Permit (3) CITY OF TIGARD PLUMBING PERMIT
II , COMMUNITY DEVELOPMENT Permit#: PLM2019-00303
r I(;A h.h 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/30/2019
Parcel: 2S 115BA00100
Jurisdiction: Tigard
Site address: 16200 SW PACIFIC HWY N
Project: Planet Fitness Subdivision: None Lot: None
Project Description: TI to add plumbing fixtures for new tenant.
Contractor: PMSI LLC Owner: TECOLOTE RESOURCES INC
21195 NW EVERGREEN PKWY#204 KELLY'S LEGACY LLC, ET AL
HILLSBORO, OR 97124 BY HESSLIN HOLDINGS INC
23421 SOUTH POINTE DR STE 270
LAGUNA HILLS, CA 92653
PHONE: 503-466-2222
PHONE: 503-764-7595
FAX: 503-466-2211
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 09/30/2019 $31.27
Specifics: 2 ea Drinking Fountain 09/30/2019 $50.04
7 ea Floor Drain/Floor Sink/Hub 09/30/2019 $175.14
Type of Use: COM 7 ea Primer 09/30/2019 $87.57
Class of Work: ALT 11 ea Sink 09/30/2019 $275.22
Type of Const: 9 ea Tub/Shower/Shower Pan 09/30/2019 $112.59
Occupancy Grp: 2 ea Urinal 09/30/2019 $50.04
Stories: 7 ea Water Closet 09/30/2019 $175.14
4 ea Water Heater 09/30/2019 $150.08
1 Plan Review 09/30/2019 $276.77
1 12%State Surcharge- 09/30/2019 $132.85
Plumbing
Total $1,516.71
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: /i�
�L- Iie4._Aind — .rte
Call 503.639.4175 by 7:00 a.m.for the next available inspectio ate.
This permit card shall be kept in a conspicuous place on the job site until - pletion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application _7 - -1 •7 7
Building Fixtures 1 ', FOR OFFICE USE ONLY
City of Tigard Reeetved
. 13125 SW Hall Blvd..Tigard,OR 97223
11,1 Plan Review
: O Phone: 503.718.2439 Fax: 503.598.1960
Inspection Line: 503.639.4175 . ,
TIGARD ; - - Date ReadyBy: ti ,i,
"ei sr., Jari.,,, suE cSrepienTieta2tifunrfor tion
• ,
,
Internet: www.tigard-orgov - . -
, . .
Notified Method:f i
TYPE OF WORK dll/30,44...4 00 ... FEE* SCHEDULE
0 New construction 0 Demolition For special information use checklist.
Description F-Div.ThEa7 Total
EI Additiontalteration/milacement 0 Other: New 1-2-family dwellings(includes 10011.for each utility connection)
- - I
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
SFR(2)bath
0 1-and 2-farrfly dwelline
t - El commerciauindustrial 437.78
-
-
SFR(3)bath 500_32
0 Accessory building [, Multi-family
Each additional bathli -1-
tchen - 725.02
0 Master builder 0 Other: Fire sprinkler( sq.h.) Pane 2
JOB SITE INFORMATI9 AND .0CATION Site utilities:
Job site s f i
add re's--/610i,--5Ari ae i C ' /A___ Catch basin or area drain I 8.76
x.--,- Dryivell./each hoc,or'trench dram
City/State/ZIP:Tigard/OR/97223 / 18.76
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: I-- Project name:Planet itness Manufactured home utilities 50.03
Cross street directions to job site:Corner of SW Pacific Hwy Manholes ' .
18 16
Rain drain connector 18.76 I
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: 1 Page 2
Water service(no.linear ft.:_) i Page 2 I
Subdivision: Lot no.: Fixture or item:
Elackflotv preventer 1 1 31.27 1 31.27
Tax map/parcel no.: X'h cenco/06
Bkirlv12.51
DESCRIPTION OF WORK acwater ae
Clothes washer 25.02
New wettirMers.linatem+fixtures for new gym
Dishwasher /5.01
--
-
Drinking fountain I i 25.02 ' 25.02
- -
Ejectors(sump 25.02
0 PROPERTY OWNER 0 TENANT Expansion tank 12.51
Fixture,sewer cap -15.01
Name:Town Square Fit LLC
---1 Floor drain--floor sink25.02
(hub 6
150.12
Address: 15171 Bangy Road
Garbage disposal 25.01
City/State/ZIP:Lake Oswego/Oregon/97035 _ J Hose bib 25.02
Phone:(503)764-7595 I Fax:( ) lee maker 1 12.51
0 APPLICANT k "rt CONTACT PERSON Interceptor/grease trap 15 01
_-. _
1 Medical gas(value:S ) Page 2
Business name:Town Square Fit LLC f
Primer 12.51
Contact name:Gary Van Drew
--I Roof drain(commercial)
/ - 12.51
Address: 15 t 71 Bangs Rdf Sinkibasinlavatory- 11 25.02 275.22
_
C ity/StatelZIP:Lake Oswego/Oregon/97035 Solar units(potable water) 62.54
Phone:(503)764-7595 i Fax::( 1 Tub-showershower pan ; 9 12.51 112,59
i I.-
I.rmal _ 2 25.02 11.04
E-mail:gvandrew5(rumsnsom -
Water closet 7 25.02 17).14
CONTRACTOR
Water heater " 15-0.08
4 11 _3„7)...5129
Business name:Not yet determined (a 04 ,..i.: Water piping'DWV 1
i-----
Address: 2. jyy.,S- iya....) , -.:0--AG,...0_6i,-/v (14. wi4i Other:
City/State/ZIP: i/445,a9V.0 0 IL .77/zx -
Phone:Cct,31 _ .
pi,e'( -/-/-/Aa
„ . .
C C B LIC.:/323 Plut *Mg Lie.n .311-311, 6
-*AFLMinimum permit feeS:uSh7754:: 969.48
Plan review (25°ii of permit fee)
State surcharge(12'14 of permit fee)
Authorized signature:
. ..._414.......--
TOTAL Namur FEE 1 1
This permit application expires if a permit is not obtained within MI days
Print name: ZUr y rail iree Date: . 9
after it has been accepted as complete.
*Fee methodology set by Tti-Countv Building Industry Service Board.
I:BuildOciPanut,PLMU-PermitApp cinc: 10 01,09 44046161-610 02 COM VitBi
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental information
Fee Schedule: Residential Fire Suppression Systems:
Qty. Fee(ea) Total
Site Utilities Square+ Footage: Permit Fee:
Fooling drain- E'` 100' 50,03 0 to 2,000 $121.90
Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69
1 3.601 to 7.200 5233.20
Sea-er- 1st 100' t 6'-54 62.51 7?01 and greater I $327.54
Sewer-each additional 100' 37.52
Water Service- 1st 100' r 62.54 62.54 Medical Gas Systems:
Water Service-each additional 100' 37.52
Slums&Rain Drain-1st 100" 62.54 Valuation: Permit Fee:
51.1)0 to S5.000.00 Minimum tee$72.50
Storm&Rain Drain-each additional 100' 37.52 55,001.00 to 510,000.00 $72.50 for the first S5.000.00 and 51.52 for
Other 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 S 10.00 1.00 to$25,000.00 $148.50 for the first$10.000.00 and$1.54 for
which no tee is specifically indicated 91)J)0 hr each additional$100.00 or fraction thereof to
(minimum charge-1:"_hour) i and including$25.01)0.00,
inspections outside of normal business 90.011hr 525 0111.00 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 Sf and including$50,000.00.
Additional plan review for revisions 90.00 hr f $50•001.00 and up $742.00 for the first$50,000.00 and$1.20 for
(minimum charge I.2 hour) �_ _ _ _ each additional$100.00 or faction 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 Tuh.Shuvver y ❑ Any new commercial building with water service 2"and
Jacuzzi Whirlpool _neater.except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ New exterior plumbing site utilities for any complex structure
Cuspidor'VvaterAspiratur 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 I ❑ Any complex structure as defined in OAR9I8-780-0040.
Eve Wash
Floor Drain-sink -2" 6 Submit 2 sets of plans with any of the above.
-3"
-4„
Car Wash Drain Isometric or Riser Diagram
Garbage Domestic-neon-fond ❑ 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 Maclt./'Rcfrig.Drains
Oil Separator(Gas Station) - Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall 9
SinktLav -Non-food related t I
-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 7 fees assessed for the sewer increase must be paid before the
Urinal 2 plumbing permit can be issued.
Other Fixtures:
C:'\Usets`.Uary Van Drcw':Documents',Barbantine lnc`•2018'..18022 Tigard\l rmit\Plumbing`PLMF_PcrmitApp.doc
Plumbing Permit Application
Building Fixtures
Received
City of Tigard Permit No.: S
gi 13125 SW Hall Blvd.,Tigard,OR 97223 Date/By: / / f/? S'✓ / Atm`9-01 ti*-00 43
Plan Review
I Phone: 503.718.2439 Fax: 503.598.1960j Other Permit No.: /,
Date/By: �'��--f t1 />�1,,0;261,,�1
jj
T 1 G ARD Inspection Line: 503.639.4175 Date Ready/By: Juris: H See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK ;. FEE* SCHEDULE
0 New construction ❑Demolition For special information use checklist
Description I Qty. Ea. Total
Addition/alteration/replacement ❑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 dwellingCommercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INI1ORMATION AND LOCATION Site utilities:
Job site address: i is 344)... r��f_t_ 1'tI/ SS 44 47°- Catch basin coh aree drain 18.76
.1 r� Drywall,leach line,or trench drain 18.76
City/State/ZIP: "'C'-1 ci0. d R C'9 tst oi3
Q t Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: 1 Project name: Pie-to et Ft°tt,eSS 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: 1 Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer / 31.27 3I.2 R
DESCRIPTION OF WORK' Backwater valve 12.51
Clothes washer 25.02
n'' "c"-i6r` P(Li Wi•b;`z . Dishwasher 25.02
d Drinking fountain a 25.02 50,()4
Ejectors/sump 25.02
ROPERJV OWNER I ❑'TENANTI Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub- t"t' 17 25.02 /176,/4
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) I Fax:( ) Ice maker 12.51
0 APPLICANT E]'CONTACT'PERSON: Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51 6 ,S 11
Contact name:
Roof drain(commercial) 12.51
Address: .4)-Sink/basin/lavatory /( 25.02 ` S Al
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: :( ) Tub/shower/shower pan (3 12.51 /'J 2,59
E-mail: Urinal ;, 25.02 50,04
C TRACTOR .rt 4
Water closet q 25.02 95, /4
Water heater 37.52 /5.0,O 8
Business name: Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal 1167,6q
Phone:( ) Fax:( ) Minimum permit fee: $72.50
Plan review (25%of permit fee) ,D,16,t19
CCB Lic.: Plumbing Lic.no.: State surcharge(12%of permit fee) 13 8 5
Authorized signature: TOTAL PERMIT FEE g 1,11 f
Print name: Date: 1` This
q permit application expires if a permit is not obtained withii 180 days
after it has been accepted as complete.
'Fee methodology set by Tri-County Building Industry Service Board.
1: uildingermitsPLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB) L ALS .`
\B \P \
S i rti1C$ 14
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-15'100' 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
Storm&Rain Drain-1st 100' 62.54 Valuation: Permit Fee:
$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 FeesQty
' 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
(minimum charge-1/2 hour) each additional$100.00 or fraction thereof,to
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*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Rept Please check all that apply.
Work Performed: Capped Added Relocate
0 Any new commercial building with water service 2"and
Baptistry/Font
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall
0 New exterior plumbing site utilities for any complex structure
Drive Ther as defined in OAR918-780-0040.
Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial
0 Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain a
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2" fj
3" Isometric or Riser Diagram
0 Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall Q
Sink: -Lav/Bar non-food related Q
-Bradley
-Com/Serv/Util food related
-Service . *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet 1'j plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
Accumulative Sewer Tally
10111 Tenant Name: PLANET FITNESS SWR# 2019-00278
Site Address: 16200 SW PACIFIC HWY SUITE N PLM# 2019-00303
TIGARD
Parcel#: 2S1 1 5BA001 00
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 2 2 2 2
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 5 10 5 10
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 2 12 2 12
-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 9 18 9 18
Sink:
-Lay/Bar-Non-Food Related 2 0 0 9 18 9 18
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 2 6 2 6
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 7 42 7 42
Urinal 6 0 0 2 12 2 12
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 38 120 38 120
Current Fixture Value 120 divided by 16= 7.500 Current EDU 1 EDU= $5,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 120 divided by 16= 7.500 over (under) $ 43,500.00
Enter EDU Change Here 7.500 *
*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: BRANDEN TAGGART X2449 Date: 9/19/2019
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_5800_070119.xlsx