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Permit ,. . CITY OF TIGARD SEWER CONNECTION PERMIT ; �r, -I DEVELOPMENT SERVICES PERMIT #: SWR2003 -00288 � III 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 7/14/03 SITE ADDRESS; 13470 SW HOWARD ST PARCEL: 2S103CA 01800 SUBDIVISION: WOODCREST ZONING: R -4.5 BLOCK: LOT: 003 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: Connect existing house to sewer lateral. Reimbursement dist. #22 paid. Owner: FEES TUCKER, ANTHONY K AND JOYCE E Description Date Amount 13470 SW HOWARD DR [SWUSA] Swr Connect 7/14/03 $2,400.00 TIGARD, OR 97223 [SWUSA] Swr Connect 7/14/03 $0.00 Phone: 503 -590 -3557 [ SWINSP] Swr Inspect 7/14/03 $35.00 [SWINSP] Swr Inspect 7/14/03 $0.00 Contractor: Total $2,435.00 Phone: Reg #: Required Inspections Sewer Inspection Septic Tank Filled 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" Perm Issued by: Permittee Signature: --R Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day • • f= t - `--- & C 4/ % ��,� FOR OFFICE USE ONLY • 1u1C1�� t- - NPU i 1 Received Plumbing Date/By: Permit No.: Planning Approval Sewer , `�' - d City of Tigard Date/By: No.:��1/ R-2W 3 00? 13125 SW Hall Blvd. Plan Review Other Tigard, Oregon 97223 Date/By: Permit No.: Phone: 503- 639 -4171 Fax: 503- 598 -1960 Post - Review Land Use ,n��;,�JIJ l Date/By: Case No.: Internet: www.ci.tigard.or.us n . Contact Juris.: 1:E1 See Page 2 for 24 -hour Inspection Request: 503- 639 -4175 Name/Method: Supplemental Information. .�: _� -.. ex �'.:i o wpm ' - ; EE * <.SCHED a fors ec ation use cl'e wan s. �4�: �J�'' r��� ;�z��,�,��..��T�Y¢PEKOF��.W, .ORIC�° Wit.. ;.�:,._- �����.�.r°�a �, • F. � �.. _. (_._ _. p _ _ )' ❑ New construction ❑ Demolition Description I Qty. I Fee(ea) I Total ❑ ,.,.. ` W 4t4 New 1 & fa "' d •n 7 Addition/alteration/replacement ❑ Other: `, * , „:( �„ues 100 , q _ t il _tyco nne ct 1 j r '` ., C�.ATEGORYKOF,CONSTRMMO =1 _ ' "� "` SFR (1) bath 249.20 2 I & 2- Family dwelling ❑ Commercial /Industrial SFR (2) bath 350.00 MI Accessory Building ❑ Multi- Family SFR (3) bath 399.00 . ❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00 F JOBiSITEINFORMATION an dlLOCATION ID__ Fire sprinkler - sq. ft.: Page 2 13` '.: M: A' Slte Utilities Job site address: D 5 ��� r /oc��1-�l� ID le_ Suite #: Bldg. /Apt. #: Catch basin /area drain 16.60 • Drywell /leach line /trench drain 16.60 Project Name: Footing drain (no. linear ft.) Page 2 Cross street/Directions to job site: Manufactured home utilities 110.00 Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.) Page 2 Subdivision: Lot #: Storm sewer (no. linear ft.) Page 2 Tax map /parcel #: _ e_, _ c e � k'ixt i' o tem rk „ ;� k Water e (no. linear Page W v DESCRIPTION'OP WORK ff" -,'. , a ; . `: _ valve 16.60 ., .., .��..�- ,..�.� _ Absorption val _ e (, t /1//f�/6�` t , Div Backflow preventer Page 2 Backwater valve 16.60 Clothes washer 16.60 Dishwasher 16.60 Drinking fountain . 16.60 '% imomocovglowasa s mi 1TENAN =T mtwt - ,:t4 Ejectors /sump 16.60 Name: A v k, 1 � keIe Expansion tank 16.60 Address: 13 -/7O S,1J. /- foltio4-l20 De • Fixture /sewer cap 16.60 Cit City/State/Zip: 22 3 _ Z� $ Floor drain/floor sink/hub 16.60 Y p: Tvi 'e_0l ©i 9 Garbage disposal 16.60 Phone 5o3 510 3 55 Fax Hose bib 16.60 ontorozwoRfitMa if iii ..00Ntio-TR;rmosmag Ice maker 16.60 Name: Interceptor /grease trap 16.60 . Address: Medical gas - value: $ Page 2 Primer 16.60 City /State /Zip: Roof drain (commercial) 16.60 Phone: Fax: Sink/basin/lavatory 16.60 E -mail: Tub /shower /shower. pan 16.60 ; ._ Ni ` WOONTRA€3,01 : 4 '' ';X Urinal 16.60 Business Name: Water closet 16.60 Water heater 16.60 Address: Other: City /State /Zip: Other: Phone: Fax: -0 .. - „." i Plumbing Permiilnatr. , l' - ,Milt Subtotal $ CCB Lic. #: Plumb. Lic. #: Minimum Permit Fee $72.50 $ Authorized Residential Backflow Minimum Fee $36.25 Signature:CL ,- F1. 1 1/ _ �ti Date:') - 4- z �Q3 Plan Review (25% of Permit Fee) $ State Surcharge (8% of Permit Fee) $ (Please print name) TOTAL PERMIT FEE $ 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 Building Industry Service Board. i:\Dsts\Permit Forms\PlmPermitApp.doc 01/03 Plumbing Permit Application - City of Tigard - - Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: SMULf Wit .11:41Ati 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 r 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 SUSIOViitialtitteACA.Sanl* KWeii 4.FeTtiC 04010,10 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 $100.00 or fraction thereof. Fixture Work: Are you capping, moving or replacing existing fixtures? If "yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. r 4- 0$: Comments regarding fixture work: ;412 ,A4141e6:0 Pewit 44-.0414Atie.:Ik:ggita Moyed. Exlstii 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" Car Wash Drain . If the fixture work under ths 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: • \Dsts\Permit Forms\P1mPermitAppPg2.doc 01/03