Permit a CITY OF TIGARD PLUMBING PERMIT
a ., COMMUNITY DEVELOPMENT Permit #: PLM2009-00172
T I G,A R D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/30/2009
. Parcel: 2S101AD03200
Jurisdiction: Tigard
Site address: 12909 SW 68TH PKWY 430
Subdivision: TIGARD TRIANGLE CENTER Lot: 0
Project: Reference Capitol Management
Project Description: Install (1) breakroom sink.
Owner: FEES
PACIFIC REALTY ASSOCIATES Quantity Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY
#300 1 ea Lavatories 06/30/2009 $16.60
PHONE: 1 12% State Surcharge - 06/30/2009 $8.70
Plumbing
56 ea Minimum Fee Adjustment - 06/30/2009 $55.90
Contractor: Plumbing
DEAN WARREN PLUMBING & REMODELING
INC
PO BOX 14701
PHONE: 503 - 236 -4152
FAX: 503 - 296 -2218
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. n
Issued By:
461 t�Z /� ` � ^ Q AA Permittee Signature: // (�
Call 55 175 by 7:00 a.m. for an inspection that b sifess day. /�`'
This permit card shall be kept in a conspicuous place on the job site tintli completion of the project.
Approved plans are required on the job site at the time of each inspection.
. Plumbing Permit Application RECEIVE 1
FUR OFFICI•: uSE ONLY
City of Tigard JUN 3 0 2009 Received
Date/By: Nola, W12 009 , 0/3\ 7Z
ll
q 13125 SW Hall Blvd., Tigard, OR 97223
C Plan Review
Phone: 503.639.4171 Fax: 503.598.196(>C`I OF TIGARD Date/By: Other Permit Nc lip
T l G A R D Inspection Line: 503.639 BUILDING DIVISIO III ate Ready/By: ru is: ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: 1 e Supplemental Informat
•
- TYPE OF WORK - • FEE* SCDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 Total
j . 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: /2- 50 9 S 6'st (/ Q b.i y Y 3d Catch basin or area drain 16.60
City /State /ZIP: • .- Drywell, leach line, or trench drain 16.60
R . (f ' Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: t
VVl 1` Y ► Manufactured home utilities 110.00
Cross street/directions to job site: r\
��n��� I • A e Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.:
Water service (no. linear ft.: ) Page 2
Tax map /parcel no.: Q 3 ` ' 1 ACS ci 3 2 QO
Fixture o item
OO'' V A v alve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
. -0 - ►TJ` / dr-44/6.89 s'pa Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
1 PROPERTY OWNER I ❑ T ENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: i Expansion tank 16.60
Address: 15-3 fci 4 o., tro re A4 Fixture /sewer cap 16.60
City /State /ZIP: /C4?1. 4 )LjN Floor drain/floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
. • ❑ APPLICANT ❑ CONTACT PERSON • Hose bib 16.60
A J Ice maker 16.60
Business name: a wJ✓Y�..1 6tyJ , Interceptor /grease trap 16.60
Contact name: 1be AJ.?6 Medical gas (value: $ ) Page 2
Address: P. 0. A /t/7e / Primer 16.60
City /State /ZIP: PIA 9 >.2 S1 Roof drain (commercial) 16.60
Phone: (�)) 7 $ U- Sy$ 6 Fax:: ( )
Sink/basin/lavatory ( 16.60 / 6. 6 0'
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
• CONTRACTOR Water closet 16.60
Business name: S 4 Water heater 16.60
Address: Other:
City /State /ZIP:
Subtotal / 6. 6c.)
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 7
�
CCB Lic.: / 5"t/ t' $ Plumbing Lic. no.: j 6 -)? C /24 Plan review (25% of permit fee)
State surcharge (12% of permit fee)
Authorized signature:
TOTAL PERMIT FEE
Print name: -fir. x_Jaj Date 10 - g This permit application expires if a permit is not obtained within
�I " 180 days after it has been accepted as complete. ,24
*Fee methodology set by Tri -County Building Industry Service
I ABuilding\Permits\PLM- PermitApp doc 12/27/06 440- 4616T(10/02 /COM/WEB)
20`
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 $I 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 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 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
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 ❑ New exterior plumbing site utilities for any complex structure
-Tub/Shower 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 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 *Note: If the fixture work under this permit results in an
- Bradley
- 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