONTACT PERSON Interceptor/grease trap 1 25.02 25.02
Business name: Medical gas(value:S ) Page 2
Primer 12.51
Contact name: _ Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02 _ I
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR -"
Water heater 37.52
Business name:PMSI LLC WaterpipingiDWV 56.29
Address:21195 NW Evergreen Pkwy Suite 204 Other: 25.02
City/State/ZIP:Hillsboro,OR 97124 Subtotal 100.08
Phone:(503)466-2222 Fax:(503)466-2211 Minimum permit fee: $72.50
CCB Lie.: 158286 �lumbing Lie,no.:34 434P6 Plan review (25%ofpennit fee)
`7 /1/ ( � State surcharge(12%of permit fee) 12.01
Authorized signatur e `� ...q kc. f "-L TOTAL PERMIT FEE 112.09
Print name:Lanell Robinson I Date:6/29/15 This permit application expires if a permit is not obtained within ISO days
after it has been accepted as complete.
'Fee methodology set by Tri-County Building Industry Service Board.
I‘lholding Permits PLMU-PermitApp doe 10 0100 44046161(10.02.COM'WFB)
From: 07/01/2015 20:23 #348 P.002/002
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
'
Site Utilities Q0. Fee(es) TQat Squat C.Footage: . Permit F.,ce� ; ;.
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 5233.20
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 572.50
Storm&Rain Drain-each additional 100' 37.52 S5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other lCns actions or Fees Fee,1ea) Total, each additional$100.00 or fraction thereof,to
h and including$10,000 00.
Inspection of existing plumbing or for 510,001.00 to 525,000.00 $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 S25,001.00 to 550,000.00 5379.50 for the first$25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional 5100.00 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 5100.00 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 z` At! c' sr;Fll)>�liplutl� u)stRllaticills
Fixture Type for Replace/ Plan review is required for any of the following.
Work Performed: Capped Added Relocate
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 OAR9 I 8-780-0040.
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.
-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 MachiRefrig.Drains
Oil Separator(Gas Station) Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/tav -Non-food related 2
-Bradley
-Commercial-food related
-Service
Swimming Pool Filter
Washer-clothes *Note: If the fixture work under this permit results in an
Water Extractor increase of sewer EDUs,a sewer permit will be issued and
Water Closet-Toilet I fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
•
C:\Users\Irobinson\Down loads\PLM F_PermitApp.doc 2
Accumulative Sewer Tally
N ,or Tenant Name: MOD Pizza ***CREDITS*** SWR# N/A
Site Address: 12196 SW Scholls Ferry Rd PLM# 2015-00208
Parcel#: 1 S 1 34BC00200
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value. total#s t tal 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 11
Eye Wash 1 0 0 0 0 0
Door 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 (1
-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 IIP) 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 2 4 0 -2 -4
-Bradley - 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 (1
Water Closet-Toilet 6 0 I 6 0 -1 -6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 _ 3 10 0 0 -3 -10
Current Fixture Value -10 divided by 16= -0.625 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -10 divided by 16= -0.625 over (under) $ (3,213.00)
Enter EDU Change Here -0.630
Notes: ***CREDITS***
Authorized Name/Signature: Debbie Adamski Date: 7/2/2015
Building Division
Note: The property owner shall retain the ORIGIN,\L 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.
1:\Building\Sewer Tally\Sewer fallytiheet_49(0._0711114.xlsx