Permit (176) CITY OF TIGARD PLUMBING PERMIT
8 COMMUNITY DEVELOPMENT Permit#: PLM2016-00568
13125 SW Hall Blvd.,Ti Date Issued: 11/21/2016
Tk°C�tft. and OR 97223 503.718.2439 9
Parcel: 2S112DC00201
Jurisdiction: Tigard
Site address: 15865 SW 72ND AVE, BLDG#C
Project: ChemWest Subdivision:.HERN PACIFIC TIGARD INDUSTRIAL Lot: 3
Project Description: Cap(1)lay&(1)water closet. Relocate(1)break room sink.
Contractor: DEAN WARREN PLUMBING&REMODELING INC Owner: PACIFIC REALTY ASSOCIATES LP
PO BOX 14701 ATTN: N PIVEN
PORTLAND, OR 97293 15350 SW SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: 503-236-4152 PHONE:
FAX: 503-296-2218
FEES
Quantity Description Date Amount
2 ea Fixture/Sewer Cap 11/21/2016 $50.04
Specifics: 1 ea Sink 11/21/2016 $25.02
1 12%State Surcharge- 11/21/2016 $9.01
Type of Use: COM Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $84.07
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 • ' .tiomnter. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or."ect questions to O C 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 d e.
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.
Accumulative Sewer Tally
. .
11 - Tenant Name: Chemwest SWR# N/A
Site Address: 15865 SW 72nd Ave PLM# 2016-00568
TIGARD
Parcel#: 2S112DC00201
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 0 0 0
-3inch 5 0 0 0 0 0
-4inch 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 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 1 2 0 -1 -2
-Bradley 5 0 0 0 0 0
-Com/Sery/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 1 6 0 -1 -6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 2 8 0 0 -2 -8
Current Fixture Value -8 divided by 16= -0.500 Current EDU 1 EDU= $5,300.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -8 divided by 16= -0.500 over (under) $ (2,650.00)
Enter EDU Change Here -0.500 *
*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: ***CREDITS***
Authorized Name/Signature: Debbie Adamski Date: 11/21/2016
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
Plumbing Permit Application
Building Fixtures
CI Of TI and RECEIVED Received f 7-\ ,
City g
Date/By: it/a( /(0 J� Permit No.: 144,9.0/4,_00 (0,
• 13125 SW Hall Blvd.,Tigard,OR 97��223Plqq��pp )
£1\116 V G 1 2 016 Dan By Review:14 = i o,(.LP��ID'�5/
Phone: 503.718.2439 Fax: 503.59 Other Permit No.:
Date/By:Line: 503.639.4175 s: H g
TIG A R D Date Ready/By: JuriSee Page 2 for
Internet: www.tigard-or.gov CITY OF- .1 i(4 fYRD Notified/Method: Supplemental Information
TYPE 0601tROING DIVISION FEE* SCHEDULE
❑New construction 0 Demolition For special information use checklist
Description Qty. Ea. Total
{,Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY.OF CONSTRUCTION SFR(1)bath 312.70
a�.
0 1-and 2-family dwelling `Commercial/industrial SFR(2)bath 437.78
0 Accessory building 0 Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
0 Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 15. (Q5 .5 L `--alarm AO El Catch basin or area drain 18.76
.�f g....if-A0 � � Drywell,leach line,or trench drain 18.76
City/State/ZIP: V
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: "3 Project name: el-fi'v1/4..E 51' 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.: ) Page 2
Subdivision: () I ' l I Lot no.: Fixture or item:
Tax map/parcel no.: Otto , Backflow preventer 31.27
�s t �`oZ 1
DESCIR 'ION.OF WORK
Clothes washer 25.02
Backwater valve 12.51
9E�U 1 t�; `r
Dishwasher 25.02
ee.,OLA �-- 1 .t e,EV\ 1,c._ 5r i)Y'_ Drinking fountain 25.02
Ejectors/sump 25.02
PROPERTY OWNER , 0 TENANT Expansion tank 12.51
Fixture/sewer cap 'Z 25.02 „J. °
Name: y
P C u 5� Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT Q CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory 1 Ile 25.02 , 6:€%'9--
City/State/ZIP:
S 9-
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: V pr '�A � (� '('L � . f\�1 1_1(K). G,,vim, Urinal 25.02
Water closet 25.02
CONTRACTOR
:c:
Water heater 37.52
Business name: ��4� oma' ,{��.E}� rLt/�..fl /3 i C2 Water piping/DWV 56.29
Address: PC) t30)L 4!.j --1.01 Other: 25.02
City/State/ZIP: (beg-LA 0 _ C1" 2((-. Subtotal 7S.oCp
Phone:(c,, c�� G� ( ) Minimum permit fee: $72.50
`�w,3) .��� - t�{ �jl Fax:
CCB Lic.: ISLI ll I Plumbing Lic.no.: a Le...-7,312e8 Plan review (25%of permit fee)
State surcharge(12%of permit fee) 9.of
Authorized signature: Cog
( (I m o f ; Q (G' TOTAL PERMIT FEE CL/.O6'1 l V MPEC- This permit application expires if a permit is not obtained within 180 da s
Print name: !6� Date: (�-t�C. ' L. pp after it has been accepted as complete. y
*Fee methodology set by Tri-County Building Industry Service Board.
\
I:Building\Permiitts\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-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 Fee(ea) Total each additional$100.00 or fraction thereof,to
pand 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 Plum ! g Installati+as
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for 4 Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
0 Any new commercial building with water service 2"and
Baptistry/Font 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
as defined in OAR918-780-0040.
-Drive Thru
Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities.
CW
C Dishwasher: -Commercialirator 0 Any multipurpose fire sprinkler system.
Domestic 0 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 x.h
4"
0 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 J /
-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 fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet a plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2