Permit (89) LCL1 1V ' I
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City of Tigard 0 I O\Im UNIT)" DB.VELOPiNd LINT DEPARTNIENT MAR 1 4 "2018
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: 2 Request for Permit Action
CITY (It'TIGARb
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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
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FROM: n Owner Applicant , ..,,
' : („ ntractor City Staff
check(v.„o.i.,
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REFUND OR Name:
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PLEASE TAKE ACTION FOR THE l'rEM(S) CHECKED (1'):
' .., CANCEL/VOID PEMEIT APPrAcATI( N.
REFUND PERMIT FEATS (attach copy of original receipt and provide explanation below).
I INVOICE', R.)R FEF.S DUB (attach case fee schedule and provide explanation below).
L RENR)v-E/REpi..ACE CONTRACR.)R ON PERMIT (do not cancel permit).
Permit 4: 21)/1
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Project Name: ,. / 7-
Subdivision Name: 1.ot#:
EXPLANATION: )1 e• (... .;11,4,Ci2..if ti''''Cia•-tt 10
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Signature: c..... : ....... -4' a ......e,c„,.,„,--eLte_ Date:
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Refund Polic
I. The city's Community Development Director,Building Official or Ciro i',,nOncer may authorize the refund of:
• Any fee which was erroneously Hid or colhvict I.
fir Not more Titan 8trfi,of I heap plicizion Cr plan review fee when an application is withdrawn or canceled before review effort
has been ciTended.
• NOi more than SO ro ofthe application its permit to hit issued periling prim to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via l'S p,s,tal eerYke,
Please allow 3-4 weeks for processing refund rcqucszs.
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FOR OFFICE USE ONLY
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Refund Processed: Dare By 4e, Invoice Processed: Date By
Permit Canceled: Date ,.. , I Bv ----- -Pared'fag Added: Dare By
le,Biaiding‘,,IS ifirI„ReuPeimiLAr tion j m'2:14.doc
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TIGARD
City of Tigard
April 18, 2018
Power Plumbing
PO Box 19418
Portland, OR 97280
Re: Permit No. PLM2017-00522
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12909 SW 68th Pkwy, #350
Project Name: Williston Financial Group
Job No.: N/A
Refund Method: ® Check#228217 in the amount of$64.96.
❑ Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 Trust account"deposit"receipt in the amount of$ .
Comment(s): Per applicant's request as job was cancelled. Refund 80% of permit fees.
f 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
71 CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2017-00522
Date Issued: 12/14/2017
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 350
Project: Williston Financial Group(WFG) Subdivision: WEST PORTLAND HEIGHTS Lot: 9-25,PT
Project Description: CAP(1)2"floor drain and(1)sink for TI.
Contractor: POWER PLUMBING CO Owner: PACIFIC REALTY ASSOCIATES
PO BOX 19418 ATTN: N PIVEN
PORTLAND, OR 97280 15350 SE SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: 503-244-1900 PHONE:
FAX: 503-244-8825
FEES
Quantity Description Date Amount
2 ea Fixture/Sewer Cap 12/14/2017 $50.04
Specifics: 1 12%State Surcharge- 12/14/2017 $8.70
Plumbing
Type of Use: COM 22 ea Minimum Fee Adjustment- 12/14/2017 $22.46
Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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:e/112"51:/// Permittee Signature: ��5 64-77 a�
``��// 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 ApplicatiorH I ; ';/E Ii"y
Building Fixtures DEC1 2017
City of Tigard Received / �r
DateBy: / 2//y �7 -PermitNo14/7 /7 G'o$2 '.
41 13125 SW Hall Blvd.,Tigard,OR 972 �S k. j m r -•.; '-?'''' Plan Review
IPI1 Phone: 503.718.2439 Fax: 503.5 Other Permit N .
Inspection Line: 503.639.4175 e c�,1+ `t,l t ! ','".L ateBy: 626/4?Q`2 fa/
i I G A R U Internet: www.ti ard-or. ov bate Ready/By: f ^� 7ur s: ® See Page 2 for
g g Notified/Method/2//'// / AJ1 Supplemental Information
TYPE OF WORK e--47 Fj74-- <j 77 T FEE* SCHEDULE
0 New construction 0 Demolition For special information use checklist.
Description I Qty. I Ea. l Total
®Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
0 1-and 2-family dwelling ®Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address:12909 SW 68TH PKWY Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:TIGARD,OR 97223
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.:350 I Project name:17-809 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
TENANT IMPROVEMENT
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name: Fixture/sewer cap 2 25.02 50.04
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name:POWER PLUMBING CO Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:MIKE WARREN .
Roof drain(commercial) 12.51
Address:P.O.BOX 19418 Sink/basin/lavatory 25.02
City/State/ZIP:PORTLAND,OR 97280 Solar units(potable water) 62.54
Phone:(503)244-1900 Fax::(503)244-8825 Tub/shower/shower pan 12.51
E-mail:SERVICE@POWERPLUMBINGCO.COM Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name:POWER PLUMBING CO Water piping/DWV 56.29
Address:6611 SW MULTNOMAH BLVD Other: 25.02
City/State/ZIP:PORTLAND,OR 97223 Subtotal 50.04
Phone:(503)244-1900 I Fax:(503)244-8825 Minimum permit fee: $72.50 72.50
Plan review (25%of permit fee)
CCB Lic.:52378 Plumbing Lic.no.:34-150PB
State surcharge(12%of permit fee) 8.70i./'''''Authorized signature: f�/ -L/�1�� TOTAL PERMIT FEE 81.20 t
Print name:KRISTIE BwELL t Date:12-11-17 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.
1:1Building\Permitc\PLMU-PermiIApp.doc 10/01,09 440-46I6T(10/02JCOM/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-I"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
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*.
Quantiy by Fixture Type Plan Review for Plumbing Installations
Replace/
Plan review is required for any of the following.
Fixture
or Performed: Capped Added Relocate
Baptistry/Font Please check all that apply.
Bath -Tub/Shower 0 Any new commercial building with water service 2"and
-Jacuzzi/WhirlpoolTub/Sower greater,except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru 0 New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918-780-0040.
Dishwasher -Commercial 0 Medical gas and vacuum systems for health care facilities.
-Domestic 0 Any multipurpose fire sprinkler system.
Drinking Fountain 0 Any complex structure as defined in OAR918-780-0040.
Eye Wash
Floor Drain/sink -2" I Submit 2 sets of plans with any of the above.
-3"
Isometric or Riser Diagram
Car Wash Drain
0 Isometric or riser diagram is required for new buildings
Garbage -Domestic-non-food
Disposal -Domestic-food related that meet the qualifications above.
-Commercial-food related
-Industrial-food related
Ice MachiRefrig.Drains
Oil Separator(Gas Station) Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/lav -Non-food related 1
-Bradley
-Commercial-food related
-Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer-Clothes
increase of sewer EDUs,a sewer permit will be issued and
Water Extractor
Water Closet-Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
C:\Users\Laura\Downloads\PLMF_PermitApp(9).doc 2
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a Tenant Name: Williston :plativeil
SGroup
Sewer Tally SWR# N/A
T t G A K D Site Address: 12909 SW 68th Pkwy,Suite 350 PLM# 2017-00522
Parcel#: 2S101AD03200
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 1 2 0 -1 -2
-3inch 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 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/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 0
TOTALS 0 0 2 4 0 0 -2 -4
Current Fixture Value -4 divided by 16= -0.250 Current EDU 1 EDU= $5,500.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -4 divided by 16= -0.250 over (under) $ (1,375.00)
Enter EDU Change Here -0.250 *
*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: EDU CREDITS
Authorized Name/Signature: Dianna Howse Date: 12/14/2017
Building Division
INote: 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_5500_070117.xlsx