Permit if .1 :. :
f q CITY OF TIGARD PLUMBING PERMIT
0 COMMUNITY DEVELOPMENT PERMIT #: PLM2008 -00175
T1G 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 4/24/2008
PARCEL: 2 S 110C B - 08300
SITE ADDRESS: 12454 SW AUTUMNVIEW ST ZONING: R -
SUBDIVISION: MOUNTAIN VIEW ESTATES LOT: 008 JURISDICTION: TIG
PROJECT: ACCENT RESIDENTIAL HOMES
Project Description: Installing backflow
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
ACCENT RESIDENTIAL HOMES
18676 SW BOONES FERRY RD Description Date Amount
TUALATIN, OR 97062 [PLUMB] Permit Fee 4/24/2008 $36.25
[TAX] 12% State Surch 4/24/2008 $4.35
Phone : 503- 691 -1428 Total $40.60
Contractor:
CANBY PLUMBING
805 NE 4TH AVE
CANBY, OR 97013 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 266 -2091
FAX 503- 266 -1424
Reg #: LIC 33572
PLM 3 -7PB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued B Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
01/23/2008 22:09 5032661424 CANBY PLUMBING PAGE 02
.,..---- r: i, r r,..0
Plumbline Permit Applicati l c•,1; r +irgIrI. . ` ° g
P City of Tigard 2 4 2x08
APR / 'LPT g — 00
`` 4 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
I N
� I:4,, Phone: 503,639.4171 Fax: 503.598.196(1 frC`� Apra /fly. S)Ihcr Permit No.:p awe" j /
" t
Inspection Line: 503.639.417.5 a „
I; • \ 1 [ t ' g� r t tf° 7 � ate RcaJ /liy; See Page 2 for
.�,.: =,a Internet: www,t tgard- or.gov • q , I , tom, d'. ta /Method: So ,, IcmentntIntarmadon
'TYPE OF WO • e FEE* SCHEDULE
.-- New constnt ticm ❑ Demolition Fors edal 1 orma inn use checklist.
Description Qty. Ea. Total
❑ Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 F1, Fnr tech utility connccticm)
—
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
r and 2- ramify dwelling ❑ Commercial /inchrstrial SFR (2) Path 350.00
SFR (3) bath 399.00
❑ Accessory building ❑ Muhi• family
-- Each additional hath/kitchen 45.00
❑Master huildcr 0 Other: Piro sprinkler ( sq. li.) Page 2 J
30R SITE INFORMATION AND LOCATION - Site utilities
Job site address: 1 '-'t- S :+4 I/VY,V 7 eAAi G4 Catch basin or arca drain 16.60
City /State /71P : a p, ! Oa r f -7 -2.2 2 Drywall, (each Zinc, or trench drain 16.60
` J S � Foot dra (no. linear R.: _ ) Puce 2
Suite/bldg. /apt. no.: Project name: a .. . ,,, ir, i t • p
a - Manufactured home utilities 110.00
Crass street/directions to joh site:
Manholes 16.60
Rain drain ccmncctctr 16.60
Ir r * ► ST" 20 0 1 6 - bG Sanitary sewer (no. linear tL ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivit:inrt: T.rrtno.: Water service (no, linear 0.: ) Pagc2�
Fixture or item
Tax map /parcel no.:
Absorption valve 16.6;0
. DESCRIPTION OF wax ' backflow prcventer ( Page 2
-
ba `1 , A.'L ,-ce 1 CL J Backwater valve 16.60
CI SSE VV \ \ —N.-+ % .0 GV .1 Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT prinking fountain 16.60
— Ejectors /sump 16.60
Name: Expansion tank 16.60
Address: Fixture/sewer cap 16.60
City /State /ZTP: Floor drain /•floor sink /huh 16,60
Fax ( ) _ Garbage disposal 16.60
Phone: ( ) Hose hih 16.610
o AP1PLICANT ❑ CONTACT PERSON
-
-- - - -- -• Ice maker 16,60
Business name: Interceptor /(n trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State/7TP: Roof drain (commercial) 16.60
Sink/basin /lavatory 16.60
Phone: ( ) [ Fax:: ( ) -
Tub /shower /shower pan 16.60
E -mail: r Urinal 16.60
CONTRACTOR • Water closet 16,60
W
Business name: Canby Plumbing Inc Water heater 16.60
Address: 805 NE 4 '' Avenue Other'
City/State/7W: Canby, OR 97013 -7399 Subtotal
Minimum permit. fee: $72.50
- I.
Phone: (503) 266E - 2091 Fax: (503) 266 -1424 --- Residential backflow minimum permit fcc; $36.25 ' L'
CCB Lic.: 33572 -.,, Plumbing Lic. no.: 3 -7PB Plan review (25% of permit fee)
— State surcharge (12 % fcc) y, ',37
Authorized Pi gnature: ...A...--11--s--- r� {1'A _ IOTA I, PERMIT FEE 14C)/PC..
Print name te* �" T I I)atc:APB Z Y L 0 This permit application expires If a permit is not obtained within
180 days after it has been accepted as complete.
SA -em So v .S r>1"5 .S "Fee methodology set by Tri- County Building Industry Service Hoard,
• •
CITY OFTIGARD
BUILDING DIVISION
PERMIT #: PI..M2001a-00 75
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 4f24/2001;
Phone: (503)639-4171 „Iril:11111/4
Inspection Requests (24 Hrs.): (503) 639-4175
INSPECTION WORKSHEET FOR DATE: 4/25/2008 TIME: 7:01AM PAGE: ' I F . ;
SITE ADDRESS: 12454 SW AUTUMNVIE‘A` ST CLASS OF WORK:
SUBDIVISION: MOUNTAIN VIEW ESTATES LOT #: 000 TYPE OF USE:
PROJECT NAME: ACCENT RESIDE:INITIAL HOMES
DESCRIPTION: Installing backttow
OWNER: ACCENT RESIDENTIAL HOMES, PHONE #: 503-691-1428
CONTRACTOR: CANf3Y PLUMBING PHONE #: 503-266-2091
Inspection Request Scheduled For: Date: 4/25/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
39 Mic n q on 068916-01 503-266-2091 Y
Corrections/Comments/Instructions:
Ca cc-
g PASS f PARTIAL APPROVAL CANCEL NO ACCESS
El FAIL fl CALL FOR INSPECTION P1 ADDITIONAL FEES ASSESSED
Inspector: (Fa t'vx".--)0 Date: 1 //24 - W Phone #: (503) 718-
Cn
L3ACKFLOW ASSEMBLY TEST REPORT `I- . 3IVI
M I r REI!OVEC
PROPERTY f • Li re= hA.CN)
m r" OWNER: \ �" �t° /r� 4-1.,, lI C NE: • CV �l
W 2 - PJIAILtNG .._ _
ADDRESS: t AA.N_LlIt rt
CITY 11 -" STATE 0 — ZIP
ASSEMBLY f i � c. f• , —
ADDRESS Z-4 h CT (Mr Ul t GS ` 4111 to I .'R.P.BA ; .C.V.A ;:R.P.gD�A. i TL C A. IP.V.EA. FiS.V.BA. t`AA -V.B. LIAIRGAP
0 SIZE: WATER MAKE: _ til_ 1 I f -- MDDfL:— ( 111 - • SERIAL
I PURVEYO C c _ NUMBER: 2- �0 P — 0 7
!D ASSEMBLY ( _ J •
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LOCATION: ___, ti ip . d /4 . f�i q L l - - -- .
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in p r -
W ID REDS UCEDPRESSUREASSEMBLYL P.M.B.A. /S.V -BA. INITIAL TEST '
W VI
U 11 check !DOUBLE CHECK! AIR CHECK
U) Press. Dro I PASSED
Ctti 't tY 1 INLET
Q INITIAL RelielValve p FAILED 1
Q TEST Op raey a1
1 Tight T Pened al: Press. Drop -
J Date:
RESU ' m n . 2 p r Leaked , t pus
A -B= 1 ChcYktt2
a 8
— mm 3ps 1:= 3 Fsid
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RELIEF VALVE Tr9Yd • DID NOT FAILED S STEM •
PASS FAIL ! J , L...},-.1 iQ OPEN j I, !� i PS
Comments
Repa'rs
w and'or
C Parts
bst
3enuced FYes =ure A«cmi Dpubtp Chu* P.V.B.A. / S.V.BA. AFTER REPAIRS
"a Check k t
2 TEST Press_ Drop ��Ctle ::41
AFTER 'Tio` n. D -- Opened at: Press. Drop Date:
m RE PAIRS Gp n ( Rua .. /
m a, in,, 2 p i - (Check t: 2 J
Cri U' E:ReI
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t _4 -0 ^ min ;� 1 .' a acid Reid ps,d PASSED L:
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In complains and eubmlgic Us it repo n. the testei cert1Bee that the asssm my
has been tested and n iced En accordance volt; aR epplia bte rites and
10 egul •rre of the wale: system.as
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GAUGE CALI s • ■ TI DATE 2 -23-2 DETECTOR METER READING
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m E raw. - rair GENE HIGGINS
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o 'E O BRUSH PRAIRIE WA c,e s 127076
m N cern wry tdvaE Gene Higgins SAT r•axE p We-M-3523
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N SERVICE RESTORED
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