Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT E `PI ED
pri! Request for Permit Action
iy -
ion
'TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant El Contractor 0,City Staff
Check(1)one
REFUND OR Name: l
INVOICE TO: (Business or Individual) /V/9—
Mailing Address:
City/State/Zip:
Phone No.:
LEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
\1 il b ID PERMIT APPLICATION.
U REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: pLfri 4C / 3-0001.6 B
Site Address or Parcel#: /c 76 3 `'' /07/o S o1 Co t ) 4
Project Name: O&L,,I/du 46 f,JTb1
Subdivision Name: /n�"- Lot#:
EX LANATION: AID /">:iirr Ate-r/✓/Ty / & /0/x//3.
PLEA f- E A, , is PEQ-ter / / ,LED /,/SPE 770/3 •
Signature: Date: /0/7 44/
Print Name: t& /£ /41a,,-/Y /
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
I OIt OFFICE USE ONLY
Route to S s Admin: Date /p/%® n Route to Records: Date , a7f2 B .„; '
_
Refund Processed: Date , By 0 Invoice Processed: Date By
Permit Canceled: Date Aviv'% By,,r--- Parcel Tag Added: Date By
1:A Building\Forms\Re l'ermitAction_O9.314.doc
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2013 00268
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/06/2013
Parcel: 1 S135BC00202
Jurisdiction: Tigard
Site address: 10763 SW GREENBURG RD 100
Project: Subway Subdivision: HILLSBORO Lot: PTS 1-2
Project Description: One hour inspection for review of previous plumbing fixtures that were capped at 10763,suites 100, 110& 120,
and 10765.
Contractor: Owner: BELANICH, ROGER M
22020 17TH AVE SE#200
BOTHELL,WA 98021
PHONE
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 hr Hourly Plumbing Rate 08/06/2013 $90.00
Specifics: 1 ea Hourly Plumbing 12% 08/06/2013 $10.80
Surcharge
Type of Use: COM
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $100.80
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State sf O". Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expir- if ws k is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to fol.w -e rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001 0090. Y• may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
-or By: . /1\ ' — Permittee Signature: / c
Call 503.639.4175 by 7:00 a.m.for the next available inspe,tion date.
This permit card shall be kept in a conspicuous place on the job site un completion of the project.
Approved plans are required on the job site at the time of,<ch inspection.
Plumbing Permit Application
Building Fixtures RECEIVED ED hOlz OFFICE USE ONLY
III City of Tigard AUG ® Date/By: �/(��-..; _ Permit No/JLZy,�,j_ a_4 rP
EN 13125 SW Hall Blvd.,Tigard,OR 97223 2 13
Plan Review
9 Phone: 503.718.2439 Fax: 503.598.19 Other Permit Ny� y �t 'J/
CITY OF TIGARD DateBy: G//�/�VQ�7(CJ
Inspection Line: 503.639.4175
C I G A R U Date Read B y. luris: ® See Page e 2 for
Internet: www.tigard-or.gov BUILDING DIVISIOn Notified/Method: Trty Supplemental Information
ormation
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 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: /0 6.3 ' /D 26_5. N �rCatch basin or area drain 18.76
City/State/ZIP: Drywell,leach line,or trench drain 18.76
Footing drain(no.linear ft.: ) Page 2
.. Suite/bldg./apt.no.: I Project name: 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
Clothes washer 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
. ❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
11 � Medical gas(value:$ ) Page 2
Business name: "3": 1,,,,,. L 8„.I �,,,t,r Cor.t9i, 11',,v,
Primer 12.51
Contact name: `1y5 k,�
Roof drain(commercial) 12.51
Address: /0 76 3 /0 76� fSink/basin/lavatory 25.02
City/State/ZIP: T q o✓C/` Solar units(potable water) 62.54
Phone:(-5733) Bps' _0/5U Fax: :( ) Tub/shower/shower pan 12.51
l �\ CC}�1 Urinal 25.02
E-mail: L g Csz✓15�tuC�Ur�1 u t t
Water closet • 25.02
CONTRACTOR
• Water heater 37.52
Business name: /,¢ Water piping/DWV 56.29
Address: ,/ Other: /ht, 9'd 25.02
City/State/ZIP: Subtotal 9®,p-j)
Phone:( ) Fax:( ) Minimum permit fee: $72.50
CCB Lic.: Plumbing Lic.no.: Plan review (25%of permit fee)
State surcharge(12%of permit fee) /Q ,.k(
. e---
Authorized signature �� - TOTAL PERMIT FEE 4t0,fd
Print name: / , i Date:A // This permit application expires if a permit is not obtained within 180 days
3i 15 •L / ' after it has been accepted as complete-
/ "Fee methodology set by Tri-County Building Industry Service Board.
t:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(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 Fee: .
Footing drain-1S1 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
Storm&Rain Drain-1st 100' 62.54 Valuation: Permit Fee:
$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*. Plan Review for.Plumbing Installations
Quantity by Fixture Type .Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added ,Relocate
Baptistry/Font ❑ Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
engineer.
-Jacuzzi/Whirlpool
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2"
3" Isometric or`Riser Diagram
4" ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -LavBar non-food related _
-Bradley
-Com/Serv/Util food related
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewerincrease must be paid before the
Water Extractor
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures: •
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2