Permit (229) CITY OF TIGARD PLUMBING PERMIT
1 1 COMMUNITY DEVELOPMENT Permit #: PLM2012 -00318
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/01/2012
Parcel: 2S115BA02500
Jurisdiction: Tigard
Site address: 16200 SW PACIFIC HWY S
Project: Gentle Dental Subdivision: 2004 -015 PARTITION PLAT Lot: 1
Project Description: Installation of plumbing for new dental office.
Contractor: PMSI LLC Owner: SN PROPERTIES PARTNERSHIP
21195 NW EVERGREEN PKWY #204 1121 SW SALMON ST
HILLSBORO, OR 97124 PORTLAND, OR 97205
PHONE: 503 - 466 -2222 PHONE:
FAX: 503- 466 -2211
FEES
Quantity Description Date Amount
4 ea Backflow Preventer 10/31/2012 $125.08
Specifics: 2 ea Floor Drain /Floor Sink/Hub 10/31/2012 $50.04
1 ea Ice Maker 10/31/2012 $12.51
Type of Use: COM 2 ea Sink 10/31/2012 $50.04
Class of Work: ALT 7 ea Lavatories 10/31/2012 $175.14
Type of Const: 2 ea Water Closet 10/31/2012 $50.04
Occupancy Grp: 1 ea Water Heater 10/31/2012 $37.52
Stories: 1 12% State Surcharge - 10/31/2012 $60.04
Plumbing
Total $560.41
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:
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.
Oct. 30. 2012 11:24AM No. 6714 P. 2
Plumbing Permit Application
Building Fixtures RECEIVE
City of Tigard OCT 3 0 2012 y /o , // ij Pe�i1N :/Y111 /2-oa, le
q 13125 SW Hall Blvd., Tigard, OR 97223
Plan Review �0 /2.��7
% Phone; 503.718.2439 Fax 503598t iTV Y Other Permit No.:
Inspection Lino: 503.639.4175 j ��1�1G�1�
T l `"' R" ie go B UILDING DIVISIC Read y/By: �r /3/ � -' '� I seePene2 for
Internet wwwli d or. v / 14 Supplemental See Paget for
TYPE OF worm FEE SCHEDULE
❑ New construction ❑ Denmlition For special information use checklist:
Description I Qty. I Ea. ( Total
® Add i lion/alteration/replacement ❑ Other. New I- 2-family dwellings (includes 10011. for each utility connection)
CATEGORY OP CONSTRUCTION SFR (1) bath 312.70
❑ 1- and 2- family dwelling ® Commerial/induslrial SFR (2) bath 437.78
spR (3) bath - 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kilchen 25.02
❑ Master builder ❑ Other. Fire sprinkler ( sq. ft.) Page 2 1
JOD SITE INFORMATION AND LOCATION Site utilities: O
Job site address: 16200 SW Pacific Hwy Suite S Catch basin or area drain 18.76 -N1
City /Stato/ZTP: Tigard, OR 97224 Drywall, leach line, or trench drain 18.76 \
Fooling drain (no. linear fl.: _) Page 2
Suite/bldg./apt. no.: I Project name: Gentle Dental Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 1816
Sanitary sewer (no. linear 0.: , ) Page 2
Storm sewer (no. linear 0.: ) Page 2
Wafer service (no. linear 11.: ) Page 2
Subdivision: I Lot no.: Fixture or Item:
Tax map/parcel no.: a / / 564 O; 500 Backflow preventer 4 31.27 T 125.08
• DESCRIPTION OF WORT{ Backwater valve 12.51
Clothes washer 25.02
Plumbing for new dental office Dishwasher 25.02 _
Re: permit DUP2012 -00071 Drinking fountain 25.02
~
Ejectors/sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 ,
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/ 2 25.02 50.04
Address: Garbage disposal 25.02
City /State/ZIP: Hose bib 25.02
Phone: ( ) Fair ( ) Ice maker 1 12.51 12.51
❑ APPLICANT ❑ CONTACT PP.nsoN Interceptor /grease trap 25.02
Business name: Medic ga s (value: S ) y Page 2
Primer 12.51
Colltnet name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 9 25.02 225.18
City /StateZTP: Solar units (potable water) 62.54
Phone: ( ) l Fax: : ( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 2 25.02 50.04
Water heater 1 37.52 3732
Business name: PMSI LLC
Water piping/D W V 56.29
Address: 21195 NW Evergreen Pkwy Suite 204 Other: 25.02
City /State/ZIP: Hillsboro, OR 97124 Subtotal 500.37
Phone: (503) 466-2222 k (ie' T Fax (503) 466 -2211 Minimum permit fee: 572.50
' Plan review (25 %ofpermit fee) ._125.09 4
CCE Lie.: 158286 Plumbing Lie. no.: 34 -434PB
State surcharge (12 %ofpermit fern) 60.04
Authorized siguetu p r TOTAL PERMIT PEE St85 fr d i
This permit opplicallon a 1piros ire permit is not obtained within 180 days e n •
` `
Print name: Lana inson I Date: 10/30/12 , i /
after ft has been accepted as complete.
'Poo methodology set by Tri.Couoty Building Industry Service nosed,
Oct. 30. 2012 11:24AM No. 6714 P. 3
, 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 - la 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 5233.20
Sewer - let 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
Stone & Rain Drain - each additional 100' 37.52 $5.001.00 to $10,000.00 $72.50 for the first 55,000.00 and $1.52 for
Other Inspections or Fees Qty. Fee (ea) Total and including $10,000.00. fraction thereof, to
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $145.50 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 ofnormal 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
Reinapection Fees 90.00/hr and including $59,000.00.
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 *.
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type !br Replace/
Plan review is required for any of the following.
Work Perrbrmed; Capped Added Relocate
Please check all that apply.
Baptistry/Font
Bath - Tub/Shower ❑ Any new commercial building with water service 2" and
- JacruJWlrirlpool greater, except systems designed and stamped by licensed
Car Wash - Each Stall etrgineer.
- Drive 11uu • ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918- 780-0040.
Dishwasher - Commercial _ ® Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system
Drinking Fountain ❑ Any complex structure as defined in OAR918- 780•0040.
Eye wash
Floor Drain/sink - 2" 2 Submit 2 sets of plans with any of the above.
- 3"
Isometric or Riser Diagram
Car Wash Drain ❑ 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
- Induslrial -food related
Ice MaelJRefri& Drains
Oil Separator (Gas Station) Comments regarding fixture work:
_ltec. Vehicle Dump Station
-
Shower -Gang
-Stall
-
SiukfLav - Non -food related _ 6 1
- Bradley
- Commercial -food related 1
- Service 1
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer - Clothes
Water Extractor increase of sewer E)DUs, a sewer permit will be issued and
Water Closet - Toilet 1 1 fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
NATIONAL ITC /C1,2o0 w l�� c � � Receipt
p
501 SHATTO PLACE, #201
LOS ANGELES, CA 90020 p ( /,,7 - 00 / ?f
Phone # (877)457 -6482
Fax # (213)351 -7632
E -mail Diana @nationalitc.com
Bill To:
Order # 00037142
Russ Kosters Jr Date 11/12/2012
21195 NW Evergreen Pkwy -
Suite 204
Hillsboro, OR 97124 CREDIT CARD
Date Description Qty Rate Billed Paid
11/12/2012 Braze Continuity for Kenny Flaig (12017384) 1 $25.15 $25.15 $25.15
Payable To: N.I.T.0 Total: $25.15
Credit Card Type: ❑ Visa ® Mastercard ❑ American Express Amount Paid: $25.15
Credit Card Number: Auth Code: 012184
Expiration: 04/2016 Ref No: 101592147
Name: Russ Kosters Jr Check Acct:
Address: 21195 NW Evergreen Pkwy, Suite 204 City: Hillsboro State: OR Zip 97124