Permit CITY TIGARD SEWER CONNECTION PERMIT
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DEVELOPMENT SERVICES PERMIT #: SWR2005 00404
�� 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 12/12/2005
PARCEL: 1S135DA-02702
SITE ADDRESS: 11230 SW 90TH AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Sewer connection. A PLUMBING PERMIT is required for legal connection.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: SF • NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
NATHAN GATES
11230 SW 90TH AVE. Description Date Amount
TIGARD, OR 97223 -'` 1 "'
`, [SWUSA] Sewer Connection Fee 12/12/200`. $2,600.00 4
qt [SWINSP] Sewer Inspection Fee 12/12/200E $35.00
Phone: 503- 905 -5147 tiw
Total $2,635.00
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Contractor:
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C ontact #: REQUIRED ITEMS AND REPORTS
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Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR /.6u
may obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1-)00- .32- 2344. //7
Issued by: 44 Permittee Signatur• . � / -"
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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.
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Building Fixtures - . . . R :
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. 2005 Received
FOR OFFICE USE ONLY
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City of Tigard Re eve Permit 1917• -0-• Y
13125 SW Hall Blvd., Tigard, OR 97223�e .. Plan Review
Phone: 503.639.4171 Fax: 503.598.1
, � Y OF .rfU t, p r .� f1( .; � ; : I \ D �� Oher Permit No.:
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24- Hour Inspection Line: 503.639.41x76 nr DING DT - ,p • - 5 :
Internet: www.ci.tigard,or.us V iLlJil� T Date Ready/By: ® See Page 2 for
g Notified/Method: - � Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description • ( Qty. I Ea. I 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
El Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: (('L3 J S l� �1 l p f A , / / , I ..... _ Catch basin or area drain 16.60
City /State /ZIP: Drywell, leach line, or trench drain 16.60 A. Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
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
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DESCRIPTION OF WORK
Back flow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OWNER ❑ TENANT
//�J Ejectors sump 16.60
/ /ITT � �
Name: �4 - 5 - Expansion tank . 16.60
Address: (( 2� c. ) ; LA,/ '7 0 -I't- fiA f L Fixture /sewer cap 16.60
City /State /ZIP: 7l -! et Ro Ug_ G, 721/5 Floor drain/floor sink/hub 16.60
Phone: 66 g0s , 5/y7 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
Phone: ( ) Fax:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: Water heater 16.60
Address: Other:
City /State /ZIP:
Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: / /7 Plu ,in Lic. no.: Plan review (25% of permit fee)
Authorized signature: / �Oi / r / State surcharge (8% of permit fee)
r(/ iGc a 0f) TOTAL PERMIT FEE
Print name: /14 L 5 Date: / 2 � 2 � T
��his permit application expires if a permit is not obtaine within
( / ft r 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
i:\ Building \Permits\PLMF- PennitApp.doc 06/05 4404616T(10/02/COM/WEB)
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Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
=Site•Utilities - Qty. - Fee (ea) Total . Footage; Permit: Fee: _ , y. _
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
Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit
$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
Commercial Back Flow Prevention Device 46.40
including
148. i0g for the first $
$10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Back flow 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.
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Fixture Work: Plan Review, for Complex Structures `
Are you capping, adding or replacing fixtures? If "yes ", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria.
accurately report fixtures could result in increased sewer fees *. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building.
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous ° Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool providing services to human beings.
Car Wash - Each Stall ❑ Plumbing installations, alterations or additions to food service
- Drive Thru facilities where new plumbing fixtures, including interceptors,
Cuspidor /Water Aspirator are being installed for the food service area.
Dishwasher - Commercial ❑ Any new residential building containing three (3) or more
- Domestic dwelling units.
Drinking Fountain ❑ Any NFPA 13 -D multipurpose fire sprinkler system.
Eye Wash
Floor Drain /sink 2" Submit 2 sets of plans with any of the above.
-3"
-4" -
Car Wash Drain Isometric or Riser. Diagram • •
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: - plumbing permit can be issued.
i: Building\Permits\PLM- PermitApp.doc 07/06/05