Permit Support Document City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMEN D
Request for Permit Action /00, z10'"--...
T I C;A k n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov
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 n Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ,b--i-yr--E.:-)0,..7-,y-/ • , !w a.ArrsffAiM.
Site Address or Parcel #: 'I' 5t)0 5 44 JA/PI J �� /J i
Project Name: L ' kG, f e /`�-''/
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Subdivision Name: Lot#:
EXPLANATION: /4E4,J' �-, ice, `/de::i, jr 7 rC-,./' ,,;..,„/
.,I. c--it. et 1, .. _ . -di • Ai.' . __ �- f r- 1
Signature: �� ,, Date: 7/// //Gr
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Print Name: ,Qr i;/e,,,,i— y
Al
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date/1/ /i y By , .7) Route to Records: Date //P. Ar---- By 4Y-417'
Refund Processed: Date / By ,r•• Invoice Processed: Date By
Permit Canceled: Date /j//9/i� B /', 'Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 2314.doc
Plumbing Permit Application V0 I 0 ����� ,.... ) E
1 Building Fixtures ,> FOR OFFICE USE ONLY
n :
` K ). "' Received
Cityof Tigard Permit No..
41 13125 SW HallllBlvd.,Tigard,OR 97223 Date/By: p t7���� �'��'1 J��- �jC/
Phone: 503.718.2439 Fax: 503.598.19;1,ij("1 ' 0 �.��� Plan Review f
Irril
Date/By: Other Permit No.: 1/2 f Hyl
T I GARD 0243
Inspection Line: 503.639.4175 Date Ready/By. J 0 See Page 2 for s(/ (l/
Internet: www.ti and-or. ov y.^` i �
g g t� x 't i.:4 ro 1^„ Notified/Method:
'77-P-5 Supplemental Information
TYPE OF W>aL,wiu'' „r . _ FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist.
Description Qty. I 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
0 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
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 a Catch basin or area drain 18.76
dress: _ SW Washington Square Rd#6H
City/State/ZIP:Tigard Oregon 97223 Drywell,leach line,or trench drain 18.76
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: / Project name:L'Occitane Washington Sq. Manufactured home utilities 50.03
Cross street/directions to job site:Washington Square Mall Manholes 18.76
. Rain drain connector 18.76
-'y • Sanitary sewer(no.linear ft.:_) Page 2
t:11, _ A. __ A. r..,- r.'"1 r�_
Storm sewer(no.linear ft.: ) Page 2
Vfi/ie t7.- Water service(no.linear ft.: ) Page 2
Subdivision: s` Lot no.: Fixture or item:
�" r1Jt e•�lL1/t/
Tax map/parcel no.: 'S' -, ., . Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Dishwasher 25.02
Install 1 small service sink with In Line Water Heater Drinking fountain 25.-02
Ejectors/sump 25.02
❑ PROPERTY OWNER ►1 TENANT Expansion tank 12.51
Name:L'Occitane Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:1430 Broadway 2nd Floor
- _ Garbage disposal 25.02
1 City/State/ZIP:New York,NY 10018 _ Hose bib 25_02
Phone:(407)378-6682 Fax:(407)469-3499 Ice maker 12.51
® APPLICANT ® CONTACT PERSON Interceptor/grease trap 25.02
Business name:Team K5 Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:Dennis Godsey
Roof drain(commercial) 12.51
Address:176 E Highland Ave Sink/basin/lavatory1 25.02
:iS`ri►1-
City/State/ZIP:Clermont FL 34711 Solar units(potable water) 62.54
Phone:(407)3786682 Fax: :(407)4693499 Tub/shower/shower pan 12.51
E-mail:dennis.godsey@expeditepermit.com Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 1 37.52 3 7,
Business name:Out to Bid Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal ‘‘)..., 71/
Phone:( ) Fax:( ) Minimum permit fee: $72.50 .7)..,_51)
Plan review (25%of permit fee)
CCB Lie.: Plumbing Lic.no.: State surcharge(12%of permit fee) . -70Authorized signature: � � TOTAL PERMIT FEE ri-
le�� p J
Print name: > £t„pr.S 4 ppy� Pate: p/,.r }F 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:\Buildirg\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Rage 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities 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
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*.
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 1:1 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 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" Submit 2 sets of plans with any of the above.
Car Wash Drain Isometric or Riser Diagram
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 Install 1 small service sink with IWH
Shower -Gang
-Stall
Sink/Lav -Non-food related
-Bradley
-Commercial-food related
-Service 1
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer-Clothes
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: 1
C:\Users\Lacy\Desktop\PLMF_PermitApp.doc 2
407-469-5599 office
SP:SP Zile 112 W 407-469-3499 Fax
Sevelsometil of i
TRANSMITTAL SHEET
TO: FROM:
Plan Intake Dennis Godsey
COMPANY: DATE:
City of Tigard 8/15/2018
PIIONE NUMBER: FAX NUMBER:
503-178-2439
RE:
L'Occitane—9585 SW Washington Square Rd#6H
❑ URGENT X FOR REVIEW ❑ PLEASE COMMENT 0 PLEASE REPLY 0 PLEASE RECYCLE
L'Occitane
9585 SW Washington Square Rd#6H
Tigard OR 97223
1. 2 SETS OF PLUMBING PLANS
NOTES/COMMENTS:
This submittal is for a Tenant Improvement in Washington Square Mall unit# 61-1.
Please contact me should your require anything additional to complete this process
Thanks
Dennis R Godsey III
Commercial Project Manager
dennis.gods ey@expeditepermit.com
407.469.5599 xt 358 office
407.469.3499 fax
Team K5 Construction&Development Coordination,LLC
176 East Highland Ave.
Clermont,FL 34711
1.4.„ M CERIC
August 3, 2018
Sargenti Architects
Simone Koufakis Short,
461 From Road, Second Floor
Paramus, NJ 07652
(T) 973.253.9393
Re: L'Occitane @ Washington Square__H06
Dear Simone Koufakis Short,
Final drawings submitted for the above project are "Approved" and ready for permitting. Any
changes needed as requested below can be made and resubmitted to the Landlord in a subsequent
submittal.
If you should have any questions, comments, or concerns regarding this review, please feel free
to contact me.
Sincerely,
Charlene Sirokman, RA
Sr. Manager, Tenant Coordination
11411 N,stun i Boule.",ar-d
Fhoeni::,AZ 0502
P.602.953.6200 IF:602.953.6449