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Permit Plum. Permit App1' t , Buildin Ixtures .. 't' s .,. _.;. . FoR OFFICE OS E, oi y� City of Tigard Received Date/By: �oya7 /a R Permit No 2 96 , 7_ 00 6Z 7 L 1001 a 13125 SW Hall Blvd., Tigard, OR 9k 4 '( J C . • Phone: 503.639.4171 Fax: 503.598.1960 Plan Review . J Other Permit No.: Date/By: Inspection Line: 503.639. � '� (J 1 1 W WARD Date Read /B Juris: See Page 2 for r f c n l 1 p� 131 \gJ' Ready /By: - ► g , Internet: www.tigard - or.go ,(' ` 7 �r Notified/Method: *--./ Supplemental Information G DIVISION FEE* SCHEDULE ❑ New construction ❑ Demolition For special information use checklist Description 1 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 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: /Q ,S 5 S A' 3p� kf O *, S Catch basin or area drain 16.60 City /State /ZIP: 7; �, .- a y C'. ,/ Or / 2 9-z-Z_3 Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: I Project name: D 9 Z_ C oQ�S e Footing drain (no. linear ft.: ) Page 2 t Manufactured home utilities 110.00 Cross street/directions to job site: Manholes 16.60 Rain drain connector 16.60 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 11 g 4l re K S u) . l S t co K Jc cl-e .- Backwater valve 16.60 , t yA.c9 O H G Clothes washer 16.60 Dishwasher 16.60 El-PROPERTY OWNER, • 1 ❑ TENANT Drinking fountain 16.60 A Ejectors /sump 16.60 Name: dJ ' c ` oo C d v q \ Z _ C , k� Expansion tank 16.60 Address: '// 0 ..-/.5---- s v O ('I 4-f' D a V Fixture /sewer cap 16.60 City /State /ZIP: - t-I Gp c} :m.._ / © /',y2_z 2-____T. Floor drain/floor sink/hub 16.60 Phone: (3 s'Q q 3,5 Fax: ( ) Garbage disposal 16.60 ❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60 Ice maker 16.60 Business name: 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/ vato 16.60 Phone: ( ) Fax: : ( ) Tub /shower /shower p // G2. 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet / 16.60 obo Business name: Water heater 16.60 Address: E Other: City /State /ZIP: Subtotal Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 `253 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (8% of permit fee) 6, 4, Authorized signature: TOTAL PERMIT FEED C1 ( A Print name: c.t tO k Z _ �,Q e-, Date: /e/ 2 / - f p.-- 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:\ Building \Permits\PLMF- PermitApp.doc 12/27/06 440- 4616T(10/02 /COM/WEB) /41'7 . Li-7 Plumbing Permit Application - City of Tigard 4firr Page 2 - Supplemental Information • Fee Schedule: • ResidentialFire,Suppression Systems: Site Utilities • Qty. Fee (ea) Total _ . Square Footage: Permit Fee: Footing drain - 1' 100' 55.00 0 to 2,000 $l 15.00 • 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' 55.00 Medical Gas Systems: Water Service - each additional 100' 46.40 Storm &Rain Drain - 1st 100' 55.00 Valuation: Permit Fee: $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: $50,001.00 and up .• $742.00 for the first $50,000.00 and $1.20 for each additional $100.00 or fraction thereof. 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" 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\PLM- PermitApp.doc 12/27/06 Construction Contractors Board -44%6. , Permit # c,o —7�v5 `Thin 2w 700 Summer St NE Suite 300 Address: )C(6 3 L t-, .:_l % PO Box 14140 : t Salem OR 97309 -5052 Y �� �� /a. "7�(� r. r .,:i Issued by Date: Phone: 503- 378-4621 .4'." Phone: Address: www.ccb.state.or.us Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4) 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. This statement is required for residential building, electrical, mechanical and plumbing permits. Licensed architect and engineer applicants, exempt fr1lon... s ; ORS 701.010(7), need not submit this statement. This statement will be fi . 1 , 6a71 he t ! .. Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B: ` 2 001 P 1 1 • I own, reside in, or will reside in the completed structure. CH 1 Ur nuARD BUILDING DIVISION 2. I understand that I must become licensed as a construction contractor it e structure is sold o r offered for sale before or on completion. ❑ 3A. My general contractor is (Name) (CCB #) I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR pr 3B. I will be my own general contractor. 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 hereby certify that the above information is correct and that I have read and do understand the Information Notice to Property Owners about Construction Responsibilities on the reverse side of this form. "V11 IZ ©"" (Sign..:.'. • - •• applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant.) Property_owner.doc 06 -01 -04 • 1 . .. . . . .. . , •. _• „ • - Acting as Your Own General Contractor? • - INFORMATION NOTICE TO PROPERTY OWNERS , . • , . _ . ' . ABOUT CONSTRUCTION RESPONSIBILITIES . • . -_ - - - - . . . .. • NOTE: This Notice to Property Owners about Construction Responsibilities was developed by the Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature. . . If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and concerns. Employer Responsibilities , „ . . • . . . You will, in most instances,be ruled to be an "employer" and the contractors you contract with will be "employees" if youuse contractors not licensed with the Construction Contractors Board to do labor in constructing or to assist in the construction or improvement of a residential structure. As the,employer,you must comply with the following: . Oregon's Withholding Tax Law: As an employer, you must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your , -• ernployee0IF6r more:information; call the Department of Revenue at 503-378 - ' • - ' - Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance purpos on the.wages of all empldyee's For more information, call the Oregon Employment Department at 503-947-1488. . .. The Oregon Business Identification Number (BIN) is a combined number for both Oregon 'Withholding and Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or jvw.dor.stateor.us/fmspay.htmli for the . appropriate . forms. , . . . . . , . . . . . Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you could be subject to penalties and be liable for all claim costs if one of your employees is injured on the . job. For more information, call the Workers' Compensation Division at the Department of Consumer and Business Services at 503-947-7815. U.S. Internal Revenue Service: As an employer, you must withhold federal income tax frorn employees' wages.. You will be liable for the tax payment even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 1-800-829-4933 or visit their.web site www.irs.gov. • • • • - . , . . • • Other Responsibilities and Areas of Concerns Code ComplianCe: As the permit holder for this project, you are responsible for resolving any failure to code requirements that may be brought to your attention through inspections. . . • _ Liability and Property Damage Insurance: 'Contact Your insurance- agent to . see if you have adequate insurance coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe punctures, fire or work that must be redone. Time: Make sure you have sufficient time to supervise your employees. • . .. • . Expertise: Make sure you have the skills - to act as your own general contractor, to coordinate the work of rough-in and finish trades, and to notify building officials as the appropriate times so they can perform the required inspections. If you have additional questions call the Construction Contractors Board (503-378-4621) or write the agency at PO Box 14140, Salem, OR 97309-5052. . . Property_owner.doc 06-01-04 kis, CITY OF TIGARD i: BUILDING DIVISION PERMIT #: PLM2007 -00 &7 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12/27/2007 Phone: (503) 639 -4171 al A .� I Inspection Requests (24 Hrs.): (503) 639-4175 ...� -_.. INSPECTION WORKSHEET FOR DATE: 4/7 /2008 TIME: 7:01AM PAGE: 18 SITE ADDRESS: 10f;1f, SW JOHNSON ST CLASS OF WORK: SUBDIVISION: COTTONWOOD PLACE LOT #: 018 TYPE OF USE: PROJECT NAME: DIAZ - CORTES DESCRIPTION: (5) fixtures replacement. Converting (2) bathrooms into (1). OWNER: DIAZ-CORTES, ALEJANDRO PHONE #: 503 309 - 3540 CONTRACTOR: OWNER PHONE #: Inspection Request Scheduled For: Date: 4/7/2008 Pour Time: Code # Inspection Description Confirm # Contact # Message 322 Shower pan 057980 -01 503. 329 -9407 N Corrections /Comments /Instructions: g PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS ❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED `._ Inspector:��cw- jNxv -%... Date: 7 Phone #: (503) 718- • CITY OF TIGAR ® BUILDING DIVISION PERMIT #: Pi.M2007 -005 7 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12/27/2007 Phone: (503) 639 - 4171 41111 �* Inspection Requests (24 Hrs.): (503) 639 - 4175 4 R _.. INSPECTION WORKSHEET FOR DATE: 1/2312008 TIME: 7 :00AM PAGE: 2 SITE ADDRESS: 10 515 SW JOHNSON ST CLASS OF WORK: SUBDIVISION: COT1ONWOOD PLACE LOT #: 018 TYPE OF USE: PROJECT NAME: [)IP1 CORTE_S DESCRIPTION: (5) fixtures replacement. Converting (2) bathrooms into (1). OWNER: DIAZ - CORTES, ALEJANDRO PHONE #: 503.303 - 3540 CONTRACTOR: OWNER PHONE #: Inspection Request Scheduled For: Date: x/23/2008 Pour Time: Code # Inspection Description Confirm # Contact # Message 320 Piurn•ing rough 063763 -01 503 - 30933540 N Corrections /Comments / Instructions: 1,4 a— �--e✓ i\A 1►A -wA.---..- t --,,J o IP o F O �d �J �e r✓ PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS FAIL n CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: Date: j (2.\ OZt Phone #: (503) 718- Case Activity Listing ,(� to/si2oos CCEL/ N 9:27:42AM Case #: LM -00567 - Assigned Done Updated Activity Description Date 1 Date 2 Date 3 Hold Disp To By By Notes PLM 1010 Application received 12/27/2007 None RECD BB 12/27/2007 BB PLM1020 Permit created 12/27/2007 None DONE BB 12/27/2007 BB PLM 1030 Check for parcel tags 12/27/2007 None DONE BB 12/27/2007 BB PLM 1270 Ready to issue permit 12/27/2007 None REDY BB 12/27/2007 BB PLM1280 Issue permit 12/27/2007 None DONE BB 12/27/2007 BB PLM2320 Plumbing rough -in 1/22/2008 1/23/2008 1/23/2008 None PASS JW 1/23/2008 063763 -01 -- 503- 309 -3540 — VM - STI N PLM2322 Shower pan 4/4/2008 4/7/2008 4/7/2008 None PASS JW 4/7/2008 067980 - 01 — 503 329 - 9407 — VM - STI N 10/ Cr LoVN w. r"I VC Page 1 of 1 CaseActivity ..rpt