Permit C ITY OF TIGARD PLUMBING PERMIT
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COMMUNITY DEVELOPMENT PERMIT #: PLM2009 - 00044
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/26/2009
PARCEL: 2 S 113 B 0 - 00600
SITE ADDRESS: 16580 SW 85TH AVE ZONING: I -
SUBDIVISION: SEWER TREATMENT PLANT LOT: JURISDICTION: TIG
PROJECT: CLEAN WATER SERVICES
Project Description: (stall eyewash /shower, water heater, and relocate service sink.
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: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES: 1
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
CLEAN WATER SERVICES
2550 SW HILLSBORO HWY Description Date Amount
HILLSBORO, OR 97123 -9379 [PLUMB] Permit Fee 2/26/2009 $72.50
[TAX] 12% State Surch 2/26/2009 $8.70
Phone : 503- 681 -3600 Total $81.20
Contractor:
BRYAN R GREEN CONSTRUCTION
1336 NE 73RD
PORTLAND, OR 97213 REQUIRED ITEMS AND REPORTS
Contact # : PRI 253 -2521
Reg #: LIC 00027068
PLM 26 -439pb
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
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: Permittee Signature:
l �
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 RECEIVE Building Fixtures RECEI I' E i FOR OFFICE USE ONLY
City of Tigard Received
• .Q Pennit No.: 1rlZ y y
• 13125 SW Hall Blvd., Tigard, OR 97223 FEB 2 6 2009 y. •
Plan Review II Phone: Permit No
.i
Phone: 503.639.4171 Fax: 503.598.1960 Other 'v c �+.�
Inspection Line: 503.639.4175 CITY OF TIGARD
T I R n Date Ready/By: . y: .r +s: 0 See Page 2 for
Internet: www.tigard - or.gov BUILDING DIVISIO i otified/Method: 1 Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. Ea. Total
X 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: 1 67580 S 8G Pe Catch basin or area drain 16.60
City/State /ZIP: ' ' .A �' 172 -M- Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: rpUru..t S ��_._ Footing drain (no. linear ft.: _) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
S T z j' . TE Recovuoi FACT Lt Rain drain connector 16.60
( / Q)bE. H ) GOY- F- 6 Sanitary sewer (no. linear ft.: _ ) Page 2
_' Storm sewer (no. linear ft.: _ ) Page 2
Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK ^ i� Backflow preventer Page 2
(� S��w_ E\' C /( t..� a4U � A--AA Backwater valve 16.60
1w `G S VtW StNie..-- Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: C( Y4 -tea U Q SC�(Z■t CeS Expansion tank 16.60
Address: Fixture /sewer cap 1 16.60
City /State /ZIP: Floor drain/floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
t �- ^ `, Interceptor /grease trap 16.60
Contact name: S ('I � LI,w.J , Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 1 16.60
Phone: ( ) I Fax: ( ) Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
Business name I R , C�.:e•,� jr f f �V104 ter heater \ 16.60
Address: i37 NE 73 46.6-. Other: E`J t�e Wck h I
�/ Subtotal
City/State /ZIP: Fart- /17243
Minimum permit fee: $72.50 �
Phone: (93) Z53 2 cZ 1 Fax: ( ' 242, g 40T Residential backflow minimum permit fee: $36.25 2' ` �
CCB Lic.: 2 .706 0 a Plumbing Lic. no.: 74, ^4 31 pa Plan review (25% of permit fee)
State surcharge (12% of permit fee) g, ri 0
Authorized signature: Z TOTAL PERMIT FEE S •
Print name: ,� 4(. Date: / O� This permit application expires if a permit is not obtained within
I 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
I:\ 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
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or
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.
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 El 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.
-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:
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PURVEYOR: (J 7 fit^ ! ' r SERIAL
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LOCATION: -4-747--7-4-o+-7,.. UY/r
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REDUCED PRESSURE ASSEMBLY P.V.B.A / s.v.B.A. . INITIAL TEST
�ICHECK Pg0EU3IiigitiliI00.,t AIR. . CHECK PASSED
PRESS.DRAP (AEI . CHECK /11 ... INLET FAILED
INI TI OPENED AT
AL . RELIEF VALVE '
' ,} (B)TIGHT' ® 1.3 OPENED AT. PRESS DROP
TL/S7 . MIN �lD I pin DAT •
RESULTS LEAKED D
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• • IN COMPLETING AND SUBMITTING This TEST REPORT/Oa TESTER CERTIFIES THAT THE
,. • ASSEMBLY HAS BEEN TESTED AND MAINTAINED,DI ACCORDANCE Wtf1'XLL APPWCABLE'
• RULES AND REGULATIONS OF UB WATER • SYSTEM• • AND STATE REGULATIONS
GAUGE ALIB ;_ TION . PA ' f!'.: DETECTOR METER READING : •
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TESTER S ' N
TESTERS N MI! PRIIrTfiD • : Q / /°r� 7 9
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