Permit (115) g CITY OF TIGARD f { PLUMBING PERMIT
1114 2; COMMUNITY DEVELOPMENT MEM Permit#: PLM2015-00410
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/07/2015
TIGARD Parcel: 15136C604400
Jurisdiction: TIGARD
Site address: 8500 SW SPRUCE ST
Project: Japanese International Baptist Church Subdivision: WEST PORTLAND HEIGHTS Lot: M
Project Description: Plumbing fixtures for new multipurpose building.6/3/2016: REPRINT permit to include underground plumbing only
for 50'of water service and(3)floor drains.
Contractor: MIKE PATTERSON PLUMBING Owner: JAPANESE INTERNATIONAL BAPTIST C
15028 S MITCHELL LN 8500 SW SPRUCE ST
OREGON CITY, OR 97045 PORTLAND, OR 97223
PHONE: 503-632-7374 PHONE:
FAX: 503-632-5647
FEES
Quantity Description Date Amount
50 If Water Service 12/07/2015 $62.54
Specifics: 3 ea Floor Drain/Floor Sink/Hub 12/07/2015 $75.06
73 Plumbing Permit 12/07/2015 $72.56
Type of Use: COM 25 12%State Surcharge- 12/07/2015 $25.23
Class of Work: NEW Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $235.39
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 questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature: O,c, ,�i��L /C��7d�✓
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.
CITY OF TIGARD MASTER PERMIT
11
8 v COMMUNITY DEVELOPMENT ? a Permit#: MST2016 00012
• 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/08/2016
TIGARD G ARD Parcel: 2S 111 AB02700
Jurisdiction: Tigard
Site address: 9425 SW MOUNTAIN VIEW LN
Subdivision: ELROSE TERRACE Lot: 23
Project: Freeman
Project Description: Construct 488 sq ft detached shop/garage. 5/26/2016: REPRINT permit to remove electrical
work as this work was completed and inspected under ELC2016-00294.
BUILDING
Floor Areas Required Setbacks Required
Stories: 1 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 11 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke
Dwelling Units: 0 Third: 0 sf Right: 5
Detectors: No
Total: 0 sf Value: $20,000.00 Rear: 5
PLUMBING
Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0
Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF RainStorm Sewer: 0
0
Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0
Other Fixtures: 0
Drywell-Trench Drain: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0
Heat Pump: N Hoods: 0 Other Units: 0
Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp SrvclFeeders Branch Circuits
1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add.'500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc,/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing: N
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
ACS SF VB U 0
Owner: Contractor:
FREEMAN,DANA H&CHARLES W JR OWNER Required Items and Reports(Conditions)
9425 SW MOUNTAIN VIEW LN
TIGARD,OR 97224
PHONE: 503-453-6743 PHONE:
FAX:
Total Fees: $801.10
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 questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Al/
Issued By: /� Permittee Signature: e/f� /PG/���Q
Call 603.639.4175 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.
:,ii r; _ PLUMBING PERMIT
. ;(yl„ CITY OF TIGARD
°'- It :•..' COMMUNITY DEVELOPMENT Permit#: PLM2015 00410
Date Issued: 12/07/2015
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1S136CB04400
Jurisdiction: TIGARD
Site address: 8500 SW SPRUCE ST
Project: Japanese International Baptist Church Subdivision: WEST PORTLAND HEIGHTS Lot: M
Project Description: Plumbing fixtures for new multipurpose building.(1)drinking fountain,(3)2"floor drains,(1)breakroom sink,(6)
lays,(1)mop sink,(1)urinal,(4)toilets&(1)water heater.Also,50'of water service.
Contractor: MIKE PATTERSON PLUMBING Owner: JAPANESE INTERNATIONAL BAPTIST C
15028 S MITCHELL LN 8500 SW SPRUCE ST
OREGON CITY, OR 97045 PORTLAND, OR 97223
•
PHONE: 503-632-7374 PHONE:
FAX: 503-632-5647
FEES
Quantity Description Date Amount
50 If Water Service 12/07/2015 $62.54
Specifics: 1 ea Drinking Fountain 12/07/2015 $25.02
3 ea Floor Drain/Floor Sink/Hub 12/07/2015 $75.06
Type of Use: COM 2 ea Sink 12/07/2015 $50.04
Class of Work: NEW 5 ea Lavatories 12/07/2015 $125.10
Type of Const: 1 ea Urinal 12/07/2015 $25.02
Occupancy Grp: 4 ea Water Closet 12/07/2015 $100.08
Stories: 1 ea Water Heater 12/07/2015 $37.52
1 12%State Surcharge- 12/07/2015 $60.05
Plumbing
Total $560.43
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 questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signaturq�`-c—�-� G�.�
'AI' Lam'- i c�%7` ���
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.
Dec. 02 .2015 10:27 AM Mike Patterson Plumbing 5036554349 PAGE. 1/ 1
Plumbing Permit Application q
Building Fixtures RECEIVED
City of Tigard Received �� �s Pormlt No
1,101 • 13125 SW j•In11131vd„'I'igard,OR 9f C 2 2015 -Datc/Ry; "�"'� (f�°y���/QS�`�, %,o
I Phone: 503.718.2439 Fax: 503.5. 1960 Pian ty; Other Permit No•:er5g4" 20, 51 e
Dnlulny; (�/�
Inspection Line: 503.639 4175 CITY OF TIGARL7 Y Y to See page 2 for
ttt.ARtl Ditto Road /t3 lurk
Internet: www.tigtird-or ov ,<f�
g (R NolificdlMotho< �� Supplemctthdlnforntntlat
_:fi .. .4,.. iA ;.,i :J4.= ,.,,,i,?,• ,. .Fi,0.0.10'400Crl+;;•'i.0 ,.,.
gel New construction ❑ Demolition For special hl(orntn4nn use_checklist.
Description I Qty. [ Ea. 1 Total
❑Addition/alteration/replacement 0 Other: New 1.2-family dwellings(includes 100 0.lir each utility connection) 13
.rCg;° '',,. ,„yi <,, ; .{.. ,,)- I.. - :i;:,;. S1 R t bath
:. :.'.,.. `;.i'..:, .',4, ` .01 tri .- �#.�,,J •� �,, .:, O 312,70
,. ,•i ,.r:�r;:;IN';, 7,f',-' v ,� ,, ,��'•'s.,�,,,.�. �d.n ,,.,:7a�.a�.�.'rv.:a..��'{••„ , <'���''r�p•,.,•�;�, .. _ :,
I-and 2-Minify dwelling SFR(2)bath 437.78 (�
❑ ED Commercial/industrial
SFR(3)bath 500,32
Q Accessory building 0 Multi-family Each additional bath/kitchen 25.02
❑Master builder Li Other;
�t'..:•> q,a .rta ,:?,• -,_ ,,, Fire sprinkler(_____sq.ft.) (rage 2
^:ia";i:1' `� s:1;,�_.i�I'i: ,'' 't ''f `rj ( ';l' is- ;'' Site utlliti' A
,.::.,•-.�;�� ,,,.:,::a; �?b,'yt Q!T ..,�'.��;•�;�� � �Pi,��aG�,,��. "� ,t- '..>:':,;..,,,-V,, t.ra:
:' .,`y'. .,,jY,{?,: ttT..-n �:;�1^;, „ 4«q. ,n..'.3 :.,1'..21,:,,q,..i,:i.:l.i.� • `'
Job site address:8500 SW Spruce St Catch basin or arca drain 18.76
Dr well,leach line,or trench drain 18.76
City/State/ZIP:Tigard,OR 97223 Dry
well,
drain(no.linear It.: ) Page 2
Suite/bldg./apt.no.: LProject name: f ai r�k_ Manufactured home utilities 50.03
Cross street/directions to Job site: (Armholes 18.76
Rain drain connector 18.76
‘rt\
Sanitary sewer(no.linear Il.: ) Page 2
Storm sewer(no.linear fl.: ) Page 2- b
Water service(no.linear ll.:i) 1 Page 2 te2.64,
Subdivision; Lot no.: Fixture or Item:
'fax map/parcel no.: /6/36 Cs(J woo -13acktlow preventer 31.27 41
',tip ':1,,- -;;X::,i yy`` -'-_ ■ •",:r ••r,•` .r. ..r-, - :i,"' i{7 13nekwntcr valve 12,51 1
(lotltos wesher 25,02
Plumbing for new church building. Dishwasher 25,02
0
Drinking fountain I 25.02 .25.O1 -.p
Ejectors/Sump 2.5.02 �J
-
�� y, .,.,,:,, i�.",'�,, . ff�1�'x ,',, �., l.r .,,. •:I;. .i•;,' Expansion tank 12,51
,;, ��t\�"'ra.. ..,�M,;x�,`�, � .�a�i'i•�,;;e•...,�"i '• �':"�I .� ,,yak=!:': ,�i`;'.. ,
Name: Fixture/sewer cup 25.02
Floor drain/floor sink/hub 3 25.02 75;04
Address:
Garbage disposal 25,02
City/State/ZIP: I lose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
•iii '.i:•i ;FI.:: 0i`,.}•A'�. :�`'.•it�. ' ,r1,; :,�.>: '.i'.. . .,p,.,,,).. -.^'!'t
>!P (irl .E 1 Interceptor/greasc trap 25,02
Business name: Medical gas(value:$�) Page 2
Primer 12.51
Contact name:
Roof drain(conunercinl) 12.51
Address: Sink/basin/lavnlory 7 25.02 /76- /y
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
f mail: Urinal 1 25.02 A6.0'3
M nn lM. a Ger. b . .tory)
:,,,' • .,.,.. Water closet 4 25.02 MOD.0`�
'` • e,... ,..,•,.:,i :. ;: Water heater 1 37.52 37,5
Business name:Mike Patterson Plumbing,lac. Water rIr' �
to I)WV 56.29
_ _
Address:PO Box 850 Other: 25.02
City/State/ZIP:Gladstone,OR 97027 Subtotal 500.3,
^Phone:(503)655-4306 Fax:(503)655.4309 Minimum permit lee: $72.50 -
CCB Lia;81746 Plumbing Lie.no.:3-35)1'11 Plan review (25%ol'permlt fee)
State surcharge(12%of permit fee) 46.06"
Authorized signature; TOTAL PERMIT PLG ,05‘6,9�e
Print name: v n i t Date: 12/02/2015 This psi-mit application expires If n permit Is not obtnhted within iso days
atter It has been accepted as complete,
"Foo methodology not by Tri-County Building Industry Sorvlco l3oard.
I:0.luilding1PuralilPll'LMIJ-I'mntitApp don 10/01/09 140.4616'1'(10/OR/CUM/WaII)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
'Site Utilities • Qty7'. Fee 0?) ...Total .Square Footage:,:. :•r Permit Fee: ,r-. -
Footing drain- 1" 100" 50.03 0 to 2.000 SI2I.90
Footing drain-each additional 100' 37.51 2.001 to 3.600 $169.69
3,601 to 7.200 523320
Sewer- 1st 100' 62.54 7,201 and greater S327.54
Sewer-each additional 100' 37.52
Water Service- Ist 100' 622.i4 Medical Gas Systems:
Water Service-each additional 100' 37.52 '- - •
• Valu `Perm
ation:. it Fee :
Storm Rain Drain- 1st 100' 62.54
S1.00 to S5.000.00 Minimum fee S72.50
Storm&Rain Drain-each additional 100' 37.52 S5.001.00 to 510,000.00 $72.50 for the first$5.000.00 and SI.52 for
each additional SI00.00 or fraction thereof:to
Other Inspections or'Fees Qt`'• Fee(ea) •Totaly.:
and including S10.000.00.
Inspection of existing plumbing or for S10.001.00 to$25.000.00 S148.50 for the first S10,000.00 and S I.54 for
which no fee is specifically indicated 90.00/hr each additional SI00.00 or fraction thereof.to
(minimum charge- 1/2 hour) and including S25.000.00.
Inspections outside of normal business 91).1)0/hr S25.001.00 to$50.000.00 S379.50 for the first S25.000.00 and S1.45 for
hours(nininuun charge-2 hours) each additional S 100 00 or fraction thereof:to
Reinspection Fees 90.00/hr and including S50.000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first 55)).0))0.00 and SI.20 for
(minimum charge- I/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*. 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--
El Any new commercial building with water service 2-and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower i
engineer.
-Jacuzzi/Whirlpool
Car Wash: -Each Stall ❑ New exterior plumbing site utilities for any complex structure
Stall as defined in OAR9 I S-730-0040.
-DrivCuspidor/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 OAR9I S-730-0040.
Drinking Fountain r
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2.. •
Isome 'or-RiserDiagram=•, z..
tric
❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
that meet the qualifications above.
Garbage -Domestic non-food
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/Bar non-food related (�
-Bradley
-Com/Sery/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 t
Other Fixtures:
I:\Building\Permits\P LM F_PermitApp.doc 03/04/2011 2
A
City of Tigard . COMMUNITY DEVELOPMENT DEPARTMENT
1at
11 5, Request for Permit Action
- TIGARD 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 0 Applicant E1' Contractor [] City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) ke Pat-hersoyi ? will,itiny
Mailing Address: e o, g ox g5D
City/State/Zip: £ f 16td t OVit, Op 61/027
Phone No.: 50a— (p66-43 Op
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(1):
r(0 =___ :':-.i►APPLICATION.
' FU 1 • - •141T FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
O REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: PLIA 2015- .0011I 0
Site Address or Parcel#: (360 J slit) 6F YU C &L •
gGt 1 a 017223
Subdivision Name: 't/a 1' e4e) 1 ?a.f S,k- Cituff6ii
EXPLANATION: p ,(ml LA04elrj�YII Uri Cb prU,ry1.1a rW 6/11,k4 •
SW R A015 Do l (47 ffES�P#I C . 1
/4/v2S ' Po277ON of A-7211/7" s Pe-72- u«o/,/G D /C I.& . ..4,`
''
Signature: ��� i � Date: x3,12'71 1 Lo
Print Name: / Jh • Y -rhe
)tefund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund oh
• 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 ria US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
;lite to Sys Mina "bate By Route to Record's: date ��3 4.
-
Refund Processed: Date 4731/s„ By Invoice Processed: Date By
Permit Canceled: Date A// Byd ParcelTagAdded: Date By
L\Builder\Porins\RegPemutitction 092314.doc
1111
TIGARD
City of Tigard
June 3, 2016
Mike Patterson Plumbing
Attn: Jennifer Bergen
PO Box 850
Gladstone, OR 97027
Re: Permit No. PLM2015-00410
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 8500 SW Spruce St.
Project Name: Japanese International Baptist Church
Job No.: N/A
Refund: ® Check#221206 in the amount of$325.04.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of$
Comments: Plumbing fixtures reduced to install unground plumbing only. Refund
difference at 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Mike Patterson Plumbing DATE: 5/26/2016
Attn: Jennifer Bergen
PO Box 850 REQUESTED BY: Dianna Howse
Gladstone, OR 97027
TRANSACTION INFORMATION:
Receipt#: 400925 Case#: PLM2015-00410
Date: 12/07/2015 Address/Parcel: 8500 SW Spruce St
Pay Method: CreditCard Project Name: Japanese Int'l Baptist Church
EXPLANATION: Refund 80%of permit fees for plumbing fixtures removed from scope of work.
Contractor performing underground plumbing only.
13,MJND:IN_FORMATION: rcy .°
Fee Descripton`From ReceiptRevefne Aocbunt No ;_"R 4iiii F,`
Example. $u,>kl g Permit Fee Example: 2300660-4104 $: itowit
Plumbing Permit Fees 230-0000-43101 $290.22
12% State Surcharge 100-0000-24001 34.82
TOTAL REFUND: $325.04
APPROVALS: SIG RES DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: ,/„3//,(, By: /ts -'
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
,
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
lII
i 1. Request for Permit Action
TIGARD 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 TigardBuildingPemiits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Er Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: , ,
INVOICE TO: (Business or Individua !�t k e Pa,tl' soy ?i urn b rl)
er
Mailing Address: p O, Box gat
City/State/Zip: alacgton(i, 02 .1/02-7
Phone No.: 5'03— 656 43010
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(1):
liIj,_, • , P O ID PE APPLICATION.
V
Er di i ��j v :A• I FEES (attach copy of original receipt and provide explanation below).
I ❑ •`• . FOR FEES DUE(attach case fee schedule and provide explanation below).
0 e 0 REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: ✓'PLM 2OI5- 00141 0
Site Address or Parcel#: - 06 ao SR) 6 peu U •
l icyd 1 DR X7223
Subdivision Name: japtuiaei Intl 1 af1[a sA- a 044/1
EXPLANATION: p , yyy IN EL!ilei e , yll Lin Ct pt ryi j r"0 O 1i l,/ .
SWR?oI5 00 t (.0 '' FES H 1 �,r��,
A cuN.A /f- P0277oAl bf /4672/P 7 , .S dam2 uf1_6,A/Fr D�efiz_ . `
Signature: +4141 Date: 03,12q I 1 to
Print Name: am i f er ,r6tri
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 payerinthe form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests_
FOR OFFICE USE ONLY
Route'to Sys Aclmux !?ate - .By Route to Records: " ' bite- e �0. R-__=..
Refund Processed: Date 0/3�/io By ..1a Invoice Processed: Date By
Permit Canceled: Date A " By � ., •arcel Tag Added: Date By
I:\Building\Forms\RegPcnnitAct:ion_0923l4.doc
Accumulative Sewer Tally
■ Tenant NIII " ame: Japanese Intenational Baptist Church SWR# 2015-00168 REVISED
Site Address: 8500 SW Spruce St PLM# 2015-00410
TIGARD
Parcel#: 1S136CB04400
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 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 0
Eye Wash 1 0 0 0 _ 0 0
Floor Drain/Sink: -2 inch 2 0 0 3 6 3 6
-3 inch 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 IIP) 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 0 0 0 0
-Bradley 5 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 0
Water Closet-Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 1 16
TOTALS 0 0 0 0 3 6 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 *
*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:Reduction in plumbing fixtures resulted in reduction of sewer EDU and a credit for this project and sewer permit is voided.
Authorized Name/Signature: Dianna Howse Date: 6/3/2016
Building Division
Note: 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\ScwerTallySheet_5100_070115.xlsx
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
8500 SW SPRUCE ST, TIGARD, OR, 97223
Record Type: Record ID:
Commercial - Plumbing PLM2015-00410
Inspection Type: Inspector:
399 Plumbing final Don Sylvester
Result:
PASS - NoCofO
Comments:
Violation Summary:
Inspector Contractor