Permit i
CITY TIGARD SEWER CONNECTION PERMIT
+' I� DEVELOPMENT SERVICES PERMIT #: SWR2005 -00075
c 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/11/2005
SITE ADDRESS; 10610 SW DERRY DELL CT PARCEL: 2S103DA 03100
SUBDIVISION: DERRY DELL PLAT 2 ZONING: R - 3.5
BLOCK: LOT: 033 JURISDICTION: TIG
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection to street lateral. Septic system to be pumped and filled or removed.
Owner:
FEES
HANSEN, HARRIS H SARA J Description Date Amount
10610 SW DERRY DELL
TIGARD, OR 97223 [SWINSP] Sewer Inspection Fee 3/11/2005 $35.00
[SWUSA] Swr Connection Fee 3/11/2005 $2,500.00
Phone: 203 - 639 - 6515 Total $2,535.00
Contractor:
0w NJ�(—
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
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.
Issued b . `��� �. i� Permittee Signature: k
Call (503) 639 -4175 by 7:00 P.M. for an inspection the next business 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.
PJigily � ,!'� r �.�'if 10 s lication FOR OFFICE' USE ONLY ,
City of Tigard Received permit No..
13125 SW Hall Blvd ,Tigard, OR 97223 Date/By / ( O�
?if* ; / . 5 - O o D7 S
Plan Revie
Phone: 503.639 4171 Fax. 503 598 1960 - ao ■. # , �y1101 _ Date/By Other Permit No
24- Hour Inspection Line: 503.639 4175 t! r"Lt Date Ready/By Juris El See Page 2 for
Internet. www.ci.tigard.or.us Notified/Method Supplemental Information
TY PE=. ®R WORK -- " -._ '.FEE S'CHED
> ��. �, -. .�,;�,,,, ,��;:u _„ . :,�s Y�
.`: � -. o a .. �.. , � <. ...,ate. " , ,
❑ New construction ❑ Demolition For special information use checklist.
Description Qty. Ea Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
gu q t;a ,- =,�," nn�'� ° �` �`'`? ` »;� ='n»�. a, �;;:a, .. , a` ;� s rc°�€,. - �z<z .:i�`g.,k #, �� ,' - '??eut•` r y a "'' ,� " "`" `' •
SFR (1) bath 249 20
°' . °;° , ; .� : „` y `:tj ATEGUR '.,OF` CONSTRUGTYON1; ° �.' •*`' R, e
�: � � �xg ...,��., - ds*sa%,�.,u� �> �ba ,��....�'.*.�.�v.��a��.;.,•,�a ��,A�.; -.max .:' ...
❑ 1- and 2- family dwelling ❑ Commercial /industnal SFR (2) bath 350 00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
El Master builder Each additional bath/kitchen 45 00
❑ Other:
:. x '. Sze .y _,,;„ ,: ., .,, s. ,, , Site utilities
„ , Fire sprinkler ( sq ft.) Page 2
�,�_£ 'P'IO?� ANA { � O'CATION:��- �.._�` r' ��
�,�.. �... a „r �. �. �'+r°- �r..:�.az�E. _ .��.,. �._ �3.xs.:� s';: . >A".. : i;�� �.,.
C Job site address: � O Zo / D S a) f a lam” Catch basin or area dram 16.60 enA City/State /ZIP: Q 7 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: Lot no.: Water service (no. linear ft. ) Page 2
Tax map /parcel no.: Fixture or item
.3 _ '. r ,. :, w . , .a:x ., Absorption valve 16 60
. i r;; , 4 Kr. s ` - ' OF WO , =x " :' , I f -r: ,,
a-as . ` y, 1' ;,- " ' -. ; 4,--,..- 4..4. >," , ,4 ;- ' ".. Alf: 11.: :' : °, y 1 . �: .'1M 1 -` Backflow preventer Page 2
Backwater valve 16 60
Clothes washer 16 60
Dishwasher 16 60
, ;tom , , ,v, , .• " ,. .,-, t a,. ,w .,;,.. :,•; ° :.F, Drinking fountain 16 60
l'A ; `; • O WNE R` t6 ' �t�,
. ,. " "'t: ^* 6a8 - -. -; E�`sras ce=�.c °ia� i `�^�..�:..a"�� .�"�'•�s ��+u�, "ka "° '.,..r'�'� Ejectors/sump 16 60 •
Name: �{
,Cl Q � �v i Expansion tank 16.60
Address: /O In j O S w jQ t "` , / Q. Fixture /sewer cap 16 60
City/State /ZIP: Floor drain/floor sink/hub 16 60
` Phone: .(5-0.3 )_ b3 _ 6 C Fax: ( ) Garbage disposal 16 60
to ' ,• f' _, ... r f '�.. . •.':a fi r. , E,;, °y, Hose bib 16 60
- = : AP PLIC�AN L':� ; - , „ ` Piiiii ONrTACTI_PEi2SON` `
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:
, 1 p: `;: v v;.:3 Urinal 16 60
-:: " .
� . - ;; - ; �:, ' . < . CON iX- 4 , V i II :3 ., -,•
. � <,� ~ a TRA T,OR' � .a,. � * v , , < , .. Water closet 16 60
= '�'?l ;:u.��E ;sue �;h =- •...�.,>�- <. :�_.:,� ° - ;s
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)
7‘,S
' \ Authorized signature: ` LA State surcharge (8% of permit fee)
TOTAL PERMIT FEE ,2 v 6_ (gy
Print name: C «, r r, (4 o h S f n Date: 3 /it ( G This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tn -County Building Industry Service Board
1 \Budding\Permns\PLM- PemutApp doe 12/03 440- 4616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: - Residential Fire Suppression Systems:
�- P 1' ;SUN 's .. ,:; IFee:`
Site of lit><eSr ;•.., , ', E: Q. = ter ., (.. )` " °::. , t Square )1joota e�A: Pe=,_m._ •.
Footing drain - 1 100' 55.00 0 to 2,000 $115 00
Footing drain - each 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 100' 46.40
Water Service - 1st 100' 55 00
Medical Gas Systems:
Water Service - each additional 100' 46.40
Storm &Ram Drain - 1st 100' S5 00 4Vah atlon . ; ;, °:g,'`,3;1 _
I e>C,mlt ee: Wes •,. „.,,_ .r>
$1.00 to $5,000 00 Minimum fee $72 50
Storm & Rain Drain - each additional 100' 46 40 $5,001 00 to $10,000 00 $72.50 for the first $5,000 00 and $1.52 for each
w ';y' additional $100.00 or fraction thereof, to and
' %tUre',gJ, ITI ° ate =i ` Fge' (ea Total
r,a�„ ',19 � including $10,000.00
Commercial Back Flow Prevention Device 46 40 $10,001.00 to $25,000 00 $148.50 for the first $10,000 00 and $1 54 for
Residential Backflow 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 00 $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:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
R ,.
••<�,'t�h�: ;� ;�.; ';, �Q'vantit�liya( Fixture) �QVork= Perfornied'>..`
'44;"7:: , ; : ; t +1W.Xe i i t : nMuvca3 �z,st;og . Pe ` Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Dnve Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain /sink - 2"
-3”
-4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial
Ice Mach /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar /Lavatory
Quantity Total
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
- Service total is >9. •
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures'
i \Bu Idmg\Permits\PLM- PernutApp doc 3/03