Permit CITY OF TIGARD PLUMBING PERMIT
0 7 , 6 : < COMMUNITY DEVELOPMENT Permits PLM2009 -00159
Date Issued 06122/2009
TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503 639 4171 Parcel 2S103DD00414
Jurisdiction Tigard
Site address 10820 SW FAIRHAVEN ST
Subdivision Lot 0
Project Wnterbourne
Project Description Irrigation backflow for front yard sprinklers
Owner FEES
WINTERBOURNE, JEANI & MICHAEL Quantity Description Date Amount
10820 SW FAIRHAVEN ST
TIGARD, OR 97223 1 ea Backflow Prevention - RES 06/22/2009 $27 55
PHONE 1 12% State Surcharge - 06/22/2009 $435
Plumbing
9 ea Minimum Fee Adjustment - 06/22/2009 $8 70
Contractor Plumbing
(, &AJC,C
PHONE
FAX
Type of Use SF
Class of Work OTR Type of Const
Occupancy Grp
Stories
Total $40 60
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 -0100 You may obtain a copy of the rules
or direct questions to OUNC by calling 503 246 6699 or 1 800 332 2344 ��r777
Issued By �� i - Permittee Signature ' / /� ^ / ^ 1 j / —
Call 503 639 4175 by 7 00 a m for an inspection that 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
Plumbing Permit Application RECEIVE.1
. • Building Fixtures FOR orrlcet USE ONLY
JUN 2 2 200' Recewed
City S Tigard s%
SW Ilan Blvd , Tigard, OR 97223 Date/B) �o ° Z J. 0 I � Permit Nan�L DQ�s
n 13125
Ill 2
Review
Phone 503 639 4171 Fax 503 598 1960 � l CITY OF TIGAR,) Plan elBy Other Permit No
TIGARD Inspcetion Line 503 639 4175 BUILDING DIVISIS�, to Readv/By runs, ® See Page 2 for
Internet www tigard -oz gov
Notified/Method 77�� Supplemental Information
,"f'/,, °..-`pm, �'V 1. 1 • Tr 4 a• T\'PE 011: 5r s '' 'A"WA' rr fi ' cai-{
+ar Per, '' " >•' rari k : f c, « "t" i '-■ A n t
WY :CV *� u .� i }r ?� =s:, c O ORi au'.x. a °;in I + "yu'"� ±.'ST'S+ = " =rt�.9.v':�.^at; .:+a ' �.� "�FEE� 'SCHED'IILE ';
❑ New construction ❑ Demolition For special information use checklist
Description I Qty I Ea I Total
❑ Addition/alteration/replacement ❑ Other Ness 1 - 2 - family dwellings (includes 100 ft (or each utility connection)
•-li j'y' n : ` ,. p CATEGORY(OFj.'COnST:RUCI70h,' y/.`' a dire l;91 SFR (1) bath 249 20
❑ I- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350 00
❑ Accessory building III Multi-family SCR (3) bath 399 00
❑ Master builder ❑ Other Each additional bath/kitchen 45 00
Fire sprinkler ( sq ft) Page 2
k t' Y _ '_'°' `J OB S TfEwINFORtilk+f7bieANIPeff ATION� t h `'
.'S t. 4_, „e,„_ c is __ - %. ,„ e - -- ..„„9„ . _ - , „i- ..fit -. a..* ,, Site utilities
Job site address I Q 620 S 1k) EA 1 Iti t V G tJ SI Catch basin or area drain 16 60
Qty /Slate/ZIP'T/ ¶I A ruo C IL 9 - 7 '2_7_3 Drywell, leach line, or trench drain 16 60
Suite/bldg /apt no Project name
Footing drain (no linear ft ) Page 2
Manufactured home utilities 110 00
Cross street /directions to job site \JA T/C / NS S -rP
Manholes 16 60
GRDS5 I- Ai t /44 Uc'U>r Rain drain connector 1660
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
4I- 7x ""kfi'= yurva. .
,�.ox= .�...,.. „: a=u; ,,,_„ x xaq Absorption valve 1660
y,,3;„, ;, „ ;;s,t agar* = r*SCRIP.TIKAT WORK” '= , rteatea -t
+�'�*s^ •• a"✓✓ �` �' Baekfl ow preventer i Page 2
F / Ill 'S 4rLp S P /LI,v (CLC2 SC Backwater valve 16
Clothes washer 16 60
Dishwasher 16 60
❑r.PROPE7:V- OW�'FR ":i "w
. ' "
I, "`� '('• _ '3 4 Drinking fountain 16 60
Name EA, 1J'�/ /v'1 f LN. L 1�T �� Ejectors/sump tan k 1660
111 E RI V 2 NL- Expansion tan 16 60
Addi 10 8 ZO -C 4_) FA l l2 Nil S A/ ST
Fixture/sewer cap 16 60
City /State /ZIP f c A 2 0 Q /Z et 7 m �3 Floor drain/floor sink/hub 16 60
Phone (503) 610 - d 3 c1, I Fax ( ) Garbage disposal 16 60
; '? x..Ce '�B =APPUIC NT_ff " ,fee:. - {
'" ye rd" s„ "x r - >^» .y<. " \Cam Hose bib 16 60
;? r- l_ to -_, } f. ®,CONTA_GTPFRS ON ,
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 1660
Pub /shower /shower pan 16 60
E -mail
n .p1�, ' s _ Urinal 16 60
` -;•'!" ai ::1:It 1 4 7 ° CONTRACTOR C''r.;"Z ."!;iS.xS°v`xst. !s *,
� .:v. _ *�±a, av” s 1` 7 3:3,„ ; Water closet 1660
Business name Water heater 16 60
Address f W1 1 e \ Other
City /State /ZIP Subtotal
Minimum permit fee $72 50
Phone ( ) Fax ( ) Residen backflow minimum permit fee $3 25
CCB Lie - PI mbmg Lie no Plan review (25% of permit fee)
Authorized signature � .
State surcharge (12% of permit fee) L(, 35 ✓
TOTAL PERM11 FEE 40•(GO V
Print nameH, C 1441 EL \,4 ,Vt EIj jo on. Flo DatCU/Vt_` 2 -c 9 This permit application expires if a permit is not obtained w ithin
ISO clays after It has been accepted as complete
"Fee methodology set by Tn -County Building Industry Service Bo
I AauildmgwermneAFLMF- Perm'iApp doc 12/29/06 410- 46169(10 /0^_+COM/wW)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
nr a -r. ^ 5k r.:n c s ..: st r .u: y � ' � . '
Qry Fee t Tocal''� nS uare"FOOt - mo d e: Y , <F° x: ,y,': -
_�. -m� - �.� x � q g I'erinit -Fee:a �".>" ' """ ,
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' 5500 Medical Gas Systems:
Water Service - each additional 100' 46 40 xr"^ ��^^4* hP '*x' �• y`=s3 ""S �" `f '"'"`°`r
�aluatfon:Rw 4 ermet l ee: ;.� ,"
Storm & Rain Drain - I st 100 55 00 $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
:rFiR ✓*� - xxcax,> �'"'' '"` Qty'` ? §Feel {ea)N3 4 To° "tat:#+' additional $100 00 or fraction thereof, to and
tllrQ Org4ltemi' ;e� 'svi*;' - - -_o- s r' vatTo%%
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 Backflo • - — • � each additional $100 00 or fraction thereof, to
(minimum permit ee $3625) 27 55 .��P • �. and including $25,000 00
Rain Drain, single . • e ing 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 $50,001 00 and up $742 00 for the first $50,000 00 and $1 20 for
Subtotal' each additional $10000 or fraction thereof
Commercial Fixture Work: Plan Reviewfor P..lumbing=Iistallatiori "se
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following
please indicate work performed by fixture. Failure to Please check all that apply
accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2' and
n RA 1 76 6 . 8 Quintify'tiy,(Edtu're) Work Perfo'roied't$/ greater, except systems designed and stamped by licensed
. ` 4x"F - ' Re la`ce`s" engineer
AFizture T e:�f� T "• � "^ t, ap „ - ' ��• , en
'."_ - r_,,,a a.=s. .:,. "7 tYRreaioua`�' a.Cappea,. ❑ New exterior plumbing site utilities for any complex structure
Baptistr■/Pont 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
-Dine 1 hru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic ax- •xy+c^a�' csyz,a: *� .rx- ..
Drinking Fountain * 4'S'''t, ",.:"�. SOIIICtGICror- Magra11112- _+a„�yy_3,
Eye 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 /Retrig 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
- Commercial increase of serer 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 Fixtuies
VBwldmgIPenmis\PLM PermitApp doc 12/27/06