Permit (26) CITY OF TIGARD PLUMBING PERMIT
'> COMMUNITY DEVELOPMENT Permit#: PLM2017-00266
and OR 97223 503.718.2439
13125 SW Hall Blvd.,Ti Date Issued: 07/05/2017
f[ al1L 9
Parcel: 1 S134CD03900
Jurisdiction: Tigard
Site address: 12020 SW 121ST AVE
Project: CEBULA Subdivision: LERON HEIGHTS NO.3 Lot: 69
Project Description: Replacing existing water piping throughout house.
Contractor: OWNER Owner: CEBULA, KENNETH P&LISA WAI YIN
KENT CEBULA 12020 SW 121ST AVE
12020 SW 121ST AVE TIGARD, OR 97223
TIGARD, OR 97223
PHONE: 503-270-9087 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Water Piping/DWV 07/05/2017 $56.29
Specifics: 1 12%State Surcharge- 07/05/2017 $8.70
Plumbing
Type of Use: SF 16 ea Minimum Fee Adjustment- 07/05/2017 $16.21
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232 •- • ;00.332.2344.
�t f
Issued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
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
Building Fixtures FOR OFFICE", USE ONLY
City Of Tigard ` Received
R Date/By: ?/5/% i�7�- Permit No.: /��r/L rt'7r11 7-u /
.74
- 13125 SW Hall Blvd.,Tigard,OR 97 J'J ! YTS' [sa<rn
Plan Review
Phone: 503.718.2439 Fax: 503.598. 00 Date/By: Other Permit No.: ��)-
T 1 G A P.D Inspection Line: 503.639.4175 `t\� ate Ready/By: 7ur See Pagel 7 `/ /
Internet www.tigard-or.gov J AVann Y 1 ,ed/Method: 1,d..e, Supplemental Information
TYPE OF WORK O U1 i
�� FEE* SCHEDULE
New construction ❑De ,s , .0 For special information use checklist
Description I Qty. Ea. I Total
Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
y 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
❑Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
} 1- Catch basin or area drain 18.76
Job site address:
-1 RC1 J .) i�. / A ite,
Drywell,leach line,or trench drain 18.76
City/State/Z1P: ,�.� E
1`�jrVC� ? T , Page 1 ( Footing drain(no.linear ft.:_) Pa e 2
Suite/bldg./apt.no.: 1 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
.. 14''''
t '.,,, ` DESCRIPTION'�OF WORK; ;;4.
,, ° V"...,,,,,2`,4 Backwater valve
12.51
5s C � Clothes washer 25.02
A -c 11" _., Dishwasher
25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Vi 'PROPERTY WNER -;< 1 *:41:0 J,N. Expansion tank 12.51
Name: ii C,,---?ti t ) ' Fixture/sewer cap 25.02
[-) 11 C-
Floor drain/floor sink/hub 25.02
Address: /d-,a) i.O <-11.�e j f -fC4 i./(,"
City/State/ZIP: , t r"' -
Garbage disposal --_ 25.02
� t-7/_' �� eG' Hose bib 25.02
Phone:(I" ) ) ' 1,�1 r-�� c�� Fax� ( ) Ice maker 12.51
APPLICANT - " ❑ CONTACT ER N 7 < Interceptor/grease trap 25.02
Business name: ���� J ` Medical gas(value:$ ) Page 2
Contact name:
%G Primer111
12.51
Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
CONTRACI<OR Q Water closet 25.02
Water heater 37.52
Business name:
�*r
Water piping/DWV
Address: l 5�.
Other: 25.02
City/State/ZIP: Subtotal ,
Phone:( ) Fax:( ) Minimum permit fee: $72.50
Plumbing Lic.no.: Plan review (25%ofpermit
CCB Lic.: fee) --
State surcharge(12%of permit fee) S/'70
Authorized signatt � 9
(----719,,..„.e/9 eTOTAL PERMIT FEE er J a
Print name: Ai,-„, / Date: -, This permit application expires if a permit is not obtained wit in 180 days
Z 1 4. (.���//�1 J 1�`� after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\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-151 100' 50.03 0 to 2,000 $121.90
2,001 to 3,600 $169.69
Footing drain-each additional 100' 37.52
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
Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
Other Inspections or Fees 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
each additional$100.00 or fraction thereof.
(minimum charge-1/2 hour)
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to =r
accurately report fixtures could result in increased sewer fees*. " Plan jtvlew for 1'luinbi ' Insta1la ns fi
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 0 Any new commercial building with water service 2"and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower engineer.
-Jacuzzi/Whirlpool 0 New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Thru 0 Medical gas and vacuum systems for health care facilities.
Cuspidor/Water Aspirator 0 Any multipurpose fire sprinkler system.
Dishwasher: -Commercial
0 Any complex structure as defined in OAR918-780-0040.
-Domestic
Drinking Fountain Submit 2 sets of plans with any of the above.
Eye Wash
Floor Drain/sink: -2"
3>, 1,:; .Al' 0meti1 0T , , er Al
0 Isometric or riser diagram is required for new buildings
-Car Wash Drain that meet the qualifications above.
Garbage -Domestic non-food
Disposal: -Domestic food related
-Commercial food related
-Industrial food related Comments regarding fixture work:
Ice Mach./Refrig.Drains
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav/Bar 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 sewer increase must be paid before the
Water Extractor plumbing permit can be issued.
Water Closet-Toilet
Urinal
Other Fixtures:
I:\Building\Permits\PLMF PermitApp.doc 08/04/2011 2
FOR OFFICE USE ONLY—SITE ADDRESS:
This form is recognized by most building departments in the Tri-County area for transmitting information. ,
Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
-1:..71; Transmittal Letter
I , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www gard-or.gov
TO: 1JGtto `�.\ 4� AT '
DEPT: BUILDING DIVISION t rrL V ED
X' FROM:
31 2017
4FROM: 1�111�c ov 1 ��� e ,
� I't"�t'OF T[GAItI}
COMPANY: cub v`ta �l iv d— . BUILDING DIVISION
v+ v By:JT
PHONE:
L G — ur7v v
RE: 606k6‘ le -")OcO .1,1 / vV\'-, illir7 �t~1 - Guu lit
(Site Address) (Permit urn
' oject name or su.'rvrsion name an. of n M.•r
-r 2S ATTACHED ARE THE FOLLOWING IT' MS:
i
Additional set(s)of plans. �..-* Revisions: 11 Ati .) S
l _ Cross section(s)and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
Beam calculations. Engineer's calculations.
,_ E i Other(explain):
Z. REMARKS: RA" V eA( yLi VLS 5e_3 v.;%Wel ✓:CA_ASI A'-r_C.A
Routed to Permit Technic'. • -Date: 0 •7f, 7 Initis aro'
Fees Due: ■ Yes IT o Fee Description: Amount 1 ue:
$
$
$
$
Special —
Instructions:
Reprint Permit(per PE): ❑Yes 0 No 0 Done
Applicant Notified: Date: 7/3/i 7 Initials:
1:\Building\Forms\TransmittalLetter-Revisions.doc 05/25/2012
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
12020 SW 121ST AVE, TIGARD, OR, 97223
Record Type: Record ID:
Residential - Plumbing PLM2017-00266
Inspection Type: Inspector:
399 Plumbing final Don Sylvester
Result:
PASS - NoCofO
Comments:
Violation Summary:
Inspector Contractor