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Permit CITY OF TIGARD MASTER PERMIT F1 ' COMMUNITY DEVELOPMENT Permit #: MST2009 -00133 TLCARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/19/2009 Parcel: 2S112CC21800 Jurisdiction: Tigard Site address: 15657 SW 81ST AVE Subdivision: GAGE FOREST Lot: 25 Project: Gage Forest Project Description: New SFR. BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 4 First: 880 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 23 Bathrooms: 3 Second: 1201 sf Garage: 367 sf Front 15 Smoke Dwelling Units: 1 Third: 0 sf Right: 5 Detectors: Yes Total: sf Value: $228,596.58 Rear: 15 PLUMBING Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 1 Rain Drain: 0 Catch Basins: 0 Lavatories: 4 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Other Fixtures: 0 Tubs /Showers: 3 Garbage Disp: 1 Water Heaters: 1 Water Lines: 1 Drains: Bckflw Prevntr: 0 MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 5 Clothes Dryers: 1 Natural Gas Heat Pump: N Hoods: 1 Other Units: 0 Fum <100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4 Fum > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits 1000 sf or less: 1 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0 Ea add'I 500 sf: 3 20 1-400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr: Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea add'I Br Cir: 601 -1000 amp: 0 601 +amp- 1000v: 0 1000 +amp /volt: 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: Owner: Contractor: Required Items and Reports (Conditions) TIMBERLAND HOMES INC TIMBERLAND HOMES INC 12670 SW 68TH AVE #300 12670 SW 68TH AVE STE 300 TIGARD, OR 97223 TIGARD, OR 97223 PHONE: PHONE: 503- 620 -8860 FAX: 503- 598 -9081 Total Fees: $14,622.79 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 if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. • '. = egon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 95 •11 -0010 through OAR 2 -0 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1. 0.332.2344. lss . • By: Perm ittee Signature: l� M ' ilui ing Permit Application Residential RECEIVED FOR OFFICE USE ONLY Received City of Tigard JUN 1 7 2009 Date./13 : r , Permit No.: u . ` •b. , a ` 1 • 13125 SW Hall Blvd., Tigard, OR 97223 evie R Phone: 503.639.4171 Fax: 503.598.1960 Plan Plan R : �< ' E V;1411110 other Perri : 1 _ Z i O • Os J -t G A R D Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready /: y: • 7 , /� 1 M j L a . . ; Pa 2 for Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method v - 1 _ eatat luf TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING ® New construction ❑ Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all ❑ Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. ® 1- and 2- family dwelling ❑ Commercial/industrial Valuation: $ ZZ ) 5 El Accessory building ❑ Multi- family Number of bedrooms: 3 ❑ Master builder ❑ Other: Number of bathrooms: 2.5 JOB SITE INFORMATION AND LOCATION Total number of floors: 2 Job site address: 15657 SW 81st New dwelling area: 2081 square feet City/ State/ZIP: Tigard, OR 97224 Garage/carport area: 367 square feet Suite/bldg. /apt. no.: I Project name: Gage Forest Covered porch areaC(' square feet Cross street/directions to job site: Hall to Langtree to 81st Deck area: 0 square feet Other structure area: 0 square feet REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: Gage Forest Lot no.: 25 Permit fees* are based on the value of the work performed. Tax map/parcel no.: Indicate the value (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. New single family residence Valuation: $ Existing building area: square feet New building area: square feet ® PROPERTY OWNER ❑ TENANT Number of stories: Name: Timberland Homes, Inc. Type of construction: Address: 12670 SW 68 Ave, Suite 300 Occupancy groups: City/ State/ZIP: Tigard, OR 97223 Existing: Phone: (503)620-8860 Fax: (503)598 -9081 New: ❑ APPLICANT ❑ CONTACT PERSON NOTICE Business name: Timberland Homes, Inc. All contractors and subcontractors are required to be Contact name: Maureen Denny licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: 12670 SW 68'" Ave, Suite 300 jurisdiction in which work is being performed. If the City/ State/ZIP: Tigard, OR 97223 applicant is exempt from licensing, the following reasons apply: Phone: (503) 620-8860 Fax: : (503) 598 -9081 E -mail: maureen@timberlandhomes.net CONTRACTOR Business name: Timberland Homes, Inc. BUILDING PERMIT FEES* Address: 12670 SW 68th Ave, Suite 300 (Please refer to fee schedule) City /State/ZIP: Tigard, OR 97223 Structural plan review fee (or deposit): Phone: (503) 620-8860 Fax: (503) 598 -9081 FLS plan review fee (if applicable): CCB lic.:141715 Total fees due upon application: Amount received: Authorized signature: _ This permit application expires if a permit is not obtained - within - -' Co within 180 days after it has been accepted as complete. Print. name: Maureen t enny Date: 1 /7 * Fee methodology set by Tri�ruuty Building Industry Service Board. 1: \BuildingiPermits\BUP -RES PermitApp.doc 11/6/07 440 - 4613'1'(11/0 EB) I Plumbing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard Received Date/By: Permit No.: • 13125 SW Hall Blvd., Tigard, OR 97223. Plan Review C Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No.: F t i A R n Inspection Line: 503.639.4175 Date Ready/By: rte: ® 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 I Qty. I Ea j Total ❑ Addition/alteration/replacement ❑ Other: . New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 ® 1- and 2- family dwelling ❑ Commercial/mdustrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 ? , Each additional bath/kitchen 45.00 ❑ Master builder 0 Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: 15657 SW 81 Ave Catch basin or area drain 16.60 City/State /ZIP: Tigard, OR 97224 Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: I Project name: Gage Forest Footing drain (no. linear ft.: ) Page 2 Manufactured home utilities 110.00 Cross street/directions to job site: Hall to Langtree to 81st Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: Gage Forest I Lot no.: 25 Water service (no. linear ft.: ) Page 2 Fixture or item Tax map /parcel no.: Absorption valve 16.60 DESCRIPTION OF WORK Backflow preventer Page 2 New single family residence Backwater valve ( 16.60 Clothes washer ( 16.60 Dishwasher ` 16.60 ® PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60 Ejectors/sump 16.60 Name: Timberland Homes, Inc. Expansion tank 16.60 Address: 12670 SW 68 Ave • Fixture/sewer cap 16.60 City/State/ZIP: Tigard, OR 97223 Floor drain/floor sink/hub 16.60 Phone: (503)620-8860 Fax: (503)598 -9081 Garbage disposal ( 16.60 ® APPLICANT I ❑ CONTACT PERSON Hose bib Z 16.60 Ice maker 1 16.60 Business name: Timberland Homes, Inc. Interceptor /grease trap 16.60 Contact name: Maureen Denny Medical gas (value: $ ) Page 2 Address: 12670 SW 68 Ave, Suite 300 Primer 16.60 City/State /ZIP: Tigard, OR 97223 Roof drain (commercial) ` 16.60 Phone: (503) 620 -8860 I Fax: : (503) 598 -9081 Sink/basin/lavatory (/ /4 Lj 16.60 Tub /shower /shower pan ` 3 16.60 E -mail: maureen @Timberlandhomes.net Urinal 16.60 CONTRACTOR Water closet 3 16.60 Business name: MEI Plumbing Water heater I 16.60 Address: PO Box 207 Other: City/ State/ZIP: Banks, OR 97106 Subtotal 3 . cilo Minimum permit fee: $72.50 Phone: (503) 324-0759 Fax: (503) 324-0580 Residential backflow minimum permit fee: $36.25 CCB Lic.: 102535 Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (12% of permit fee) 47,f58 Authorized signature: VIWS ny _I J_ / TOTAL PERMIT FEFj 4 Print name: Kris Malmedal „� 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 Industry Service Board, 1:1 Building \PermitstPLMF- PermitApp.doc 12/27/06 440- 4616T(10/02/COM/WEB) 'te rical Perinit Application FOR OFFICE USE ONLY City of Tigard Received Permit No.: 11114 Date/B : e 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review ' 11 . Phone: 503.639.4171 Fax: 503.598.1960 Date/B : O rer Permit: TIC A R D Inspection Line: 503.639.4175 Date Ready/By: 1uri 121 See Page 2 for Internet: www.tigard - or.gov Notified/Method: Supplemental Information TYPE OF WORK PLAN REVIEW ® New construction ❑ Addition/alteration/replacement Please check all that apply (submit 2 sets ofplans w /items checked below): ❑ Service or feeder 400 amps or more ❑ Building over three stories. ❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural ® 1 - and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ `A ", "E", "1 -2", "l -3 ", Job no.: Job site address: 15657 SW 81 Ave 1001IP or more. occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. City/ State/ZIP: Tigard, OR 97224 ❑ Health-care facilities. ❑ Supply voltage for more than ❑ Hazardous locations. 600 volts nominal. Suite/bldg. /apt no.: Project name: Gage Forest ❑ Service or feeder 600 amps or more. FEE SCHEDULE Cross street/directions to job site: Hall to Langtree to 81st Description I Qty. I Fee. I Total I • New residential single- or multi- family dwelling unit. Includes attached garage. Subdivision: Gage Forest . Lot no.: 25 1,000 sq. ft. or less I 145.15 l , 15 - 4 Ea. add'I 500 sq. ft. or portion •2, 33.40 l 2O 1 Tax map /parcel no.: Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) New single family residence Limited energy, multi - family ew sin g y residential (with above sq. ft.) 75.00 2 Services or feeders installation, alteration, and/or relocation _ 200 amps or less 80.30 2 ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2 Name: Timberland Homes, Inc. 401 amps to 600 amps 160.60 2 601 amps to 1,000 amps 240.60 2 Address: 12670 SW 68 Ave Over 1,000 amps or volts 454.65 2 City/State /ZIP: Tigard, OR 97223 Temporary services or feeders installation, alteration, and/or relocation Phone: (503)620 -8860 Fax: (503)598 -9081 200 amps or less 66.85 I • Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2 Owner signature: Date: Branch circuits — new alteration, or extension, per panel A. Fee for branch circuits with ® APPLICANT 1 ❑ CONTACT PERSON above service or feeder fee, each branch circuit 6.65 2 Business name: Timberland Homes, Inc. B. Fee for branch circuits without service or feeder fee, Contact name: Maureen Denny first branch circuit 46.85 2 Address: 12670 SW 68 Ave, Suite 300 Each add'l branch circuit 6.65 2 Miscellaneous (service or feeder not included) City/ State/ZIP: Tigard, OR 97223 Each manufactured or modular 90.90 2 Reconnect service and/or feeder Phone: (503) 620 -8860 Fax: : (503) 598 -9081 Reconnect only 66.85 2 E -mail: maureen@timberlandhomes.net Pump or irrigation circle 53.40 2 CONTRACTOR Sign or outline lighting 53.40 2 Business name: Lighthouse Electric Signal circuit(s) or limited - energy panel, alteration, or Address: 27750 SW 95th Ave, Suite 109 extension. Describe: Page 2 2 • City/State/ZIP: Wilsonville, OR 97070 Each additional inspection over allowable in any of the above Per Phone: (503) 582 -9600 Fax: (503) 582 -8484 inspection Investigation 62.50 per hour (1 hr min) 62.50 CCB Lic.: 154897 Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75 _ • ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: 0405, ' Print name: Mike Neel Date: Plan review (25% of permit fee): State surcharge (12% of permit fee): V , 44- l ��J Authorized signature: ( TOTAL PERMIT FEE: Z7 r 7 cis Print name: Date: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. �Permits \ELC PemitApp.doc 05/23/06 440 4615T(1 Uo5 /COM/WEB t 1 Number of inspections allow / . 1:\ Building w"V �l �--� "7 tz� qxe . 08- 07 -'09 10:43 FROM- T -123 P002/002 F -058 tiiediarHeal j e p___tla1 City of Tigard � Re N; a t�a ; . 1111 � • � 1 1I" Stk Hal! 1-3Rd fI •'u:c1.;!R u ,, , , i ..-- :.. ,- �._..,.._.,._... ?Inn ftr.oe* Phvnc. 50 .3 630 4171 1'0 .511.i. :0S, IC'hll i �r'a 0 b;, •":: : l,t patio. Luse: 5(i3 e s � ----. o -- - Z T^ - ...__ • _, . L '.\' ri_an1 -or ._ I Nr e . „ t : ,1'pp:einest i••w v 1 0 W h S' `M:' lid- I Et.' S'.Ki_,- r__r' ' i .`'i, . i.E;; S:,I :.: 0 .� .!tamca! pe; mi[ lees` :u, hazed . :tit the value ;:f the •,Murk �� evr cUrUtructio) 1 t Additionialteraconircplaccmcnl i " L. i performed. Indicate the value (rounded to the nearest dollar) oi' ai! i I ❑ Demolition © Other: i mechanical materials, eRuipmenl. labor. overhezd. and profit. CATEGORY OF CONSTRUCTION r ---- Value $ ' r dwailin Commercial/industrial g ; RESIDENTIAL EQLIIPititENT!SYSTEMS FEES* -� l• and? 2-family g . ❑ 0' Accessor building r Fur .cpecial information use chrcklisr. I ❑ Multi family ❑ Master builder ❑ Other: 1 • i -� Description I Qty. I Ea. 3 Total 1 • I JOB SITE INFORMATION AND LOCATION Heatio cooling _ • Job site address: / S 7 s (,� g ` _ (requires conditioning o wi n pump t 1 l Q wres site plan slwn placement? ' Cityi$tate/ZIP: -rt t, A 4,0 cr A- ` t 1 2.74 _I Furnace 100,000B ducts/vents) , 14.00 ; Furnace 100,000+ BTU (ducts/vents) 17.90 Suite/bldgJapt, no. Project name: et f°'4f< Fc Gas heat pump 14.00 Cross street/directions to job site: Duct work 14.00 ""'"- Hydronic hot water system 14.00 Residential boiler (radiator or hydrortip) 14.00 r ..._.• - - — ---- Unit heaters (foe) -type. pat electric) in- wal4in -duct, suspended. etc. 10.00 . { ^ t Flue/vent for any of above I � Subdivision: I Lot no.: •' SS r Other: j ��. 10.00 10.00 i _� Tax map /parcel nooqfzel„,c, Other fuel appliances heater _ ter h I Water t ! DESCRIPTION OF WORK C IOOG Gas fireplace _ I 10.00 I i Flue vent for water heater or 8 as - - fire ate _ i i 10.170 tsv ..,,) $ t n.1 C L Frw`✓t 1 t.�-( 9-5(1) . Cta �t.n 1,4 $l`. -r . oti L c Log lighter (gas) L 1 0.00 I I Wood/pellet stove 1 0.00 Wood Fireplace/insert . 10.00 - ['fPRGPERTX OWNER TENANT Chimney/liner/flue/vent 10.00 — - Other: I , 10,00 Name: rf:ti'lPi 1,41 „tt� t ��5 (,tic_ • I Environmental exhaust and venfilation Range hood/other kitchen Address: ( S(_•_) ( s rvE -.0 ' V i.ment 10.00 City /State/ZIP: T(Ct .4{a i) , pfL • 41''� -3 Clothes . er exhaust 10.00 Single -duct exhaust (bathrooms, • • Phone: (,Se3) C 1.13 . 8 96,0 Fax: ($a ) i ' • -cos( toilet compartments, utility rooms) 6.60 0 0 CONTACT PERSON Attic/crawtspace fans 10.00 Other: 10.00 Business name: - Fuel pip Contact name; L r` e 5 -40 for first (our- $1.00 (or each additional • Address: Fumece, etc. Gas heat •urn• Mil� City /State/ZIP: Wall/sus. nded/unitheater Phone: ( ) Fax :: ( ) Water heater MIN Fire 'lace _� E-mail: Ran - c C CONTRACTOR Barbecue _� Business name: k L � Q . I C Clothes d er as T Other: MI Address: ? e low 133 • MECHANICAL PERMIT FEES” Subtotal — City/ State /ZIP; [�1 ,4t It./rr+rlh�j -" Q(� 0(S- Minimum permit fee (S72.50) Phone: ( 92) ) ( . tg OQ Fax: ( ) Plan review (25% of permit fee) CCB tic.: _ / r r or h State surcharge (8% of permit fee) - r % TOTAL PERMIT FEE Authorized signature: / Thi pert app li ca tion expires it permit is oot obtained within 130 - ( - - days after it has been accep an complete. print namt:; r - 1 7 Date; . Pee stetlmd y oIo set by Tri -County Building Inc/ugly Service Board � a !' ew•idorPermirthlEC doe oLd33"16 ,an.ad! T7 t i voJCrr t/wv.B C_ , ?1 c��l0 , 11-05-09; 03:06FM; f ) ( � �S i�� i # 1! 1 Brown La bell - 77 kNA 111. 1 � �.� .� 1 Blowing insulation with ECOSE ® Technology Attic Cord When rnstalleil in oa Ordonco with inn manulacluror's Thermal Performance (Attic; Application) rocemmondatlons, Maui bans and blankets WI provide The stated thermal resistance (R•va1uo) fa provided by installing in accwrd6n09 01(h the manufacturer's Instructions. the flul R•vn the required number of bags per 1.000 sq.11. Moot area. at not loss than Ino labeled minimum thickness. Filure 10 Instal both tiro required number of bags end tit least the minimum lhkknesa tv1i1 result in Iowa? 'mutation Mollie, Minimum Weill Minimum ` ,I1 njlie 1-hk* r s llh0'u rvinxirntrnt toin(rnunl in t filed S-etli+.d ' m'atit ta installed Insulation. ;ft-Value , •, 1;000 Sr • CD.Qr.ipo ,- „ VYtight - 7hlckr wss, _ „Thie Haas ", ^' '•• lndulxttritilaal face'.' chaiuld be ::• 4Ranraabor,clkgstr • . 5'utitvetaaltSfof' . • (I;Ya(ao •k losx lhan; Taofrfnlaaj •;- 1;a0bdldaekama tiaateeteafatle frratalI M.sut8114R Jnstalf3dlalal ItumlradlnvI t Io4 • t;ito elPffel!r "�:tlRourd40tbo • . ahohldnof t:ovot ' sbo iiWirottid ' •i hbfbo .hautdnat•ho • R•38 12.0' :_ (R-Valuakat .: .:,:• mit Ilient manWenI loisthsh' • •Iptr len than: R30HD 8;26• R•60 _ 42.3 1 23.0 SF 1.3111106. j _- 27.60'_ 27.50' R-39 10.& - R49 33.7 ^ - ~ Zg6 SF_ 1 .P � 4Gfbs 231)0' � _ R . - 9 ' ~_ R 44 �� 30.2 4 _ - 33.2 SF 930 1105. 2100' -� 23.00" � 21.00" R•21HD 6g _. R-38 ... v 25.8 _ � ••••. � . 38,7 SF _ _8011bs. - 18.50' 18.10' R.19 8, r'.• R -30 _W 20.1 40.7 SF E .624 Ib11. 1540' 15.00' R -151-1D 3.5 R -20 17.0 . - 58.7 SF 1 .528lbs. 13.00 " - _� - -- 1390' _.._ R.13 3,.r' R -22 .^_� . ' 14.4 " " "-- - 69.3 9F ! .4471bs.t 1125' _ I 11.210' 3,00" _, ~ _ R -1D _ 12.6 792 Sr .392ibs. O, OO' IOW' ---- - R -13 1 8.5_ 117 5 SF 2341100. -1 m 7,00• .. � - 7.00• Cmtuuto am/ Athol .51.t a'aNa 11/146a1F R_�i -- 7.2 138.9 SF 22 31106. 6.00" -_._ 6 - .._ -..- • • R' ma; awmctctatarohodeav .lMtieritheR•ralue, wooly __i_ .0...�....,. eta mcub'vq poi/cr./eh our cowl& Ws atal (last to It-Mos. , ••n. ib in a SW Wdtt Dap NM Widght- NoMSi31 I6a. tbtaatmSQ 14S, Ca tttahr10a11 WoitwJt,W9 aVa6a -kbrtdd 9 hbx,'rG naarll,n In third vas wilt I9' aalu cwn'rD, 2013 Na teMyJ 150 at r twinti I•oungau0J apse • re indidd n‘dcazow 1010(411(m. RP, Ili fee E0.11+ g." am ecaangpaso .Bs wit thamattudrvoilvo,it6 IMO tuRIhto Framing Adjustment amuatcxt bsintorad praprnr. uru. it l.*xcolt. yct Wwwrna and ra;aw thorn twenty hart ens 1 coact ease r+aa lnvpa4 To cornponaale forframing marmots, the number of "mod on 1U'd Party 'Ayers silo otaly, the frw!Jn.l tdlim,r t foam n fAWm pono4 *PAU SO 1 apt. nt los. 214 annunJ alswrMq U Ramey ingsa sartl bags per 1,000 ^ . 11. Discos 10 be insulated s hould bo aa<r rm alb maNal ynt Wend doktuscee co ueo ettythesun a aq vd,pja ell w ortaalmaa uwuntao m loann. as shown below. - - Builder's Inscription Statement ' , j ? n 'SF , 13aaitJl? Batts and/or blankel5 hove been installed in totdorm8nca vr8h Ma above recommendations to provide o thermal Jpirt -15 0.C. , 24 D tatt C. reslste ... of R -,R Phial Diets i rnmira , , t rrnnin:: , . IIIEZal 41.0 42.0 .. .. - ..i _ . ::: ; R - Value. Thickness R00 2x9 4L6 41.8 AticArea R. 3 y ism (Z !aches 2x8 41.3 41.7 - 2x4 t , 33.5 $loped Ceilings R. at R40 2x8 33.0 I Walls ft- 2_( al f � itches 2x8 12.8 33.1 Flinn {over on unhealed crawl spate) R . t at Inches R-44 2N8 2x4 20.8 Crawl5PacePodmeter R. � �, - at i Itches - . -- . w 29.1 .......,....._20.4 _._ 2x4 ... - 26 a.. 20.a 2 . 2,u__.' Dato !natation,*,. -- ( -t _ 0 - R -38 240 25. __. r - ,.... _ 254 Blown Insolation has hoes Installed In conformance with the abovo recommendations to 2x8 w 24.9 25.2 provide an R -voluo of: R. VC 3e. using ba o of this Insulation to cover 19.7 19.8 0 - , � _.._ 9 R.30 2xG 7.x4 „ foot of aroa at a minimum thickness of j � r r 2 - inches, 8 - - ---. m® fnmtatlon C ( 2xa 16.0 18.7 R -2e [ s a t t _ -� ,_ 1 Ci • axu ,6.a 16.6 • Company -- ---._..._.._....._.....__ .......... -- Co ........_-__._.._ __- __.----- __...._.___.._.._... mpanp - - �.._- _._.._ _ _. _ Data 2x8 18.1 16.4 I 2x4 14.0 14.1 - _........ - .... Harps ea09el I:IQnnh - r.1 R -22 2x6 13.8 14.0 2x8 13.8 ,..._ ..._.._.___....__._-------------._....._.__.___..- .___._ _.._.___._........- ..,_... -..., 2.0 1 12,2 12,4 company _.. ... _ ._.. _ M__„ . ono, 12.19 2x8 12.0 12.2 2x8 11.7 12.0 FCASE" 1'acbnolagy 1, o revafurionary, now rustoinablo binds bored on 2x4 8.1 0,2 ropid/y- rsnowabla bio -ba;od materials instead al petmleunt•based chemicals. 2x6 7.9 8,1 - Up to 70% loss ambodlod *nosy +bon ovr troditrpnal binders _ 2x8 • 7.7 7,9 w Wjth S . Conve hie based, rapidly ron mokriat, info an inert 2x4 6.8 0.9 lvxgtoc patyaiorlora upartoranvtmntnonralsusrofncblli + E G 613 . Does not mntarn phenol, Iomraldehydo, nery litx or artificial color,. n 6.4 6.6 www.KnaultnsulutIon.us Knout Insulation GmbH One Knauf Olive Shelbywlle, IN 40176 Tel; {800) 825-4434 exl, 8300 FAX. (317) 398.3675 nitV Af tsu I O 00 452004 Kneuf tnsukzlon q ib3-I. PACIFIC LUMBER CO 5974 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 - 858 -9663 FAX 503 - 636 -2502 NO _ 2 2 1. 3 8 5 3 2 NVO 2 CE R' 10/21/09 13:17 01I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST LB 230 S 2 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE CB 230 P5210 TIGARD OR 97223 TIGARD, OR DB 219 A 203 MISC: MAIN FRAME TK 14 W 203 C 3 P 3 CUST #: 8060.0550 DEL DATE:10 /21/09 TERMS: 1% 10TH FROM: 0 4283222 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 1D RUNO5 MID DAY - 10AM THRU 1PM 2D LOADO6 FIRST FLOOR WALLS 3D TYPEO3 QUARTER LOAD 4D 5 2 BC6Z 6X6 POST CAP 18GA Z -MAX 271320240 2 9.75 EA 19.50 6 1 6X10 HVY REVERSE FLNG HANGER 270441920 1 7.75 EA 7.75 * * * *UXR610 * * ** 7 4 MSTA30 1 1/4" X 30" STRAP TIE 27082152A 4 1.63 EA 6.52 SILVER MSTA30 SIMPSON MSTA30 8 12 TDX8 SILVER HOLD DOWN HD8A SIMP 270261600 12 13.75 EA 165.00 SILVER TDX8 SIMPSON HD8A 9 36 785HB 7/8X5 HEX BOLT ZP 41365132A 36 1.49 EA 53.64 10 12 787HB 7/8X7 HEX BOLT ZP 42164532A 12 1.94 EA 23.28 11 48 78HN 7/8 HEX NUTS 43105570A 48 .29 EA 13.92 12 36 78W 7/8 WASHERS [50# 325PC IND] 43106471A 36 .28 EA 10.08 13 14 68 2X4 -104 5/8 GDF STUDS 110210450 408 240.00MBF 97.92 15 203 2X6 -104 5/8" STUD GR S -GRN DF 120220570 1827 225.00MBF 411.08 16 546 2X4 -RL STD & BTR GRN DF 10416000 364.02 190.00MBF 69.16 39/14 17 816 2X6 -RL #2 & BTR S -GRN DF 20618000 816 225.00MBF 183.60 32/14 23/16 18 160 4X 6 -RL #2 & BTR S -GRN D/F 60652000 320 350.00MBF 112.00 16/10 19 12 4X10 -RL #2 & BTR S -GRN D/F 61054000 40 350.00MBF 14.00 1/12 20 24 4X12 -RL #2 & BTR S -GRN D/F 61255000 96 350.00MBF 33.60 2/12 21 100 6X 6 -RL #2 & BTR S -GRN D/F 70661000 300 495.00MBF 148.50 10 /10 CONTINUED TO NEXT PAGE PACIFIC LUMBER CO. 5974 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 -858 -9663 FAX 503 -636 -2502 NO — 2 2 1 3 8 5 3 2VIVO 2 CE 111 R lor 10/21/09 13:17 02I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST LB 230 S 2 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE CB 230 P5210 TIGARD OR 97223 TIGARD, OR DB 219 A 203 MISC: MAIN FRAME TK 14 W 203 C 3 P 3 CUST #: 8060.0550 DEL DATE:10 /21/09 TERMS: 1% 10TH FROM: 0 4283222 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 22 20 6X 8 —RL #2 & BTR S —GRN D/F 70862000 80 495.00MBF 39.60 1/20 23 24 6X10 —RL #2 & BTR S —GRN D/F 71063000 120 495.00MBF 59.40 2/12 24 20 6X12 —RL #2 & BTR S —GRN D/F 71264000 120 495.00MBF 59.40 1/20 25 24 6X 6 —RL P.T. #2 /HF S4S ACQ.60_ 96656000 72 1150.00MBF 82.80 2/12 26 44 7/16 — 4X8 WAFERBOARD 24/16 241020350 1408 225.00MSF 316.80 27 28 8 5- 1/8X12 XRL GLULAM ARC AITC 160415000 8 7.70 LF 61.60 1/ 8 SUBTOTAL 1989.15 D THANKYOU!!! .00 TOTAL 1989.15 PLEASE PAY THIS AMOUNT: 1989.15 RECEIVED BY: X SIGNATURE: PACIFIC LUMBER CO. 5974 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 - 858 -9663 FAX 503 - 636 -2502 NO _ 2 2 3 3 9 8 4 2 N\TO I CE R* 10/26/09 07:08 01I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST LB 202 S 2 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE CB 202 P5210 TIGARD OR 97223 TIGARD, OR DB 173 A 203 MISC: UPPER LEVEL FLOOR TK 9 W 203 C 3 P 3 CUST #: 8060.0550 DEL DATE:10 /26/09 TERMS: 1% 10TH FROM: 0 4283327 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 1D LOADO7 SECOND FLOOR I -JOIST 2D LOADO7 SECOND FLOOR I -JOIST 3D TYPEO2 HALF LOAD 4D 5 18 29 OZ. SF450 CONST. ADHESIVE 671050470 18 3.00 EA 54.00 6 24 ITT11.88 HANGER, TJI SIMPSON 271006110 24 1.95 EA 46.80 7 20 11 -7/8" TOP MT I -JOIST HANGER 270622520 20 2.25 EA 45.00 SIMP.ITT2.06 /11.88 SIL.TH020118 8 3 LBV1.81 /11.88 TOP FLANGE HANGER 270555610 3 7.85 EA 23.55 9 2 TH015118 1 -1/2 "X11 -7/8" TF HANG 27062204A 2 2.15 EA 4.30 SILVER TH015118 SIMP. ITT211.88 10 1 HUCQ1.81 /1188 REVERSE HANGER 271350810 1 12.50 EA 12.50 11 1 4X12 HVY 14GA SILVER HANGER 270441600 1 7.75 EA 7.75 SIMPSON HU412/ SILVER HD412 12 13 FROM IWP PO# 3228764 14 20 7" X 11 -7/8" RIGIDLAM_2.0E 151406100 20 21.50 LF 430.00 1/20 15 16 231 1 -3/4" X 11 -7/8" RFPI -20 150105900 231 1.25 LF 288.75 9/16 7/ 6 9/ 4 3/ 3 17 680 2- 1/16 "X11 -7/8" RFPI -400 150307100 680 1.45 LF 986.00 34/20 18 90 1 -1/2" X 11 -7/8" LVL RIM RD 150805150 90 2.75 LF 247.50 5/18 19 28 1 -3/4" X 11 -7/8" RIGIDLAM 150706100 28 2.95 LF 82.60 1/12 2/ 6 1/ 4 20 244 3 -1/2" X 11 -7/8" RIGIDLAM_2.0E 151206100 244 7.25 LF 1769.00 8/24 1/20 1/16 1 /10 1/ 6 21 12 1 -1/8" X 11 -7/8" X 12' RIGIDRIM 150806100 144 1.75 LF 252.00 CONTINUED TO NEXT PAGE PACIFIC LUMBER CO. 5974 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 - 858 -9663 FAX 503 - 636 -2502 NO _ 2 2 1 3 9 8 4 2 NVO 2 CE F r R. 10/26/09 07:08 O2I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST LB 202 S 2 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE CB 202 P521O TIGARD OR 97223 TIGARD, OR DB 173 A 203 MISC: UPPER LEVEL FLOOR TK 9 W 203 C 3 P 3 CUST #: 8060.0550 DEL DATE:1O /26/09 TERMS: 1% 10TH FROM: 0 4283327 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 22 23 60 2X8 #2 & BTR DRY DF 214020000 80 275.00MBF 22.00 6/10 24 60 2X12 #2 & BTR DRY DF 214024000 120 350.00MBF 42.00 6/10 25 5 1 "X 11 -1 /2 "X 12'0SB STEPPING 232255250 60 1200.00MBF 72.00 26 44 3/4 -4X8 T &G WAFERBOARD (23/32) 240850480 1408 395.00MSF 556.16 SUBTOTAL 4941.91 D THANKYOU!!! .00 TOTAL 4941.91 PLEASE PAY THIS AMOUNT: 4941.91 RECEIVED BY: X SIGNATURE: PACIFIC LUMBER CO. 5974 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 -858 -9663 FAX 503 - 636 -2502 NO _ 2214043 =NVO2CE R 10/27/09 10:20 O1I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST LB 145 S 2 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE CB 145 P521O TIGARD OR 97223 TIGARD, OR DB 173 A 203 MISC: UPPER WALL FRAME TK 9 W 203 C 3 P 3 CUST #: 8060.0550 DEL DATE:10 /27/09 TERMS: 1% 10TH FROM: 0 4283344 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 1D RUN06 EARLY PM - NOON TO 2PM 2D LOAD09 2ND FLOOR WALLS 3D TYPE03 QUARTER LOAD 4D 5 10 2 "X48 "12GA.STRAP TIE SILVER 270841660 10 6.75 EA 67.50 SILVER KST248 SIMPSON MST48 6 7 200 2X4 -92 5/8 GDF STUD GRADE 110210350 1066.66 200.00MBF 213.33 8 211 2X6 -92 5/8 STUD GRADE S -GRN DF 120220350 1688 175.00MBF 295.40 9 1050 2X4 -RL STD & BTR GRN DF 10416000 700.04 190.00MBF 133.01 1 /10 65/16 10 832 2X6 -RL #2 & BTR S -GRN DF 20618000 832 225.00MBF 187.20 2/ 8 24/14 3/16 24/18 11 48 2X6 -RL #2 & BTR S -GRN DF 20618000 48 225.00MBF 10.80 3/16 12 96 4X 6 -RL #2 & BTR S -GRN D/F 60652000 192 350.00MBF 67.20 12/ 8 13 34 4X12 -RL #2 & BTR S -GRN D/F 61255000 136 350.00MBF 47.60 1/16 1/18 14 16 6X 6 -RL #2 & BTR S -GRN D/F 70661000 48 495.00MBF 23.76 2/ 8 15 54 7/16 - 4X8 WAFERBOARD 24/16 241020350 1728 225.00MSF 388.80 SUBTOTAL 1434.60 D THANKYOU!!! .00 TOTAL 1434.60 PLEASE PAY THIS AMOUNT: 1434.60 RECEIVED BY: X SIGNATURE: PACIFIC LUMBER CO 5974 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 - 858 -9663 FAX 503 - 636 -2502 1�0 . 2 2 1 4 0 9 5 21\11V0 2 CE R 10/29/09 06:17 01I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST LB 145 S 2 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE CB 145 P5210 TIGARD OR 97223 TIGARD, OR A 203 MISC: ROOF LOAD W 203 C 3 P 3 CUST #: 8060.0550 DEL DATE:10 /29/09 TERMS: 1% 10TH FROM: 0 4283345 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 1D RUNO3 FIRST LOAD BY 8:30AM 2D LOAD10 ROOF PACK 3D TYPEO3 QUARTER LOAD 4D * *DELIVER W /TRUSS TRUCK 5D 6 200 2X4 -RL STD & BTR GRN DF 10416000 133.34 190.00MBF 25.33 10/20 7 84 2X6 -RL #2 & BTR S -GRN DF 20618000 84 220.00MBF 18.48 6/14 8 8 2X8 #2 & BTR DRY DF 214020000 10.67 275.00MBF 2.93 1/ 8 9 10 120 2X8 PRIMED WHITE WOOD 176710140 160 750.00MBF 120.00 6/20 11 120 1X3 PRIMED WHITE WOOD TRIM 176710050 30 925.00MBF 27.75 6/20 12 13 20 1/2 -4X8 CCX PTS 5PLY (15/32) 240630250 640 660.00MSF 422.40 14 68 7/16 - 4X8 WAFERBOARD 24/16 241020350 2176 225.00MSF 489.60 SUBTOTAL 1106.49 D THANKYOU!!! .00 TOTAL 1106.49 PLEASE PAY THIS AMOUNT: 1106.49 RBCBIVBD BY: X SIQIATDRE: PACIFIC LUMBER CO. TRUSS 5895 JEAN ROAD LAKE OSWEGO, OR 97035 PH 503 - 858 -9663 FAX 503 - 636 -2502 NO _ 2 3 3-3 3 3 3 Z NVO Z CE g2 10/29/09 13:37 01I SOLD TIMBERLAND HOMES, INC. SHIP LOT 25 GAGE FOREST S 3 TO: 12670 SW 68TH AVENUE #300 TO: 15657 SW 81ST AVE P5210 TIGARD OR 97223 TIGARD, OR A 203 W 310 C 3 OUR P0: 11151 P 3 CUST #: 8060.0550 DEL DATE:10 /29/09 TERMS: 1% 10TH 503 - 620 -8860 L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT 1 1 ROOF TRUSS PACKAGE 37000301E 1 2398.00 EA 2398.00 SUBTOTAL 2398.00 D THANKYOU!!! .00 TOTAL 2398.00 PLEASE PAY THIS AMOUNT: 2398.00 RECEIVED BY: X SIGNATORR: `tvi col S.3 H0 12670 S.W. 68 AVENUE, SUITE 300, TIGARD, OR 97223 Mark van Dome103) 620 - 8860 • FAX (503) 598 -9081 • COI 141715 Building Official City of Tigard 13125 SW Hall Blvd Tigard, OR 97223 RE: MST2009 -00133 15657 SW 81 Ave Gage Forest #25 Mark, The purpose of this letter is to summarize the meeting with you, Chip Barnett, Mark Stewart, Dennis Ross, Maureen Denny and myself on Wednesday, April 21, 2010. As requested, we are providing the materials list showing the material used in framing this house. We are also including the file from Pacific Lumber & Truss Company showing the truss layouts and the insulation certificate from Magellan Insulation. During the field meeting the spacing of 12" on center of the upper floor joists was verified by our framer Dennis Ross with a stud finder. Using the same method he also verified solid blocking between floor joists for the IBP walls on the second floor. The physical inspection, along with the inspection of similar houses under construction in the same development, it was agreed that along with the items listed below the framing of the house is accepted by the building inspectors. The following steps will be taken as agreed to satisfy the framing inspection: 1. Additional SDS screws will be added at 6" OC at the right side of the front door and the left side of the sidelight. 2. In addition each side the nook windows are required to have additional screws to secure the trimmer to the installed 4 x 6 posts. Final framing inspection will be called in prior to any sheetrock touch up in order for the building inspector to verify the above steps have been completed satisfactorily. Thank you for working with us to get this resolved in a timely matter. As always, Timberland Homes strives to do all possible to produce a solid, quality product and look forward to future 0 p • cts in the Cit of Tigard. • er ly, S 411101 :row T berland Homes, Inc. 0 M: rk Stewart M -rk Stewart Home Design .1 T , i+ ,,, )=,,,; 1 °5 ,, o„ ,......._.. t I ,A v - j e , Vi , Owner /Agent f or 1 /, �s , tor � � ;y (PLEASE PRINT) (PERMIT HOLDER) rs 1 r Do hereby certify that the following location meets 1` City of Tigard land use and development standards i for street tree installation. Y. %i 4 ADDRESS: /5 S 7 -54-A--) 8/ S e.. z SUBDIVISION: Y�S� LOT: F SIGNATURE: < b _ DATE: W2 /`o (OWNER/AGENT) RECEIVED BY: DATE: (CITY OF TIGARD) 1: \ l3uildiug \ Forms \StreetTreeCertificate 01/19/07 Oregon Residential Specialty Code R318.2 MOISTURE CONTENT ACKNOWLEDGEMENT FORM I, Steve Brown , am the general contractor or the owner- builder at the following address: Site Address: 15657 SW 81 Ave. City: Tigard Permit #: MST2009 -00133 Subdivision/Lot #: Gage Forest #25 and/or Map and Tax Lot #: To conform with the 2008 Oregon Residential Specialty Code (ORSC), Section 8318.2 and OAR 918- 480 -0140, I am notifying the building official that I am aware of the moisture content Requirement of ORSC Section R318.2 and have taken steps to meet this code requirement. [Section R318.2 is provided for reference]. R318.2 Moisture Content: Prior to the installation of interior finishes, the building official shall be notified in writing by the general contractor that all moisture- sensitive wood framing members used in construction have a moisture content of not more than 19 percent by dry weight of dry framing members. / 1970674 - 1 - 4 0 . 4 6 nn mk:5 T.•j c_ Signature: IZ C J&Li, way ✓ P Date: 7 /2-6 �/ 0 G Contractor or Owner - 'Builder I: \Building\ Form \RES- MoistureSensitiveWood.doc 09/25/08 Oregon Residential Specialty Code N1107.2 HIGH- EFFICIENCY INTERIOR LIGHTING SYSTEMS Permit No.: MST 2009 -00133 Jurisdiction: Tigard Site Address: 15657 SW 81 Ave. Tigard, OR 97224 Subdivision/Lot #: Gage Forest #25 and/or Map and Tax Lot #: By my signature below, I certify that a minimum of fifty (50) percent of the permanently installed lighting fixtures in the above mentioned building have been installed with compact or linear fluorescent, or a lighting source that has a minimum efficacy of 40 lumens per input watt. (Oregon Residential Specialty Code N1107.2) 774 ht..641, N Signature: Date: 4/26/10 Owner /General Contractor /Authorized Agent Print Name: Steve Brown ORSC Section N1107.2. High - efficiency interior lighting systems. A minimum of fifty (50) percent o the permanently installed lighting fixtures shall be installed with compact or linear fluorescent, or a lighting source that has a minimum efficacy of 40 lumens per input watt. Screw -in compact fluorescent Lamps comply with this requirement. The building official shall be notified in writing at the final inspection that a minimum of fifty percent of the permanently installed lighting fixtures are compact or linear fluorescent, or a minimum efficacy of 40 lumens per input watt. 1:\Building\Forms\RES- HighEfficiencyLighting.doc 07/01/08 Apr 05 10 09:07a Redwood Lane 5036783252 p.1 .- (l 7, �I(j l .jam , EW , J. O EXISTING / pNWS•AWWA BACK TiLOwASSFNIBI.YTE Q R£pL O A V CEMENT I I PROPERTY k J / / , rr:, a�..'C.pHONE: OWNER: 1 — r f.? %N :1 v r� l' cl MAILING e:,7 - ,, ' --) f ; � i t �- ADDRESS: , . / �. ZIP CITY U ✓ ' ' - - -- �, - r — ST ATE �-- I I ASSEMBLY / /� _ S . IG'I✓' �' / r ADDRESS: {� STR ET V.B.A. ❑ S.V.B.A. ❑ AV.B. D AIR GAP �.. i ❑R.P.B.A. �D.C.V.A ❑ R.P.D. A DD.C.D;A. P. ` r MODEL: j � ' MAKE: ✓'.J i % � : i %� � -___,.._a--'- SIZE: W•� SERIAL ' - , WATER c C* ?'(l NUMBER: e l v .— / ' -.. ' 1 , ASSEMBLY - k % � ' tT f a Ci V "."-I. C: / - r r'- V �` LOCATION: — INITIAL TEST- -. REDUCED PRESSURE ASSE!uIBLY PASSED / s 1'_t • .K' NSW FAILED ❑ `� w1 CHECK (A 1 CHECK 81 PRESSDROP ( B)ITIGIiT Q t - OPENED AT PRESS DROP DATE: INITIAL RELIEF VALVE PsID ' / / 1 /. ") , OPENED AT MIN: Io LEAKED ❑ PSID PSiD ---•---- RESULTS BUFFER CHECK #1 A - H = MIN P� . ,,i DID NOT FAILED SYSTEM TIGHT no OPEN ❑ ❑ PSI RELIEF VALVE LEAKED Li v ���� - - - -- — - -- _. - — _�_-_ - -_ p� FAIL ❑ I I COMMENTS FAIR AND /OR PARTS - - --- - ---- - - - AFTER REPAIRS a EDUCEDPRESSt1REAS5y EL R_ DATE: I►CHEUC AT PRESS DROP PRESS DROPS CHECK #I TE OPENED ST USE cel 1 TIGHT 0 PSID AFTE REOPENED CHECK PASSED ❑ • REPAIRS BUFFER Pslo TSID PsID A -B- , TIGHT ❑ CERTFIESTTIATTHE W COMPLETING AND SUBMTITTNG THIS TEST REPORT. THE TESTER ASSEMBLY HAS BEEN TESTED AND MAMTATNED IM ACCORDANCE WITH ALL APPLICABLE REGULATIONS/DE THE WATER SYSTEM, AND STATE REGULATIONS. Rules AND R METER READING GAUGE CALIBRATION :DATE � � %DETECTO TESTER ER SIDNATURE l • , i t GAUZE l! II TESTERS NAKE PRINTED PHONE TESTERS ADDRESS C SERVICE RESTORED COMPANY NAME (REPRESENTATIVE OF OWNER) REPORT RECEIVED BY: – YELLOW �Toter Copy — — -- _ . Winn . Water SYS1Lm COPY PINK • Custom C°Py