Permit CITY OF TIGARD PLUMBING PERMIT
• COMMUNITY DEVELOPMENT Permit #: PLM2012 -00065
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/23/2012
Parcel: 2S 102CD03005
Jurisdiction: Tigard
Site address: 9965 SW MCDONALD ST
Project: DelaCruz Subdivision: FREWING'S ORCHARD TRACTS Lot: 30
Project Description: Plumbing permit for 65 lin ft of sanitary sewer line for connection.
Contractor: JACK HOWK PLUMBING /RESCUE ROOTER Owner: DELACRUZ, ELDON
P.O. BOX 2830 9965 SW MCDONALD ST
CLACKAMAS, OR 97015 TIGARD, OR 97224
PHONE: 503 - 235 -8784 PHONE: 503-705-2933
FAX: 503 -491 -2932
FEES
Quantity Description Date Amount
65 If Sewer Service 03/23/2012 $62.54
Specifics: 1 12% State Surcharge - 03/23/2012 $8.70
Plumbing
Type of Use SF 10 ea Minimum Fee Adjustment - 03/23/2012 $9.96
Plumbing
Class of Work: OTR
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
•
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952- 001 -0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By:,(j / Permittee Signature: dA/ A, JCg 7-7O//
Call 503.639.4175 by 7:00 a.m. for the next available inspection date. ��//
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.
MRR- 23- 2012(FRI) 10:56 AR5 /JackHouk /RescueRooter (FRX)503 491 2932 P.001 /003
Plumbing, Permit Application
RECEIV - - -
Building Fixtures MAR 2 3 2012 FOR OFFICE USE ONLY -
Ilh City of Tigard CITY OF TIGARD R e" "e; f[►/,L_- P ermit No. A0/a_�06'
r 13125 SW I loll Blvd., Tigard, OR 9 t' tTatdlt ' a3 �� _ `rTy �L/�
7 ILDING DIVi ;,n „� eW
Phone: 503.639.4171 Fax: y su/ie�ia -D00S3 Fax: 503.598. Other Permit No-
Inspection Lint: 503 - 639.4175
TIGARD Min ltea /p
dY Y: RI Sec Page 2 for
Internet:.www.ligurd- or,gov Notified/men!:
r Supplemental Information
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❑ New construction ❑ Demolition _ For special information use checklist
Description -I Qty, 1 Ea. I Total
Addition/alteration/replacement ❑ Other: New 1- 2- family dwelliugs (includes 100 IL for each utility connection)
NAIMI Iyty„+el � ,� ts Sri+ , "11'�11d� �7ll�iC ' "
)!fi ;�I 11f11 ' ...:,14151171`• !'v !i+1rlia?��,���u n ., i a I � I klt ATE SFR(1) p 312.70
, J I- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
❑ Accessory building 0 Multi - family SFR (3) bath 500.32
Each additional bath/kitchen 25.02
❑ Muster builder ❑ Other, • Fire sprinkler ( sq. tt.) Page 2
J t((� 1 o I t n; (,t4, „. r � -, u.n:... y 17 +� p E B�r� I + f i . ,, , 1 n
�^ tlfir•l ? II1 l itiiif . 1 P t,t� , k. =IFI r.- .>>illf (l,l ;�'}I� Site • utilities:
J` 4 i 4 :-
Joh site address: ./ , J , Catch basin nr area drain 18.76
City/State/ZIP: `'! r/2/L; # 4V' _ /4� Drywcll, lt;.lch line, or trench drain 18.76
J' Footing drain (no, linear tt.: , Page 2
Suile/hldg. /apt. no,; Project flame: P r
Manufactured home militia; 50.03
Cross slreet/direclinns to job site: Manholes 18.76
Ruin drain connector 18.76
Sanitary sewer (no. linear 1t.: ) 0 Page 2
Storm sewer (no. linear It: ,__J Page 2
Wilier service (no- linear IL: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map /paredI no.: Beckflow preventer 31.27
� , )w r rl t r 1 "•xi uev: 1�� 1, v i ,. l v
f('i 1 ' . 7 I ,n� J Tj',Y "1.(, l 1 7 fir'' !(, Backwater valve 12.51
,'. .� {h" 111 Ih r.:..1 � I�Ct` tip t .al.�i,,,.,;m -t- , r u i v� 4;
i�% �� Clothes washer 25,02
,�,/ ) �� _ Dishwasher 25,02
'0/ .�. e • a�' �'�' h • thinking fountain 25.02
Ejectors/sump 25.02
1- a Y t 'i 1�� v ^Yl r" uu .1G.: Y S*+t r
t'' ,'lc "tiil n t� ff tll,_ rill ff , { %h� { l i l{YI P + t ; 9� J�A�fi a ��j l laii�l?lki�if;ti {, _Expmisiontunk 12.51
r r r.. t v1x�r' ,Y:4E�:,1� 41" rr^r' �, I
Name: i0D "' � +! / Fixnits/scwer cap 25.02
L ���r 1% Floor drain/floor sink/hub 25.02
Address: � / (/ S�
Garbage disposal 25.02
City/State/ZIP: ri / A /-- . Hose bib 25.02
-
Phone: ( ±,4;/"" 0 9. ' ..4W.:( ) Ice maker 12,51
Pi" i l firljl , It Ili lw !t !�� I''PiTi tau} e a;zry u lt ui tat Y�yc, {rt i ,p Inter
i +� il4ti!W S ,�, ti ?���;E, i`�, t I,II ,1�ri101� r I� o �r� 4 ll, ti� tor/ ease
l „1 , I l ti � �;, !t�](ri;,t�,ti: r:. � : u,.. � uata.:an,. �,�,f !t(lilJ<'�,� �P P,a ' trop 25.02
Business name: ARS dba JACK HOWK/RF-SCIJE ROOTER Medical gas (value: $ ) Page 2
. Contact name: JOYCE DENNIS
Primer 12.51
Roof drain (commercial) 12.51
Address: P.O. BOX 2830 Sink/basin/lavatory 25.02
City /Slate/ZIP: CLACKAMAS, OR 97015 • Solar units (potable water) 62.54
Phone: (503) R50-3100 I Fux:: (503) 491 -2932 Tub/shower /shower pun 12.51
E -mail: JDENN1S@ARS,COM Urinal _ . _ 25.02 - _ - -
1 .,�, .;t {A,i;r:r, �4'!TI;',t li; ;7 ,r 1', U use w;0' 1'.an,;};�• 1ii� �
�ca '1, +�{n,C �'t5�' i f )' `lie h. � , �' ,� l'�I, "lei t' 11 •r1' I -Wm" 25.02.
o � r � � �a�a��„c!lnI l,!,Idt ��af iii• , .� Iti�:t^ n l�;;, ` i,?I,ti!? + G.• 'Sill►,u .l,,>±lt)C'i -- •
S+ ^' "! Water heater 37.52
Business name: ARS dba JACK 11OWK/RESCUE ROOTER Water piping/Owv 56,29
Address: Y.O. BOX 2830 Other.
25.02
City /Statc/ZII': CLACKAMAS, OR 97015 Subtotal
Phone: (503) 850-3100 Fax: (503) 491-2932 Minimum permit fcc: $72.50 - J,
CCB I.ic.: 127325 Plum 'ng Lic. no.: 34 -16$PA Plan review (25% of permit fee) uts....
�J�,� State surcharge (12% of permit fee) ,-
Authorized signature: € . F `/ V`4 . ` �
'I'O'I'AL PERMIT FE
Print name: JOYCE DENNIS j Date/ T rho permit application expires i t permit in not obtained thin I rays
otter It has been accepted ax comakte.
415 ?3. n *Fee nMhptlo1oly set by Tri- County Budding Imtl;try Service Board.
kII:u wu U'I.atU -P.irn nap lone + ..,14.4,,,,,./-, e-'1?/
7-1): 4dwt6teTl
MAR- 23- 2012(FRI) 10156 RRS /JackHouk /RescueRooter (FAX)503 •91 2932 P. 002/003
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule:
4R ., ,, , � 1 .0 , 4 7ity , Ns ! ; ` , r - y.: LN Residential Fire Su ression S sterns:
or r V- ,y n i � � ` rl- '�i't • ' � ! �v G� �a"fi.' i Yd T'M
A. ' ,,,,,,rez`;Ent �14'e r tt� ' 2 a� ,.t16. ' ,k 4: '� t• z. h i , , ,, f y� �r , , �, , . ,s� - > r • �. i_.ul !:t ! ,,-. ' : ,...1 !tar 'Y., .�,r_` L r ;.' .:d .. :,.%:.1.1 twit : :, IL ;1. .+:1∎, i cZ .11 .�, it
Footing drain - I" 100' 11.1111 50.03 0 to 2,000 5121.90
Footing rain - each additional I00' 2,001 to 3 600
B 37.52 � 5169.69
Sewer - 1st 100' / Y 3,601 to 7 00 5233.20
�� 62.54 7.201 and w 'ter 532754
Sewer • each additional 100' 37.52
Water Service - 1st loo' 62.54 • NXedical Gas stems:
Water Service - each additional 100' 37.52 T R
-.
Storm & Rain Drain - 1st 100' Storm & Rain Drain - each additional 100' 337 55,001` 00 to $10,000.00 •c, � first for the t $5,000.00 and $1.52 for n1.
,. ,�� 'r�, .. �v u , �i - --% `-. - ... rag i t tll ."� X1 7 3 :1 t M j r r r { �� :" N Y , r each additional $100.00 or fraction thereof, to
_.....,,� s....., ,, ,„L. � „ : ,.� 4� l. {i ;1 :,6 and including $10.000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
minimum chit .c - 1/2 hour) and includes $25,000.00.
Inspections outside of normal business 90.00/hr - $25,001.00 to $50,000.00 S379.501br the first $25,000.00 and $1.45 for
hours minimum ch a - 2 hours each additional $100.00 or fraction thereof, to
Rcinspectlon Pees 90.00/hr and including $$0,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum cho • e -12 hour) _ each additional $100.00 or fraction thereof.
Subtotal: /.:, dr-W •
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes", E N ' ',;T�� ` , 7 tn ' K'R,�r 1'"l {`,, , 1.4 i lF- . ; , ,tl'n` {;: , I
please indicate work performed by fixture. Failure to Plan review is required . '`- ;_ ? ;. :14 1 ' " f or any of the following.
J °llowi ..111 : :r..:,r�j..� ,rt,•..�•� -,
flowing:
accurate) report fixtures could result in increased sewer fees *. Please check all that apply.
, srt �, ❑ My new commercial building with water service 2" and
i1dY w i! 1 y 1 q -r" ,, t -v r'r� r
+� .0 � err ,I�A`It •M1� 1 ox ��- ..�1t�Yr�:, i'�le �a'l�a'�._uu`l�d�1
1.t;; �A a ffi l (i i . a ;t' { _ y t j "t w M ,� "r 1.1 {. 1 r l'IrA a tai 4 7 1 greater, except systems designed and stamped by licensed
l.. .. ; ;;;;r SR+ .. --", ..+... -nti cF� ii.y± :115.71 ' teik741_iJ t ' i,2. �P: .LrijI1G.l
13 .tie /Font r engineer.
❑ New exterior plumbing site utilities for any complex structure
��� as defined in OAR918. 780.0040.
iiiiiMMERI Car Wash -Each Stall r 1 ❑ Medical gas and vacuum systems for health care facilities.
-Drive rim ❑ Any multipurpose fire sprinkler system.
Cu . idor/Water As , irator MIN - MEM ❑ My complex structure as defined in OAR91 S -780 -0040.
Dishwasher - Commercial
- Domestic _ ��MOM - Submit 2 sets of plans with any of the above.
Drinkin_ Fountain
E e Wash MIME l ' , ,,p ,
11.,....r. � .�il'11�:�thWv.� �Y7vr Fe c lua6lt- p1�7r,� ,' T
Floor Drain/sink - 2 - ��� ❑ isometric or riser diagram -_ for new buildings . _ 1 It-. ,
- 3. �� diagram is required fo
- 4 - that meet the • ualifications above.
Car Wash Drain - MINIM
Garbage -Domestic MME
Disposal - Cornmereiul
-Industrial - Comments regarding fixture work:
Ice MachJRefri• Drains
Oil -avatar Gas Station ill
Rec. vehicle -Gang Station
Shower .
Shower -Gang --_
-Stall
Sink - Bar/Lavatory - MIN
- Bradley MIINIIMMI
Commercial -�� *Note: If the fixture work under this permit results in an
- service increase of sewer EAU
Swintmin_ Pont Fihcr ���� s, a sewer permit will be issued and
Washer - Clothes r� -� fees assessed for the sewer increase must be paid before the
Water Extractor - - r te . plumbing permit can be issued.
Water Closet - Toilet 1.II
Urinal
Other Fixtures; MEM
•
h llp: / / or.gov /city hall / departments /cd/docs/PLMF- PennilApgdoc • •
Ell 111
4
TIGARD
City of Tigard
August 22, 2012
Jack Howk Plumbing
Attn: Joyce Dennis
PO Box 2830
Clackamas, OR 97015
Re: Permit No. PLM2012 -00065
Dear Ms. Dennis:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9965 SW McDonald St.
Project Name: Delacruz
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $64.96.
Note: Please allow 2 -5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of $ .
Comment(s): Per applicant's request, refund 80% as job was canceled.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4 .7) / i,- /
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Building \Refundaa5 nHat:${ ,,,Rl ,o gbn 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
E
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Jack Howk Plumbing DATE: 07/26/2012
Attn: Joyce Dennis
PO Box 2830 REQUESTED BY: Dianna Howse
Clackamas, OR 97015
TRANSACTION INFORMATION:
Receipt #: 186054 Case #: PLM2OI2 -00065
Date: 03/23/2012 Address /Parcel: 9965 SW McDonald St
Pay Method: CreditCard Project Name: Delacruz
EXPLANATION: Refund 80% of permit fees per applicant's request as customer canceled job.
REFUND. INFORMATION:.
Fee Description Frorn Receipt Revenue Account No • Refund'
E sample: Building Permit Fee " Example: 2300000 - 43104. $ Amount
Sanitary sewer service 230- 0000 -43101 $58.00 )
12 /� State Surcharge ge 100 - 0000 - 24001 6.96 / ,
TOTAL REFUND: $64.96 v'
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager
If under $25,500 Department Manager PAP/ a—A.,_
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM MINISTRATION_USE. ONL
Case Refund Processed: Date: �'``t' / Z By: �
L \Building\ Refunds \RefundRcqucst.doc x 09 /01/2010
MAY- 11- 2012(FRI) 15:31 RR5 /JackHouk /RescueRooter (FRX)503 491 2932 P. 001 /002
"NAIL JACK HOWK / RESCUE ROOTER
PLUMBING & DRAIN m � PO Box 2830 •. Clackamas, OR 97015 IRJJ
1 : 8 niG Phone: 503- 235 -8784 •Fax: 503- 491 -2932 n
0,(11 2Qfi2
IC F TIGAD
BUILD��',.. • ;NON
To: e "'�"/ From: 7 e.6
Fax:
�� ✓/l ,. /t pages:
g OI +
es: �.
Phone: IC5V/ 6 :-- ( 7 ( . Date: 7p /ja/
Re: J ,l 2 0) I ' r cc: •
/&Urgent ❑ For Review 0 Please Comment ' ❑ Please Recycl
REFUND REQUEST FORM
Permit No.: nfil 0 —AQQ Issued: j
Address: c v. A/ ° / "d
Project Addr �� /� � l 77G
Reason for Cancellation: a //' �1 ��/ eaC4Y3
Refund Amount Requested:
q •.
Requested by: Joyce Dennis, email: jdennis @ars.colm
Thank you for your prompt response. Joyce Dennis,
CSR/Dispatch, 503-850-3100
3
Certified Plumbing & Drain Specialists
CC 73 #127325