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Plumbing Permit Application

Building Fixtures FOR OFFICE USE ONLY Received City of Tigard Date/By: Permit No.: 13125 SW Blvd., Tigard, OR 97223 Plan Review Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit No.: Inspection Line: 503.639.4175 Date Ready/By: Juris:  See Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information TYPE OF WORK FEE* SCHEDULE New construction Demolition For special information use checklist. Description Qty. 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 SFR (3) bath 500.32 Accessory Multi-family Each additional bath/ 25.02 Master builder Other: ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Catch basin or area drain 18.76 Job site address: Drywell, leach line, or trench drain 18.76 City/State/ZIP: Footing drain (no. linear ft.: ) Page 2 Suite/bldg./apt. no.: Project name: Manufactured 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: Lot no.: Fixture or item: Tax map/parcel no.: preventer 31.27 Backwater 12.51 DESCRIPTION OF WORK Clothes washer 25.02

Dishwasher 25.02 Drinking 25.02 Ejectors/sump 25.02 PROPERTY OWNER TENANT Expansion tank 12.51 Fixture/sewer cap 25.02 Name: drain/floor /hub 25.02 Address: Garbage disposal 25.02 City/State/ZIP: bib 25.02 Phone: ( ) Fax: ( ) Ice maker 12.51 APPLICANT CONTACT PERSON Interceptor/grease 25.02 Business name: Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: drain (commercial) 12.51 Address: Sink/basin/lavatory 25.02 City/State/ZIP: units (potable ) 62.54 Phone: ( ) Fax: : ( ) Tub//shower pan 12.51 E-mail: 25.02 Water 25.02 CONTRACTOR Water heater 37.52 Business name: Water /DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal Phone: ( ) Fax: ( ) Minimum permit fee: $72.50 Plan review (25% of permit fee) CCB Lic.: Plumbing Lic. no.: State surcharge (12% of permit fee) Authorized signature: TOTAL PERMIT FEE Print name: Date: 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 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 - 1st 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 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 (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. Capped Added Relocate Work Performed: 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 Medical gas and vacuum systems for health care facilities. Cuspidor/Water Aspirator Any multipurpose fire sprinkler system. Dishwasher: -Commercial -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 -Car Wash Drain that meet the qualifications above. Garbage -Domestic non-food Disposal: -Domestic food related -Commercial food related -Industrial food related Ice Mach./Refrig. Drains Comments regarding fixture work: Oil Separator (Gas Station) Rec. 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 Filter increase of sewer EDUs, a sewer permit will be issued and Washer - Clothes Water Extractor fees assessed for the sewer increase must be paid before the Water Closet - plumbing permit can be issued. Urinal Other Fixtures: I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2