Permit CITY OF TIGARD SEWER CONNECTION PERMIT
• COMMUNITY DEVELOPMENT Permit #: SWR2012 -00058
T I G A R D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/03/2012
Parcel: 151260000300
Jurisdiction: Tigard
Site address: 9611 SW WASHINGTON SQUARE RD L03
Project: Jos A Bank Subdivision: VASHINGTON SQUARE ESTATES NO. Lot: 108
Project Description: .1 EDU increase
Contractor: Owner: PPR WASHINGTON SQUARE LLC
BY THOMSON PROPERTY TAX SERVICES
ATTN HILARY RAYMOND
2235 FARADY AVE, STE 0
CARLSBAD, CA 92008
PHONE PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 05/03/2012 $450.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: 2
Number of Dwelling Units: .1
Total $450.00
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. se rules are - - t forth in OAR 952- 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUN by calling 503.232.19: , :01.332.2344.
Is ed By: � , � Permittee Signature: / %! oae_e
Call 503.639.4175 by 7:00 a.m. for the next available inspect of n 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.
Accumulative Sewer Tally
I I p ; a Tenant Name: Jos A Bank * *REVISED 4/3/12 ** SWR # 2012 -00058
TIGARD Site Address: 9611 SW Washington Square Rd PLM # 2012 -00070
Parcel #: 1S1260000300
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Baptistry/Font 4 0 0 0 • 0 0
Bath: - Tub /Shower 4 0 0 0 0 0
' - Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash: - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher: - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eyc Wash 1 0 0 0 0 0
Floor Drain /Sink: - 2 inch 2 0 2 4 1 2 -1 -2
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash 6 0 0 0 0 0
Garbage Disposal:
- Domestic (to 3/4 I-IP) 16 0 0 0 0 0
- Commercial (to 5 UP) 32 0 0 0 0 0
- Industrial (over 5 IIP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower: - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink:
- Lav /Bar - Non -Food Related 2 0 0 0 0 0
- Bradley 5 0 0 - 0 0 0
- Com /Sery /Util - Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 2 4 1 2 -1 -2
Current Fixture Value -2 divided by 16 = -0.1 Current EDU 1 EDU = $4,500.00
• Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -2 divided by 16 = -0.1 over (under) S (450.00)
• Enter EDU Change Here -0.1
Notes:
EDU CREDIT .1
Authorized Name /Signature: Dianna Howse Date: 4/3/2012
Building Division
otc: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I:\ Building \ Sewer Tally \Scwcrl'allyShcet- 4500.xls 01/18/12
•
vOI
Community Development 7// / // 2. -
T I G A Request for Permit Action
TO: . CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) 1J / /
Mailing Address:
City/State /Zip:
Phone No.:
• PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
t- CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: A.0g. ANA-60051
Site Address or Parcel #: 96// A et)96- #44 ON . RD.
Project Name: —� S . 4 .766-tJ k
Subdivision Name: Lot #:
EXPLANATION: 04, ('p E #J adDvoF of 4302A.. fcJE,e v�l D
L wAic.cz cQ 2.f b .
Signature: �I.! , /��� j, Date:
Print Name: 1 aj81C - _ Ab#H6kf
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date 5 te /, - By ID Rte to Bldg Admin: Date 7 j/ / 2- By
Refund Processed: Date 79- By i ••• Invoice Processed: Date By
Permit.Canceled: Date 3/402.— _By V" Parcel Tag Added: Date By
Receipt # Date Method _ Amount $
I: Building \forms \RegPermitAction.doc Rev. 04 /26/2011
I
Plumbing Permit Application - City of Tigard a
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Syste ':
Site Utilities • . Qty. Fee (ea) ' Total • Squsre Footage • Perltui Feed •
Footing drain • l 100' 50.03 0 to 2,000 _ $121.90 I f
Footing dr - each additional 100' 37.52 2.001 to 3,600 $169.69 I 1 ,
3.601 to 7100 $23320 I 1
Sower - tat 100' - 62 .5 4 01 and greater $327.54 I i .
Sewer - each additional 100' 37.52
Water Service - 1st too• 62.54 Medical Gas Systems: a
Water service -tacit additional 100' 37.52 'Valuations ' .... .. Permit Fee; '
Storm & Rain Drain • 1st 100' 62.54 51.00 to $5.000.00 Minimum fee $72150 1
Storm & Rain Drain • each additional 100' 37.52 $5,001.00 to S 10,000.00 S72.50 the fi S5,000.00 and $1.52 for
Fee (ea) Total each additional $ 00.00 or talon thereof, to
Other Inspections or Fees Qty. and including S1 000.00.
Inspection of existing plumbing or for $10.001.00 to $25,000.00 S148.50 for the fist $10,000190 and $1.54 for
which no fee Is specifically indicated 90.00/hr each additional $100.00 or Lion thereof, to
(minimum charge -1/2 hour) and including 525,000.00. i
Inspections outside of normal business 90.00/hr $25.001.00 to $50, 000.00 $379.50 for the (list $25,00000 and S I.45 for
hours (minimum charge - 2 hours) each additional E 00.00 or fi(actlon thereof. to
Relnspection Fees • 90.00/hr and Including SS(000.00.
Additional plan review for revisions ` 90,00/hr ' $50.001.00 and up S742 (br the fist $50,O0dF00 and $1.20 for
(minimum charge -1/2 hour) _ each additional $ 00.00 or fraction thereof.
Subtotal: t
•
I
I
Commercial Fixture Work: fi
Are you capping, adding or replacing fixtures? If "yes ",
please indicate work performed by fixture. Failure to i
accurately report fixtures could result in increased sewer fees *. t
— • Quantity by Fixture Type , . 'PhD Review for Plumbing Insthllations
Fixture Type for Replace/ Plan review is required for any of the following. Work Performed: Capped Added Relocate Please check all that apply.
Baptistry/Font ❑ Any new commercial building wit water we 2" and
- Jeeuecu zzi/WhI rlpool
Bath - greater, except systems designed d stamp by licensed
/Whl
Car Wash -Each Stall engineer.
-Drive Thru [I New exterior plumbing site utiliti for any l omp l ex structure
Cuspidor/Water Aspirator —
as defined in OAR918- 780.0040.
Dishwasher - Commercial ❑ Medical gas and vacuum systems r health care facilities.
.Domestic ❑ Any multipurpose fire sprinkler sy
DrinkinkFountain ❑ Any complex structure as defined OAR9t 780•0040.
Eye Wash I
Floor Drain/sink - 2 ,2., t 14 #f Submit a sets of plans with ny of the above.
•3-
4 Isometric or Riself I)Ilagl m
Car Wash Drain
Garbage - Domestic - non - food t isometric or riser diagram is repaired for new buildings
Disposal •Domcstlo related 15 that meetflle qualifications abct I ,
Commercial -food related r i I r
- Industrial -food related leN
Ice Mach /Refrig. Drains - ,� 11' VV
Oil Separator (Gas Station) , - o� a regarding fixture(work:
Rec. Vehicle Dump Station n i I
Shower •Gang '_,)
-Stall �� '
lir .
Sink/( -av -Non -food related 1 - j
Bradley I II I
- Commercial -food related {
-Service f
Swimming Pool Filter _ *Note: If the fixture work under this pert results in an
washer - clothes , _
Water 8tctractor increase of sewer EDUs, a sewer permit wig be issued and
Water Closet - Toilet I fees assessed for the sewer increase must b paid before the
Urinal plumbing permit can be issued. rr
Other Fixtures: _ f
C:1Documents and Senings\Cascade Plumbing\My Documents \DownloadeLMF•PernitApp (1).doc }
1
E0 /Z0 39 3G 39V0 bt96E8ZE06 bE :et ZtOZ /9Z /E0