Permit C ItY OF TIGARD SEWER CONNECTION PERMIT
rr COMMUNITY DEVELOPMENT PERMIT #: SWR2007 -00110
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 5/15/2007
PARCEL: 2 S 102 C C -01900
SITE ADDRESS: 10225 SW HILL VIEW ST ZONING: R - 3.5
SUBDIVISION: FRELEON HEIGHTS NO.2 LOT: 022 JURISDICTION: TIG
PROJECT: UPHOFF
Project Description: Sewer connection - Sewer Reimbursement District #39 fee paid on this date.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner:
RICHARD & E UPHOFF FEES
10225 SW HILL VIEW ST Description Date Amount
TIGARD, OR 97223
[SW USA] Sewer Connection Fee 5/15/2007 $2,700.00
[SWINSP] Sewer Inspection Fee 5/15/2007 $35.00
Phone: 503- 639 -5755 Total $2,735.00
Contractor: G ��' }" D
0 00 Q
iS140G • Z - C ,�Zpl� •
Contact Cod REQUIRED ITEMS AND REPORTS
A "
V ° g A
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 or 1.800.332.2344.
Issue by: /� I/ I Permittee Signature: �� //
,(�
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
FOR. OFFICE USE ONLY
City of Tigard Received Date /By: h / if, No.: ��,. ,YL1 ^a7_ pt��5
l
. n 13125 SW Hall Blvd Tigard, OR 97223 K.d (/L(/
Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Other Permit No.:
Date /By:
Inspection Line: 503.639.4175 Date Read /B u�n�
J
TiGARD Internet: www.tigard- or.gov Notified/Method: // to Supplemental S mentalInformation
• TYPE OF WORK • FEE* ;SCHEDULE. ,
❑ 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)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath • 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder . ❑ Other:
Fire sprinkler ( sq. ` Page 2
JOB SITE INFORMATI N AND' LOCATION Site utilities
Job site address: / 2.7-c � u) j /t J I Et t t, Catch basin or area drain 16.60
City /State /ZIP: Drywell, leach line, or trenc i drain 16.60
Suite/bldg. /apt. no.: l Project name: P�p /C Footing drain (no. linear ft.: Fag-
l_
Manufactured home utilities I i.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.: _) l'age 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
•
DESCRIPTION OF WORK Backflow preventer ` Page 2
G e 2 n^ _o rJ E _i��p ; f Backwater valve 16.60
Clothes washcr 16.60
Dishwasher 16.60
[[PROPERTY OWNER l'
Drinking fountain 16.60
I , Ejectors /sump 16.60
Name: 1. P - (-4-6 l =F Expansion tank 16.60
Address: - .71-tg_ 4-5 /9 Ca. Fixture /sewer cap 16.60
City /State /ZIP: Floor drain/floor sink/h . 16.60
Phone: (b / . 5 7 ' Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT' PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor/gre. :e trap 16.60
Contact name: Medical gas ( alue: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drai (commercial) 16.60
Phone: ( ) Fax: : ( )
Sink/basin/lavatory 16.60
Tub /sh wer /shower pan 16.60
E -mail:
Urinal 16.60
CO CTOR Water closet . 6.60
Business name: Water heater 16:60
Address: Other:
City /State /ZIP: t'Subtotal
Minimum permit fee: $72.50
Phone: ( ) (:d .---.------' ax . ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature:
TOTAL PERMIT FEE
Print name: 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 Tri- County Building Industry Service.Board.
I:\ Bmldin g\Permits\PLM- PermitApp.doc 12/27/06 440- 4616T(10/02 /COM/WEB)
Plumbing Permit Application - City of Tigard '
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Sup pression Systems:
Site Utilities. , , n . Qty. Fee (ea) • ' Total` Square Footage r "Permit fee: , : .
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
Valuation: PermitLFee:
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
Fixture ‘or Item . ' Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and
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
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50 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, adding or replacing futures? If' yes ", Plan..Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: - .Replace greater, except systems designed and stamped by licensed
Erevions , Capped _ Added Existing' engineer.
Baptistry/Font
Bath -Tub/Shower ❑ New exterior plumbing site utilities for any complex structure
_ as defined in OAR918- 780 -0040.
- Jacuzzi /Whir!poo!
Car Wash Each Stall
El Medical gas and vacuum systems for health care facilities.
Drive Stall CI Any multipurpose fire sprinkler system.
Cuspidor/Water Aspirator 111 Any complex structure as defined in OAR918- 780 -0040.
•
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash -Isometric orRiser Tliagram,
Floor Drain /sink - 2" ❑ Isometric or riser diagram is required for new buildings
3 that meet the qualifications above. •
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
- Commercial 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:
i \ Building \Permits\PLM - PermitApp.doc 12/27/06