Permit CITY OF TIGARD PLUMBING PERMIT
m : ' COMMUNITY DEVELOPMENT Permit #: PLM2009 -00140
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/08/2009
(r' O 9 Parcel: 2S101AD02400
Jurisdiction: Tigard
Site address: 12753 SW 68TH AVE
Subdivision: WEST PORTLAND HEIGHTS Lot: 32
Project: George Fox University
Project Description: TI - remodel lunchroom. Relocate (2) sinks, add (3) floor drains /sinks & (1) new sink.
Owner: FEES
GEORGE FOX UNIVERSITY Quantity Description Date Amount
ATTN: FINANCIAL AFFAIRS, 414 N MERIDIAN
NEWBERG, OR 97132 3 ea Floor Drain /Floor Sink/Hub 06/08/2009 $49.80
PHONE: 3 ea Sink 06/08/2009 $49.80
1 12% State Surcharge - 06/08/2009 $11.95
Plumbing
Contractor:
OWNER
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $111.55
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 -0100. You may obtain a copy of the rules
or dire .uestions to Ol . by c• ' 503.246.6699 or 1.800.332.2344.
Is- ued By: ` I Permittee Sig ature:
Call 503.639.4175 by 7:00 a.m. for an inspection that.. • ess 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
-Building Fixtures FOR OFFICE USE ONLY
City of Tigard Received t �
Permit No.:
g Date/By: (! / 67
e . a p N.
III V 13125 SW W Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.639.4171 Fax: 503.598.1960 DateBy: Other Permit N o.: A Q F, ...
T I G A R D Inspection Line: 503.639.4175 Date Ready /By: luris: 63 See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 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
❑ Master builder ❑Other: Each additional bath/kitchen 45.00
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 1 Z. 7 $ 3 S w 6e/l ,q Catch basin or area drain 16.60
City /State /ZIP: i , y ., 0 2 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: 6,0,. ( o ✓. 64- . Footing drain (no. linear ft.: ) Page 2 Manufactured home utilities 110.00 .
Cross street/directions to job site: Manholes 16.60
17 4....p,04,-, r -, 7( 7 Z -, a 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
Tax map /parcel no.: A 6.101 /'✓Oalieo Fixture or item
. Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
L. / t Backwater valve ■ 16.60
� a."1"d n4[ Zv. c ro e .•■•. 4:31 /N L e.
mod: C..--e washer 16.60
Dishwasher 16.60 El
PROPERTY OWNER I ❑TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: (7.p o/ 5 ,e, /` o) O„" V. Expansion tank 16.60
Address: L • v � v
// t A., Fixture /sewer cap 16.60
•
City /State /ZIP: wewb -U' . 19 A 9 7 /3 Floor drain/floor sink/hub 3 16.60 eif,g
• Phone: f_CID3 $ S"v Z • / y Fax: ISD 3) ,ss-y 20 ., el Garbage disposal 16.60
Hose bib 16.60
21, APPLICANT ❑ CONTACT PERSON
lce maker 16.60
Business name: (7 -e . r F. A Interceptor /grease trap 16.60
Contact name: , De-,1 „.1 G 4 . sli -t.i' • Medical gas (value: $ ) Page 2
Address: p ` 1/ n Primer ■ 16.60
City /State /ZIP: r A f drain (commercial) 16.60
. asin/lavatory MI 16.60
Phone: ( ) Fax:: ( ) • �
�// G� �//►► ub /shower /shower pan 16.60
E- mail:: cS f l v T � e, Ci 920,�lb k.-e�� Urinal 16.60
CONTRACTOR Water closet ■ 16.60
Business name: Water heater 16.60
Address: Ot0A1E/Z- Other: •
City /State /ZIP: Subtotal
Minimum permit fee: $72.50 �00
97
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 l"j • "'
CCB Lic.: P , bing Lic. no.: Plan review (25% of permit fee) '-
O �� ��� State surcharge (8% of permit fee) UM
Authorized signature: / TOTAL PERMIT FEE IMMII
Print name: Doh S J , 1 Date: 6• y. 01 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.
:\ Building \Permits\PLMF- PermitApp.doc 12/27/06 440- 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 - 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' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
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
specially requested inspections - per hour 72.50 and including $50,000.00.
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 lease 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 Isometric or Riser Diagram
Drinking Fountain g
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain/sink - 2" 'J„_ that meet the qualifications above.
3" * 1
- 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 Z 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