Permit C ITY OF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 -00133
11- 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 4/13/2005
PARCEL: 2S111 BC -02500
SITE ADDRESS; 10205 SW MURDOCK ST ZONING: R - 3.5
SUBDIVISION: TIGARDVILLE HEIGHTS LOT: 023 JURISDICTION: TIG
Project Description: Connect existing house to lateral. Reimbursement District #27 Pai
P.i,e.,► p..SIA t f WA.Q -el L .e. W6t / y
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
PATRICIA GALICH
10205 SW MURDOCK Description Date Amount
TIGARD, OR 97224 [SWUSA] Swr Connection Fee 4/13/2005 $2,500.00
[SWUSA] Swr Connect Credit 4/13/2005 $35.00
Phone: 503 - 598 - 0686 Total $2,535.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
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.
i b
Issued by: 411. _ Vii. 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.
RECEIVED S - u4/
PWimrbhiir Permit Application FOR OFFICE USE ONLY
City of Tigard APR 13 2005 Received / > Bed n �j / Permit No. 5uJ 006 - L�/3
CITY OF TIGA
13125 SW Hall Blvd., Tigard, OR 97223 ';�
Date/
By:
503.639.4171 Fax: 503.598.1960 Other Permit No.:
Dae � � tBy:
24 Hour Inspection Line: 503.639.4175 BUILDING • DIVI m 'I P lan Revi
e t l Date ReadyBy: °� / ® See Page 2 for
t 6
Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I 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 •
1:1 Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: / 0 a h, S ‘...) fM V (-L. Lic Catch basin or area drain 16.60
Cily /State /ZIP: -- �� 22 _ _Dr leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
r Manufactured home utilities 110.00
Cross street/directions to job site:
t In J rc (Y 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
DESCRIPTION OF WORK Backflow preventer Page 2
.3 -W L r C Ail Q. CA: J i Backwater valve 16.60
Clothes washer 16.60
(PROPERTY Dishwasher 16.60
OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: Prt 1 c t 4 G a It d-, Expansion tank . 16.60
Address: S ct 4 � G 'i ( Fixture/sewercap 16.60
City/ State/ZIP: Floor drain/floor sink/hub 16.60
Phone: ( 5kj) J 4' ( 5 b 6 -4 Fax: ( ) Garbage disposal . 16.60
[.APPLICANT CONTACT PERSON Hose bib 16.60
Ice maker I 16.60
Business name: a iN, C, ....s cial 0 t 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
•
CONTRACTOR Water closet 16.60
Business name: 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 Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature: TOTAL PERMIT FEE
.'")
Print name• / 0. Date: t-(J ( 3/ S 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\PLM- PermitApp.doc 12/03 440- 4616T(l0 /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 - l' 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: Permit Fee:
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 fdr
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 * .
Quantity by (Fixture) Work Performed
Fixture Type: Replace
New Moved Existing Capped 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"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice Mach./Refrig. Drains
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 • Isometric or riser diagram is required if fixture quantity
- Commercial
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:
is\ Building \Pcnnits\PLM•PertnitApp.doc 3/03
ORVALL T. CADE JOB INVOICE
BYER'S SEPTIC TANK :SERVICE. !NC.
P.C. BOX 549
OREGON CITY. OREGON 97045 CUSTOMERS ORDER NO. DATE ORDERED
(503) 656 -3326 9- / i - QS
ORDER TAKEN BY DATE PROMISED ❑ A.M.
f ❑
�� s awl. P M.
BILL TO PHONE
GP/+'- LA Ora I
ADDRESS MECHANIC
CITY H .
`r ..
JOB NAME AND LOCA TION
/ �/�� �J/ NNNN
D of $ L-4 I - '0/ V`.1 C ❑ DAY WORK
❑ CONTRACT
DESCRIPTION OF WORK
❑ EXTRA
OUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT
/
2-
j.4•0,7 — - — - 3 v�
> -
HOURS LABOR AMOUNT TOTAL
MECHANICS MATERIALS
HELPERS TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR TAX
completion of the above described work.
SIGNATURE DATE COMPLETED
TOTAL