Permit Plumbing Permit Auulicatio \/ 0 1 D 3/2c/i5
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Building Fixtures FOR FOR OFFICE USE ONLY
1111 . I3I of Tigard 2014 Daffy ( Permit No.. `!e 7.J�
131 5 SW Hall Blvd.,Tigard,OR 97223
OCT 3 0 1`F ����`� `-I
I Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By:
CITY Permit No.: '1¢....9414-QIG1/15
TIGARD
Inspection Line: 503.639.4175 �TY OF TIGARD Date Ready/By. Jurist Ill See Page 2 for
Internet: www.tigard-or.gov R�i=i n �1i Notified/Method: iR���Sr Supplemental Information
TYPE OF wiLDiN D[.IsIUN FEES SCHEDULE
❑New construction ❑Demolition For special information use checklist.
Description I Qty. 1 Ea. ] 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
building SFR(3)bath 500.32 •
❑Accessor y g ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
Cno6-D JOB 817E INFORMATION AND LOCATION Site utilities:
Job site address:9 S.W.Washington Square Road Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Protland,OR 97223
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.:a/5- I Project name:Ivivva Washington Square Manufactured home utilities 50.03
Cross street/directions to job site:S.W.Scholls Ferry Road 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.:1S1260000300 Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
'--- Clothes washer 25.02
Installation of sink inservice area and upgrade of existing restroom to meet ADA Dishwasher 25.02
requirements as necessary 6616/4- Drinking fountain 25.02
Ejectors/sump 25.02
al FRROPEpTY OWNER I ® TENANT Expansion tank 1 12.51 fig-5
Name:Lululemon Athletics Canada,Inc. Fixture/sewer cap 25.02
Floor drain/floor sink/hub , 1 25.02 ("4-:0}'
Address: 1818 Cornwall Avenue
Garbage disposal 25.02
City/State/ZIP:Vancouver,BC V6J1C7 Hose bib 1 25.02 25.02
Phone:(604)732.6124 I Fax:( ) Ice maker 12.51
E•
-.. NT ® CON'rACF PRISON Interceptor/grease trap 25.02
Business name:MBH Architects Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:Lilly Sippel
Roof drain(commercial) 12.51
Address:2470 mariner Square Loop Sink/basin/lavatory f 1 25.02 25.02
City/State/ZIP:Alameda,CA 94501 Solar units(potable water) 62.54
Phone:(510)814.3457 Fax::(510)865.1611 Tub/shower/shower pan 12.51
E-mail:lillys @mbharch.com Urinal 25.02
Water closet 25.02
CONTRACTOR -
Water heater 1 37.52 37.52
Business name:TBD Water Pip g/r in DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal / j Del
Minimum permit fee: $72.50
Phone:( ) Fax:( ) _
-
CCB Lic.: Plumbing Lic.no.: Plan review (25%of permit fee) ---
State surcharge(12%of permit fee) /6.p
Authorized signature: C�)�. ) TOTAL PERMIT FEE Ho,10
Print name-: lt` ,n -ry Date:/pi-Lei/ This permit application expires if a permit is not obtained within days
`�tt1�� 1�1✓ ` after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
c:\Building\Permits1PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
10111 Request for Permit est for
3 ,s( *
1 , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.go
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: El Owner El Applicant El Contractor RI City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Ai//l/�
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0. CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not/cancel permit).
Permit#: P (�1-i c9jit(' Cho 3S`t
Site Address or Parcel#: g L0 50 tk.•. (-0/%4+l,j&z Q 1-, .
Project Name: / V 1 A/,4
Subdivision Name: Lot#:
'LANATION: *PLICfi-TI0/3 6u(4)'1/41 1 Ttd 84 A P4.14 r- c--r:
r rr -— �. g� To Co�JT12f)C TO Q. t�}r L4-7-0)
--rte -rte . e_ Poi aloe s-c)000 4
Signature: (X Date: , J/q I i S
Print Name: fal)/9._ f}-jAe-/SiANI
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.
FOR OFFICE USE ONLY
Route to S s Admin: Date ,r-iggimErmara Route to Records: Date 24, /s ?�•-
Refund Processed: Date ZIME B Zgli Invoice Processed: Date B
Permit Canceled: Date 3 26 /$ By I T Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_0' 14..oc
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-1'1100' 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
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/ any review is required for of the following.Performed: Capped Added Relocate q Y ow g
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 OAR918-780-0040.
Eye Wash
Floor Drain/sink -2" / ' Submit 2 sets of plans with any of the above.
4" .',.- • Isometric or Riser Diagram
Car Wash Drain
Garbage -Domestic-non-food ❑ Isometric or riser diagram is required for neNN 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 -water heater: 1/2"hw 1/2"cw
Shower -Gang -exansion tank; 1/2"cw
-Stall y
Sink/Lay -Non-food related ` �C
-Bradley
-Commercial-food related
-Service
Swimming Pool Filter
Washer-Clothes *Note: If the fixture work under this permit results in an
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:
R:\Ivivva\Projects149690_Washington Square_Portland_OR\Survey\Due t2iligence\Plumbing PermitApp.doc