Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2003 -00178
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/7/03
SITE ADDRESS: 10215 SW HALL BLVD PARCEL: 1 S135AA 01400
SUBDIVISION: METZGER ACRE TRACTS ZONING: C -N
BLOCK: LOT: 037 JURISDICTION: TIG
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: B FLOOR DRAINS: 1 TRAPS:
STORIES: WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 21 URINALS: GREASE TRAPS:
LAVATORIES: 4 OTHER FIXTURES: 3
TUB /SHOWERS: 1 SEWER LINE: ft
WATER CLOSETS: 4 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: New 2 -story dermatology clinic. Other fixtures: (2) hose bibs & (1) primer.
FEES
Owner:
Description Date Amount
INTEGUMEND LLC BY SCOTT COLLINS MD
& MARIA ROSS MD [PLUMB] Permit Fee 10/7/03 $581.00
9495 SW LOCUST STREET [PLMPLN] Plan Review 10/7/03 $145.25
PORTLAND, OR 97223 [TAX] 8% State Tax 10/7/03 $46.48
Phone : Total $772.73
Contractor:
BEAVERTON PLUMBING INC
13980 SW TUALATIN VALLEY HWY
BEAVERTON, OR 97005
REQUIRED INSPECTIONS
Sewer Inspection
Phone : 643
Water Service Insp
Reg #: LIC 12889 Top -out Insp
PLM 34 - 4PB Rain Drain Insp
Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Issued / Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
I J3liu1 n I ixtur,es
. g D 3 . , A �, r. FAR OFFICE USE ONLY
PI'1Ig1b1IT 1 er1 ° Received Plumbing t
., u •° - Date/By: 3 �U Permit No.: ai j -Gy % 7 S
n
City Of Tigard MM 0 5 . Z0d3 Planning Approval
Date/By: PermitNo.: "- O03 - e''/7J
13125 SW Hall Blvd. Plan Review //��22 Other
an
Ti d Oregon 97223 CITY OF TIGAF. Date/By: P MP Permit No.:
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Phone: 503- 639 -4171 Fax: 50 598 O�V '�®N Post - Review Land Use , ,?�O Qq�Od
�iiia�iii,,� f � I elp �. 'tit Date/By: Case No.: .7'
Internet: www.ci.tigard.or.us _�J Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 Name/Method: s •,q:- Supplemental Information.
checklist )9r
fez Vi c , e m o ion :g g.` Flt ->SC,IIE :Vtt(for�s eelai,anformaton use,
�z„ :� ��4 �� 4. _, ��T,XPE�UF�WORIC ,��� : � � :� � -�� � P
New construction ❑Demolition Description I Qty. I Fee(ea) I Total
'^5-' p.R+ '- "a- txg, '` .."03'# i `° ' fs L A[ \
❑ Addition/alteration/replacement [I Other: - i �� Ne l & family 04 , -lmgs . 1 ,
� -. �„ d , „.,. �� �'�;;`>(mclgdesC100,ft:�foreach utdity�eone ��e�P .` �"�� ?� }
"�� .w CATEGfJRY OF..C®N TRUGTIp1V:., ;.
1 & 2-Family dwellin Commercial/Industrial SFR ( bath 350.00 e
111 Y g SFR (2) bath 350.00
['Accessory Building Multi- Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional th/k tchen
E a al ba t 45.00
JOBiSITEINFOTi andO C Fire sprinkler sq. ft Page 2
c:' b site /' ►"V VIA i'..: iii •
- � � - �` z `Site utilities , .��i �'�° ti �''` -. .,;� \
Jo site address: ja L1 S % ‘1,P..) y7• .
Suite #: Bldg. /Apt. #: Z9, Catch basin/area drain 16.60
Project Name: t �( U Footing dr line/trench linear drain 16.60
Footing drain (no. linear ft.) P age 2
Cross street/Directions to job site: Manufactured home utilities 110.00
G ti'. 1 V. `T�J Manholes 16.60
or 1.156 1T'ES(' �'• * e37Ti4 • Ave - Rain drain connector 16.60
Sanitary sewer (no. linear ft.) Page 2
S torm sewer (no. linear ft.) y /Page 2 lc
Subdivision: -n... Lot #�
Tax ma / arcel #: L.C57 � 4 Qp Water service (no. linear ft.) • , Page 2
P P m ,4, ure r. 0.0 Aw. l Z_
: OF ()W .e. . x rpt e
�:�K -�,� : �. .�DS;C .' �IO N�,.� .�, A . ��:. �� 16.60
��./� "" Absorption valve
I` e W Gds('. I V" R( 1G Dr A L Backflow preventer Page 2
eI.4M c- C10:30 1 c -� K/ �- Backwater valve 16.60 I N
/ Clothes washer 16.60 N
Dishwasher 16.60
Drinking fountain • 16.60
`l aela. *' ',DOE'WO, 0 F - 1 <T I 0 b.... ,h g 16.60
E jectors/sump ,
ame: 1 I wG v �4i l l l) u....0_,.. Expansion tank 16.60
Address: CIA-9. 5 ' ) (JtrGIT fir. Fixture /sewer cap 16.60
City/State/Zip: • 2, Floor drain /floor sink/hub it 16.60 /(o. !6t) r�I � 9 7 � Garbage disposal 16.60
R Nt one: 245 24Is F 563 2.44.142 ✓ Hose bib 16.60 .55 .64)
v
wag , U�1_T�AC.�T �� i I'ER.SQN�. Ice maker 16.60
PL�C� IT��i:�� .
Name: '7 \J' I D As FIs T Interceptor /grease trap 16.60
Address: 2..2... N im -- }r 301 Medical gas - value: $ Page 2
Primer i 16.60 /&•66
City /State /Zip: r. ii • ► 0 • 1 20 oof drain (commercial) _
16.60 114
Phone: '1..7). � J • 726 7 ' .0. Fax: j .L I to in/lavato i d 16.60 ` 0 _
E -mail: c4,191--,e„, a« Gl'1e'b • r-o'M u s owe howerpan t 16.60 //v./a)
r ;w.. z. , y � .- `Ss Y 5' N� -Vi o a E 'a.':s Urinal 16.60
=:i�:.r =., . . CO TRACTOR. ;
Business Name: 'NA/644.- `Q(4 jy.(C, _ Water closet i, Gf 16.60 1�.4')
_ Water heater 16.60 / le .(jp
� 3�i � J 'T-
Address:.' Z S'i, Y Other: LA, v t{ /6•60 6,1,,•.Ya
City /State /Zip_ ii , Gi *1tx. Other: (b ../ / ' 3 / G t o tf9• 50
. � . Fees, -
. f, "`Plumbing Permit .. _ * �� ���;�:
Phone: € )'- "X 1c7 Fax. . - �
Subtotal $ 5g/ • °O
CCB Lic. #: 01 Plumes Llc.#: " - Minimum Permit Fee $72.50 $
Authorized /� / � Residential Backflow Minimum Fee $36.25
Signature: ..ii / /ate ...0 / / /Ar�/ %`re: 5 �• d� ° /
$ l � o�
Plan Review (25 /° of Permit Fee) S S
.� State Surcharge (8% of Permit Fee) $ 4 16. 4I
/�i l �1/ii
(Please print name) TOTAL PERMIT FEE $ 72 73
Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans with isometric or •
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri -County Buildin Industry Service Board.
i:\Dsts\Permit Forms \PlmPermitApp.doc 01/03 .
r �
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
eattrwir ►te Utilities ; ` ` " Qty 4:eez(e#1 111°tal Square, Footage;Permit`F ee:
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' e 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
l .., Permrt Fee i7i fal:...- _..
Storm & Rain Drain - 1st 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
additional $100.00 or fraction thereof, to and
is i°r a Fl %t e ur 011 Q'ty f ee o r e so,o 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 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees *.
g A
- a Comments regarding fixture work:
'�;�. �. s ���s Quantrt��by (Fixture) }'York�erfor�ed
rtxtureType . ° ,� s. ,�'3 '°`,r -, . koNgl,q, sgty. `-�
1
tat r'1$ewNtove . -� 6pg . T - Capped:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall •
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic -
Drinking Fountain •
Eye Wash • •
Floor Drain/sink - 2"
3"
Car Wash Drain *Note: If the fixture work under this permit results in an
Garbage - Domestic
Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice Mach. /Refrig. Drains - plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang •
•
-Stall
Sink - Bar /Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\Dsts\Permit Forms\PlmPermitAppPg2.doc 01/03
CITY OF TIGARD
13125 S.W. HALL BLVD.
TIGARD, OR 97223
IMPORTANT PERMIT NOTICE
BEAVERTON PLUMBING INC
13980 SW TUALATIN VALLEY HWY
BEAVERTON, OR 97005
Plumbing Signature Form
Permit #: PLM2003 -00178
Date Issued:
Parcel: 1 S135AA -01400
Site Address: 10215 SW HALL BLVD
Subdivision: METZGER ACRE TRACTS
Block: Lot: 037
Jurisdiction: C -
Zoning: TIG
Remarks: New 2 - story dermatology clinic.
Your company has been indicated as the plumbing contractor for the permit indicated above. In order for the
plumbing permit to be valid, please have the appropriate individual from your company sign below and return
this Plumbing Signature Form prior to the start of the work to the address above, ATTN: Building Division.
No plumbing inspections will be authorized until this completed form is received
OWNER: PLUMBING CONTRACTOR:
INTEGUMEND LLC BY SCOTT CI BEAVERTON PLUMBING INC
& MARIA ROSS MD 13980 SW TUALATIN VALLEY HWY
9495 SW LOCUST STREET BEAVERTON, OR 97005
PORTLAND, OR 97223
Phone #: Phone #: 643 -7619
Reg #: LIC 12889
PLM 34 -4PB
AN INK SIGNATURE IS REQUIRED ON THIS FORM
•
X
Signatur f Authored Plumber
If you have any questions, please call 503.718.2433.
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received / / ✓ � � 3 / Requested a 3 AM PM BUP
/
Location / O 1 Suite MEC
Contact Person .2/ � '_ _t / � t ( ) i2 2/ lfJ 2.57 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Acce s:
Ftg Crawl ELR
Dr ain '� hp� . � L
Crawl Dr �r-� +� t +/
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm _ '
AO
Susp'd Ceiling �� ' �'
Roof
Other: i.
Final PP
PASS PART FAIL
PLUMBING /
Post & Beam
Under Slab -
Rough -In J - ✓ -
Water Service
Sanitary Sewer MEW /
Rain Drains , Alr '
Catch Basin / Manhole
Storm Drain
Shower Pan
`i PART FAIL /
CHANICA
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE. ❑ Please call for reinspection RE: Unable to inspect – no access
Fire Supply Line tilibqb ADA Approach /Sidewalk Date Inspector '� Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL