Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2003 -00154
- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/13/03
SITE ADDRESS: 10865 SW WALNUT ST PARCEL: 2S103AA -00101
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: El FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS: 35
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 1,200 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replacement of storm drainage system at track, catch basins in parking lot and connect roof drains to existing.
FEES
Owner:
Description Date Amount
SCHOOL DISTRICT NO 23 J
13137 SW PACIFIC HWY [PLUMB] Permit Fee 6/13/03 $1,163.00
TIGARD, OR 97223 [PLMPLN] Plan Review 6/13/03 $290.75
[TAX] 8% State Tax 6/13/03 $93.04
Phone : Total $1,546.79
Contractor:
EAGLE ELSNER
PO BOX 23294
TIGARD, OR 97281
REQUIRED INSPECTIONS
Phone : Storm Drain Insp
Rain Drain Insp
Reg #: LIC 27112 Final Inspection
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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
Iss d By: _,! ;� � � ,11 X 1 1 Permittee Signature: V � kj
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the ext business day
Site Utilities
Plumbing Permit - Application Received , FOR OFFICE USE ONLY
Plumbing /
Date/By: PA 3 Permit No.: � �. C ' 4 c- O «
t Tigard Approval Sewer
City of 1 lgilY'(� , . Date/By: Permit No
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 , s , . _ Date/By: Permit No :
Phone: 503-639-4171 Fax:- $03- X 98- I960 ,. Post - Review Land Use
Date/By: Case No •
Internet: www.ci.tigard.or.as , j,. � I Contact ,, is.. ® See Page 2 for
1
24 -hour Inspection Request: 503- 639 -4175 Name/Method. I to Supplemental Information.
OO
TYPE OF WORK FEE* SCHEDULE (for special information use checklist) O
❑ New construction ❑ Demolition Description I Qty. I Fee(ea.) I Total W
p1! Addition/alteration /replacement ❑ Other: _ New 1 - & 2 - family dwellings
CATEGORY OF CONSTRUCTION (includes 100 ft. for each utility connection)
1 & 2-Family dwelling Commercial/Industrial SFR (1) bath 249.20
❑ Y g � il/Id SFR (2) bath 350.00
Accessory Building ❑ Multi- Family SFR (3) bath 399.00 a
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Fire sprinkler - sq. ft.: Page 2
Job site address: /pP ,i5 SW GJl trr I liGgekto Site Utilities
Suite #: Bldg. /Apt. #: Catch basin/area drain 3 16.60 5 OG
Project Name:rDW ,12 t' 4 AY 14,1F-440 (2.
Footing line /trench drain 16.60
Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110.00
Manholes 16.60
Rain drain connector / 16.60 ((a. 60
Sanitary sewer (no. linear ft.) Page 2
Subdivision: Lot #: Storm sewer (no. linear ft.) /iOO Page 2 566 90
Tax map /parcel #: Water service (no linear ft.) Page 2
DESCRIPTION OF WORK Fixture or Item ��
LAGIL WA' G w 666 1 N (%t')1 Absorption valve ag
Backflow preventer Page 2
2
Ore..* »06- LOOT feff41 J % %QJ' )I -) f tbej Backwater valve 16.60
-Fate./ . ,., <,; ,:, , ko NCO i rrt Clothes washer 16.60
01%14 TUC) b ce eti 10KAri+1 -To vest Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OW ER I ❑ TENANT Ejectors /sump 16.60
Name: licw Y ) - 1V/54.41.1) p3 Sciii L i2i i . Expansion tank 16.60
Address: (ilk) S W SA ND ea) le& s `. Fixture/sewer cap 16.60
City /State /Zip: ij c 7 ie. e 7223 Floor drain/floor sink/hub 16.60
Garbage disposal 16.60
Phone:503 - 4,1 - 40041. Fax: 4'51- 4o41 Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON Ice maker 16.60 _
Name: Interceptor /grease trap 16.60
Address: Medical gas - value: $ Page 2
Clt City/State/Zip: Primer 16.60
Y p Roof drain (commercial) 16.60
Phone: - Fax: Sink/basin/lavatory 16.60
E -mail: Tub /shower /shower pan 16.60
CONTRACTOR Urinal 16.60
Business Name: 646 t! g - a-so%e____ Water closet 16.60
Water heater 16.60
Address: Other:
City /State /Zip: Other:
Phone: Fax: Plumbing Permit Fees*
CCB Lic. #: Plumb. Lic. #: Subtotal $ / /45 3.
Minimum Permit Fee $72.50 $
Authorized 44 ,� u - tf� / Residential Backflow Minimum Fee $36.25
Signature: D ate: ` i Z�o3 Plan Review (25% of Permit Fee) $ A9O.75
r tik . ssbo Nvickscr State Surcharge (8% of Permit Fee) $ 9Q1 0 ; (Please print name) TOTAL PERMIT FEE $ /5 7 9
Notice: This permit application expires if a permit is not obtained within All 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.
i \Dsts\Permit Forms\PlmPermitApp.doc 01/03
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 - l 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 S Gj $1 00 to $5,000 00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' i i 46 40 S? 0,40 $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 Mach /Refrig. 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
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Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
is \Dsts \Permit Forms \PlmPermitAppPg2.doc 01/03