Permit ' n CITY OF TIGARD •
PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2008 - 00420
TIGA 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 10/31/2008
PARCEL: 2 S 103 C B - 02000
SITE ADDRESS: 12220 SW JAMES ST ZONING: R -4.5
SUBDIVISION: WILLAMETTE LOT: JURISDICTION: TIG
PROJECT: IVERSON
Project Description: Replacing 200 ft. of water line and installing recirculating pump.
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES: 1
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: 200 ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
LARRY IVERSON
12220 SW JAMES ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 10/31/200€ $118.00
[TAX] 12% State Surch 10/31/200E $14.16
Phone : 503- 709 -3214 Total $132.16
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # :
Reg #:
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requir- .. • follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OA: •52- 0001 -0 10. You may obtain copies of
these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. /
Issued B / �— Permittee Sig ature:
■1�1
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.
Plumbing Permit Application
Site Utilities /\\ v 3 / w. /37i I l FOR OFFICE USE ONLY
• `,
CI of Tigard 0 Received Pei mit No.: /�/ ,�in, �. �, / ` vV /a �y' y `
Date /By: v
• 13125 SW Hall Blvd., Tigard, OR 9722 9. Plan Review
0 : Phone: 503.639.4171 Fax: 503.59: ; ' At r&' DateBy: Other Permit No.:
Inspection Line: 503.639.4175 . ;Ready /By: Juris: ® See Page 2 for
T I G A R D Internet: www.tigard- or.gov c' \ o � , ;Z-
,itfied/Method: 'r2 , Supplemental Information
V • TYPE OF WORK ,�' ` 'A i FEE* SCHEDULE
❑ New construction ❑ Dem. `�, °� Description For special information use checklist
1 Qty. 1 Ea. 1 Total
❑ Addition/alteration/replacement ❑ Other4ve New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: /o?22 D 1‘520 . /7j : 5 Catch basin or area drain 16.60
City /State /ZIP: - // '2�e,,v DA_ 9722.3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: 1 Project name: -p , ci yr /
Manufactured home utilities 1 10.00
Footing drain (no. linear ft.: ) Page 2
-
Cross street/directions to 'ob site: /6,?/.5"7"--- `-[�I
/ / Manholes 16.60
AA/r /a/J- r Aie.t Lec� Rain drain connector 1 6.60
ZtO _: _ /o t ===.... ....//k/ Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: _) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
A - )�/ ` 4 . - �� A. a , ' Backwater valve 16.60
-, i ` .. . /i A � , Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: Lr92e", � e .5270 j Expansion tank 16.60
Address: /,,,Z2 2 o �� e f Fixture /sewer cap 16.60
City /State /ZIP: 0, ,e�1z7 69 e 97J 2 Floor drain/floor sink/hub 16.60
`'
Phone: (�3) 7 szr/e. Garbage disposal 16.60 Fax: ( ) Hose bib 16.60
APPLICANT -. ❑ CONTACT PERSON
Ice maker 16.60
Business name: _ _ „ - x _, Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 16.60
Phone: ( ) I Fax: : ( )
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: v!‘,i4)/111-, ', . Water heater 16.60
Address: � Other: Iraj/ (AA`t p op. . /67'4C City /State /ZIP: f Subtotal
Minimum permit fee: $72.50 i `tom
Phone: ( ) ,gx: ( ) Residential backflow minimum permit fee: $36.25 //
Plan review (25% of permit fee) 1I
CCB Lic.: P1 . bing Lic. no.: �/
if �_� State surcharge (12% of permit fee) - !-, l
Authorized signatu f . TOTAL PERMIT FEE
' �- p (3a.
Print name: - �,���` w ` Date: A7 U This permit application expires if a permit is not obtainea within
180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
:\ Building \Permits\PLMU- PermitApp.doc 12/27/06 440- 4616T(10/02 /COM/WEB)
_ , i
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 - 1' 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' j 55.00 5-5.2% Medical Gas Systems:
Water Service - each additional 100' 46.40 KC, /1 J
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Commercial Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain/sink - 2" that meet the qualifications above.
-3"
- 4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
I:\ Building \Permits \PLMU - PermitApp.doc 2
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Information Notice to Property Owners About
Construction Responsibilities Statement
Oregon Law requires residential construction permit applicants who are not licensed
with the Construction Contractors Board to sign the following statement before a
building permit can be issued. [ORS 701.055 (4)]
This statement is required for residential building, electrical, mechanical and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010(7), need
not submit this statement. This statement will be filed with the permit.
Please check the appropriate box and complete the following statement:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will instruct my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
P /9r
I will be performing work on property I own, a residence that I reside in or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. if I change my mind and hire a general contractor, I will contract with a
contractor who is licensed with the CCB and will immediately notify the office issuing this building
permit of the name of the contractor.
I have read and understand the Information Notice to Property Owners about Construction
Responsibilities contained on these two pages and I hereby certify that the information checked and
completed above is correct and accurate. / - __Z. 1/-- --.c.)
Ai
Print name o Pp
of permit applicant Signature of permit applicant
P
/ — ?/— dr-63
Date
Permit #: / o?WR
This form is supplied to building of i
permit offices by the Oregon ' °'� I Address: (64,2- S T/
iv i't1S
Construction Contractors Board, y;tc =�, ' -�-
as required by ORS 701.055 (6) ' `_ . ` \ � 70 -
f 9'
Issued by: ' /' Date: ��R"
This copy to issuing permit office