Permit giCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
Request for Permit Action �r���s A
13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor K. City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) /i),4—
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOI ERMIT APPLICATION.
RMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: d1.1/4.2)1 a.0 1 '5- DOOc?'
Site Address or Parcel#: q`i s5 a.,._) 11.-- p%O1J c ), 1
Project Name: [_.t 1 L-T - A----) E/9 lQ
Subdivision Name: Lot#:
EXPLANATION: 31 . .CCU �E__ O ' , Ru r X7-1,l12
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Signature: 1� �d%Cc.--1AA-4 1J Date: 74-7 S
Print Name: --iTh 6 6 J c ,41 A-ILI Sk )
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to S s Admin: Date i0/� !' Route to Records: Date 7 Q� B 4
Refund Processed: Date /(//q By Invoice Processed: Date By
Permit Canceled: Date 7/9/j f' By ,.f_,- •arcel Tag Added: Date By
■
I:\Building\Forms\RegPermitAction_09�31 C.(IOC
I- rnm 07/01/2015 23:36 #349 P.001/002 rEIVEP
'CI Plumbing Permit Applic1ioil'
Building Fixtures FOR OFFICE USt. ONLY
JUL 1 2015 Received 7 q �� _
City of Tigard Date B : I A :)O Pewit vo.:
1 3125 SW Hall Blvd.,Tigard. y ~ �'��l5 � �
1 I iliAftil Plan Review �,1.9.6/5 $3
pr Phone: 503.718.2439 Fax: Plan Review Other Permit No
TIGARD Inspection Line: 503.639.4t(ILDING DIVISION Date Ready By Jurit: ® See Page 2 for
Internet: www Tigard-orgtr��UV Notified.•Method: Supplemental Information
TYPE OF WORK Vim. �k
..:..` -,?� .'?v--.=..- r... :" _... a=...� FEE' SCHEDULE
❑New construction ❑Demolition For special information use checklist.
Description I Qty. I Ea. I Total
®Addition'alteration,replacetnent ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) V
CATEGORY;OF CONSTRUCTION SFR(I)bath 1 312.70 (\
❑ I-and 2-family dwelling ®Commercial,industrial SFR(2)bath 437.78
❑Accessory building ❑Multi-family SFR(3)bath 500.32
Each additional bath/kitchen I 25.02 di
❑Mast r builder ❑Other: Fire sprinkler(_sq.ft.) Page 2
.. SITE INFORMATION AND LOCATION Site utilities: Q
Job site address N Washington Square Rd Catch basin or area drain t 18.76
:95
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,OR 97223
Footing drain(no.linear ft.:_) Page 2 (f%)
Suite/bldg./apt.no.:hoj„pt Project name:Build-A-Bear 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.:_) 1 Page 2
Subdivision: l CO _ 01 Itlr' i Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer F 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Plumbing for tenant improvement
/� n Dishwasher 25.02
,J L(... ft�ruje c'T P/I9(€Z C / 4 7 e i9 7Z, Drinking fountain 25.02
• /VC /VEAI / -c 1c Tlt d--c3 Ejectors/sump 25.02
❑ PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name:
Fixture/sewer cap 25.02
Floor drain/floor sink/hub 1 25.02 25.02 1
Address: Garbage disposal 25.02
City/State/ZIP: I Hose bib 25.02
I
Phone:( ) : Fax:( ) Ice maker 12.51
APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name:
Medical gas(value:S ) Page
Primer 12.51
Contact name:
Roof dram(commercial) I 12.51
Address: Sink'basin/lavatory 2 25.02 50.04
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) i Fax::1 ) Tub/shower/shower pan 12.51
E-mail: ry Urinal 25.02
CONTRACTOR I Water closet 1 25.02 25.02
Water heater 1 37.52 37.52
Business name:Pb1S1 LLC _ Water piping/DWV 56.29
Address:2i 195 NW Evergreen Pkwy Suite 204 Other: _ 25.02
City/State/ZIP:Hillsboro,OR 97124 Subtotal 137.60
Phone:(503)466-2222 Fax:(503)466-2211 Minimum permit fee: S72.50
CCB Lie.:158286 , Plumbing Lic.no.:34-434PB Plan review (25%of permit fee)
Authorized signatu kvv
/' State surcharge(12%of permit feet 16.51
. 1...-:.,i,(4_�L TOTAL PERMIT FEE 154.11
L- i This permit application expires if a permit is not obtained within 180 days
Print name:Lanell Robinson Date:7/1/15 I after it has been accepted as complete.
•fee methodology set by Tri-County Building Industry Service Board
I Bwlding-PermisPLMMIJ•Pmn,App.doe lo 01 440-4516T(10 02 COM WEB)
gi Accumulative Sewer Tally
Tenant Name: Build-A-Bear SWR# 2015-00083
Site Address: 9485 SW Washington Square Rd PLM# 2015-00209
Parcel#: 1S126000300
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptisery/Font 4 0 0 0 0 (1
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 (I
-Drive through 16 0 0 0 0 I I
Cuspidor/Water Aspirator 1 0 0 ; 0 0 II
Dishwasher: -Commercial 4 0 0 0 (1
Domestic _2 0 0 0 0 0
Drinking Fountain 1 0 C O 0 0 O
Eye Wash 1 0 :.1/ 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 1 2 1 2
-3inch 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 11P) 32 0 0 0 n-Industrial(over 5 I IP) 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 (I Shower: -Gang(per head) 1 \10
0 0 0 (1
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 0 0 0
-Bradley 5 0 0 0 0 0
-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 I:DU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 5 2 5
Current Fixture Value r, divided by 16= 0.313 Current EDI 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 5 divided by 16= 0.313 over (under) $ 1,581.00
Enter EDU Change Here 0.310
Notes:
Authorized Name/Signature: Debbie Adamski Date: 7/2/2015
Building Division
ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
•ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
r
l:\Building\Sewer Tally\Sewer 1'allyShect_4900._070114.xlsx