Permit C ITY OF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 00174
.. 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 6/7/2005
PARCEL: 2S 103CA -00203
SITE ADDRESS; 11820 SW JAMES CT ZONING: R - 4.5
SUBDIVISION: LOT: 017 JURISDICTION: TIG
Project Description: Sewer connection existing residence. Septic system must be pumped and filled or
removed. PLUMBING PERMIT IS REQUIRED.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
MODE, DEBRA KAY
FIELDS, TERRY LEE • 1=1 Description Date Amount
11820 SW JAMES COUR M [SWUSA] Swr Connection Fee 6/7/2005 $2,500.00
TIGARD, OR 97223 [SWINSP] Sewer Inspection Fee 6/7/2005 $35.00
Phone: W d • Total $2,535.00
Contractor: Z M N
V
a W 0 REQUIRED ITEMS AND REPORTS
Phone:
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Reg #: 0
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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.
Issued by: 6....cla-coc.-/167 Permittee Signature /�%V
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.
Building Fixtures / / II A)
' FOR OFFICE 'USE ONLY
City of Tigard DateBed
Plan Review PemutN 6d
13125 SW Hall Blvd., Tigard, OR 97223 U y � /7/
Phone: 503.639.4171 Fax: 503.598.1960 1,
Date/By: Other Permit No.:
L
24- Hour Inspection Line: 503.639.4175 _ Date Ready/By: Juris g El See Page 2 for
Internet: www.ci.tigard.or.us W
g Notified/Method: Supplemental Information
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: ,• -,e TY r OF ` WORK, -i ,_ � . re , * � F'EE S.CIIEDULE
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❑ New construction ❑ Demolition For special information use checklist.
Description Qty. I Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
"'�' �;� e � ^.; ?` a -a d ° "':'�' ,9' :ea',� �?"" .. :f'.a_:.• � a; =r �•� • ' :.. y �:'. E r a ' ' �. „' ' �" "` �'-
, k , . .-1. 'o t :- GATF,: , ' OFD °C0i RTJ,CT ,ot,M g _; ; , ( 5 , t ! SFR (1) bath 249.20
c.. rn+ i3'.'-16 -' rv: .,:."• &.;a.:r_', iii-^:^ trit' ta4tA# GJiz:";,' q: i_ 4MS`:ks.h�.'.:�:5'z's;'�J�, i „ ,.�93cR;sa_`�,
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❑ 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:
e k n � <.. Fire sprinkler ( sq. ft) Page 2
' y 7 y irdi SITi INFORiVIAT30N ANA OC T ION
m� � ��z,�a.�� +:emu �. x�- �:.. >�.. x � M Si te ut
Job site address: / al2a S c J. Tq.*K.,, C T Catch basin or area drain 16.60
City/State /ZIP:
..... I o `e ` .- . � Z� Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name: Footing drain (no. linear ft.: ) Page 2
1 10.00
.� r- Manufactured home utilities
Cross street/directions to job site: S a - Ca ��l
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
_ „� Absorption valve 16.60
- t ' tt °e OF 1 ,, i. 4 � ,5 av . . iso � Backflow preventer Page 2
' L � . g , s # err s..�,rx� t iP ,fix s,..a�.
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
°,- Mr.444 mr ,....: -- ate: , .1, ir; w,, ' € ' Drinking fountain 16.60
w1 ; , PROBER' �.gt_O /WN itCAT I ' .
- - ;: , : "® .TENANT , : ' ; ^°^
»§� X ..f =�s :r . • t rsr ha tlr. a� ,wzs ter. g. s Y �.`� ».
rr Q E jectors /sump 16.60
Name: �€ d GI . k' mead... /77e.‘ 7 e. i e /� Expansion tank 16.60
Address: f/ & p .5 a Fixture /sewer cap 16.60
City/State /ZIP: Q. 0 9 'Vt..? Floor drain /floor sink/hub
16.60
� G � O _ f � / ( ) Garbage disposal
Phone: l Fax: �-
� - "�:a�, -x�r, �. e ' ,� .�� 4 a �. �,- r±�;..��, � Hose bib 16.60
1 t E 'AF P,I , :ICA NT= , fi �t ® C® IIACT PERSON , "; °
. ^3G;:.'� .:i'�?' ac r Y ...,,rxa:.,. z'+*: .`'.'^S'3;, *`.':•s ';,... �T <: x.�..a a. ;'�fletcnl". =.i.,, ":h'r:^s,''Id',::�
� "�`' ''� "`��' °" ��` � Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax:: ( ) Sink/basin /lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
, 4 , + z i q,� t �. r € ,-f'e; :54'",Se�s�'.- v7";':z :': , :%` - { ,'z .^ r t ;'i=.Y °.. S,:N .f;.a "v`.'a�'' ;t, t';.w ""ri?�R 'r.2 . ;
;; `,, , � ,: a` s t CON > "x S g r e , `'' •�.: Water 16.60
� �' �::�..� . � ,� � .� ��.. � �, �:�.. .� � �' �. _x���r. ater closet
Business name: r".1A.r/19-h--- Water heater 16.60
Address: Other:
City/State /ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lie.: Plum g t . no.: Plan review (25% of permit fee)
X
State surcharge (8% of permit fee)
Authorized signatur / ��� TOTAL PERMIT FEE
rint 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:\ Building \Permits\PLMF- PermitApp.doc 12/03 440- 4616T(10/02/COM /WEB)
Plumbing Permit Application - City of Tigard ,
•
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
. ;k's ' . . � v !,:�a;}...� �...y��r,,r, a;„,.'u:.4. w. ;i"," :i= _ _ �>! »5.::�i�:= ^ .. � b' rtfa y , a . � . eic mi3cz:�
! �.., ,,x�;. :. .,, •
Lt ;: P� d . ;: t�tj': i'>=s XP8'8 ,ea) °t s�:fi 1TOt / ..;',- ;8 �,
S>< t e ` U ti'l ti es l i .G wS ua �e F,o a Pe xrn><t F ee ,
ire .. ,. z,..,..�,6r.; ; ,��. � Via. -.�� ���. -° . � c q n.. �� .g...: �����S�. �. ,..�.
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 AV- : t =^ ter• r •; -? rs *x
6 0 v P erm Pre 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
si "..aa ;;a ` iu-. WE IV additional $100.00 or fraction thereof, to and
'1Xt� _ � � Qty. ee=(ea) " � 'Total
ur.e or Item ,. _ a . �.
�� ,�a.�,'�:� -� .�r� i�a 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
•
specially requested inspections - per hour 72.50 and including $50,000.00:
Subtotal: $50,001.00 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, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
; , a ,A TOR A 7
t " Quantii by ( iztiire) Work erformedj
F ggiggyp a i O ti . grill Rag , Replace i � g ,
, � . iig ry , `ggeW� gn Etogg g ggligttg Comments regarding fixture work:
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"
- 4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial
Ice Mach. /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory
Quantity Total
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
- Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
i: \ Building \Permits\PLM- PermitApp.doc 3/03