Permit CITY OF TIGARD PLUMBING PERMIT
.114
S COMMUNITY DEVELOPMENT Permit #: PLM2012 -00210
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/30/2012
Parcel: 25101 CB00100
Jurisdiction: Tigard
Site address: 8100 SW HUNZIKER RD
Project: Huttig Building Products Subdivision: 2007 -064 PARTITION PLAT Lot: 1
Project Description: Replace existing 8" backflow device only on fire sprinkler line.
Contractor: SIMPLEXGRINNELL LP Owner: HUTTIG, INC
6305 SW ROSEWOOD ST. 555 MARVILLE CENTER DR
LAKE OSWEGO, OR 97035 PO BOX 1041
CHESTERFIELD, MO 63006
PHONE: 503 - 683 -9000 PHONE:
FAX: 503 - 675 -6521
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 07/30/2012 $31.27
Specifics: i Plan Review 07/30/2012 $18.13
1 12% State Surcharge - 07/30/2012 $8.70
Type of Use: COM Plumbing
Class of Work: ALT 41 ea Minimum Fee Adjustment - 07/30/2012 $41.23
Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $99.33
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: Permittee Signature: ��
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.
Plumbing Permit Application
Site Utilities RECE/E FOR OFFICE USE ONLY
City of Tigard Da 2/1,0.2...
4 Permit No.101,420 /2 - eO� /D
n 13125 SW Hall Blvd., Tigard, OR 97223/11 3 0 2012 Plan Review
C Phone: 503.718.2439 Fax: 503.598.1 Date/By: Other Permit No.:
Inspection Line: 503.639.4175 /�y'�/ T � Date Read B luris: &I See Page 2 for
T I G A R D Internet: www.tigard-or.gov + d 4 / t l i f ? C ,n F f ! ,UARD Notified/Method: Supplemental Information
TYPE OF W :��t�l� LYNISIO p 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 312.70
❑ 1- and 2- family dwelling ® Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 8100 SW Huntziker St. Catch basin or area drain 18.76
City/State /ZIP: Tigard, Or. 97223 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: Page 2
Suite/bldg. /apt. no.: I Project name: Huttig Building Products Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
replacing old 8" backflow device on line suppling buildings' fire sprinkler Clothes washer 25.02
Dishwasher 25.02
system Drinking fountain 25.02
Ejectors /sump 25.02
® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Huttig Building Products Fixture /sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 8100 SW Huntziker St. Garbage disposal 25.02
City /State /ZIP: Tigard, Or. 97223 Hose bib 25.02
Phone: (503)620 -1411 Fax: ( ) Ice maker 12.51
® APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: SimplexGrinnell Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: Don Donaldson
Roof drain (commercial) 12.51
Address: 6305 SW Rosewood St. Ste. A Sink/basin/lavatory 25.02
City/State /ZIP: Lake Oswego,Or. 97035 Solar units (potable water) 62.54
Phone: (503) 683 -9000 Fax: : (503) 675 -6521 Tub /shower /shower pan 12.51
E -mail: ddonaldson @simplexgrinnell.com Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: SimplexGrinnell Water P�P� � r in WV 56.29
Address: same Other: 25.02
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( )
Minimum permit fee: $72.50 rfa_ So
34 / Ste$ Lic.: / " ' 9 is / Plumbing Lic. no.: Plan review (25% of permit fee) 49, /3
'l�! State surcharge (12% of permit fee) 8, 70
Authorized signature: _ / 9 7 pP 4. /641 N l lrfr i - TOTAL PERMIT FEE 77, 3'i
Print name: Don V Donaldson Date: 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\PLMU•PermitApp.doc 10/01/09 440-4616T(10 /02/COMIWEB)
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' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
P 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 charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
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 charge - 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees
Quantity by Fixture Type Plan Review for Plumbing Installations
Fixture Type for Replace/
Work Performed: Capped Added Relocate Plan review is required for any of the following.
Please check all that apply.
Baptistry/Font
Bath - Tub /Shower ❑ Any new commercial building with water service 2" and
Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed
Car Wash - Each Stall engineer.
- Drive Thru • ❑ New exterior plumbing site utilities for any complex structure
Cuspidor/Water Aspirator as defined in OAR918- 780 -0040.
Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ Any complex structure as defined in OAR918- 780 -0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above.
Isometric or Riser Diagram
Car Wash Drain ❑ Isometric or riser diagram is required for new buildings
Garbage - Domestic- non -food
Disposal Domestic -food related that meet the qualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav - Non -food related
- Bradley
- Commercial- food related
- Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer - Clothes
Water Extractor increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
http: / /www.tigard- or.gov /city_hal l/ departments /cd/docs/PLMU -Perini tApe doc
, .
TIGARD
City of Tigard
October 18, 2012
Simplex Grinnell
Attn: Don V. Donaldson
6305 SW Rosewood St., Ste. A
Lake Oswego, OR 97035
Re: Permit No. PLM2012 -00210
Dear Mr. Donaldson:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 8100 SW Hunziker Rd.
Project Name: Huttig Building Products
Job No.: N/A
Refund Method: r1 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.
n Trust account "deposit" receipt in the amount of $
Comment(s): Per applicant's request as existing backflow device test was acceptable.
Refund 80% of permit fees only.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
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 Requuest 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: Simplex Grinnell DATE: 10/2/2012
6305 SW Rosewood St., Ste. A
Lake Oswego, OR 97035 REQUESTED BY: Dianna Howse
Attn: Don V Donaldson
TRANSACTION INFORMATION:
Receipt #: 187754 Case #: PLM2012- 00210
Date: 7/30/2012 Address /Parcel: 8100 SW Hunziker Rd.
Pay Method: CreditCard Project Name: Huttig Building Products
EXPLANATION: Per applicant's request as existing backflow device test was acceptable. Refund 30% of
permit fee only.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000- 43104 $ Amount
Plumbing Permit Fee 230- 0000 -43101 $58.00
/Z P./A e , t4 - 26- leo - 0oa0 `f00/ 6,96
TOTAL REFUND:
t.
APPROVALS: ' W y'
If under $5,000 Professional Staff •=11. PkA)
If under $ 12,500 Division Manager !
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: I fQ / /4, //Z By: ,C"(�'�'IT
L \Buildin \Refunds \RcfundRcqucst.doc x 09/01 /31110
Fax: Sep 11 2012 02:21pm P002/002
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
L�
u.! Request uest Permit Action
;;' R 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • vvt
TO: CITY OFTIGARD S E P 1 1 2012
Building Division Services Supervisor
13125 SW Hal. Blvd., Tigard, OR. 97223 CITY Of TIGARD
Phone: 503.718.2430 Fay 503. 598.1960 www.tigard -or.go Mp ry� npino ,
FROM: ❑ Owner ® Applicant ❑ Contractor ❑ City Staff
(d c k ono
REFUND OR Name: SimplexGzinnell
INVOICE TO: (Busincvs or individual)
Mailing Address: 6305 SW Rosewood St Ste. A
City /State /Zip: lake Oswego, Or. 97035
Phone No.: 503 -683 -9052
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (I):
►mot CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below)-
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: PLM2012 -00210 rt
Site Address or Parcel #: 8100 SW Hunziker Rd.
Project Name: Huttig Building Products
Subdivision Name: Lot #:
EXPLANATION: Flushed existing backflow and was able to get it the test to hold.
Signature: 1:4(44/1/4-A-- Date: g/!// Z—
Refund Policy 3 -
I. The Director or l3uildi ng Of5cial may authorize the refund of 74'
a) any fee winch was aavnaously paid or collected (° ' 27
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- ti � /r!•
c) not more than 80% of the land use application fee fox issued permits. 6
d) not more than 80% of the buildiogplan review fee when an application is canceled before any plan review effort has been expcoded
e) not snore than 80% of the building permit fee for issued peonies prior to any inspection requests.
2. Refunds will be returned to the mistral Payer in the creme method in which payment was received Please allow 2.4 weeks for procesing refunds-
FOR OFFICE USE ONT.y 9 2 , S0
Rte to S Admit : Date MEM Rte to B • • Admire: Date /a0 13- ?Q
Refund Processed: Day , mom B . Invoice Processed: Date B
Permit Canceled: Date /e /� / �Z By 07- ' atcel Tag Added: Date Bp f (/ Z
�m )
Receipt # Date Method Arnmt $ ft, 9 (a
I'\ + lding\Fomu \RegPezmitA,cdon.doc Rev 05/25/2012
to