Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009 -00357
T [ G!1 R L? 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 12/22/2009
Parcel: 1S126DCO5000
Jurisdiction: TIGARD
Site address: 9385 SW LOCUST ST, BLDG# 1
Subdivision: Lot: 0
Project: Fisher Chiropractic
Project Description: Cap (4) sinks and (1) shower, add (1) sink, relocate (1) toilet
Owner: FEES
TSE INVESTMENTS LLC Quantity Description Date Amount
PO BOX 1754
LAKE OSWEGO, OR 97035 1 ea Sink 12/22/2009 $25.02
4 ea Lavatories 12/22/2009 $100.08
PHONE: 1 ea Tub /Shower /Shower Pan 12/22/2009 $12.51
1 ea Water Closet 12/22/2009 $25.02
Contractor: 1 12% State Surcharge - 12/22/2009 $19.52
PRO SOURCE PLUMBING LLC Plumbing
980 SE SACHA PLACE
HILLSBORO, OR 97123
PHONE: 503 - 936 -7784
FAX:
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $182.15
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 No ion Center. - .se ru -s are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy f the rules
or dir questions to OUNC by • = ling . 46.6699 or 1.800.332.2344.
Is ued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Accumulative Sewer Tally Parcel # 1S126D.0O5000 ' ' .
Tenant Name: Fishei Chiropractic This SWR#
Site Address: 9385 SW Locust St: This PLM# PLM2009 00357 . •
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptistry /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
-4inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 I -IP) 16 .• 0 0 0 0 0
Commercial (to 5 11P) 32 0 0 0 0 0
- Industrial (over 5 1 -IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Scp (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 2 4 0 -2 -4
Sink - Bar /Lavatory 2 0 4 8 0 -4 -8
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 • 0 0 0
- Service 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 • 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
'I'O'I'Al.,S 0 0 6 12 1 3 -5 -9
Current Fixture Value -9 divided by 16 = -0.6 Current EDU 1 EDU = S 3,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -9 divided by 16 = -0.6 over (under) S (2,160.00)
Enter EDU Change Here -0.6
Notes: ** *CREDITS * **
Authorized Name /Signature: Dianna I -Iowse Date: 12/22/2009
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 \Sewer fallyShect- 3600.xls 06/25/08
• Plufhbing Permit Application
Building Fixtures RECF' FOR OFFICE USE ONLY
City of Tigard Received .'
a 13125 SW Hall Blvd., Tigard, OR 97 n • ; 2009 Date/By: No . "L�oZOO9 ....,)0.3 SJ
a Phone: 503.639.4171 Fax: 503.598. • Dan Review ateBy: Other Permit `'ail/JV{// CG R / Q - xx
TIGARD Inspection Line: 503.639.4175 CITY OF T %GAS; ' Date Ready /By: Juris VI See Page 2 for
Internet: www.tigard or.gov Notified /Method: Supplemental information
TYPE OF Alt-DING D!VIr FEE* .SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 Total
X Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
❑ 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 ❑ Other: Fire sprinkler (_ sq. ft.) Page 2
JOB, SITE INFORMATION AND LOCATION Site utilities:
Job site address: 3 P S 5 l0 C./S 5 Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City /State /ZIP: Footing drain (no. linear ft.: __) Page 2
`l
Suite/bldg. /apt. no.: Project name: , - /S /7 7 Cff� foe'/U9C7/L'_Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
6 -r .e A.d 6 Vlee; c / cal - 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.: /_5 6 Backflow preventer 31.27
DESCRIPTION OF WORK . Backwater valve 12.51
• L Clothes washer 25.02
C4,o,, "°> U j -/ " S / S `'Ve'- �' Dishwasher 25.02
X s•% e.,;4 /i P 5 /. IL, her) Drinking fountain 25.02
4e,4., / „ 5. y 4' Ejectors /sump 25.02
❑ PROPERTY OWNER l ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap 25.02
Floor drain /floor sink/hub 25.02
Address:
Garbage disposal 25.02
City /State /Z1P: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: - Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin /lavatory S 25.02 /A 5, /0
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan J 12.51 47 5
E-mail: Urinal / 25.02
Water closet / 25.02 025" , cJ.
CONTRACTOR
Water heater 37.52
Business name: 'r® S4.,U -6 _ PJL 411;' /lam Water piping/DWV 56.29
L O U
Address: - 5C 5 L_�� net e Other: 25.02
City /State /Z1P: (l f ' 15- / &/Z "77/a ; Subtotal /6 ,4_5
Phone: (5,,7 736- 77 vi Fax: ( ) - ?j1 Minimum permit fee: $72.50
� r1 Plan review (25% of permit fee)
CCB Lic.: 1�f Plumbin g I Lic. no.:#6
\ State surcharge (12% of permit fee) I / 4 /, S 5
oZ
Authorized signature: /�� s /'( 17 ? TOTAL PERMIT FEE I/ g t
'goy D ale: r This permit applic ation expires if a permit is not obtained within 180 days
Print name: C y C - 1 t J ci `� �? - D�
after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
1 \Building\Permits \PLMU - PermitApp doc 10/01/09 440- 4616T(10 /02 /COM/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 - l' 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 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:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", Plan Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees * . Please check all that apply.
Quantity_ by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: • Replace greater, except systems designed and stamped by licensed
Previous Capped Added Existing engineer.
Baptistry /Font
Bath -Tub/Shower / El New exterior plumbing site utilities for any complex structure
- Jacuzzi/Whirlpool
as defined in OAR918- 780 -0040.
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive tall ❑ Any multipurpose fire sprinkler system.
Cuspidor /Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
- Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash Isometric or Riser Diagram
Floor Drain /sink - 2" ❑ Isometric or riser diagram is required for new buildings
qualifications meet the ualifications above.
-4 "
Car Wash Drain
Garbage - Domestic
Disposal - Commercial
- Industrial Comments regarding fixture work:
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley
- Commercial *Note: If the fixture work under this permit results in an
- Service 1 increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be paid before the
Washer - Clothes p
Water Extractor plumbing permit can be issued.
Water Closet - Toilet
Urinal
Other Fixtures:
I: \Building \Permits \PLMF - PermitApp.doc 2