Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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►� Request Permit Action
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T l ( ,1,A ; D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www. ' an or l v/
u LI N G TI CA
TO: CITY OF TIGARD DnI SjON
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223 V I
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov ZS / '
FROM: ❑ Owner ❑ Applicant ❑ Contractor )4Cit Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) /h
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
,_ 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 #: l d`1 AO t 3 0.01 5
Site Address or Parcel #: I 2.5 d O 2M Nrr AJ r✓
Project Name: • A •TV t)tJ» 5 Q0111 -1 wiiry CE&Y eiz
Subdivision Name: Lot #:
EXPLANATION: V p t -r ) 11-115 (t M i T �v 4 �. � �P +� Pay
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Signature:
G T). Date: (e I ( c1/5
Print Name: f,,sPoi Pi-D Prt'L`diA..)
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b) not more than 80 of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) 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.
FO OFFICE USE ONLY 1.
Rte to S s Admin: Date ' , 3 B AMMA Rte to Bld: Admin: Date ®�� B
Refund Processed: Date /11 r fr By il� Invoice Processed: Date By
Permit Canceled: Date 7 /ZS /j3 By f . Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPcrmitAction.doc Rev 05/25/2012
Plumbing Permit Application Site Utilities FOI2 OFFICE usE ONLY v City of Tigard Received 2 / /n
Date /By: 5 7 / 3 Permit No.: L Na0 /,� "� a �
1111 2 • 13125 SW Hall Blvd., Tigard, OR 9722AY 0 7 2013 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Other Permit No.:
Inspection Line: 503.639.4175 CITY OF TIGARD Date /By:
TIGARD Date Ready /By: Juris: RI See Page 2 for
Internet: www.tigard- or.gov
BUILDING DIVISION Supplemental Information DIVISION
TYPE OF WORK 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 I SFR (1) bash 312.70
❑ I - and 2- family dwelling ® Commercial /industrial SFR (2) bath 437.78 ,
SFR (3) bath 500.32 ! V n
❑ Accessory building ❑ Multi- family Each additional bath/kitchen 25.02 V
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2 -1>
JOB SITE INFORMATION AND LOCATION Site utilities: .
n 5 c5� /I 1 r 4, Y Catch basin or area drain 5 18.76 93.80 ft,
Job site address: 9 07 � IV , Jt/ 1 -
Drywell, leach line, or trench drain 18.76
City/State /ZIP: Tigard, OR 97223
Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: J Project name: St. Anthony Community Cen Manufactured home utilities 50.03
Cross street/directions to job site: SW Grand and SW Johnson Manholes 18.76
Rain drain connector 18.76 ���((
Sanitary sewer (no. linear ft.: 177) 177 Page 2 91.43 V
Storm sewer (no. linear ft.: 983) 983 Page 2 393.84
Water service (no. linear ft.: 145) 145 Page 2 79.42
Subdivision: I Lot no.: 2S10D Fixture or item:
Tax map /parcel no.: T2S 1W 2BD TL 100 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Site work for Community Center. Dishwasher 25.02
Drinking fountain 25.02
E
Ejectors/sump 25.02
® PROPERTY OWNER II ❑ TENANT 1 Expansion tank 12.51
Name: St. Anthony in Tigard Catholic Church & School Fixture /sewer cap 25.02 1
Floor drain /floor sink/hub 25.02
Address: 9905 SW McKenzie Street Garbage disposal 25.02
City/State /ZIP: Tigard, OR 97233 Hose bib 25.02
Phone: (503)639 - 4179 Fax: (503)624 - 2364 Ice maker 12.51
® APPLICANT Interceptor/grease tra 25.02
1 ❑ CONTACT PERSON I trap
Business name: Ankrom Moisan Architects Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: Drew Rocker
Roof drain (commercial) 12.51
Address: 6720 SW Macadam Ave., Suite 100 Sink /basin/lavatory 25.02
City/State /ZIP: Portland, OR 97219 Solar units (potable water) 62.54
Phone: (503) 245 - 7100 Fax: : (503) 245 - 7710 Tub /shower /shower pan 12.51
E -mail: drewr @amaa.com Urinal 25.02
Water closet 25.02
„� CONTRACTOR - - . - l
Water heater 37.52
Business name: R &H Construction Water piping/DWV 56.29
Address: 1530 SW Taylor St. / Other: 25.02
City/State /ZIP: Portland, OR 97219 Subtotal 658.49
Phone: (503) 228 - 7177 Fax: (503) 224 - 3638 Minimum permit fee: $72.50 658.49
CCB Lie.: 38304 ;Plumbing Lie. no.: Plan review (25% of permit fee) 164.62
_ _ State surcharge (12% of permit fee) 79.02
Authorized sigitature:� TOTAL PERMIT FEE 902.13
Print name: Drew : , c • Date: 5 -07 -13 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 10:01i09 440- 4616T( 10:02/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 F ee:
Footing drain - r 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' 100 62.54 62.54 7,201 and greater $327.54
Sewer - each additional 100' 77 37.52 28.89
Water Service - 1st 100' 100 62.54 62.54 Medical Gas Systems:
Water Service - each additional 100' 45 37.52 16.88
Storm & Rain Drain - 1st 100' 100 62.54 62.54 Valuation: Permit Fee:
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 883 37.52 331.30 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Inspeetaiol §,.or-,
Vies Qty. ` Fee des} -, 'ho each additional $100.00 or fraction thereof, to • 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
klan Review for Plumbing I
Fixture Type for Replace/
Work Performed: Capped Added Relocate Plan review is required for any of the following.
Baptistry/Font Please check all that apply.
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 OAR9I 8- 780 -0040.
Eye Wash
Floor Drain/sink - 2" Submit 2 sets of plans with any of the above.
-3"
Car Wash Drain Aso c
Garbage Domestic- non -food ❑ Isometric or riser diagram is required for new buildings
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:
C:\ Users \MarkV \AppData \Local \Microsoft \Windows \Temporary Internet!iles\ Content. Outlook \HSJSWTGU \PLMU PermitApp.doc
IN
a
0 Site Utilities — Plumbing Permit Application
Plan Submittal Requirements
TIGARD
A plumbing permit for site utility plumbing work is required for sanitary sewer, storm sewer
and potable water systems on private property.
1. SITE PLAN and vicinity map showing the geographic location (fully dimensional, drawn
to scale) labeled with:
A. ® map & tax lot # ® project name ® site address ❑ suite number
® zoning ® applicant name ® phone number
B. North arrow.
C. Scale (architectural or engineering only).
D. Street names.
E. Building pads with project location.
2. PLUMBING PLANS - Two (2) complete sets, civil only.
All details listed below shall be incorporated into the plumbing plans:
A. Storm drainage plan showing:
1) Finish elevations throughout the developed site.
2) Grade breaks determining area serving each catch basin.
3) Location of catch basins.
4) Pipe size.
5) Type of material.
6) Slope of piping.
7) Manholes and field drains.
8) Cleanouts provided for each 100 feet or fraction thereof.
9) Roof drain laterals specifying cleanouts at each upper terminal.
10) Location of existing or proposed connection to a public sewer line.
B. Utilities plan showing:
1) Sanitary sewer line location, pipe size, type of material, slope of piping, manholes
and cleanouts provided as required for storm.
2) Size and location of domestic water piping and drainage.
3) Proposed location of connection to a public water or sanitary sewer line.
I: \Building \Permits \PLMF - PermitApp.doc 12/30/05