Permit •
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2011 -00205
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/30/2011
Parcel: 2S103DC00820
Jurisdiction: Tigard
Site address: 11270 SW FAIRHAVEN ST
Project: GRANT Subdivision: VIRGINIA ACRES NO. 2 Lot: 13
Project Description: Connect existing house to sewer. Sewer Reimbursement District fee paid.
Contractor: OWNER Owner: GRANT, JOHN III & KRISTEN
11270 SW FAIRHAVEN CT
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
50 If Sewer Service 06/30/2011 $62.54
Specifics: 1 12% State Surcharge - 06/30/2011 $8.70
Plumbing
Type of Use: SF 10 ea Minimum Fee Adjustment - 06/30/2011 $9.96
Plumbing
Class of Work: ALT
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 1.800.3 4.
Issued By: , , ittee Signature: L1 , / v Al4 `l w
Call 51 .639.4175 by 7:00 a.m. for the next available inspect 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 r 1
Site Utilities FOR OFFICE USE ONLY
•
City of Tigard DateB Yf /�� 11 Permit No.: D(itn 1Ls1 ,�y �r
.i 13125 SW Hall Blvd., Tigard, OR 97223 1� y { I,1Y �(,[ ,
Er
Plan Review Other Permit No.:
Phone: 503.718.2439 Fax: 503.59 Date /By:
TIGARD Inspection Line: 503.639.4175 �0 \\ Date Ready /By: El See Page 2 for
Internet: www.tigard ® Notified /Method: /C Supplemental Information
r, a : 144 � - "ate ':, ORT{ , a `` � � u .�' � ' z �� a per. .�.. •. E i � .. . � ': � � � �
... ,. TYPE OF W
, �_ � � .. FEE SCHEDiIL 4 �t`
❑ New construction ❑ De 1� �� o �'� j For special information use checklist.
•
V � Description Qty. Ea. Total
® Addition /alteration /replacement 1=1 New 1- 2- family dwellings (includes 100 ft. for each utility connection)
A : , 41 ' t EG - O RY OF "COSTR, SFR l bath 312.70
CA1I' ( )
i ®I - 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:
'ate' Fire sprinkler ( sq. ft.) Page 2
tJO &SITE INFORMATION ND LOtffATION Site utilities:
'v,' ...-
Job site address: 11270 SW Fairhaven Court Catch basin or area drain 18.76
City /State /ZIP: Tigard, OR 97223 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: I Project name: Sewer Connection Manufactured home utilities 50.03
Cross street/directions to job site: Fairhaven St & Fairhaven Court Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: 50) Page 2 62.54
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: _) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map /parcel no.: Backtlow preventer 31.27
Backwater valve 12.51
'. , .... . DESCR OF/WORK
', 0 , . IA": ..
Clothes washer 25.02
Decommission of septic tank and system, and connect to city sewer Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
tom` '� ' Ex ansion tank 12.51
, ;. ''' ® PROPERTY OWNER TENAN P
Name: John Grant III Fixture /sewer cap 25.02 7
Floor drain /floor sink /hub 25.02 I
Address: 11270 SW Fairhaven Court
Garbage disposal 25.02
City /State /ZIP: Tigard, OR 97223 Hose bib 25.02
Phone: (503)639 - 8400 Fax: ( ) Ice maker 12.51
••, ®CONTA PERR Interceptor /grease trap 25.02
Business name: SELF Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: John Grant
Roof drain (commercial) 12.51
Address: 11270 SW Fairhaven CT Sink/basin/lavatory 25.02
City /State /ZIP: Tigard, OR 07223 Solar units (potable water) 62.54
Phone: (503) 539 - 6749 Cell Fax: : ( ) Tub /shower /shower pan 12.51
E - mail: jvg.cobra @frontier.com Urinal 25.02
./
R - . 4. c x ., CON R TOR :' , :
t Y Water closet 25.02
"� Water heater 37.52
Business name: NA UL+.iikrcr Water piping/DWV 56.29
Address: Other: 25.02
City /State /ZIP: Subtotal 62.54
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50 72.50
Plan review (25% of permit fee)
CCB Lic.: Plumbing Lic. no.:
State surcharge (12% of permit fee) 8.70
Authorized signature: TOTAL PERMIT FEE 81.20
Print name: John Grant Date: This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industr Service Board.
t\ Building \Permits \PLMU- PermitApp.doc 10 /01/09 440- 4616T(10 /02 /COM /wEB) 0?!
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information •
Fee Schedule: Residential Fire Suppression Systems:
(
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
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 1 62.54 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation Perm1tFee , ; . .
Storm & Rain Drain - 1st 100' 62.54 $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
Qty Fee
Qth (ea Total each additional $100.00 or fraction thereof, to
r�Inspect><ans Fees
_- � - 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:
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 b� FtxfurerType & plan, Rev for,Plun Jn Installat><ons ,, ,
Fixture Type for 4 R 7 hl ac e i ' Plan review is required for any of the following.
;.Capped R 4 Added Relocate 9 Y
Baptistry /Font Please check all that apply.
Bath Tub /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"
Car Wash Drain a .. a ,.. IlletrI 01' RI3et Dlagra�m �,
Garbage Domestic- non -food ❑ Isometric or riser diagram is required for new buildings
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/Lay - Non -food related
- Bradley
- Commercial- food related
- Service
Swimming Pool Filter *Note: If the fixture work under this ermit results in an
Washer - Clothes p
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:
http: / /www.tigard -or. gov /city_hal l /departments /cd /dots /P LM U- PermitApi2 doc
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0 .���
Information Notice to Owners About
- ''': Construction Responsibilities
tip
•
701.055 (5))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503 - 378 -4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503 - 947 -1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to
http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms.
• , Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503 - 947 -7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough -in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052
Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007
Website Address: www.oregon.gov /ccb
f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant
%° Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
lice ed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
• Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
t k
Print Name of Permit Applicant
A1r.1114 i1v 4 (6 Al
si47, re of Permit Applicant Date
Permit #: 11 - 13 1/ 9 0 / ( S
77,04 e
Address: 1 I � 7C) &W Of ~ r ;r
',� _mss, ;
Issued by: Date: (/3( // (
This Copy for Permit Offices
C Community Development
T I Gn Iz D 1" enit>rnbur°semtent District Payment Worksheet
Planning /Engineering to complete:
Site Address: f/ Z 7 0 SCJ rCi-` r C4
Parcel No.: `� `3C - o 0SU6
Reimburse nt District No.: 3 Amount Due: $ ( 40 0 0
Date: / By: j� , - ��.•�F�y —�
Note: Amount due is as of date shown above.
Deferred Accounts:
Name:
Phone Number:
Legal:
Amount paid: $
Remaining to be paid; deferrer. amount: $
uilding Division to complete:
Reimbursement amount paid: $ ow, -
y
Received by:
Return completed worksheet with copy of receipt to planning /engineering permit technician.
Planning /Engineering to complete:
Enter "paid" parcel tag.
Enter "deferral" parcel tag, if applicable.
Route copy of receipt and parcel information printout to Finance Department.
l: \CURPLN \Masters \ReimburseWorksheet.doc 2/23/07