Permit CITY OF TIGARD PLUMBING PERMIT
1111q COMMUNITY DEVELOPMENT Permit #: PLM2011 -00135
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/28/2011
Parcel: 25114DB00100
Jurisdiction:
Site address: 17005 SW 92ND AVE
Project: Cook Park Shelter & Bathroom Subdivision: Lot:
Project Description: Installation of less than 100' each of sanitary sewer line and water service for new pre -fab restroom. Fixture count
inside of pre -fab restroom is (3) water closets, (1) urinal, (2) lays, (2) floor drains & (1) drinking fountain.
Contractor: SORENSEN PLUMBING Owner: TIGARD, CITY OF
19010 SW BONNIE MEADOWS 13125 SW HALL BLVD
ALOHA, OR 97006 TIGARD, OR 97223
PHONE: 503 - 522 -2052 PHONE.
FAX:
FEES
Quantity Description Date Amount
100 If Sewer Service 04/28/2011 $62.54
Specifics: 100 If Water Service 04/28/2011 $62.54
1 12% State Surcharge - 04/28/2011 $15.01
Type of Use: COM Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $140.09
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
Utilit •• . "cation e - . Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtai - . . the rules
or •erect questions to OUN •y c 'nt 5 or 1.800.332.2344.
I
I ued By: . f / Permittee Signature: i
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.
Plumbing Permit Application
Building Fixtures
R eceiv I�
City of Tigard y ed ';/ g' Ij Permit No.: ^
l !30/ 5
DateB
Iii . • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit No.:
T I G A P. D Inspection Line: 503.639 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
El New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. I Total
ir Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
El 1- and 2- family dwelling [Commercial/industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 1 s 5 W T Z ~ Au G Catch basin or area drain 18.76
/1R_ 8 2 Drywell, leach line, or trench drain 18.76
City/State /ZIP:
T( r � Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: e oo l_ (? R � Manufactured home utilities 50.03
Cross street/directions to job site: -6,4 R Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.:40 Page 2 4 Z . 5'
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear Eta) ) Page 2 , 2.51
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: g l lei 0600166 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
( Nl S I L l Y vh `*1 S �.(LUtt^ L d. bet / C t)v.(� Dishwasher 25.02 -
6 L --w ca _ . r p Ft. c2. B'l"A-� cj 4-- e.-�,,/°•e� Drinking fountain 25.02
fZ LtZIT J7t°e\ Ejectors /sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State /ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name:
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 25.02
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: 51, a eye 15 '65% P1,4
," 4 Water piping/DWV 56.29
Address: ' elaio 5w 13 0 A i 1 1 /14 `y),0ow CA..4 Other: 25.02
City /State /ZIP: p 14 pit__ q2.06 Subtotal I 0 8
Phone: (,v5) 5-- zZ_ Fax: (---)- Minimum permit fee: $72.50
, -. ; _ Plan review (25% of permit fee)
CCB Lie.:
(G 151, 0_� 4 ic. no.: 4 $ 1 ■ State surcharge (12% of permit fee) j
�� �
Authorized sign. I re:
l / TOTAL PERMIT FEE ( 10, 01
Print name: (/I J�,t, (_ dp ([ Date: t -� - (( This permit application expires if a permit is not obtained within 180 days
E+ �S t` � after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I: Building \Permits\PLMU- PermitApp.doc 10/01/09 440- 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 - 1s` 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
/ Z Sy 3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54
G 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 6 ZS
Medical Gas Systems:
Water Service - each additional 100' 37.52
Storm & Rain Drain - 1st 100' 62.54 Valuation: Permit Fee:
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other ec
Ins tions or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
Inspections and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $ 1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 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
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection 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 $1.20 for
(minimum charge - 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal: 11,s:et
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
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace/
Work Performed Capped Added Relocate Plan review is required for any of the following.
Baptistry/Font Please check all that apply.
Bath l'ub /shower ❑ Any new commercial building with water service 2" and
- Jacuzzi /Whirlpool greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer.
-Drive Thru ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918- 780 -0040.
Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ 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"
4„ Isometric or Riser Diagram
Car Wash Drain ❑ Isometric or riser diagram is required for new buildings - Domestic-non -food s
g q g
Disposal - Domestic - food related that meet the qualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav - Non -food related
- Bradley
- Commercial -food related
- Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer - Clothes
Water Extractor increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
I: \Building\Permits\PLMF- PermitApp.doc 2
Accumulative Sewer Tally Parcel # 2S114DB00100
Tenant Name: City of Tigard - Cook Park This SWR# N/A
Site Address: 17005 SW 92nd Ave This PLM# 201 1 -00135
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s 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 1 1 1 1
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 2 4 2 4
- 3 inch 5 0 0 0 0 0
- 4inch 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 2 4 2 4
- 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 3 18 3 18
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped EDU Credit 2.9 46.4
TOTALS 0 0 _ 0 0 9 33 9 -13.4
Current Fixture Value -13.4 divided by 16 = -0.8 Current EDU 1 EDU = $ 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -13.4 divided by 16 = -0.8 over (under) $ (3,280.00)
Enter EDU Change Here -0.8
Notes: Credits used from PLM2009- 00091. Credit balance of -.8 still remaining.
Authorized Name /Signature: Debbie Adamski Date: 4 /28/2011
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \ Building \ Sewer Tally\ SewerTallySheet- 4100.xls 07/01/10
Accumulative Sewer Tally Parcel # 2S114AC00700
Tenant Name: City of Tigard - Cook Park * *REVISED ** This SWR# N/A
Site Address: 17005 SW 92nd Ave This PLM# 2009 -00091
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count value #5 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 2 10 0 -2 -10
- 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 3 6 0 -3 -6
- 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 4 24 0 -4 -24
Urinal 6 0 1 6 0 -1 -6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 10 46 0 0 -10 -46
Current Fixture Value -46 divided by 16 = -2.9 Current EDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -46 divided by 16 = -2.9 over (under) $ (8,990.00)
Enter EDU Change Here -2.9
Notes: ** *CREDITS ** *4/28/11, 2.1 EDU credits applied to PI ,M2011-00135, remaining balance is -.8
Authorized Name /Signature: Debbie Adamski Date: 4/16/2009
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \ Building \Sewer Tally \SewerTallySheet- 3100.xls 06/19/08