Permit C ITY OF TIGARD PLUMBING PERMIT
A. �� DEVELOPMENT SERVICES PERMIT #: PLM2002 -00264
, .� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/30/02
SITE ADDRESS: 11636 SW PACIFIC HWY PARCEL: 1S136DB -02500
SUBDIVISION: ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: - MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: FLOOR DRAINS: 3 TRAPS:
STORIES: WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 4 URINALS: GREASE TRAPS:
LAVATORIES: 2 OTHER FIXTURES: 8
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 2 WATER LINE: ft
DISHWASHERS: 1 RAIN DRAIN: ft
Remarks: Plumbing tenant improvement to convert fast food restaurant to a Starbuck's.
4 sinks, 2 lays, 1 dishwasher, 3 floor drains, 2 w.c. Other: 1 serv. sink, 1 ice maker, 5 indirect drains, 1
expansion tank.
FEES
Owner:
Type By Date Amount Receipt
STARBUCKS COFFEE COMPANY PRMT CTR 8/30/02 $365.20 27200200000
2401 UTAH AVE. SOUTH PLCK CTR 8/30/02 $91.30 27200200000
SEATTLE, WA 98134 5PCT CTR 8/30/02 $29.22 27200200000
Phone 1: 206- 318 -1575 Total $485.72
Contractor:
REQUIRED INSPECTIONS
1: Top -out Insp
Phone Reg 1: Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. 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
than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility
Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0080.
You ma • btain copies of these rules or direct questions to OUNC by cal , • 13) 246 -1987.
• Issued - 6414X4-fal Permittee'Signature. u.�
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the ne i si s day
I
1 -O�
- ;; Raffia —06
h Pl Permit Application
Date received: 6 a 7 O 2, Permit no.: Lt/A90A- ,a&V
r- ���= City of Tigard Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223 J
Cii)' of Tigard Phone: (503) 639 -4171 Project'appl. no.: / Expire date: V,
Fax: (503) 598 -1960 Date issued: Cyr f Receipt no.: o
Land use approval: Case file no.: Payment type: N
U 1 & 2 family dwelling or accessory U Commercial /industrial U Multi - family Tenant improvement
U New construction U Addition /alteration/replacement U Food service U Other:
JOB SITE INFORMATION FEE SCIIEDULE: (for special information use checklist)
•
Job address: 11 43t ,S(,t.) Petc...cci L Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: 1 New l- and 2- family dwellings only: —
(includes 100 ft. for each utility connection)
Tax map /tax lot/ account no.: 15 13 4. ,08 }&' I D+ 3S )O SFR (I) bath A/ /4
Lot: ,3.5Z)(1 Block: — I Subdivision: — SFR (2) bath
Project name: - 1Z{r, 1 ju[,k, S NO r'k1". T ci .-r.,l SFR (3) bath
City/county:Tj a r / InIfc I I. I ZIP: � 7 3 Each additional bath/kitchen
Dqscription and-Ibcation of work on premises: - 1'p rra n•}- Site fr utilities:
) ✓vt t9V'e* a ,+' -r9 P.vt4 -t i- r 6u l' I , t ( Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line /trench drain
Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: T vvl t Manholes
Address: Rain drain connector
City: I State: I ZIP: Sanitary sewer (no. lin. ft.)
Phone: I Fax: I E -mail:
Storm sewer (no. lin. ft.)
NIC
CCB no.: I Plumb. bus. reg. no: Water service (no. tin. ft.)
City /metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve 0
Print name: Date: Back flow preventer 0
Backwate ve r)
Basin lavato ]
Name: Al/nay-ado, D F , Q l-� /wilt' -kc }3 Clothes washer 0
Ct � W p '-. 1 e- ao Dishwasher I
Address: Drinking fountain(s) 0
City: S.t I State: DA I ZIP: C{'gQQt - f- Ejectors /sump 0
Phone:lac. $).33► • Fax: ;_ E $, G?fi9 Expansion tank
O‘VN'ER •.t,.'i -wer cap •
Floor drain floor sinks /hub // 3
Name (print): 56 ,/• 1 J' 1/ S Cjw► n (I .: , age • isposal n
Mailing address: at U 473, l-t so,...ts, J Hose bibb
City: se, State:IA 4 ZIP: ct 51 I- Ice maker I
Phone:'.06,31 1251 Fax: I E -mail: Interceptor /grease trap Q
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular . • rain (commercial)
employee on the property I own as per ORS Chapter 447. a) basin(s), lays(s) s
Owner's signature: Date: 0
ENGINEER Tubs /shower /shower pan •
Name: i f g h" hee vs
Urinal 0
Address: 1) 1 SS I 0 WE , 5 t • .e. Water heater I
City: t,'r`cl u Hr .State: W I ZIP: 'j $b 3' Other: 'Cart �trr c, 1.� ivtS 5,
Phone: yag; Ge
. 5/ I Fax: ?3q,7.3 4 E- mail: Ae , r •0 / , Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $
Notice: 'This permit application Plan review (at )S % ) 7. s
dd
U Visa U MasterCard expires if a permit is not obtained /7
Credit card number: / / within 180 days after it has been State surcharge (8%) u) $ .1. ° l
Expires TOTAL $ I t 6 3 . G`t
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -46(6 (6:00 /COM)
(A
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PLUMBING PERMIT FEES:
:::A :VINO :i3N..V .
: : . . C i:.::: >::::TO:r: ::::
16.60 : >:th !.0#0.i!t fltE;•t ::#kSt1141:: k: 0.: .QTYY: >:... : : <: :' � :: »::: Pi >:
Lavatory / 16.60 33. a0 E '• KSf # 4 II :i 011k16fik /i41 ::•;:.;;:.::.;:.::.::.:::: :::.;:.;::.:.;:.;:.>:.:.;:.:;.::.;. :.;:.;:.: >:.;:.::. :.;:.:
One (1) bath $249.20
Tub or Tub /Shower Comb. • 0 16.60 Two (2) bath $350.00
Shower Only Q 16.60 Three (3) bath $399.00
Water Closet 16.60 33 . a a SUBTOTAL :':' > 'rr? 1: :: : : > : ::: :
Urinal 16.60 •
0 4i,ii iitij:;;i , :I"Fu+:l . :;.jt.
/ o STATE SURCHARGE : ::::> ::::::>:: >:::'::::: z:`:;;:;: >:'•
Dishwasher r I 16.60 1 , 6 D PL= . REVIEW 25% OF SUBTOTAL :: >:: >; < >: i <`::': # #•,'•: :::: >r
Garbage Disposal • n 16.60 TOTAL :: ::.........,.................
Laundry Tray V 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" 16.60
3° . 3• 16.60 41 go PLEASE COMPLETE:
4° 16.60
Water conversion l kind 16.60 ": i>': iii> �»># : :>:" �< � >:� >::>:>:i>:«� <::<i>:is:: >:� : :: " "`'`F:; .�.
. .
Gas I
er Heater O co / O : In re uires a se arate mechanical € ! :it: Tito ::: :: : : >: : >: : > < : : >: : : : < . W<::i ::: 09::! ! :.; :: : : 0 00i : : ::: >: 4 ::s
Pe
pP 9 q P � � Co t0
............ .. . . .
.. ::::fie � • il<:: >::
...... ..... .. . . ............ . ...... .. Imo. - - --
MFG Home New Water Service 0 46.40 Sink
MFG Home New San /Storm Sewer L O 46.40 Lavatory
16. Tub or Tub /Shower .
Hose Bibs
I. 60 L (o • C D Combination
Roof Drains 0 16.60 Shower Only
Drinking Fountain ( 16.60 Water Closet .2,
16.60 Urinal
Other Fixtures (Specify) Dishwasher 1 •
ir.e. v4t pw. - 1 . [6. C, 0 Garbage Disposal
TA„,•D Ie r S ' u 3 0 0 Laundry Room Tray
(xp M 0 T44 L F . /4 Was D Machine
r� Floor r Drr ain /Sink: 2°
Sewer - 1st 100' WA 55.00 3° 3 .
Sewer - each additional 100' 1 46.40 4°
Water Service - 1st 100' 55.00 Water Heater I
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00 j� r 1
Storm & Rain Drain - each additional 100' 46.40 ty R I •
Commercial Back Flow Prevention Device 46.40 T.'re'r' i r'
Residential Backflow Prevention Device' 27.55 E
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections per /hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling t 65.25
Grease Traps .Y 16.60
QUANTITY TOTAL:
c or riser is r
d
a
Isometrl o diagram s
ag required
Quantity Total is > 9 .................... . ..........
*SUBTOTAL :: ::::: €: € >:>: > ::': : .^!!�. ':;;;
':yr(•;: •:: ir } {y e r�.
8% STATE SURCHARGE: i::::::> >'� €<: ::'.:s >:::: >:::;:; .
* *PLAN REVIEW 25% OF :< ; : : : ::.::::::::::: >: :: >: >::: ::•< #
SUBTOTAL:
Required only if fixture qty. total is 9 : :<: ' ': >•' >' :::'• >: <: >: >: ::::::>
TOTAL PERMIT FEE ':: € : : $
* Minimum permit fee is $72.50 + 8% stale surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
"All New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
i:ldstslformslplm- fees,doc 02/05/02
Accumulative Sewer Tally
Tenant Name: f # t A .. This SWR#
Address: n - # _ _ =E, This PLM #: R0og'e u 1
Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New
# Value Capped off value added # added • #s total
Count off #s count value values
Baptistry/Font 4 ,
Bath - Tub /Shower 4
- Jacuzzi/Whirlpool 4 _
Car Wash - Each Stall 6
- Drive Through _ 16 .
Cuspidor/Water Aspirator 1 �N
Dishwasher - Commercial 4 14
- Domestic 2
Drinking Fountain . 1 ,
Eye Wash 1 , •
Floor Drain /sink - 2 inch 2 . .
-3inch 5 3 1S1
- 4 inch 6
- Car Wash Drn 6
Garbage Disposal 16
- Domestic (to 3/4 HP)
- Commercial (to 5 HP) 32
- Industrial (over 5 HP) 48 .
Ice Machine /Refrigerator Drains 1 1 / ,
Oil Sep (Gas Station) 6
Rec. Vehicle Dump Station 16 .
Shower - Gang (Per Head) 1
- Stall 2
.Sink - Bar /Lavatory 2 1 E4., g
- Bradley 5 - /
- Commercial 3 .. i'/ r f
- Service 3 . / 1
Swimming Pool Filter 1 , •
Washer - Clothes 6 1
Water Extractor 6 _
•
Water Closet - Toilet 6 / o)
Urinal 6
TOTALS \
Total fi xtur e values: divided by 16 = EDU
HISTORY (�� J
PLM# EDU# SWR# •PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
i:ldststswrtay.doc
Sewer Permit Worksheet
Fixture Unit Ratings
Fixture Value Times (x) # of Fixtures Total Fixture Value
Baptistry/Font 4
Bath - Tub /Shower 4
- Jacuzzi/Whirlpool 4 •
Cuspidor/Water Aspirator 1
Dishwasher - Commercial 4 I
- Domestic 2
Drinking Fountain 1
Floor Drain - 2 inch 2 •
- 3 inch 5 I
- 4 inch 6 S
Garbage Disposal 16
- Domestic (to 3/4 HP)
- Commercial (to 5 HP) 32
- Industrial (over 5 HP) 48
Oil Sep (Gas Station) 6
Shower - Gang 1
- Stall 2
•
Sink -Bar 2 4-
- Bradley 5
- Commercial 3
- Service 3
Washer - Clothes 6
Water Extractor 6
Water Closet 6 a l
Urinal 6
TOTALS
Business ∎ S i�o Total Fixture Value L
Address I i 6:3 a)-) lc- cc, L , divided by 16 = 3, D L EDU
Round EDU to nearest whole number a d multiply by $2300
i:\dstslformskswrvvkst.doc 3 ) 3 0 0 _ r�?OO
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Request 1 110- AM PM BUP
Location / / : Suite MEC
Contact Person - / Ph ( ) 65 / - ' I t PLM 6 6 4 ,
Contractor ° Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation Access: ELC
Ftg Drain ! _.!
4/�1/e ELR
Crawl Drain -- ���=
Slab Inspectio Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
. Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
ij
Susp'd Ceiling
Roof
6(p
Otthehe r: \
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
•
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
re PART FAIL
ECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE E Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date / I 6 Inspector 9W. ' Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL