Permit a CITY OF TIGARD PLUMBING PERMIT
' ', :' COMMUNITY DEVELOPMENT Permit# PLM2009 -00083
TIGARD 13125 SW Hall Blvd • Tigard OR 97223 503 639 4171 Date Issued 04/10/2009
Parcel 2S103DD00414
Jurisdiction Tigard
Site address 10820 SW FAIRHAVEN ST
Subdivision Lot* 0
Project Wnterbourne
Project Description Connect to sewer
Owner FEES
WINTERBOURNE, JEANI & MICHAEL Quantity Description Date Amount
10820 SW FAIRHAVEN ST 200 If Sewer Service 04/10/2009 $101 40
TIGARD, OR 97223 1 12% State Surcharge - 04/10/2009 $1217
PHONE
Plumbing
Contractor
OWNER
PHONE
FAX
Type of Use SF
Class of Work ALT Type of Const
Occupancy Grp
Stories
Total $113 57
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
11 1 rth in OAR
r�
R 952- 001 -0010 through OAR 952 - 001 -0100 You may obtain a copy of the rules
Issued By t� V�o�l
`l r Q ` � 1 IX „ 1 n, , Permittee Signature �l��i 1L
\ \�� Call 503 J 41 � 75byy 700 a m for an inspection that bu- ess 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
- - Plumbing Permit Application RECEIVE:
Building Fixtures F OR OFFICE U ONLY
City of Tigard APR 10 2009 Recened /� p Penult Date /B �` I ll l 7 L r r 1Zv�r7'LI�/�d3
III 13125 SW Hall Blvd Ilaud, OR 97223 Plan Review
I Phone 503 639 4171 Fax 503 598 196GITY OF TIGARD Dale/By Other Perron No
TIGARD
Inspection Line 503 639 4175 BUILDING DIVISION goy Date Ready /By �p El See Page 2 for
Internet www ugard -or
g Date eady/Byti 1st Supplemental Information
TYPE OF WORK FEE*. SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description Qty Ea I Total
' Addition /alteration/replacement ❑ Other New 1 - - family dwellings (Includes 100 ft for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 24920
gJ I_ and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350 00
El Accessory building ❑ Multi-family SFR (3) bath 399 00
Each additional bath /kitchen 45 00
❑ Master builder ❑ Other
Fire sprinkler (_ sq ft ) Paget
JOB SITE INFORMATION AND LOCATION
.5. / CSi[e uhies
lit
Job site address I Ono S, (Ai, en it Y4 1�21e1 -, Catch basin or area drain 1660
City /State /ZIP 1 14 Q yr o Q q Zf3 Drywell leach line. or trench drain 16 60
Suite/bldg /apt no J Project name Wt —k rb o o on e. Footing drain (no linear ft Page 2
V Manufactured home utilities 110 00
Cross street/directions to job site
)( Manholes 16 60
W C i14 6 51- - )( 'hte Rain drain connector 16 60
Sanitary sewer (no linear ft 1 Ocam, ) Page 2 l0i,
Storm sewer (no linear ft ) Page 2
Subdivision. 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
0 i n p C--+ kn(tSe- Setter +0 Backwater valve 1660
et-
E. b 5 - 0 Clothes washer 1660
Dishwasher 16 60
PROPERTY OWNER I ❑ TENANT Drinking fountain 16 60
1
Ejectors/sump 16 60
Name ` fen v) t C)) (. -e-✓ / M 1) e— Expansion tank 16 60
Address /0 8 20 5 -/r / i ra (V(}:fl)t "', Fixture /sewer cap 16 60
City/State /ZIP ¶'l a vd, 01-2_. " { 1tz- Floor drain /floor sink/hub 1660
Phone (EL3 k i — 11-3111 Fax ( ) Garbage disposal 16 60
E APPLICANT ❑ CONTACT PERSON Hose bib 16 60
Ice maker 16 60
Business name
I Interceptor /grease trap 16 60
Contact name 'CCen / WI niter knu roe Medical gas (value $ ) Page 2
Address I () t a n 30 Fa .4 rha ve_ in _4 Primer 16 60
City /State /ZIP —ri ,ten - nlle_ G 1333 Roof drain (commercial) 1660
Phone (503) � a - L 3 JJ Fax ( ) Sink/basin / lavatory 1660
/�
Tub/shower/shower pan 16 60
E -mail W n r b /� I C ) c t 11 hn1 - ma ; I � rn
I Urinal 16 60
CONTRACTOR Water closet 16 60
Business name Sel.c Water heater 1660
Address Other
City /State/ZIP Subtotal 10
Minimum permit fee $72 50
Phone ( ) Fax ( ) Residential backflow minimum permit fee $36 25
CCB Lie Plumbing Lie no Plan review (25% of permit fee)
State surcharge (/o of permit fee)
Authonzed signature —
TOTAL PERMIT FEE
Print name 'eon l ; nie rhoU r rc 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 Tn -County Building Industry Service Board
I\ BmldmgWermiisiPLMF- PenmtApp don 12/27/06 440-46I 6T(10 /02iCOM/WEB)
Plumbing Permit Application - City of Tigard -
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qt Fee (ea) Total Square Footage: Permit Fee:
Footing drain - J" 100' 55 00 0 to 2 000 $115 00
Footing dram - each additional 100' 46 40 2,001 to 3 600 $160 00
3,601 to 7 200 $220 00
1st 100 55 00
( - -- Sewer - _ � — � ."..171-6,11, 7 201 and greater $309 00
wer-eacha ntonanTRT 7 I 4640. 1 11/4" f Lit
Water Service -1st 100' 55 00 Medical Gas Systems:
Water Service - each additional 100' 46 40
Valuation: Permit Fee:
Storm Rain Dram - 1st J00 55 00
$1 00 to $5,000 00 Minimum fee $7250
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
Fixture or Item Qty. Fee (ea) Total additional $100 00 or fraction thereof, to and
including $10,000 00
Commercial Back Flow Prevention Dee ice 46 40 $10 001 00 to $25 000 00 $148 50 for the first $10,000 00 and $1 54 for
Residential Backtlow 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
specially requested inspections - per hour 72 50
Subtotal: /� $50 001 00 and up $742 00 for the first st $ $ 00
$50,000 00 and $1 20 for
4
lb �, ce each additional $100 00 or fraction thereof
Commercial Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following
please indicate work performed by fixture. Failure to Please check all that apply
accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building Ns ith water service T and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
Fixture Type: Replace engineer
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040
Bath =tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040
-Drive Thru
Cuspidor / Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain ISOmetriC,oi Riser Diagram
EN Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink -2" that meet the qualifications above
- 3'
-4
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach /Refrig Drains
Oil Separator (Gas Station)
Rec Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Comiercal _ increase of sewer EDUs, a sewer permit will be issued and
- Service - fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures
VBuiidingAenmaiPLM- PermitAPp doe 12/27/06