Permit „ �� CITY OF TIGARD PLUMBING PERMIT
; ! i . COMMUNITY DEVELOPMENT Permit #: PLM2011 00378
1 3125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/22/2011
TIGARD . g Parcel: 1S136CD00100
Jurisdiction: Tigard
Site address: 11705 SW PACIFIC HVVY M
Project: Sushi Hanna Subdivision: 2006 -016 PARTITION PLAT Lot: 3
Project Description: TI
Contractor: FAR WEST PLUMBING Owner: PACIFIC CROSSROADS PROPERTIES IN
PO BOX 597 BY WYSE INVESTMENT SERVICES CO
ESTACADA, OR 97023 1501 SW TAYLOR ST STE 100
PORTLAND, OR 97205
PHONE: 503 - 318 -5148 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 12/22/2011 $31.27
Specifics: 1 ea Ice Maker 12/22/2011 $12.51
1 ea Interceptor /Grease Trap 12/22/2011 $25.02
Type of Use: COM 4 ea Sink 12/22/2011 $100.08
Class of Work: ALT 1 ea Water Heater 12/22/2011 $37.52
Type of Const: 1 12% State Surcharge - 12/22/2011 $24.77
Occupancy Grp: Plumbing
Stories:
Total $231.17
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 • . a on - - • er. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 -001 -0090. You may obtain a copy of the rules
or d questions to OU ” by ' - ling 503.232.1987 or 1.800.332.2344. �/
Is ued By: ∎��
' / / , Permittee Signature: /`�-
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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
V
Building Fixtures FOR of Flee USE ONLY
City of Tigard D ate B e a t'� i �/ Permit No.: l a/9p //-,5 67g
'I 13125 SW Hall Blvd., Tigard, OR 'i ''• - \ y
I I
C Phone: 503.718.2439 Fax: 503.5 ` . t! • 0` � . Plan Review
DaDate/By: 0 Other Permit Noi a0//..,�j/ Inspection Line: 503.639.4175
T I G AR D � , ?O Date Ready/By: Juris ® See Page 2 for
Internet: www.tigard- or.gov O �� j r. .t. Notified/Method: Supplemental Information
TYPE OF WORK c �' \ � Q) � � FEE* SCHEDULE
❑ New construction ❑ De R ;14\ special information use checklist -p
� i Description I Qty. I Ea. Total %+
,-,
. vadition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection) J
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
❑ 1- and 2- family dwelling ®'C Ommercial /industrial SFR (2) bath 437.78
elk
SFR (3) bath 500.32 O
❑ Accessory building ❑ Multi - family �
Each additional bath/kitchen 25.02 2
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 ,-
JOB SITE INFORMATION AND LOCATION Site utilities: 0\
Job site address: ) ( 705 fee/ f a C, P`-e 1--/ ° A4,41 Catch basin or area drain 18.76
. J Drywell, leach line, or trench drain 18.
City /State /ZIP: � �; , 9 7 2. z
. 1 � Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: 1 " I Project name: (��/ 14Nh/rl Manufactured home utilities' 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76 ,
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: l6 f 36eD d ,0/pQ Backflow preventer / 31.27 l
DESCRIPTION OF WORK Backwater valve 12.51
�p ,LLL� Clothes washer 25.02
-.rug, `M uV Dishwasher 25.02
A j .A..! O� e...-1/
u /7,.4 it-a- ✓ 4 Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: _`
Fixture /sewer cap 25.02
Floor drain/floor sink/h poi') Z 25.02 `Z
Address:
Garbage disposal 25.02
City /State /ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker / 12.51
0 APPLICANT ❑ CONTACT PERSON Interceptor /grease trap / 25.02 /
Business name:
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory ( 2 25.02 'Z
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 25.02
CONTRACTOR // Water heater / 37.52
,c Business name: Lvf5 r P`u, - Water piping/DWV 56.29
Address: t p. C7 B , ,,T"9 7 Other: 25.02
City /State /ZIP: E cit ,e7k 97 e, Z 7 lido; Subtotal a 4
Phone: (6-'03 ) 345 -5" z /6 Fax: ( ) 3 -4244 Pb Minimum permit fee: $72.50 .---r - '
Plan review (25% of permit fee) ----,
CCB Lie.: 7 , 75 y /� /� . Plumbing Lic. no.: 34 3g ...370 State surcharge (12% of permit fee) ,
C �„ �,_ / ,2& Authorized signature: D / /' TOTAL PERMIT FEE .17
Print name: T o V i . L-/4 L t ,� -e � � Date: / .. /2 y/ / / I This permit application expires if a permit is not obtained within 180 days
t after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
I:\Budding\Permits\PLMU- PermitApp doc 10/01/09 440- 4616T(10/02/COM /WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 62.54
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
• (minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000:00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * . Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate pp y
❑ Any new commercial building with water service 2" and
Bapti stry/Font
Bash Tub /Shower greater, except systems designed and stamped by licensed
- Jacuzzi /Whirlpool engineer.
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive Thru as defined in OAR918- 780 -0040.
Cuspidor /Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918- 780 -0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain /sink: - 2"
3" Isometric or Riser Diagram
❑ Isometric or riser diagram is required for new buildings
- Car Wash Drain
Garbage - Domestic non - food that meet the qualifications above.
Disposal: - Domestic food related
- Commercial food related
- Industrial food related
Ice Mach. /Refrig. Drains Comments regarding fixture work:
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav /Bar non -food related
- Bradley
- Com/Serv/Util food related
- Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs, a sewer permit will be issued and
Washer - Clothes
Water,Extractor fees assessed for the sewer increase must be paid before the
WaterCloset - Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
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BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED
PROPERTY ++ �f ❑ REPLACEMENT
OWNER: - /4 ....ILA PHONE:
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ADDRESS: 11 76'5 SL.) A,: (— ,.e, �,.
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CITY ! i cpu�1 STATEO ZIP 77ZZ3
ASSEMBLY
ADDRESS: '•Q-t—
STREET
13R.P.B.A. ❑ D.C.V.A. ❑ R.P.D.A. ❑D.C.D.A. ❑ P.V.B.A. ❑S.V.B.A. ❑A.V.B. ❑AIR GAP
SIZE: 1 I 1.171 MAKE: CA ll5 MODEL: C 1 Z
WATER cp.../ SERIAL /S'S
PURVEYOR: I I
NUMBER:
ASSEMBLY I I
LOCATION: ON v k ./ sl,(c
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. -INITIAL TEST
01 CHECK VDOUB EXHECK��: AIR CHECK PASSED
PRESS DROP 7 ' 6 ( A)I CHECK #1 INLET FAILED ❑
INITIAL RELIEF VALVE 3 (B) TIGHT OPENED AT PRESS DROP
TEST OP ENED AT I DATE:
MIN 2 PSID LEAKED ❑ PSID
RESULTS BUFFER pslD PSID 2 X / /2—
A - B = I CHECK #2
MIN E 3 PSI
RELIEF VALVE DID NOT FAILED SYSTEM
E 'TIGHT ti
PASS ❑ FAIL ❑ ' 'LEAKED ❑ P9D OPEN ❑ ❑ PSI
COMMENTS
REPAIRS •
AND /OR
PARTS
REDUCED PRESSURE ASSEMBLY P.V.B.A./S.V.B.A. AFTER REPAIRS
MI CHECK D;CV:A c�z; =
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TEST PRESS DROP (A) ( „ CHECK #1 DATE:
RELIEF I OPENED AT PRESS DROP / /
AFTER OPENED (o TIG ❑ PSI
REPAIRS BUFFER 'm =°� I CHECK #2
A - B= b)P9 I TIGHT ❑ PSID PSID PSID PASSED CI
• IN COMPLETING AND SUBMITTING This TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRATION DATE 1A / ( Z DETECTOR METER READING ----
TESTER SIGNA11 E t( , 2CE ` R / lN 3
TESTERS NAME PRINT? D t u '2 C_ 1 u� g_.' w..v 5 lAtt yrl,/
TESTERS ADDRESS r � • !1 _ J / ` 7 T � ^ _ i 1 �� ” PHONE N
COMPANY NAME ""[(� `( J l -f D'
J • ❑ SERVICE RESTORED
REPORT RECEIVED BY. (REPRESENTATIVE OF OWNER)
WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester Copy
•