Permit (38) CITY OF TIGARD PLUMBING PERMIT
F "�. Permit#: PLM2017-00009
COMMUNITY DEVELOPMENT
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/17/2017
F['t�� Parcel: 2510361306700
Jurisdiction: Tigard
Site address: 12385 SW 121ST AVE
Project: Humphrey Subdivision: None Lot: None
Project Description: Install new bath in basement with ejector pump.
Contractor: FAR WEST PLUMBING Owner: HUMPHREY, GRETCHEN G
PO BOX 597 12385 SW 121ST AVE
ESTACADA, OR 97023 PORTLAND, OR 97223
PHONE: 503-329-6461
HONE: 503-318-5148
FAX:
FEES
Quantity Description Date Amount
1 ea Clothes Washer 01/17/2017 $25.02
Specifics: 1 ea Ejectors/Sump 01/17/2017 $25.02
1 ea Lavatories 01/17/2017 $25.02
Type of Use: SF 1 ea Tub/Shower/Shower Pan 01/17/2017 $12.51
Class of Work: ALT 1 ea Water Closet 01/17/2017 $25.02
Type of Const: 1 12%State Surcharge- 01/17/2017 $13.51
Occupancy Grp: Plumbing
Stories:
Total $126.10
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 dir' questions UNC by calling 503.232.1987 or 1.800.332.2344.
Iss ed By: ill / / Permittee Signature:
uLa +.I
A,4.4—.1,4 1-•-•"(.
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 Applicah i, ' ' }
Building Fixtures FOR OFFICE ESI: O"1.1
City of Tigard ' ' 1 i Date/By / /7 /7 (.... .-09 PermitNo.: u/gp/7--cocoq
lig 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
C Phone: 503.718.2439 Fax: 503„,59 ,1960. •€ ,t Date/By: Other Permit No.:
Inspection Line: 503.639.4175 ' '
T I G A R D Date Ready/By: Juris: H See Page 2 for
Internet: www.ti and-or. ov I./
g g t „ t , i Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist.
Description I Qty. I Ea. I Total
ra 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
1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: OR 97�23 Catch basin or area drain 18.76
�, 8`5 .s ' /2/R v. ,j p.- V Drywell,leach line,or trench drain 18.76
City/State/ZIP: J Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: ` wkr Vkre 4 0 0.1-k Manufactured home utilities 50.03
Cross street/directions to job site: r Manholes 18.76
10 f/pc) d /l)a f 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.: Backflow preventer 31.27
DESCRIPTION OF WORK '
Backwater valve 12.51
a ' Clothes washer 1 25.02 0t),
7: ,44...L...; . r°o Y'Ant vl base on e yl 4 v 5 Dishwasher 25.02
t.✓ y 41, .e v. o r p t.t.w.t r Drinking fountain 25.02
Ejectors/sump '; '--- 25.02 d,7,v,j.
PROPERTY OWNER 1 ; 0 TEN Expansion tank 12.51
/'a r• Fixture/sewer cap 25.02
Name: ll�� eH to w.--,ID e y
Floor drain/floor sink/hub 25.02
Address: 1.2.7 8S S G1 47 I Av. Garbage disposal 25.02
City/State/ZIP: 77arc i OQ 9 7 223 Hose bib 25.02
Phone:($1,3)3 _ - 64-14 l Fax:( ) Ice maker 12.51
Interceptor/grease 25.02
�.."APPLICANT 0 CONTACT' E'ENtrap
Business name:
Medical gas(value:$ ) Page 2
Contact name: Primer 12.51
Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory 1 ✓ 25.02 /5-03,
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan ( 12.51 1
5.'I
E-mail: Urinal 25.02
CONTRACTOR Water closet j '- 25.02 ,c?,.'
, Water heater 37.52
Business name: KO.,,,- We)4 1`t�� %v.3 Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: E,s I-4 C w Lk j 0 a 7l1\11 Subtotal //J S-4
Phone:(5o3)3/J S/ if ,S)- Fax:( ) 3• Ac f le Pb Minimum permit fee: $72.50
Plan review (25%of permit fee)
CCB Lic.: 7 al.5---7 1 III 1 c Plumbing Lic.no.:3(.3 p-3---r
8. / State surcharge(12%of permit fee) 1 3, s i
Authorized signattu 'r!�/�'
TOTAL PERMIT FEE l/
.1(s 10
Date: This permit application expires if a permit is not obtained within 180 days
Print name:
1 G C N !e t' .Z// / 2()/L 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-15'100' 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
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.
Dishwasher: Commercial
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"
Isometric or Riser Diagram
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
-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 plumbing permit can be issued.
Urinal
Other Fixtures:
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