Permit CITY OF TIGARD PLUMBING PERMIT
': • COMMUNITY DEVELOPMENT Permit #: PLM2013 00013
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/09/2013
Parcel: 2S 103DD00700
Jurisdiction: Tigard
Site address: 13765 SW PACIFIC HVVY
Project: Gilbertson Subdivision: MELROSE Lot: 7 -8
Project Description: Storm drain improvements, approximately 200' of storm drain line and storm water pit.
Contractor: MICAH DAY CONSTRUCTION INC Owner: GILBERTSON, LLOYD
PO BOX 113 DARLENE J
SHERWOOD, OR 97140 • 15980 SW COLONY PLACE
TIGARD, OR 97223
PHONE: 503 - 502 -6655 PHONE:
FAX:
FEES
Quantity • Description Date Amount
1 ea Drywell, Leach Line or Trench 01/09/2013 $18.76
Specifics: Drai
200 If Storm and Rain Drain 01/09/2013 $100.06
Type of Use: COM 1 12% State Surcharge - 01/09/2013 $14.26
Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $133.08
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 i • - • started within 180 days of
issuance, • • • . is suspended for more the 180 days. ATTENTION: Oregon law require •' to follow the r - -d the Oregon
Utility ' otification Cente . Those rules are set forth in OAR 952 - 001 -0010 through OA' = 2- 001 -0090. obtain a cop9 of the rules
or dir ct questions to OUNC • s 13.232.1987 or 1.800.332.2344.
Issu By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for the next avail.: e inspecti • date.
This permit card shall be kept in a conspicuous place on the job site until completion of e project.
Approved plans are required on the job site at the time of each inspecti • .
Plumbing Permit Application
ir
Site Utilities RECEIVED FOR OFFICE USE ONLY
City of Tigard
IN Received ff t� // ,
Date/B : Permit No.:
a 13125 25 SW Hall Blvd., Tigard, OR 97223 JAN 0 9 7013
11 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 DateBy: Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 CITY 1 1 OFTIGARD Date Ready/By: orris: ® See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WO I LDIAIG DNISION FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement g Other: 5 'rn nt'a ;ny 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 gki 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: /.3 76fs - pc c r c. c rJ w�/ Catch basin or area drain 18.76
City /State /ZIP: b (1 .--11 r Z ‘..-7 t 2 Z 3 Drywell, leach line, or trench drain if 18.76 / 9. 7 �j
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: ,c /(e.,,-,W� 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 fteg Page 2 /6131, Ot!/
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
n Clothes washer 25.02
Stavin Or `'tx_ £, �` ' K Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: / / c , / ( 6 j71, f'v/7 Fixture /sewer cap 25.02
Address: r Floor drain/floor sink /hub 25.02
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
Business name: /C.7 4 u y �/ �jn,J 7 c �K.. Medical gas (value: $ ) Page 2
: �� 12.51
Primer 12.51
Contact name: �
Roof drain (commercial)
Address: , t.9 , (7a)( / / 5 Sink/basin/lavatory 25.02
City/State /ZIP: .f,2.(,vWt19, 0/2 ri 7 /' /c. Solar units (potable water) 62.54
Phone: (So) ) ,)`mac 2- 6 (2.5i Fax: : (s<) 3 ) Sys - 66-5-T- Tub /shower /shower pan 12.51
Urinal • 25.02
E- mail:` y LOf'/,f7;e 2 VG 7r , mr! p/ / f Orr?
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: / f Water piping/DWV 56.29 _
Address: Other: 25.02
City /State /ZIP: Subtotal // g g 2
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50
CCB Lic.: /6$ 4 s *�� I / Plumbing Lic. no.: Plan review (25% of permit fee)
� State surcharge (12% of permit fee)
Authorized signature: TOTAL PERMIT FEE / f
133•
..
Print name: C. q 7 Date: J3 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 10/01/09 440- 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 - 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
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 ec
Ins tions or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
Inspections 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
Re inspection 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/ Plan review is required for any of the following. Performed: Capped Added Relocate
Please check all that apply.
y g
Baptistry/Font
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.
-3"
Isometric or Riser Diagram
Car Wash Drain ❑ Isometric or riser diagram is required for new buildings
Garbage - Domestic - non -food
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 Filer *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:
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