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Permit
Plumbing Permit Application -111111111111Ezzammig.5116121 , Building Fixtures RECEIVED 4 City of Tigard Received 't 13125 SW Hall Blvd.,Tigard,OR 9721 Ay 1 0 2021 Date/By: /077/_Z/ . /�- Permit No.:,(o.j y l-eV,' lie: Review� 0. Phone: 503.718.2439 Fax: 503.598.1960 Other Permit No.:DateByInspection Line: 503.639.4175CITY OF TIGARDIICAhDDate Ready/By: Juris See Page 2 for Internet: www.ugard-or.gov BUILDING DIVISIONNotified/Method: r , j�/ �� Supplemental Information TYPE OF WORK , TEE* SCHEDULE - - 0 New construction 0 Demolition For special information use checklist. Description I Qty. I Ea. I Total h.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 ®.l-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78 0 Accessory building ❑Multi-family SFR(3)bath 500.32 Each additional bath/kitchen 25.02 j ❑Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2 SITE INFORM ATIOA1 D LOCATION Site utilities: Job site address: J�(�j 2Z �,� ' Lucsre L.kJ Catch basin or area drain 18.76 City/State/ZIP: l ,<-A C„). _ Z Drywell,leach line,or trench drain 18.76 Footing drain(no.linear II.:_) Page 2 Suite/bldg./apt.no.: I Project name: lQCN t'jrr Manufactured home utilities 50.03 Cross street/directions to job site: J Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:_) Page 2 1 Storm sewer(no.linear ft.:_) Page 2 Water service(no.linear ft.: ) Page 2 Subdivision: P(-13'f Lc cizt,,l;,iK I Lot no.: Fixture or item: Tax map/parcel no.: Backtlow preventer 31.27 31•,� DESTION F'WORK - Backwater valve I2.51 l--/ae'N D Y''�Q G- i i2 R.. C,An& /{, ,1 <FI c(1/4,/ Clothes washer 25.02 Dishwasher 25.022 Drinking fountain 25.02 Ejectors/sump 25.02 geriltOPER`tT I TZ 1ANT Expansion tank 12.51 j Name: 1' ,J `,jam 0 e_n Fixture/sewer cap 25.02 VVu Floor drain/floor sink/hub 25.02 Address: 1 -1 b.2cr SW B t u e,. f-e-fri . Garbage disposal 25.02 City/State/ZIP: -r i 8et jam b A 61 7 as 3 Hose bib 25.02 Phone:(503)L.f 5 3-- 144 q D Fax:( ) Ice maker 12.51 '"CILAPPOCOPif C04ITA4T pit** Interceptor/grease trap 25.02 Business name: C E4.,1rk.1 a jZ-) H Medical gas(value:$ ) Page 2 Primer 12.51 Contact name: 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 1/V1 J GC.. L(C.,(,`. j / ' ,CC.•:V\ Urinal E-mail: j(t, Q.• , t 25.02 . Water closet 25.02 ` CONTRAC#`OR- Water heater 37.52 Business name: znl/v,1r Water piping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal 3/ ?-7 Phone:( ) Fax:( ) Minimum pennit fee: $72.50 74 50 Plan review (25%of permit fee)CCB Lic.: Plumbing Lic,no.: State surcharge(12%of pennit fec) Authorized signature: r 1v l....- t i✓l / Q � $-/�.. TOTAL PERMIT FELX f Print name: 5 k©CA j G,,' Date: s'/9 f..,jt z( This permit application expires if a permit is not obtained ssithin 180 days / after it has been accepted as complete. "Fee methodology set by Tri-County Building Industry Service Board. i.\Building\Permils\PLMU-PermiiApp.doe 10/01/00 440-4616T(10,0JCOM/WEBI uregon Barktlow V N4 BACKFLOW EXISTING REMOVED PREVENTER REPORT -REPAIRED -OLD S/N.PL:At" PROPERTY NAmt Elide Koenig PHONE 503-453-4441 CONTACT NAME PHONE MAILING ADDRESS 14028 SW Bluestem Ln crrY Tigard STATE OR ZIP 97223 PREVENTER ADDRESS 14028 SW Bluestem Ln Tigard,OR 97223 .._..... ........___.... . WATER SUPPLIER Tigard SERIALS 412367 LOCATION Under the deck in the backyard tight access MAKE Wilkins MODEL 950XLT sm.; 1" TYPE 0 IIP 0 RPDA D RPDA-li NI DC 0 DCDA u DCDA-II n PER IT]SYR u Avo n AG _ HAZARD PROTECTED n PREMISES ISOLATION[ ]. IRRIGATION D FMK SYSTEW Li mum 0 OTHER APPROVED:[Xl AS.SEMELY cgi INSTALLA170N im ORIPNTATION 0 AIROAP PIPE SIM ;. royARAD4 REDUCED PRESSURE ASSEMBLY PERA/SYBA INITIAL TEST DOUBLE CHECK AIR INLET CHECK VALVE PASSED NI CHECK PI CHECK alTYPE U111 °WIND AT: pun IPROP. MSS 110HT 1N FAILED ri INITIAL we,5 FWD 1.6 TEST RELIEF VALVE LEAKED 0 RBI I FIED SUP'(Nib tAlltipani DATE 04-26-21 RESULTS SW NIP')Al: _._ OPENED - _ 10112 MD CRUX Ifl FULLY H FAILED SYSTEM PSI 89 ... _........_....... RELIE1,VALVE: 11011T FA DID NOT Fl DETECTOR METER . PASSED iii rAPAI ri 2.2 OPEN U READING: LEAKED U MOMOD NOTES REPAIRS PARTS REDUCED PRESSURE ASSEMBLY PVBA/SVBA TEST ClIFX3C PI DOUBLE CHECK AFTER REPAIRS Pima UAW', CHECK El TYPE.II D AIR INLET CIIRCE VALVE REPAIR MM 5 ralb TIGHT iii MIND AT: Min DitnP. RESULTS RELIEF VALVE DATE MANED Al- CBS=412 MN I 751/11 MN I RID (ENI Pltin *PAH YAM% MN f>Sin TIGHT n mom 111 FURRY PASSED 0 ' mato El man El MD F510 GAUGE SIN 02143098 mARE/MoDEI. MidWest 845-5 CALIBRATION DATE 01-06-21 In completing and submitting this test mon,the tester certifies that the assembly was tested and maintained in accordance with all applicable tales laws,codes and regulations of the stake anal water system mina approved testing equipment and approved testing rocedinw. INITIAL TEST TEST ASTER REPAIRS 6756 TEETER SIONAMIE TESTER SIGNATURE TESTER CERT b R an Yance 503-491-9402 TESTER NAME(PRINTED) Ulm OR NAME(PRINTED) PHONE# PO Box 230113 Tigard,OR 97281 deanna@obtIlc.com TESTER ADDRESS Ore on Backflow Testing,LLC TESTER ADDRESS EMAIL i Eil COMPANY NAME COMPANY NAME WATER RESTORED? [2:1 FOUND OFF,LEFT OFF itEPORT RECEIVED EV OUIERLSENTATIVE OP 0WN5111 REPORT EPERIVED IKY ounmesson nvE or OWNER) Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325(2)) This statement is required for residential building,electrical,mechanical,and plumbing permits. Licensed architect and engineer applicants,exempt from licensing under ORS 701.010(7),need not submit this statement.This statement will be filed with the permit. Please check the appropriate box: [_1 • I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. a J c i1r1 --`J l"`a€:(V t (T- Print Name of Permit Applicant J r 3/ °2(— ,/Sigpe ure of Permit Applicant Date Permit#: • Address: -14 ." 11 "rf'3:,t:► Issued by: /^ -../�. Date: �/��- _ This Copy for Permit Offices Branden Taggart From: #Building Permit Technicians Sent: Wednesday, November 17, 2021 2:36 PM To: 'James Koenig' Subject: RE: Plumbing Permit for Backflow Preventer: PLM2021-00474 - 14028 SW Bluestem Ln. Attachments: Tigard Property Owners Statement Permit.pdf; Backflow Permit Invoice.pdf James, The Plumbing permit for the backflow preventer is ready to issue now. The balance due is$81.20, and I have attached an invoice above for you to reference. These fees can be paid online at https://aca- prod.accela.com/TIGARD/Welcome.aspx by searching for the permit record number PLM2021-00474 under the Building tab. There is a 3% service fee for credit cards, but e-checks do not have a service fee. Once paid, please email the Permit Technicians at TigardBuildingPermits@tigard-or.gov so that we may issue this permit and email you the permit paperwork. Thank you, Branden Taggart n City of Tigard - Senior Permit Technician Community Development rtiMIA 13125 SW Hall Blvd Tigard, OR 97223 (503)718-2449 brandent©tigard-or.gov From: Branden Taggart Sent: Wednesday, November 17, 2021 2:13 PM To:James Koenig<JAMESELIDA@msn.com> Subject: FW: Plumbing Permit for Backflow Preventer- 14028 SW Bluestem Ln. James, Thank you. I will create the Plumbing permit for you this afternoon, and I will email the instructions for online payment. Thanks, 1 Branden Taggart IN ®, City of Tigard 31,,,1 Senior Permit Technician Community Development 13125 SW Hall Blvd Tigard, OR 97223 (503)718-2449 brandent©tigard-or,gov From:James Koenig<JAMESELIDA@msn.com> Sent: Monday, November 15, 2021 12:58 PM To: Branden Taggart<brandent@tigard-or.gov>; junk4jek@msn.com Subject: Re: Plumbing Permit for Backflow Preventer- 14028 SW Bluestem Ln. Caution!This message was sent from outside your organization. Allow sender I Block sender Branden, My apologies. I thought we had taken care of everything back in May. Attached is the signed form. Please let me know if you need anything else. James Koenig From: Branden Taggart<brandent@tigard-or.gov> Sent: Monday, November 15, 2021 10:50 AM To: jameselida@msn.com <jameselida@msn.com> Subject: FW: Plumbing Permit for Backflow Preventer- 14028 SW Bluestein Ln. Hello James, I'm following up on my previous email that I sent you with regard to a Plumbing permit for the installation of a backflow preventer. We never received a response back with a signed Owner Construction Responsibilities form for us to process the Plumbing permit. Considering the backflow preventer has already been installed, a Plumbing permit is required to ensure the backflow preventer was installed correctly. Please note that since a permit has not been issued, additional fees may be assessed for working without a permit. We would appreciate it if you can complete the attached Owner Construction Responsibilities form so that we may process this permit as soon as possible. Please let me know if you have questions. Thank you, 2 Branden Taggart PhCity of Tigard :;. Senior Permit Technician Community Development 13125 SW Hall Blvd Tigard, OR 97223 (503)718-2449 brandent@tigard-or.gov From: Branden Taggart Sent:Thursday, May 27, 2021 3:50 PM To: jameselida@msn.com Subject: Plumbing Permit for Backflow Preventer- 14028 SW Bluestem Ln. Importance: High Hello James, Since you will be installing the backflow preventer on your property, I have attached our Owner Responsibility Form above for you to sign. Once we receive the signed form, I will be able to process this Plumbing permit right away. Please let me know if you have questions. By the way, we are closed this coming Monday for the holiday. Thank you, Branden Taggart a City of Tigard : Senior Permit Technician Community Development 13125 SW Hall Blvd Tigard, OR 97223 (503)718-2449 brandent©tigard-or.gov DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule." 3