Permit Ir �
•
CITY TIGARD PLUMBING PERMIT
PERMIT #: PLM2002 -00192
AA DEVELOPMENT SERVICES DATE ISSUED: 10/1/03
�I
13125 SW Ha Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 16875 SW PACIFIC HY PARCEL: 2S115BD -02600
W
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION: KIN
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 5
OCCUPANCY GRP: M FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS: 8
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 790 ft
WATER CLOSETS: WATER LINE: 0 ft
DISHWASHERS: RAIN DRAIN: 1,070 ft
Remarks: Site utility work, other fixtures are (2) oil /water separators and (3) manholes. Sewer permit is to be issued by
Clean Water Services.
FEES
Owner:
Description Date Amount
SPACE AGE FUEL INC
PO BOX 607 [PLMPLN] Addl Pln Rv 10/1/03 $218.75
GRESHAM, OR 97030 [PLUMB] Permit Fee 10/1/03 $1,346.60
[PLMPLN] Plan Review 10/1/03 $336.65
[TAX] 8% State Tax 10/1/03 $107.73
Phone : 503 665 - 5693 Total $2,009.73
Contractor:
MJD DEVELOPMENT INC
14670 SW PEAK CT
TIGARD, OR 97224 REQUIRED INSPECTIONS
Sewer Inspection RP /Backflow Preventer
Phone : 503 - 579 - 8826 Water Line Insp Final Inspection
Reg #: LIC 107753 Water Line Insp
Water Service Insp
Fire Supply Line -FPS
Storm Drain Insp
Storm Drain Insp
Storm Drain Insp
Misc. Inspection
Misc. Inspection
RP /Backflow Preventer
RP /Backflow Preventer
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
lssb •d By: 1. . /, _.a ! t ' Permittee Signature: y A
Call (503) . 9-4175 by 7:00 P.M. for an inspection needed the xt business day
Site Utilities
Plumbing Permit Application FOR OFFICE USE ONLY
I Received Plumbing 0.4 172.002... 0 0 / i n
Date/By: Permit No..
City of Tigard Planning Approval Sewer
VIF Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503 -639 -4171 a 503-3' 8 -1 ' 60 � Post - Review Land Use
_ 1 $V � \ Date/By: Case No.:
Internet: www.ci. i : aro .or. • s _i_1 . c • , 9-- Contact Juris.: ® See Page 2 for
24 -hour Inspecti. n Re. - . t- : - - 1 O ✓, Name/Method: Supplemental Information.
TYPE OF WORK FEE* SCHEDULE (for special information use checklist)
❑ New construction ❑ Demolition Description I Qty. I Fee(ea.) I Total
❑ Addition/alteration /replacement ❑ Other: New 1- & 2- family dwellings
CATEGORY OF CONSTRUCTION (includes 100 ft. for each utility connection)
SFR (1) bath 249.20
❑ 1 & 2- Family dwelling ❑ Commercial/Industrial SFR (2) bath 350.00
❑ Accessory Building ❑ Multi- Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Fire sprinkler - sq. ft.: Page 2
Job site address: Site Utilities
• Suite #: I Bldg. / A t. #: Catch basin/area drain R 16.60 /$,/. 80
Project Name: .,SPAc.€ n Drywell/leach line /trench drain 16.60
Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110.00
Manholes 3 16.60 y9.10
Rain drain connector 16.60
Sanitary sewer (no. linear ft.) ?go Page 2 079, 80
Subdivision: • I Lot #: Storm sewer (no. linear ft.) 10'70 Page 2 5/ 9 . 0 O
Tax map /parcel #: Water service (no. linear ft.) Page 2
Fixture or Item
DESCRIPTION OF WORK Absorption valve 16.60
UNOe 44 Si r` "41)/715M 4- Backflow preventer 5 Page 2 s(Aa • ov
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OWNER I ❑ TENANT Ejectors/sump 16.60
Name: Expansion tank 16.60
Address: Fixture/sewer cap 16.60
City /State /Zip: Floor drain/floor sink/hub 16.60
Garbage disposal 16.60
Phone: Fax: Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON Ice maker 16.60
Name: Interceptor /grease trap 16.60
Address: Medical gas - value: $ _Page 2
City/State/Zip: Primer 16.60
�' p Roof drain (commercial) 16.60
' Phone: I Fax: Sink/basin/lavatory 16.60
E -mail: Tub /shower /shower pan 16.60
CONTRACTOR Urinal 16.60
Business Name: Water closet 16.60
Water heater 16.60
Address: Other: 0i / 1,4.+?/ SeptivFa✓ 2 /64e Zg.AO
City /State /Zip: Other:
Phone: Fax: Plumbing Permit Fees*
CCB Lic. #: Plumb. Lic. #: Subtotal $
Minimum Permit Fee $72.50 $ 1 , Coe)
Authorized Residential Backflow Minimum Fee $36.25 re
Signature: Date: Plan Review (25% of Permit Fee) $ c 'liar ,97 4'
St to Surcharge (8% of Permit Fee) $ . /O's 7
(Please print name) 3 .5/ /t J of d $ 'Al g . 2,
Notice: This permit application expires if a permit is not obtained within MI new commercial buildings require 2 sets of plans with isometric or
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri -County Building Industry Service Board. ;j
i:\Dsts\Permit Forms\PlmPermitApp.doc 01/03 -----2--;--179-1_ ; . a )0 ® a 73
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 - 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 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
additional $100.00 or fraction thereof, to and
Fixture or Item Qty. Fee (ea) Total 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
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 Comments regarding fixture work:
•
Fixture Type: Replace
New Moved Existing Capped
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 *Note: If the fixture work under this permit results in an
Garbage - Domestic
Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice MachiRefrig. Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\Dsts\Permit Forms\PlmPetmitAppPg2.doc 01/03
______ _�41X 12:26 SPACE AGE FUEL 4 95035259266 2 , (p 2._5-- N0.562 D006
Plumbing Application _ .. ��p I9� �
f Date received: 3 , Qernnit na
_ Building permit no.:
III�!�� , ►►► City of Tigard ,� .sewer permit no.:
" I 'jeer/tip/A. no.: 1^lcpire date:
Address: 1 31 25 SW Ha11 Blvd, Tigard. DB 9'221 / '
GYey ojl Phone: (503) 639 -4171 J EM Receipt no.:
5 I Date issued:
Fax: (503) 598 -1960 P L Case file no.: Payment type:
j
\
Land use approval:
111'1, 01 PERM] l
O Multi- family Q Tenant improvement
0 I 2 family dwelling or accessory Cl Commeatndvsrrial 0 Food service 0 Other
0 New construction Cl Addition/n/altelterdtlon/rePlacom
1 0
t [E S(IILpl;1.E (fur special information use checklist) T
,cue st'rL lmrott�l:� nv� Dew , ; on M Fee( ea.)
• 5.-o ' fr •Y " L/ lN 6 Ct ' Nevi fatculy w D. oalyt
lob address: . � . Suite no (1a100S.toreadtatigtYc
Bldg. no.: ► Z - • O • SFR (1) bath �� _
Taxm. •tax lot/account no.: u 7•� ,.
Lot: Block: Subdivision:
S ' (3) bath ���
Project name: • Ea additional + . th/ki
tty /ccmin C. t)„d ZIP: Z � sitetaiucics: S ex— �
Description and loca ", n of wo on p t s: Catch basin/area drain -�
•
s 1.9 b f� ri. 1 piywel each line/trench drain � ��
Est date of cotnpletionlm Footing • (no. tin ft.)
; i r ,� r •.,. rn +r r anufactured home utilities
sr e 4 ° r : . i l Marsh• ea
Business name: Rain • • rain connector _ ifirm
C ity .: , • Stateb Salutary sewer (no" in ' .)
City •� . /1 0,.. ` ZIP: , 9?+:t AN
• Sa corm sewer oo. tin. ft. 11111111.1.1111.111 Pax e.inail: �~
� 1 � CCB no.: , • Plumb. bus. ;• no: g cute or 111111 �I� /metro tic. n . r- Contractor's representative signature: -_ : ack flow preventer - Abso +don valve � � �
Date: �
Print mute: C lo t he tava 11111111111111 X t;U�1:1C1 PERSON �� wash
� i :. washer
Name: n. _4, _ _ : fo untains) MIMI
Address: �� !.�. �� r3::i. /11 . �. AF .' ectors/ .. • r ��
133/ _;_:- n_� i Ci E E- - _ •elisiontattic -
Phone:. - ,, 1 txturelsewer cap
(1��`1E1t Floor drains/floor sinks/hub ���
Name ( p r i n t ) : ' ° 7 _ � c ... Garb - :h di . . s a l . 1/1.11.11 Mailing address: • - G • . (0 4 3 m aker
City: , • y [hit, I State: • ice �� �
nteree • o • grease tra
O er • ' The actual in �� =�
wither m ade l by mec or helmet maintenance only: installation ' "mer(s regular Roof dram (commercial)
will to be ee o n by me or the maintenance own per and repair Chapter by my Sinks . • , ;n s), lays(s) ���
employee on the property I own as per ORS Cttal� Sump
gate. �-- Tub s ower /sliow•er .an
Owner's signature _ ���
ENGINEER Urim•
• .Jae ► . = ‘ Bret beater � 1.1.. V
State: 0 _�
-mail: = o
Pbono:ZZS � Minimum fee $ ' wire -
N at au hduioor wes t mat ca rd', p lease cat )`tsd1itoo formate tomatoes. a�oes. Notice: This permit epplicetion Plan review (at ZS `70) S r
D Y1sa t] MasterCard e if a permit is not of rained State surcharge (8%) $ ?
/ within 160 days after it bas teen T $ Z 1
a ccepted as comp
Cram card number; � � lete. O t
i as sho an oRdi cell d
tVenoe of cac T 440 -4616 (6roaCO
— Ciad aalder pD Amount
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