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Request for Permit Action
TIGARD N BUILDING
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TO: CITY OF TIGARD
Permit System Administrator
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) \ p C � ^ \ \ /
Mailing Address: \ Q�y W l
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® ® City/State /Zip: r ('J�
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s Phone No.: 3 7 5 y‘
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: on 6 - P (,V r
Site Address or Parcel #: „z y" a S �J-
Project Name: e i hA,`x l� .
Subdivision Name: Lot #:
EXPLANATION: 0 \ • r - { , -e .t e
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Signature: C 4— Date: lc,
Print Name: Lo f .e— C. W , == -7 2 e '`
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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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) 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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S'sAdmin: Date , - ` -/ B�► Rte toBl•: Admin: Date iO B ��,•�r
Refund Processed: Date /OAK, _ B,irr �� Invoice Processed: Date By
Permit Canceled: Date e By • "' Parcel Ta Added: Date By
Receipt /** - �� r tp Date zoi /p ( Method ( e Amount $
1:\ Building \forms \RcgPermitAction.doe Re e05/24/06
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CITY TIGARD PLUMBING PERMIT
PERMIT #: PLM2006 -00458
DEVELOPMENT SERVICES DATE ISSUED: 10/5/2006
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 1S136AA-00301
SITE ADDRESS: 10240 SW 69TH AVE ZONING: R - 4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Repair water line break.
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
LESTER WEBER JR
10240 SW 69TH AVE Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 10/5/2006 $72.50
[TAX] 8% State Surcha 10/5/2006 $5.80
Phone : 503- 750 -6646 Total $78.30
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # :
Reg #:
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 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued By: Qiel1 Permittee Signature: 4 C )GeP"Q..
Call 503- 639 -4175 by 7:00 a.m. for an inspection that business day.
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 n
Buildin Fixtures ` °' E L L I J � ' J
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City of Tigard 0 CT 0 5 2006 p Receiv ��p . � Permit No.. \ �"
v 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review ,..5
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0 Phone: 503.639.4171 Fax: 503.598.190 Y OF TIGAF3 Date/By, Other Permit No.:
• T I G A R t� Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready/By. iwis: ® See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑ Addition /alteration/replacement ❑ Other: Uir -rcn. L r . ✓Zc �-
(' New I- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (t) bath 249.20
❑ I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: L(! 2 Kus ry C f (4 d <; Catch basin or area drain 16.60
City /State/ZIP: f', 9 ,•. 0 Re, q' 72 2 3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street /directions to job site: G/► t. • G f 4 y,
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: _) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: _) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
/2c," 4, , 44.4.4,4 L 6i,.. , f1 - te.4 Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: i_ e , 5 .4 .4 , C GA. "Jca. j r. Expansion tank 16.60
Address: /02 yv Sw 6t' Ant.. I " 1 ( 04 0^• P. el- liv44. 4'46 a", 6- Fixture/sewer cap 16.60
City /State/ZIP: / 04. 47z Li Floor drain/floor sink/hub 16.60 •
Phone: (c ) yso 6 fe y! Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax:: ( )
Sink/basin/lavatory 16.60
Tub /shower/shower pan 16.60
E -mail: Urinal 16.60
• CONTRACTOR Water closet 16.60
Business name: (2 \N'Q, f Water heater 16.60
- Address: Other:
Subtotal
City / State/ZIP: Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.:
Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature:
TOTAL PERMIT FEE ��, SO
Print name: L<-stc. C 1.-E4 i I Date: S - v 4- 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 \ Penn its\PLMF- PermitApp.doc 04/06/06 4404616T(I0/02/COM/WEB)
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
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof to and
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
Inspection of existing plumbing or each additional $100.00 or fraction thereof to
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and
Qaaotitz by (Fixture) Work Performed greater, except systems designed and stamped by licensed
• Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ Any new exterior plumbing site utilities.
Baptistry/Font ❑ Medical gas and vacuum systems for health care facilities.
Bath - Tub /Shower ❑ Any multipurpose fire sprinkler system.
- Jacuzzi/Whirlpool ❑ Any complex structure as defined in OAR918- 780 -0040.
Car Wash - Each Stall
- Drive Thru Submit 2 sets of plans with any of the above.
Cuspidor/Water Aspirator
Dishwasher -Commercial
- Domestic Isometric or Riser Diagram
Drinking Fountain ❑ Isometric or riser diagram is required for new buildings
Eye Wash that meet the qualifications above.
Floor Drain /sink -2"
-3"
-4 "
Car Wash Drain Comments regarding fixture work:
Garbage - Domestic
Disposal -Commercial
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory *Note: If the fixture work under this permit results in an
- Bradley increase of sewer EDUs, a sewer permit will be issued and
-Commercial fees assessed for the sewer increase must be paid before the
- Service plumbing permit can be issued.
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\ Building \Permits\PLM- PermitApp.doc 0922/06