Permit A ---- CITY OF TIGARD PLUMBING PERMIT
r � DEVELOPMENT SERVICES PERMIT #: PLM2002 -00429
� I � 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/8/02
SITE ADDRESS: 15705 SW 72ND AVE PARCEL: 2S112DC -00100
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION:
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: 2 SEWER LINE: ft
WATER CLOSETS: 2 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Remove (2) water closets and add (2) showers.
FEES
Owner: Description Date Amount
PACIFIC REALTY ASSOCIATES
15350 SW SEQUOIA PKWY #300 -WMI [PLUMB] Permit Fee 11/8/02 $72.50
PORTLAND, OR 97224 [PLUMB] Permit Fee 11/8/02 $0.00
[TAX] 8% State Tax 11/8/02 $5.80
[TAX] 8% State Tax 11/8/02 $0.00
Phone 1: Total $78.30
Contractor:
JOHNSON PLUMBING
181 N. GRANT ST. SUITE 209
CANBY, OR 97013 REQUIRED INSPECTIONS
Phone 1: Rough -in Insp
Final Inspection
Reg #: LIC 59426
PLM 3 -213P
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 requires you to follow rules adopted by the Oregon
Issued By: Permittee Signature: 44 ,
Ca (503) 639 -4175 by 7:00 P.M. for an inspection needed the next bus"; less day
Building Fixtures
PlumbingPermitApplication OFFICE USE ONLY
�� City of Tigard Date received: I /�k /Oo2./Permit no.4-/-fgepz-190 yay
�� - t - ' Sewer permit no. : Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 - 1960 Date issued: By t) Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
0 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Food service 0 Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist
Job address: /,5 705 70.-04v Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax map /tax lot/account no.: (includes 100 ft. for each utility connection)
SFR (1) bath
Lot: (Block: I Subdivision: SFR (2) bath
Project name: /vi t & `j D e SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells /leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name ' ... Seto/k( ° t en t hGyt 7 //11 Manholes
Address: / J7 4 ) 4.44,,, - .a,„4, ZO, Rain drain connector
City:(!pyj 6. State• ZIP: ,7 Sanitary sewer (no. lin. ft.)
Phone:$o3 - z.z, 7>l iax: Z/44— `$ /(p -mail: Storm sewer (no. lin. ft.)
CCB no.: 307 y Z Cp I Plumb. bus. reg. no: 'S Water service (no. lin. ft.)
City /metro lic. no.: 3//(03 /02/3/ "AZ. —a� / Fixture or item:
Contractor's representative signature: /5( Absorption valve
Back flow preventer
Print name d- 16. tiv- -S Date: /[ f3 OZ
Backwater valve
CONTACT PERSON Basins/lavatory
Name: <p w s N _.1 . — Clothes washer
Address: Dishwasher
Drinking fountain(s)
City: 1 State: I ZIP: Ejectors /sump
Phone: Fax: E -mail: Expansion tank
OWNER Fixture /sewer cap
Name (print): Floor drains /floor sinks/hub
Mailing address: Garbage disposal
Hose bibb
City: 'State: I ZIP: Ice maker
Phone: I Fax: I E -mail:
Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs/shower /shower pan 7�
Name: Urinal
Address: Water closet
Water heater
City: I State: I ZIP: Other:
Phone: Fax: E -mail: To tal
Not all jurisdictions accept credit cards, please call jurisdiction for more infomfatioa Minimum fee $ �o? 5 0
Notice: This permit application o
0 Visa 0 MasterCard Plan review (at _ %) $
expires if a permit is not obtained o
Credit card number: / / within 180 days after it has been State surcharge (8%) .... $ .r 8 8
Expires TOTAL $ 7 P / 30
Name of cardholder as shown on credit card accepted as complete.
Cardholder signature Amount 440 -4616 (6/00 /COM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only o� 16.60 Three (3) bath $399.00
Water Closet 16.60
a SUBTOTAL
Urinal 16.60
8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" 16.60
3" 16.60 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory
Hose Bibs 16.60 Tub or Tub /Shower
Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 1,6.60 Water Closet
Other Fixtures (Specify) 16.60 Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3 "
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
**PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
** AII New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
is \dsts \forms\plm - fees.doc 12/26/01
Accumulative Sewer Tally
Tenant Name: Nike Golf This SWRA N/A
Site Address: 15705 SW 72nd Ave. This PLM# 2002 -00429
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
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 2 8 2 8
- 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
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Dm 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 48 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (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 0 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 0 0 0
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 2 12 0 -2 -12
Urinal 6 0 0 0 0 0
Previous EDU Count 8.8 140.8 140.8
Capped EDU Credit 0
TOTALS 0 140.8 2 12 2 8 0 136.8
Current Fixture Value 136.8 divided by 16 = 8.6 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 140.8 divided by 16 = 8.8 Previous EDU
Change -4 divided by 16 = -0.3 over (under) $ (690.00)
Enter EDU Change Here -0.3
HISTORY
- --Note _ �_ �. _ - _ - _ ...:. - "U - •_ — — -. -_ ....
PLM# EDU# SWR#
PLM# EDU# SWR#
Name' ZFLL -' Date: / / / / � /Oc,
.0 74/ S gnature of person that calculated this tally sheet and date perf med s required