Permit r p CITY OF TIGARD PLUMBING PERMIT
8 ` COMMUNITY DEVELOPMENT Permit #: PLM2011 -00077
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/15/2011
Parcel: 2S113AB00500
Jurisdiction: Tigard
Site address: 16083 SW UPPER BOONES FERRY RD 100
Project: Amedisys Subdivision: Lot: 0
Project Description: Interior plumbing: Adding (1) sink and (1) tankless water heater.
Contractor: MARXMEN PLUMBING & CONSTRUCTION INC Owner: G &S FC LLC
9665 SW 163RD AVE 516 SE MORRISON #100
BEAVERTON, OR 97007 PORTLAND, OR 97214
PHONE: 503 - 579 -2200 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Sink 03/15/2011 $25.02
Specifics: 1 ea Water Heater 03/15/2011 $37.52
1 12% State Surcharge - 03/15/2011 $8.70
Type of Use: COM Plumbing
Class of Work: ALT 10 ea Minimum Fee Adjustment - 03/15/2011 $9.96
Plumbing
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 -0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: ��— Permittee Signature:
– " i1 - _ -4 -
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
24/11 2029 10:39 5035792201 MARXMEN #0388 P.001/003
Plumbing Permit Application ,5 3y4 G , % 4 i is --- w►
Site Utilities nr..r. l())R ( 1 , -r ()"l \
City Tigard RI sy: ? �,�� pCrntit No.: _ /I 7
N S 13125 SW Hall Blvd., Tigard, OR 97223 Pitei Phone: 503.71$2439 Fax: 503598 -1 2O p ig �^ ot her Permit No.: / 7
Inspection Line: 501639.4175 �fi 15 P
C: ..};.1.) Internet' www d Date le4/Me tty � Supplemental 2 fur
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S�'u $�' - 130t+�dd/A•fatbnd- Infx'®ahaa
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0 N"..Mt1151111Cli011 0 D e m o l i t i o n Forspeciali far ra7eon usecke
Description I Qty. ( Ea - ( Total
Addition /alteration/replacetuettt 0 Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
4TkGO Y 4W ;C4) ) j`) SFR (1) bath 312.70
0 1 - and 2 -family dwelling [c�- mmerciaUIDdustrial SFR (2) bath . 437.7$
0 Accesary building Q Multifamily SFR (3) bath 500.32
Each additional bath/kitchen 25.02
[] Master builder El Other
Fire sprinkler (___ sq. ft) Page 2
JIOB $ ,?11 'ORMAl: 0, LOCATION Site utilities:
Job site address: 1 tDCD� S.0 _ eiAtS
Catch basin or area drain 18.76
City/State/ZIP: Drywell, leach hne, or trench drain 18.76
fl Footing drain (no. linear ft.: ___,) Page 2
Suite/bldg./apt no.: / Project name; 1 I 1 �" Mauufhctured home utilities 50.03
Cross street/directions to job site: 1 Manholes 18.76
Rain drain coemector 18.76
Sanitary sewer (no- linear ft: _,) Page 2
Storm swot (no- linear ft: Page 2
Water service (no. linear It: ) Page 2
Subdivision: Lot no.: fixture or item:
Tax treap/perrcei no.: l3acicflow provaarter 31.27
r
Clothes washer 25 - 112
'TIT, >� Dishwasher 25.02 W
i - S l i i k 1 1 .. kf ebC) tatl Drinking futmtain - 25.02
F,jevtors/stmrp 25.02
il?;ia t> KaFX ; 0* ;a :. N. Exptlosion tank 12.51
Name: Fixture/sewer cap 25-02
- . -- . � Floor drain /floor sink/hub 25 -02
Address: ..a:., W t t . a 9
disposal 25.02
City /State:61 : SOC. IL r f Hose bib 25.02
Phone: ( ) Fax: ( ) . its 4 -. maker 12.51 • ?0,A :icAr lr: ', { 'C7EJ91F.Fri a interceptor/grease trap 25 -02
name! r ► - ' . S � Medical gas (value: S ) Page 2
Business
.4 Ili i,1 rG
Primer 1231
Contact name: 14401‹ Sher ii Roof drain (contmercfal) 12.51 2
Address: `t , G6 tx 5 Surk/ in/lavatory 25.02 Ate
City/State/ZIP: 12._veir O Solar units (potable water) 62.54
Phone: ( rJ 0;9 a W4 2 ' J) Fax: : (50 ) 57q -2, Lo 1 � Tub/shower/shower pan 12.51
Urinal 25.02
E -mail Fl o1. L ,' � -1
b 1
`' WaLet closet t r
Water I 1CpECT 3752 J l
Buaine s name ___ Water piping/DwV 5629
Address: Other 25.02
City/State2.IP: Subtotal r .
now :( ) Fax : ( )
Minimum permit foe: $72.50 12 5.1
CCB Lie.: . 4. -_. t� P1 ' i `' ing 1.ie. no.: j a 67 Plan review (25"/0 of permit fax) �_
.1 S t a t e s u r c h a r g e ( 1 2 ° h of p e r m i t f e e ) 70
Authorized signature: , 1 f _ TOTAL PERMIT FEE 7 • , -, 1. )o
�`` q , - , �/� This permit application expires if a permit is not obtained wi , 2.1 days
Print name. *4 4 �' `Q 1 ��`: after it has been accepted as complete.
A Fce methodology set by 1 County Building Industry Service 130ana
I: 1Pe. ediln3 -P antAppdae 10101A79 440- 4616P(10/O1/COM/Wfn)
24/11 2029 10:40 5035792201 MARXMEN #0388 P.003/003
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Fire S
esidential F uppress>lori Systems:
U �
au e" ., e; . . : Fee; ,
Footing drain -1 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3.600 $169.69
Sewer - 1st 100' 3 601 to 7 00
62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Wafer Service - 1st 100' - 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Storm & Rain Drain - 1st 100' 62.54 g e `
$1.00 to $5.000.00 Minimum fee $7230
Storm Sc. Ram Drain - each additional 100' 3732 $5,001.00 to $10,000.00 $72.50 for the firs $5,000.00 and $1.52 for
Other Ins or ' ' ems t _ . a Fee ( et1sY " each additional $100.00 or fraction thereof, to
and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the that $10,000.00 and $154 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof to
(minis n charge —1/ hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
how (minimum charge -° 2 hours) emch additional $100.00 or fraction thereof, to
Reinsnection Fees 90.00/hr and including $50.000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $120 for
minim charm —1/2 bota� each additional $100.00 or fraction thereof.
• Subtotal: " �'
- '"�' --
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? if "yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
c e sot Fkta.rt ; „, ..,,,,pti iiwiii Review tot';Pinti ig rs
NVotfperloraitdz , ,cape# Ate : ..a Plan review is required for any of the following..
B stry/Fotrt Please check all that apply.
$a - Tub/Shower - -- 0 Any new commercial building with water service 2” and
Jaet>TZi/Whirlpool T- - greater, except systems designed and stamped by licensed
Car wash -Each Stint ` _ engineer.
Drive Thru ❑ New exterior plumbing site utilities for any complex stnicture
' Cuspidor/Waux AsQirator as defined in OAR918- 780 - 0040.
Dishwasher -Co ciat 0 Medical gas and vacuum systems for health care facilities.
- Domestic 0 Any multipurpose fire sprinkler system.
Drinking Fountain 0 Any complex structure as defined in OAR918- 780-0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above
-3"
Car Wash Drain kg71R :
Garb Dosric- non -coal isometric or riser diagram is required for new buildings
Disposal - Domestic - food related that meet the qualifications above.
- Commercial -food rebated
- industrial -fcxxt related
Ice by achJRefrig Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. 'Vehicle Dump Station - _ -
Shower -Gang
-Stall _
Sink/Lay -Non-food related
- Bradley
-Commercial- food related
- Service
�
a Clothes
*Note: If the fixture work under this permit results in an
Water - Extractor . - increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet T fees assessed for the sewer increase must be paid before the
urinal , plumbing permit can be issued
Other Fixtures: WI P i 1
hit:p / /www.bigard- or.gov/ city_ hall /dcpa nts/cd/docs/PLMu_PermitAp f doc
1
Accumulative Sewer Tally Parcel # 2S113AB00500
Tenant Name: AMEDISYS This SWR# SWR2011 -00047
Site Address: 16083 SW UPPER BOONES FERRY This PLM# PLM2011 -00077
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count oft it, count tt value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- 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 Drn 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) 42 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 1 2 1 2
- 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 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS _ 0 0 0 0 1 2 1 2
Current Fixture Value 2 divided by 16 = 0.1 Current El )U 1 EDU = $ 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) S 410.00
Enter EDU Change Here 0.1
Notes:
Authorized Name /Signature: BRANDEN TAGGART Date: 3/15/2011
Building Division
ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
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