Permit (176) CITY OF TIGARD PLUMBING PERMIT
s COMMUNITY DEVELOPMENT Permit#: PLM2018-00374
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/14/2018
I�' ' I`Dg Parcel: 2S109AB01400
Jurisdiction: Tigard
Site address: 13285 SW BULL MOUNTAIN RD
Project: SHELBY Subdivision: None Lot: None
Project Description: 200 ft.of sanitary sewer to connect existing residence to public sewer. Septic system must be pumped and filled,
or removed.
Contractor: PORTLAND ROAD&DRIVEWAY CO INC Owner: SHELBY, MATTHEW&TABITHA
10500 SE JENNIFER ST 13285 SW BULL MOUNTAIN RD
CLACKAMAS, OR 97015-9511 PORTLAND, OR 97224
PHONE: 503-650-5006 PHONE: 503-310-8033
FAX: 503-650-8022
FEES
Quantity Description Date Amount
200 If Sanitary Sewer 08/14/2018 $100.06
Specifics: 1 12%State Surcharge- 08/14/2018 $12.01
Plumbing
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $112.07
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 tailed within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you t. follow the r.es adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0'•.. Y. y obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: / / �j Permittee Signature:
/
✓� Art A ✓re►.
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 re A l , E is
Site Utilities AUG / (�qqp /FOR OFFICE USE ONLY /�/
City of Tigard U Fd U 6 tJ Received �/,2 7[ � (L// Per Ft /1 ax-1, ,3>L/
-
q 13125 SW Hall Blvd.,Tigard,OR 97223 :\ Date/By:n l(///�/\ l�[/�
Phone: 503.718.2439 Fax: 503.598.196y911 Plan Review ,ry� q
to ` DateBy: Othel it .: 0/tr � 3
Inspection Line: 503.639.4175 `�V" 1Date Ready/By: Ju,is: H See Page 2 for
TIGARD Internet: www.ti and-or. ov y y g
g g Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
0 New construction 0 Demolition For special information use checklist.
Description I Qty. I Ea. I Total
Ad dition/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
SFR(3)bath 500.32
❑Accessory building 0 Multi-family -
Each additional bath/kitchen 25.02
❑Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2
JOS:SITE INFORMATION AND LOCATION n _ : Site utilities:
Job site address: %"3-z ',--,'c 5 1 ,,,,A\ /0w,n �l Catch basin or area drain 18.76
`^ �& Drywell,leach line,or trench drain 18.76
City/State/ZIP: �'t�,,�
1-�"."' �R. q 1�-Z z Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name:set)et ee,AK!G�4-tO,.4 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
A\1 ;vl t- e. Cr-S* "il Rain drain connector 18.76
Sanitary sewer(no.linear ft.:A oD) Page 2 /00, 06
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
�. . _ Backwater valve 12.51
DESCRIPTION OR WORK..._
. a ` Clothes washer 25.02
�\L Tro?e,eLc.O(AG� "- taZ-V C Si)aoi,' -. Dishwasher 25.02
4vx, c, wtvvi.G�stJ geyJ2C s& A' �pt.1L Ca_.Slc- 14)c4. Drinking fountain 25.02
J Ejectors/sump 25.02
�PROPERTX OWNER I _ TENANT Expansion tank 12.51
/ / Fixture/sewer cap 25.02
Name:
4 ike/l i:k t,4) cc Lt E: (tit/
/ Floor drain/floor sink/hub 25.02
Address: v Z j'-c StiJ J Il ✓t_ ` .e,, Garbage disposal 25.02
City/State/ZIP: 1 or?.._ Cj 7 Z2.4 Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
AFPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name: --- ‘,,keAL ,
"_l Roof drain(commercial) 12.51
Address: , Z b's- j ,1 tA.,(„),„...6,v, zA Sink/basin/lavatory 25.02
City/State/ZIP:Ti I,1 q 7_0,z.c/ Solar units(potable water) 62.54
1 1
Phone:( ; ) i,/0 _,s..--c,3- Fax::( ) Tub/shower/shower pan 12.51
E-mail:A 5 I Co.c,1 S� k e v �,S vt C c9 v,..-A.
Urinal 25.02
�.. Water closet 25.02
CONTRACTOR !
Water heater 37.52
Business name:{Ar`aK� ,,L. '- c.I'vG,,i,u�( Water piping/DWV 56.29
Address: 0 �.�X et 5r-'7_ �J Other: 25.02
City/State/ZIP: 6..ka-ok.S Nr,o.1c_, 0,2__ 9 7-0 2-,'7-
Subtotal
Phone:(SE'S ) Cfl S") '. SOD(p Fax:( )
Minimum permit fee: $72.50 /00, 06,
Plan review (25%of permit fee) of 0 Z
CCB Lie.: tf-t Plumbing Lie,no.: State surcharge(12%of permit fee) / ,O r
Authorized signature: TOTAL PERMIT FEE /3. .,v tf
)jj
Print name: 41- 6�e_,l,j, Date: �-`JJJ JT l /1 This permit application expires if a permit is not obtained within 180 days
/ --_(/ J / 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)
1
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site.Util ties : ' Qty Fee(ea) Total r Square Footage:
Permit Fe
Footing drain-1"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' 1 62.54 (' S'.( 7,201 and greater $327.54
Sewer-each additional 100' 37.52 bl.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
Otl!er Inspections or Fees Qty Fee(ea) Total`
each additional$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: /laa-e&
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 for Replace/
Work Performed: Capped Added Relocate Plan review is required for any of the following.
Baptistry/Font Please check all that apply.
Bath Tub/Shower ❑ Any new commercial building with water service 2"and
Jacuzzi/Whirlpool greater,except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ 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 0 Any complex structure as defined in OAR918-780-0040.
Eye Wash
Floor Drain/sink -2" Submit 2 sets of plans with any of the above.
-3"
Isometric or Riser Diagram
Car Wash Drain
Garbage Domestic-non-food
0 Isometric or riser diagram is required for new buildings
Disposal -Domestic-food related that meet the qualifications above.
-Commercial-food related
-Industrial-food related
Ice Mach./Refrig.Drains
Oil Separator(Gas Station) Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav -Non-food related
-Bradley
-Commercial-food related
-Service
Swimming Pool Filter *
Washer-clothes Note: If the fixture work under this permit results in an
Water Extractor increase of sewer EDUs,a sewer permit will be issued and
Water Closet-Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
Macintosh HD:Users:joellelewis:Downloads:PLMU PermitApp(1).doc 2
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
13285 SW BULL MOUNTAIN RD, TIGARD, December 11 , 2018 at
OR, 97224 7:14:46 AM
Record Type: Record ID:
Residential - Plumbing PLM2018-00374
Inspection Type: Inspector:
399 Plumbing final Aaron Cillo-Gobel
Result:
PASS - NoCofO
Comments:
Note: pump receipt received. Septic filled with small rock.
Violation Summary:
Inspector Contractor
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT NOV 2 9 ?'11;')
111 : Request for Permit Action
TIGARD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tiga Xolrf�N ; DIVISION
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
FROM: ® Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Matthew Shelby
Mailing Address: 13285 SW Bull Mountain Rd.
City/State/Zip: Tigard, OR 97224
Phone No.: 503-310-8033
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑ CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: PLM2018-00374
Site Address or Parcel#: 13285 SW Bull Mountain Rd.
Project Name: Sewer connection
Subdivision Name: NA Lot#: NA
EXPLANATION: Remove Portland Road and add Bla k Rock Underground LLC, 16770
SW Shaw St. Suite C, Aloha, OR 97007 La :A /96//F
` L/S.oz) .Act€.- —
Signature: Date: 11/28/18
Print Name: Matthew helby
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date By Route to Records: Date // 0229 / By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:1,13uikling\Forms\RegPennitActio ,P92314.doc