Permit (75) 4. CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2016-00519
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/13/2016
Parcel: 1S 1356 C00700
Jurisdiction: Tigard
Site address: 10831 SW CASCADE AVE
Project: Rose City Futsal Subdivision: None Lot: None
Project Description: Plumbing for restaurant kitchen:Capping:(3)drinking fountains,(3)2"floor drains,(1)shower stall,(12)lays,(1)
utility sink,(8)toilets,(3)urinals. Adding:(1)dishwasher,(1)expansion tank,(8)2"floor drains,(1)3"floor drain,
(1)ice maker,(1)primer, (2)food prep sinks&(1)water heater.
Contractor: JH KELLY LLC Owner: ICON IPC PROPERTY OWNER POOL 2 L
2311 E 1ST STREET BY INDCOR PROPERTIES
VANCOUVER,WA 98661 2 NORTH RIVERSIDE PLAZA, STE 235
CHICAGO, IL 60606
PHONE: 360-423-5510 PHONE:
FAX: 503-285-0812
FEES
Quantity Description Date Amount
1 ea Dishwasher 10/13/2016 $25.02
Specifics: 1 ea Expansion Tank 10/13/2016 $12.51
31 ea Fixture/Sewer Cap 10/13/2016 $775.62
Type of Use: COM g ea Floor Drain/Floor Sink/Hub 10/13/2016 $225.18
Class of Work: ALT 1 ea Ice Maker 10/13/2016 $12.51
Type of Const: 1 ea Primer
10/13/2016 $12.51
Occupancy Grp: 2 ea Sink 10/13/2016 $50.04
Stories: 1 ea Water Heater 10/13/2016 $37.52
1 12%State Surcharge- 10/13/2016 $138.11
Plumbing
Total $1,289.02
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
Utilitys otification Ce et Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain opy of the rules
or irect questions to OUNOV c ing 503.232.1987 or 1.800.332.2344.
sued By: / Permittee Signature:
/s 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.
Plumbing Permit Application
Building Fixtures
RV( tl AV /111
City of Tigard Received 10 / )"..0.
Permit No. F
: LH AO t 10-60 57 c?
1111 u 13125 SW Hall Blvd.,Tigard,OR Vp2-11 1 3 7016 Plan Review
I Phone: 503.718.2439 Fax: 503.59k166- - Date/By: Other Permit No.: 6u)90/4
_00/87 7
Inspection Line: 503.639.4175 Date Ready/By: Juris. fd See Page 2 for
T I(,ARD
Internet: www.tigard-or.gov it,;i It i)''.` )4,9, A!.) Notified/Method: Supplemental Information
TYPE slyttipiNG DIVISION FEE* SCHEDULE
O New construction 0 Demolition For special information use checklist.
Description I Qty. I Ea. I Total
311 Additi teratio placement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY
OF CONSTRUCTION
SFR(1)bath
312.70
, - ‘
0 1-and 2-family dwelling aCommercial/industrial _SFR(2)bath 437.78
- SFR(3)bath 500.32
0 Accessory building 0 Multi-family
Each additional bath/kitchen 25.02
O Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
,- ..
Job site address: /08 3 ( S_64i Ms cA 6 6. ifli/6. Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP: 71 ,ACI) ()„e 6 6ery; 9' 7 Z 2 ‘-/ Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: Project name: g6)S 6 C,riti 1:14754 1, Manufactured home utilities 50.03
Cross street/directions to job site: 6,e(-.--, --7,?ez,f,e6 "JD 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.:_) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: /5/ 3C6e,,Q270 0 Backflow preventer 31.27
Backwater valve 12.51
DESCRIPTION OF WORKClothes washer
25.02
#04i96 E•40 k'/'T(2.,/.)£/? Dishwasher 1 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
'PROPERTYDWNER 0 TENANT :::l:-t-?::7 ' Expansion1 12.51 i 2,S-/
Fixture/sewer cap 3/ 25.02
Name: 4,e ex/s 4 z, cy dew/.4,y77/4 6/ 6,e00 p
Floor drain/floor sink/hub 1 25.02
7,25.,0
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker / 12.51 i L .5_/
CONTACT PERSONInterceptor/grease trap
0 APPLICANT , 0 25.02
Business name:
Medical gas(value:$ ) Page 2
NTH kt--(_( 14 Primer / 12.51 1 0.,7` 1
Contact name: p /C 14 R j-t 6 Z_A Roof drain(commercial) 12.51
Je7 d'.6_2-7-
Address: 2_3 I 1 )-/i2-JY S'7,(.,,, ( Sink/basin/lavatory 2.- 25.02 Co.0
City/State/ZIP: V4 y7C.,0 M 1,45C, i,diV q8 66/ Solar units(potable water) 62.54
Phone:(5o3) ri 5'7 - (,7 B9 V Fax::(c03) 28S- 0E3...;'el Tub/shower/shower pan 12.51
Urinal 25.02
E-mail: K r e 2,1- 7-0 44 g 3---.1-1v C-e„,L,(4,con,k
Water closet 25.02
CONTRACTOR -
, Water heater / 37.52 3/5-1
Business name: 0-.44 k 6 eLi1 Water piping/DWV 56.29
Address: 7- i / c r-ilk cr- ..c7- CET- Other: 25.02
City/State/ZIP: V
A y)a 3,v,lice 4.0 A. 91:c'6 6-,/ Subtotal 86-ei,q/
Phone:6.(;) ) 5 sci 31.7 v N)1,4 Fax:( ...)3) 28 5-,--.. 00-. ci Minimum permit fee: $72.50 ----
` 14.4 ‘ Plan review (25%of permit fee) --•
CCB Lie.: 0 / /-7 .. e.,/(,_/ IV Plumbing Lie.no.: Zpi.,1 ri‘ap -
Authorized signature: A g(i...__ ' s.-7-1..2 f b State surcharge(12%of permit fee) i 3 q4\p/1
TOTAL PERMIT FEE /9‘g,„0121
This permit application expires if a permit is not obtained within 180 days
Print name: et .4,, Ritte, to,, Date:IC)- 13- 2014
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PermitApp doc 10/01/09 440-4616T(10/02/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-1st 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
Stonn&Rain Drain-1st 100' 62.54 Valuation: Permit Fee:
$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 Qt Fee(en) Total and ncladudioga$10,l$100.00. or fraction thereof,to
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*. Pion 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 ❑ Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
engineer.
-Jacuzzi/Whirlpool
Car Wash: Each Stall
0 New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities.
Dishwasher: -Commercial 1 ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain 3
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2" 3
Isometric or Riser Diagram
4„
0 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/Bar non-food related $2
-Bradley
-Com/Serv/Util food related
-Service l *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
Other Fixtures:
I:\Building\Permits\PLMF PermitApp.doc 08/04/2011 2
Accumulative Sewer Tally
II Tenant Name: Rose City Futsal SWR# N/A
T_�G n R D Site Address: 10831 SW Cascade Ave PLM# 2016-00519
Parcel#: 1 S 135BC00700
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 1 4 1 4
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 3 3 0 -3 -3
Eye Wash 1 0
0 0 0 0
Floor Drain/Sink: -2 inch 2 0 3 6 8 16 5 10
-3 inch 5 0
0 1 5 1 5
-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 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 1 2 0 -1 -2
Sink:
-Lay/Bar-Non-Food Related 2 0 12 24 0 -12 -24
-Bradley 5 0
0 0 0 0
-Com/Sery/Util-Food Related 3 0 1 3 2 6 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 8 48 0 -8 -48
Urinal 6 0 3 18 0 -3 -18
Previous EDU Count 0 0
Capped EDU Credit
0
TOTALS 0 0 31 104 13 32 -18 -72
Current Fixture Value -72 divided by 16= -4.500 Current EDU 1 EDU= $5,300.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -72 divided by 16= -4.500 over (under) $ (23,850.00)
Enter EDU Change Here -4.500 *
*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: This permit is for restaurant/kitchen being added. Credits for additional fixtures capped.
Authorized Name/Signature: Debbie Adamski Date: 10/13/2016
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\SewerTallySheet_5300_070116.xlsx