Permit CITY TI GARD SEWER CONNECTION PERMIT
i DE VELOPMENT SERVICES PERMIT #: SWR2003 - 00017
- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/13/03
SITE ADDRESS; 13305 SW HOWARD DR PARCEL: 2S103CA - 00900
SUBDIVISION: WOODCREST ZONING: R -4.5
BLOCK: LOT: 012 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer Connection. Reimbursement dist. #22 paid.
Owner:
FEES
JACK OTTERSON
38177 S. DESERT STAR DR Description Date Amount
TUSCON, AZ 85739 [SWUSA] Swr Connect 1/13/03 $2,300.00
[SWUSA] Swr Connect 1/13/03 $0.00
Phone: 503 -520 -6098 [SWINSP] Swr Inspect 1/13/03 $35.00
[SWINSP] Swr Inspect 1/13/03 $0.00
Contractor:
Total $2,335.00
Phone:
Reg #:
Required Inspections
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.
Issued by: 1/1 / ,/ ' Permittee Signature: / Li / j
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
1• �
."-- f Building Fixtures 6 E DE C iC / i o /0 10/k--
J -/ f
Plumbing P ' t A p OFFICE USE ONLY
ElVE® Date received: / — ,0?� Permitno.:�)4�� 'lj� /
City of Ti ar
1- t �`�I J I- City Sewer permit no.: Building permit no.:
Address: 13125 SW Hall BdANigiac807061223
City of Tigard Phone: (503) 639 -4171 Lu Project/appl. 'no.: - Expire date:
Fax: (503) 598 -1960 CITY OF TIGARD Date issued: • 1:=1 Receipt no.:
Land use approval: BUILDING DIVISION Case file no.: Payment type:
•
. . . . , TYPE. OF.PERMITI .. , '" • - .
V 1 & 2 family dwelling or accessory 0 Commercial /industrial 0 Multi- family ❑ Tenant improvement
O New construction 0 Addition/alteration /replacement 0 Food service ❑ Other:
JOB SITE INFORMATION • ' FEE SCHEDULE (for special information use checklist)'
Job address: Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2 -family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: (Block: I Subdivision: • SFR (2) b
Project name: SF' (3) bath
City /county: ZIP: Eac additional bath/kitchen
DesQription and location of work on premises: 6fa .2eiL eoutJ& Site u' ities:
0 )&}1 - r�0 L--_i !J E 4- tb,2-14 Catch ba in/area drain
Est. date of completion/inspection: Drywells/ : ach line /trench drain
. . 1 1!'.,' Y° ' •' PLUMBING „ Footing drai (no. lin. ft.)
E Manufactured ' ome utilities
Busine s : e: Manholes
Address: • Rain drain connec •r
City: State: I ZIP: Sanitary sewer (no. 'n. ft.)
Phone: I Fa • I E -mail: Storm sewer (no. lin. '. )
CCB no.: I Plumb. buses. t• no: Water service (no. lin.
City/metro lic. n.. Fixture or item:
Absorption valve
Contracto ': epresentative signature:
Back flow preventer
Pri , ame: Date: Backwater valve
,' ' CONTACT' PERSON ' ' . . Basins /lavatory IF
Name: Clothes washer
Address: Dishwasher /
Drinking fountain(s)
City: I State: I ZIP: Ejectors /sump
Phone: Fax: E -mail: Expansion tank
Fixture /sewer cap
Name (print): �,elt. c.� C , , 0T T c 'zrp,-1 I Floor drains /floor sinks ub
Garbage disposal
Mailing address: / 3 3 0 S St lio tk 0k2, Hose bibb
City: 776---472.0 State:01Z_ ZIP: 97223 Ice maker
Phone: -3 - 44 Fax: 1E-mail: j .iite:7air Qfloe 4t¢'t!eptor /greas trap
Owner installation/residential maintenance only: The actual installation Primer(s) /
will be made by me or the maintenance and repair made by my regular Roof drain (cor)1mercial)
employee on the prop i % I own ashapter 447. Sink(s), basin ), lays(s)
Owner's signature: MI � .
d- , vx -Bate: /-C 3 Sump
ENGINEER . Tubs /show /shower pan
Urinal \ ,
Name: Water cl et ,
Address: Water h ater
City: ---------J. • e: ZIP: Other:
Phone: U- I Fax: E"rttail: I Tota
Minimum fee $
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application
0 Visa O MasterCard / / State surcharge (8 %) .... o ) $
_ /o expires if a permit is not obtained Plan review (at
Credit card number: within 180 days after it has been $ �j , 1.q G
Expires TOTAL $ OS .
Name of cardholder as shown on credit card accepted as complete.
Cardholder signature Amount 440-4616 (6 /00 /COM)
•
PLUMBING PERMIT FEES:
, r x PRICE' ' TOTAL tNewx1'and2 =fari i yr "dwellings ° ,ortlY: '‘ '
` FIXTURES, (individual). . ,QTY." ., ,(ea) .. .,:AMOUNT,: (includes all plumbing'fzturesin PRICE TOTAL
Sink 16.60 > the4dwelling and „the first100 ft QTY;' . (ea) :i; AMOUNT
for eac utility'connection) s ::..r:'= = ". = -" ,
Lavatory 16.60 _ One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath, $350.00
Shower Only 16.60 . Three, (3) bath $399.00
Water Closet 16.60
SUBTOTAL ';;,'' „'.: ;
Urinal 16.60 8% STATE SURCHARGE `4.Z; , ,
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL - - -,*.., ,
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60
3" 16.60 PLEASE COMPLETE:
4" 16.60 Y
"' I: .;Quantity_by'Work,Performed :7 _I
Water i 1CC:er 0 GOnVCG(JiJi 1 vii :e kind 16.60
Gas i in requires a separate mechanical eType , . ' New • l i'Moyed Replaced', .Removed/
P P 9 ' Fixtur
4 P 11-,,k, ,Capped
permit. :._ � 4 � � �,.
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory
_ Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Urinal
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3"
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50
Requesie_ Inspections per /hr COMMENTS REGARDING ABOVE:
' Rain Drain, single fainiiy dwelling I ' 65.25 '
Grease Traps 16.60
. QUANTITY TOTAL s .- , -"3::. ` ?tu <:` h 'gin :; '5
I or riser diagram is required if s 1, ' F � , ,,b
Quantity Total is >9 `' -hA ` __ , $ '?"
*SUBTOTAL i ;,4 ' -' ",
_i yr. n.,. 'y, ,'
8% STATE SURCHARGE . " `: := �'
* *PLAN REVIEW 25% OF SUBTOTAL , 3 s ^ti
Required only if fixture qty. total is > 9 r °; " '_;` ".
TOTAL ' . - "r $ •
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25+ 8% state surcharge. _ - -'- . '
* New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
is \dsts \forms \plm- fees.doc 12/26/01