Permit q CITY OF TIGARD PLUMBING PERMIT
s ' COMMUNITY DEVELOPMENT Permit#: PLM2015-00396
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/19/2015
Parcel: 2S103BD00602
Jurisdiction: Tigard
Site address: 11930 SW WALNUT ST
Project: Norman Subdivision: 2007-085 PARTITION PLAT Lot: B
Project Description: Connect existing house to sewer service,approximately 200'.
Contractor: WEST SIDE DRAIN Owner: NORMAN,JACK J JR&MARY J
2155 N HOLLADAY ST 2954 RIVER VIEW ST
CORNELIUS, OR 97113 EUGENE, OR 97403
PHONE: 503-522-2727 PHONE: 541-357-0320
FAX:
FEES
Quantity Description Date Amount
200 If Sanitary Sewer 11/19/2015 $100.06
Specifics: 1 12%State Surcharge- 11/19/2015 $12.01
Plumbing
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $112.07
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>. ions to• NC by calling 503.232.1987 or 1.800.332.2344.
Issued y: / Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspection te.
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 RECEIVED FOR OFFICE USE ONLY
City of Tigard nln� 1 9 2015 DatteeByy: // /7 I`�� S" Permit No ip �13-pe,394j�
III
- q 13125 SW Hall Blvd.,Tigard,OR 97225' Plan Review �' l�r��`('�sr
Phone: 503.718.2439 Fax: 503, 4�r �GADQ Date/By: Other Permit No:
I I GARD Inspection Line: 503.639.4175 II T Date Ready/By: Rids ® See Page 2 for
Internet: www.tigard-or.gov UILD»,� DIVISION Notified/Method: Supplemental Information
❑New construction ❑Demolition For special information use checklist
Description Qty. I Ea. I Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CO I t SFR(1)bath 312.70
❑ 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory building SFR(3)bath 500.32
ry g ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other:
Fire sprinkler( sq.ft.) Page 2
AND Site utilities:
Catch basin or area drain 18.76
Job site address: / . I�( ul 1-<-1"'
City/State/ZIP: '7I,ja i' 1 ( lI 0 7�,z Footing drain line,lior near trench drain 18.76 Page
1 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: l �
J / � � � l--!/Ct_ t/< t-t-r- • Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.-Aeo 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.: , >I o3 5 D GCi 4 U4, Backflow preventer 31.27
DESCRIPTION OF Backwater valve 12.51
,{ / Clothes washer 25.02
i'`^.C' l'-/ I .c'� ' r f't �`� Dishwasher 25.02
Drinking fountain 25.02
,-� Ejectors/sump 25.02
u
❑ PROPERTY OWNER . TENA Expansion tank 12.51
3-a_ � /j Fixture/sewer cap 25.02
Name: !� �/ Imo-
Address: � rf 5 ,V U f.Q Floor drain floor siric/hub 25.02
M f� Garbage disposal 25.02
City/State/ZIP: E ka„e nE I V Y ' 7 C
Hose bib 25.02
Phone:6q+) 3 57- (9,3 2., C2 Fax:( ) Ice maker 12.51
❑ te
APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name:
Medical gas(value:$ ) Page 2
I Primer 12.51
Contact name: C,._`; & 5/,( Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) I Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
• Water heater 37.52
Business name: J,� i'4,e ,fQ t Water piping/DWV 56.29
Address: /rf M.. G a $7 Other: 25.02
��/ � ,�/� Subtotal
City/State/ZIP: CDrn,-e cf//t f G 1
Phone: r t1) ) 2 L- ' Fax:( ) �l Ail Minimum permit fee: $72.50
CCB Lie.:" ad-7.7 fi�lLI Plumbing Lic.no.: / b/ Plan review (25%of permit fee)
/;t State surcharge(12%of permit fee)
Authorized sign TOTAL PERMIT FEE
Print name: root et wt._ Date:ill 19/I S 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.\Building\Permits\PLMU-PermitApp.doe 10/01/09 440-4616T(I0/02/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-151 100' 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
El Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ 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
4' ❑ 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: -Lav/Ba 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
Water Extractor fees assessed for the sewer increase must be paid before the
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
4 _
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
ih
I Reimbursement District Payment Worksheet
1 ,,,,,,, ) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
This completed worksheet is to be submitted along with payment for sewer
connection and plumbing permit application by expiration date below.
ENGINEERING TO COMPLETE:
Site Address: 1/9 l o 5I./ Wa to ft f St
Reimbursement District#: /$ Parcel #: 2.5(03 80006 02.
0:.b-•a*
Amount Due: $ - 0 - Anaeuot-Dtie ExpiredOn: r]"4 y e 21 'iS
Applicant: tjQc.k. Ne,r+en Daytime Phone:
❑ Sewer Loan Processed (journal entry to follow for payment)
Deferred Accounts (if applicable):
Owner: Daytime Phone:
Legal Description:
Amount To Be Paid: $
Amount To Be Deferred: $
❑ Deferral Agreement (signed prior to completion of worksheet)
By: �,1 ReA7 Date: 5./re . i S
BUILDING TO COMPLETE:
Reimbursement Amount Paid: $ ---e-- Receipt #: ii//1"
SWR #: 010/5-OO/67 PLM #: 620/5-co 3'74
Enter parcel conditions in Accela (check all that apply):
❑ Enter"paid" condition.
❑ Enter "deferral" condition,if applicable.
By: Date:
Attach this worksheet to sewer permit for records scanning.
I:1Building\Riembursement Districts\ReimDistPaymentWorksheet 021014.docx
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