Permit (172) CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2019-00131
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/03/2019
T I tWy � g Parcel: 1S134BC00401
Jurisdiction: Tigard
Site address: 12442 SW SCHOLLS FERRY RD 100
Project: Providence Medical Group Subdivision: None Lot: None
Project Description: CAP(1)water closet and(1)urinal;ADD(1)mop sink.
Contractor: HARDER MECHANICAL Owner: PROVIDENCE HEALTH&SERVICES-ORE
2148 NE MLK BLVD. ATTN: REAL ESTATE&CONSTRUCTION
PORTLAND, OR 97208 4400 NE HALSEY BLDG 2 STE 190
PORTLAND, OR 97213
PHONE: 503-764-6434 PHONE:
FAX: 503-287-5284
FEES
Quantity Description Date Amount
2 ea Fixture/Sewer Cap 04/02/2019 $50.04
Specifics: 1 ea Sink 04/02/2019 $25.02
1 12%State Surcharge- 04/02/2019 $9.01
Type of Use: COM Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $84.07
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 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.
Plumbing Permit Application
Building Fixtures RECEIVED FOR OFFICE USE ONLY
City of Tigard Received Li
13125 SW Hall Blvd Tigard,OR 97223 MAR 2 8 2019 Date/By: / /y Permit s/� O/ `- c�/3,
� Plan Review
Phone: 503.718 2439 Fax: 503598.1960 Other Permit No.:
P CITY OF TIGARD t'`ite:Re
T I G A RD
Inspection Linc. 503 639.4175 Date Ready.'By: Juris• ® See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified Method �.q2"' Supplemental Information
TYPE OF WORK 14/' C.. _ ! FEE* SCHEDULE
0 New construction 0 Demolition For special information use checklist.
Description Qty. ( Ea. I Total
®Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
❑ I-and 2-family dwelling ®Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
0 Accessory building 0 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 address: 12442 SW Scholls Ferry Foad Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,Oregon,97223 ,C� � � ,�.��
✓ /' �7D. C747 Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: 100 I Project name: Diagnostic Imaging-X-ray Manufactured home utilities 50.03
Cross street/directions to job site:217 take exit 4B to SW Cascade Manholes 18.76
Turn right on SW Scholls Ferry Rd.,turn right on SW North Dakota 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.: ISI34BC00401 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Remodel of existing X-ray suite,new walls,sound board upgrades
Dishwasher 25.02
paint,mechanical,plumbing and electrical support systems Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name:PROVIDENCE HEALTH&SERVICES-OREGON Fixture/sewer cap 25.02 30 , t/
Floor drain floor sinkhub 25.02
Address:4400 NE HALSEY STREET-BUILDING 2,Suite 190
Garbage disposal 25.02
City/State/ZIP:PORTLAND,OR 97213 Hose bib 25.02
Phone:(503)215-6282 Fax:( ) Ice maker 12.51
❑ APPLICANT 0 CONTACT PERSON Interceptor grease trap 25.02
Business name:Harder Mechanical Inc. Medical gas(value:S ) Page 2
Primer 12.51
Contact name:Gary Eldrridge
Roof drain(commercial) 12.51
Address: 2148 NE MLK Jr.Blvd Sink/basinllavatoiy M"1' 5 "`V' Y 25.02
City/State/ZIP:Portland,Oregon 97212 Solar units(potable water) 62.54
Phone: (503)764-6434 Fax: :( ) Tub/shower/shower pan 12.51
E-mail:geldridge(dharder.com Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name:Harder Mechanical inc. Water piping'DWV 56.29
Address:2148 NE MLK Jr.Blvd Other: 25.02
City/State/ZIP:Portland,Oregon 97212 Subtotal 75. C76
Minimum permit fee: $72.50 Q
Phone:(503)764-6434 Fax:( ) � -_3_W-, -
CCB Lie.:#0074 Plumbing _ic.no.:#26-35P111 Plan review (25%ofpermit lee)
State surcharge(12%of permit lee) ,e 7
Authorized signature: /?j �I /2t" z
TOTALPERMIT FEE �'L/,C )
Print name:Gary Eldridge Date:3/18/2019
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.
L Building Pcnnns PLAil-Permit App.dnr 10 01(9 -140-4s16T110 02 CONI 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 IOU' 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 tee$72.50
Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 fbr the first$5,000.00 and$1.52 for
Other Inspections or Fees Qty. Fee(ea) Total' each additional 5100.00 or fraction thereof,to
and including$10,000.00.
Inspection of existing plumbing or for S10,00 1.00 to$25,000.00 $148.50 for the first 510,000.00 and$1.54 for
which no fee is specifically indicated 90,00,br 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 525,001.00 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/ Plan review is required for anyof the following.
Work Performed: Capped Added Relocate4
Ba List `Font Please check all that apply.
P ry
Bath Tub;Shower
0 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 OAR9I 8-780-0040.
Dishwasher -Commercial ❑ 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.
_3„
Isometric or Riser Diagram
Car Wash Drain
Garbage Domestic non-food
0 Isometric or riser diagram is required for new buildings
Disposal -Domestic-Rood 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 *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:
M:'v.ConmmercialyEstimating\Providence\OE-18-0271 Providence Scholls F2rry MOB X-Ray Budget\Permits`PLMF_PernitApp.doc
i II
IIIs Tenant Name: Providence Medical Group
Sewer Tally SWR# N/A
T G A KD Site Address: 12442 SW Scholls Ferry Rd,#100 PLM# 2019-00131
Parcel#: 1S 134BC00401
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 0 0 0 0
-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 0 0 0 0
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 1 3 1 3
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 1 6 0 -1 -6
Urinal 6 0 1 6 0 -1 -6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 2 12 1 3 -1 -9
Current Fixture Value -9 divided by 16= -0.563 Current EDU 1 EDU= $5,650.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -9 divided by 16= -0.563 over (under) $ (3,164.00)
Enter EDU Change Here -0.560 *
*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:
Authorized Name/Signature: Dianna Howse Date: 4/2/2019
Building Division
Note: 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_070118.xlsx
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
12442 SW SCHOLLS FERRY RD 100, TIGARD,
OR, 97223
Record Type: Record ID:
Commercial - Plumbing PLM2019-00131
Inspection Type: Inspector:
399 Plumbing final Don Sylvester
Result:
PASS - NoCofO
Comments:
Violation Summary:
Inspector Contractor