Permit Support Document (9) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action
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TIGARD 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: ❑ Owner ❑ Applicant ❑ Contractor co City Staff
Check ✓ one
REFUND OR Name: lv
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
A►: 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#: P )/ -7_OO / 1
Site Address or Parcel#: l 391 g 6 ` .) ,eywLs
Project Name: A_ A411- 7714 7-3
Subdivision Name: Lot#:
EXPLANATION: 1-1-- t.,„3 4 s `r TF 2 J-1r ,.J i o C 2 sl �J Pe.4 r73i
9-0 0-60,?-14 v- Pc M mor-7-609 .15 /ors �� wr�s IR3ei N -Del')6 /SY
a 1Dr FFE 2g ,- T�2✓}0-t—®(�S . �o JJ vG TEFr e, toe:)itc P1,4 I.\ Pi V C Q Lo,
Signature: Date: /
Print Name: �°` 4,/7
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Sys Admin: Date Co p r 7 I k r) Route to Records: Date 7 C /7 By
Refund Processed: Date /01" By 0446 Invoice Processed: Date $
Permit Canceled: Date 7/6 7/7 By - Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_00231 .doc y
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Plumbing Permit Application 7 6 /2
Building Fixtures RECEIVED I°tll (}IInit la ►=s1, t,r,l,/
City Receival ) PetmitNo.:
1 1 of Tigard pp�p�pp q Dat y: fL /7 �LI/a2p/7_,OO l St
13125 SW Hall Blvd,,Tigard,ORt;72Y32 7 2017 Flea Review
Phone: 503.718,2439 'Fax: 503.598.1960 Date/Ely: i-0 4-{i; or Other Permit No.: /4-',o3$
T/t.;:iv#is Inspection Line: 503.639,41ts IT if OF TIGARD DaneReady/By: has: sl See Page 2for
Internet: wtvw,tigard-or.gR t1i� nt tr, DIVISION Notified/htethod; S/t(__ Supplemental information
TYPE OF WORK FEE*
DIVISION W \ FEE* SCHEDULE
ANew construction ❑Demolition For special friformarfon use checklist
Description 1 Qty. r Ea. 1 Total
❑Addition/alteration/replacement 0 Other: New 1-2-family dwellinjs(includes 100 ft,for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
0 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
1::1 Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.It) Page 2
//Oil es.--- JOB.SITE INFORMATION AND LOCATION _ Site utilities: _
Job site address:, 1-�.4.,,,(.� G �- Catch basin or area drain 18.76
I 3sZ$ si„,a8
• Drywell,leach line,or trench drain 18.76
City/State/ZIP: --n rk OR. q t-i t ,
Footing drain(no,linear ft.:_) Page 2
Suite/bldg./apk,no.: ! Project name:reav‘trttottetitti 1514 ,{?ad! tL,k(S, Manufactured home utilities 50.03 /
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:l ) Page 2 160,0(n
Storm sewer(no.linear ft.:/LE) Page 2 166.06
- Water service(no.linear ft.:,_) Page 2
Subdivision: Lot no.: Fixture or items
Tax map/parcel no.: Backfiowpreventer ( 31.27 11.11
DESCRIPTION OF WORK Backwater valve 12.51
j �1 =i'} Clothes washer 25.02
t Lam-ice..J I.) {fid �r)1tl,. t.=t.�HH Lt 7 1400 Dishwasher 25,02
- Drinking fountain 25.02
Ejectors/sump 25.02
Q PROPERTY OWNER 0 TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Address[ Floor drain/floor sink/hub I 25.02 SO.04
Garbage disposal 25.02
City/State/ZIP: Hose bib 25,02
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT d CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value$ ) Paget
Contact name: Primer 12,51
Roof drain(commercial) 12.51
Address:
Sink/basin/iavatory 1 25.02 .$$,O
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/showerpan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02 _
t�
Water heater
Business name 37.52
�.tiSE � �� waterPlpintt�� 36.29
Address: 5 80x NE 8 ' S$ a _Other 25.02
City/State/ZIP: V C.e.t} qe ttr p' Subtotal�3l .7
Phone:(36 et)5-.44•443$ Pax:( ) 51- Minimum permit fee: $72.50
CCB Lic.: iffa 5 o� p Plan review(25%'of permit fee)
PlumbingLic.no.;
,� State surcharge(12%of permit fee) �3,5,$
Authorized signature: !� �-
is TOTAL PERMIT FEE D�,' ,
Print name: C' ,f,taDate: p This permit aytpltcatton exptroa if a permit is not obtained within 160 Jaye
after it bas been accepted as complete.
*Fee methodology Set by Tri-County Building Industry Service Boani.
tatuiliting\Perm#s\PLMU-YnmitAup.doe 10!01/09 440-4616T(10/o2/cowwpn)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities • Fee(ea) Total, - Square Footage: -Pernut;Fee: '
Footing drain-1"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 '*,14110.0111 Ferniit l ee
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
) ' Total each additional$100.00 or fraction thereof,to
Other inspectio It Pr Fees 'I"' , ee.( 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
accurately report fixtures could result in increased sewer fees* ;,A_ > ,f.., .v. e_,1 LW� _��.sI .Y >}
tintty4iyttture The: _ Plan review is required for any of the following.
rp tit a Type for -' -'1!-.01,#/ Please check all that apply.
W� k4? 4onned r. ... !>, <#!� . #fit` ❑ 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 ❑ New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Thru
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher:W irator ❑ Any multipurpose fire sprinkler system.
-Commercial-Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Submit 2 sets of plans with any of the above.
Eye Wash
Floor Drain/sink: 2" oL
❑ 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 C 1 , ments regarding fixture work.
Ice Mach./Refrig.Drains .
Oil Separator(Gas Station) 4,..,QO(19e-A /YLi [n �ti t- LI,D
Rec.Vehicle Dump Station - .4 6-0./vi m .*__ • / 4 - _ i
Shower: -Gang , 1
-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
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF PermitApp.doc 08/04/2011 2
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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.
.71 .. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
: z Transmittal Letter
T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: Don Sylvester DATE RECEIVED:
DEPT: BUILDING DIVISION
qac
FROM: Choncy Jones; Kevin Russell
-/7
COMPANY: DOWL
PHONE: 971-280-8660 By:f
l3.2fs 0
RE: J.�04 SW Scholls Ferry Road, Tigard, OR 97008 1 L-POsol w OD 5J
(Site Address) (Permit Number)
Tigard Apartments `" `
(Project name or subdivision name and lot number)
ATTACHED ARE THE FOLLOWING ITEMS:
Copies: Description: Copies: Description:
Additional set(s) of plans. 2 Revisions: Community bldg/Pool Utils
Cross section(s) and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
Beam calculations. Engineer's calculations.
Other (explain):
REMARKS: The pool deck area requires 3 area drains, 158 LF of Storm piping and 137 LF of Sanitary
piping, as well as 2 sanitary cleanouts. Please see attached.
CJ 0I0CSCS c-DOw I— .. 0o i`-1
FOR OFFICE USE ONLY
Routed to Permit Technician: Date: Initials:
Fees Due: ❑ Yes ❑No Fee Description: Amount Due:
-<-6 g. (-)d -A-T---n ,9-5 e't $
Special c5r,�-,04_,,yLv�t- pe21`-f`7`_
$
Instructions:
Reprint Permit(per PE): ❑ Yes ❑ No ❑ Done
Applicant Notified: Date: Initials:
I:\Building\Forms\TransmittalLetter-Revisions.doc 05/25/2012