Permit A CITY OF TIGARD SEWER CONNECTION PERMIT
d��l� I - DEVELOPMENT SERVICES PERMIT #: SWR2000 - 00316
�= 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/5/00
SITE ADDRESS; 10255 SW 90TH AVE PARCEL: 1S135AB-00100
SUBDIVISION: TOWN OF METZGER ZONING: R - 4.5
BLOCK: LOT: 005 JURISDICTION: TIG
TENANT NAME: METZGER ELEMENTARY SCHOOL
USA NO: FIXTURE UNITS: 16
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: COM NO. OF BUILDINGS: 1
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection for new modular classroom building. Building contains 2 bathrooms (2 lavatories
& 2 water closets), which increases the current EDU by 1.
Owner:
FEES
TIGARD - TUALATIN SCHOOL DIST Type By Date Amount Receipt
13137 SW PACIFIC HWY
TIGARD, OR 97224 PRMT CTR 10/5/00 $2,300.00 27200000000
INSP CTR • 10/5/00 $45.00 27200000000
Phone: Total $2,345.00
Contractor:
DAVE MCDONALD PLUMBING
PO BOX 341
SEASIDE, OR 97138
Phone: 503 - 738 -7046
Reg #: LIC 144866
PLM 4 -45PB
Required Inspections
Sewer Inspection
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. 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 r-• uires you to follow rules adopted
by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 -■ i -0010 oug •AR 952 - 001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling 03) 246 -1987.
• L-•
Issued by: �� 1 Permittee Signatur-: �� . ��
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
•
- a s= -.__
-i,:. _ Permit Application
Date received: / p /Y/oh Permit no.: Su) R 2000 d 0 3/
'..o � ii, City of Tigard Sewer permit no.: Building permit no.:
� " Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 ca:e..Qz2/ .dge_ , Project/appl.no.: Expire date:
Fax: (503) 598 - 1960 /267711 /o /yfro ,47 '- Date issued: By: Receipt no.:
Land use approval: /1" IL 2o00 —400/7 Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory 'Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction /❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
,c_
Job address: /6 Sl.J 9/) #.4-.-- Description Qty. Fee (ea,) Total
-
Bldg. no.: I Suite no.: New 1=,and 2 -family dwellings only:
(includeh.00 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: IBlock: I Subdivision: SFR (2) bath
Project name: /7 - ,_ E7_,E7'16 - 7 SFR (3) batl\
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: --5"6 Site utilities:.
lfookccP " Al aLJ ,J.. /2, /8'#77,12 - 00 YS Catch basin/area chain
Est. date of completion/inspection: (2 Ifi S Z. 7P/t. Drywells/leach lin /trench drain
PLUMBING CONTRACTOR Footing drain (no. 11 . ft.)
Manufactured home tilities
Business name: MA /in 2sDit/9 Atu/`/3 /n/&' Manholes
Address: P O 84 X 39/ Rain drain connector
City: .SEf}S //J ( State:d-� ZIP: y1/,3 �' Sanitary sewer (no. lin. ft. /
(no. lin. ft.) \
Phone:� - 73*' 7d y4 Fax: I E -mail: Storm sewer ( /
CCB no.: /e/q/6,G I Plumb. bus. reg. no: i/-1/5 /°,B Water service (no. lin. ft.) /
City /metro lic. no.: Fixture or item:
. Contractor's representative signature: Absorption valve
— Back flow preventer
Print name: Date: Backwater valve
CONTACT PERSON Basins/lavatory
Name: • Clothes washer
Address: Dishwasher
Drinking fountain(s) .
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
. OWNER Fixture/sewer cap
Name (print): Floor drains/floor si ■ ub
Mailing address: Garbage disposal
Hose bibb •
City: I State: I ZIP: • Ice maker \
Phone: I Fax: I E -mail: Interceptor /greas 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 (co mercial) .
employee on the property I own as per ORS Chapter 447. Sink(s), basin ), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs /showe /shower pan \ .
Name: Urinal
ame:
Water clo t
Address: Water he er
City: I State: I ZIP: Other:
Phone: Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $
Notice: This permit application Pl review (at %
❑Visa 0 MasterCard ( %) $
expires if a permit is not obtained
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $
Expires TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
' Cardholder signature Amount 440 -4616 (6/00 /COM)
PLEASE COMPLETE:
FIXTURES(individual) - :' .:;.::: ,jia ``:9:qi::' Iti:970h '''-10:
. F ixture Type Quantity by Work Performed
Sink 16.60 New Moved Replaced Removed/Capped
Lavatory - .2 16.60 33 , 20 Sink
Lavatory .2,
Tub or Tub/Shower Comb. 16.60 Tub or Tub/Shower Combination
Shower Only 16.60 Shower Only
02 .
Water Closet .2_ .16.60 3 , 20 Water Closet '
Urinal • .. .
Urinal 16.60 Dishwasher
Dishwasher 16.60 Garbage Disposal
Laundry Room Tray
Garbage Disposal 16.60 Washing Machine •
Laundry Tray 16.60 Floor Drain/Floor Sink 2"
3"
Washing Machine 16.60 4° ' •
Floor Drain/Floor Sink 2" 16.60 Water Heater
16.60
Other Fixtures (Specify)
3"
4" 16.60 . .
Water Heater 0 conversion 0 like kind 16.60
Gas piping requires a separate mechanical permit. •
MEG Home New Water Service 46.40 . .
. •
MEG Home New San/Storm Sewer 46.40
• COMMENTS REGARDING ABOVE:
Hose Bibs 16.60
Roof Drains 16.60
Drinking Fountain 16.60
. •
Other Fixtures (Specify) 21.75
• _
. -
• .
. .-
Sewer - 1st 100 • 55.00 '
. ...
Sewer - each additional 100' .. 46.40 .
• • . . •
Water Service - 1st 100' • 55.00 .., •
. . :.
. . .
Water Service - each additional 200' 46.40
._. . .
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
. . .
Insp. of Existing Plumbing or Specially Requested 72.50
Inspections per/hr
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
%MI Min 702, 50
8% SURCHARGE
cl. ,.;
**PLAN REVIEW 25% OF SUBTOTAL flfgri Ma74
Required only if fixture qty. total is > 9 t'' tglit*i
TOTAL VV1.4", AVIS*
• ,g04: '2,•0 •
*Minimum permit fee is $72.50 + 8% surcharge, except Residential Backflow Prevention
Device, which is $36.25 + 8% surcharge. • . .
**All New Commercial Buildings require plans with isometric or riser diagram and plan review.
•
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s . Accumulative Sewer Tally
Tenant Name: i - /E 2 EL&?VEivT This SWR# Su ap J2 o – OO-3/ Cc
2
Address: / Ss' Su 94 '" #9 This PLM #: — •
Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New
# Value Capped off value added # added #s total
Count off #s count value values
Baptistry/Font 4
Bath - Tub /Shower 4
- Jacuzzi/Whirlpool 4
Car Wash - Each Stall 6
•
- Drive Through 16
Cuspidor/Water Aspirator 1
Dishwasher - Commercial 4
- Domestic 2
Drinking Fountain 1
Eye Wash 1
Floor Drain /sink - 2 inch 2
- 3 inch 5
- 4 inch 6
- Car Wash Drn 6
Garbage Disposal .. _ 16
-Domestic (to 3/4 HP)
•
, ^ -.Commercial (to 5 HP) 32
' = Industrial (over 5 HP) 48
•'ice "Machine /Refrigerator Drains 1
Oil Sep (Gas Station) 6
•
Rec. Vehicle Dump Station 16
Shower - Gang (Per Head) 1
• • - Stall 2
Sink - Bar /Lavatory 2 a2 /
- Bradley 5
- Commercial 3
Service 3
Swimming Pool Filter 1
Washer - Clothes 6
Water Extractor 6
Water Closet - Toilet 6 a /
Urinal 6
TOTALS 57 Co
Total fixture values: _59.2_, divided by 16 = 37 EDU /t/ee T, S E Cfr 1 2 G(,
HISTORY Eou S /Ek„ /9-1R/ F} /6 /s/erel
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
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