Permit CITY OF TIGARD PLUMBING PERMIT
I COMMUNITY DEVELOPMENT Permit#: PLM2015-00241
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/05/2015
Parcel: 1 S134BC00200
Jurisdiction: Tigard
Site address: 12196 SW SCHOLLS FERRY RD
Project: Mod Pizza Subdivision: GREENWOOD TERRACE CONDO Lot: 17
Project Description: Plumbing fixtures for interior TI to convert space to pizza restaurant: ADD(1)dishwasher,(8)2"floor drains,(1)ice
machine,(7)non-food related sinks,(1)commercial food sink,(1)service sink,(3)water closets,(1)urinal and(1)
water heater.
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
1 ea Dishwasher 07/30/2015 $25.02
Specifics: 8 ea Floor Drain/Floor Sink/Hub 07/30/2015 $200.16
1 ea Ice Maker 07/30/2015 $12.51
Type of Use: 5 ea Sink 07/30/2015 $125.10
Class of Work: 4 ea Lavatories 07/30/2015 $100.08
Type of Const: 1 ea Urinal 07/30/2015 $25.02
Occupancy Grp: 3 ea Water Closet 07/30/2015 $75.06
Stories: 1 ea Water Heater 07/30/2015 $37.52
1 12%State Surcharge- 07/30/2015 $72.06
Plumbing
Total $672.53
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 • o o •e rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-009• You m: obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: ( �� - 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: 07/28/2015 23:54 #366 P.001/003
Plumbing Permit Applica EIVED
Building Fixtures ht.ka FOR OFFICE USE ONES'
Received ^/�n
III City of Tigard IJ II 2 8 2015 '7 - Permit No.: J//S' 44/
• 13125 SW Hall Blvd.,Tigard,OR 9 423
Date/B
e Phone: 503.718.2439 Fax: or TIUp�� PLan Review
Y
Other Permit N.45,0/2 e„,,Szzo 23
Inspection Line: 503.639.41
Dale Real/By: 'S hair: 0 See Page 2 for
1 il,Al:.L) Internet: www.tigard-or.gd�j1,���_D{NG DIVISION Notified/Melhod: r Supplemental Information•
TYPE OF WORK jt,.// 4/I' - FEE'S SCHEDULE
❑New construction ❑Demolition For special information use checklist
- �. - _-.. Description I Q . I Ea. 1 Total 0
®Addition.'alteration/replaccmenl 1 ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70 .ItZb
❑ 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 xis\
JOB SITE INFORMATION AND LOCATION Site utilities: (fit
I Job site address: 12196 SW Scholls Ferry Rd Catch basin or area drain 18.
Drywell,leach line,or trench drain 18.76 O
City/State/ZIP:Tigard,OR 97223
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name:MOD Pizza Tenant Improvem 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 fl.:_) Page 2
Subdi vision: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Plumbing for TI restaurant
Dishwasher 1 ✓ 25.02 25.02
Drinking fountain 25.02
- Ejectors/sump 25.02
❑ PROPERTY OWNER 0 TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
- - - Floor drain/floor sink/hub 8 `?". 25.02 200.16
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) r,' Fas:( ) Ice maker I ✓ 12.51 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name: R fdrain fen� �✓cF nercia) 12.51
Address. -- - 'basin/lav6tory / ACC J 9 ✓ 25.02 225.18
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 1 ,P 25.02 25.02
Water closet 3 / 25.02 75.06
CONTRACTOR
Water heater 1 -, 37.52 37.52
Business name:PMSI LLC Water piping/DWV 56.29
Address:21195 NW Evergreen Pkwy Suite 204 Other: _ 25.02
City/State/ZIP:Hillsboro,OR 97124 Subtotal 600.47
Phone:(503)466-2222 X IA, . Fax:(503)466-2211 Minimum permit fee: $72.50
CCB Lic.: 158286 Plumbing Lic.no.:34-434PB Plan review (25%of permit fee)
State surcharge(12%of pennit fee) 72.06
Authorized sign e' ( t TOTAL PERMIT FEE 672.53 t„„/
Print name:Lanell Robinson Date:7/28/15 This permit application expires if a permit is not obtained within Igo days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
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From: 07/28/2015 23:54 #366 P.002/003
Plumbing Permit Application - City, of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities... Qty` Feei(ea) Total Square'Footage :. Perput Fee'
Footing drain-l'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
Storm&Rain Drain-1st 100' 62.54 Valuation: Permit.Fee:,
$1.00 to$5.000.00 Minimum fee S72.50
Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to S10,000.00 $72.50 for the first$5,000.00 and S1.52 for
Yi Fee,{tsa) Tgtll each additional 5100.00 or fraction thereof,to
Qiitelf" pllpeRlUf3l�rPeels and including$10,000.00.
Inspection of existing plumbing or for 5I0,001.00 to$25,000.00 $148.50 for the first S10,000.00 and$1.54 for
which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to
(minimtun 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 S 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*.
Qusa t y Fixture Type 14.011-review Tar Plultmbing. istaU* ►ns
fixtureTypefor . Replace Plan review is required for any of the following.
Work Performedi '0*PPS Added Relocate
Please check all that apply.
Baptistry/Font
Bath Tub/Shower ❑ Any new commercial building with water service 2"and
Jacuzzvwhirlpool 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 I ❑ 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" 8 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 Mach./Refrig.Drains 1
Oil Separator(Gas Station) C9mments regarding fixture work:
Rec.Vehicle Dump Station c(r4 fi1i-
Shower -Gang L ,D>' sl E il Stall
Sink/[av -Non-food related 7 �� •e'e
-Bradley "��
-Commercial-food related y 1
-Service I
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
Water Closet-Toilet 3 fees assessed for the sewer increase must be paid before the
Urinal I plumbing permit can be issued.
Other Fixtures:
C:\Users\lrobinson\Downloads\PLMF_PennitApp(2).doc 2
11 Accumulative Sewer Tally
j Tenant Name: Mod Pizza SW 2 2015-00093 REVISED
7It,w;n
Site Address: 12196 SW Scholls Ferry Rd PLM# 2015-00241 .."4'"N Parcel#: 1 S 134BC00200 —.
Fixture Value Previous Previous Credits Capped Fixture Fixture New Nev.,
# value count capped#s value count added# added value total#s total 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 1 4 1 4
-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 8 16 8 16
-3 inch 5 0 0 0 0 0
-4 inch 6 0 (1 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 1 1 1 1
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 0 8 16 8 16
-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 3 18 3 18
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
-
Capped EDU Credit 4.13 66.08
TOTALS 0 0 0 23 64 23 _ -2.08
Current Fixture Value -2.08 divided by 16= -0.130 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -2.08 divided by 16= -0.130 over (under) $ (663.00)
Enter EDU Change Here -0.130 *
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes: .63 EDU credits applied from PLM2015-00208 and 3.5 EDU credits applied from PLM2074-00272.
Authorized Name/Signature: Dianna Rowse Date: 10/5/2015
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 1'allySheet_5110_070115.xlsx