Permit CITY TIGARD SEWER CONNECTION PERMIT
I DEVELOPMENT SERVICES PERMIT #: SWR2005 -00343
� '' II 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 11/7/2005
PARCEL: 2 S 103 6 103RD D -01700
SITE ADDRESS: 11945 SW CARMEN ST ZONING: R - 4.5
SUBDIVISION: LOT: 014 JURISDICTION: TIG
Project Description: Sewer 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
MARGARET JOHNSON
11945 SW CARMEN ST Description Date Amount
TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 11/7/2005 $2,600.00
[SWINSP] Sewer Inspection Fee 11/7/2005 $35.00
Phone: 503 690 - 3705 Total $2,635.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #: THIS IS NOT A PLUMBING PERMIT.
A PLUMBING PERMIT IS REQUIRED
FOR A LEGAL CONNECTION.
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 952 - 001 -0100. You` --.
may obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued by: :22 .�� Permittee
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that busi . • ss 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
., Plumbing Permit App 'cationm Q .
� `u E® .. OFFICE JCL•` •USE ONLY
of Tigard 1� Daz /I -• 7 -// c5 )' Permit No.5( � /ham i
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review !/ � N
Phone: 503.639.4171 Fax: 503.598.1960 Nov 7 2005 i�i�M ,;nµ y„ i �, g f�i•I Date/By. Other Permit No.:
24- Hour Inspection Line: 503.639.4175 -Al; " _ I Date Ready/By: Suds: ® See Page 2 for
Internet: www.ci.ti Notified/Method: Notified/Method: Supplemental Information
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' TYPE 6 ' frIMDivIs ION FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I 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 (I) bath 249.20
❑ 1- and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
ID 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: Catch basin or area drain 16.60
City /State /ZIP: Drywell, leach line, or trench drain 16.60
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
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER Drinking fountain 16.60
-
❑ TENANT •
Ejectors/sump 16.60
Name: , j , Y j p t L 3 47 /7 T ' ' s-6.17/ Expansion tank 16.60
Address: /1 9q5- 5 .A/ Lr9.4M4J .-7,T- Fixture /sewer cap 16.60
City /State /ZIP: 7' /L;-44 O (s/ 67 3 Floor drain /floor sink/hub 16.60
Phone: ( ) 6-v -3 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:
Subtotal
City /State /ZIP: Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
Authorized signature: State surcharge (8% of permit fee)
TOTAL PERMIT FEE
Print name: 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 Industry Service Board.
is \Building\ Permits\ PLMF- PermitApp.doc 06/05 440.4616T(10/O2JCOM/WEB)
•
Plumbing Permit Application - City of Tigard ° " i '
Page 2 - Supplemental Information a
Fee S chedule: Residential Fire Suppression Systems:
Site:,Uti>l `es.' Qty. Fee (ea) , .Total . SquareFootage: ` ' 'Permit F e: . .
Footing drain - s' 100' 55.00 0 to 2,000 $115.00
Footing drain - eac • 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 10' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems: 7"
Water Service - each addition: 100' 46.40 .
Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit /Fee: '
$1.00 to $5,000.00 Minimu /fee $72.50
Storm & Rain Drain - each additio r l 100' 46.40 $5,001.00 to $10,000.00 $72.50 or the first $5,000.00 and $1.52 for each
additional $100.00 or fraction thereof, to and
Fixture or .Item . Qty. Fee'(e Total iincccliding$10,000.00.
Commercial Back Flow Prevention Devic 46.40 $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 $50,000.1W $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof to
Inspection of existing plumbing or
and including $50,000.00.
specially requested inspections - per hour 72.50
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
Fixture Work: L iexscture" Plan Revie for Complex St w Are you capping, adding or replacing fixtures? If "yes' 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 fe: * 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 ❑ ' lumbing installations, alterations or additions to food service
-Drive Thru ilities where new plumbing fixtures, including interceptors,
Cuspidor/Water Aspirator are •eing installed for the food service area.
Dishwasher -Commercial ❑ Any -w residential building containing three (3) or more
- Domestic dwellin• nits.
Drinking Fountain
El Any NFP • 3 -D multipurpose fire sprinkler system.
Eye Wash
Floor Drain /sink 2" Submit 2 • is of plans with any of the above.
-3"
-4"
Car Wash Drain Isometn : or Riser. Diagram, .
Garbage - Domestic Isometric or riser dial , m is required for new buildings
Disposal - Commercial three (3) or more stories , height.
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture , ork:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavate
- Bradley -
- Commercial
- Service
Swimming Pool, Filter
Washer - Clothes *Note: If the fixture work under this permit res Its 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.
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