Permit II ,` `- CITY OF TIGARD MASTER PERMIT
. COMMUNITY DEVELOPMENT Permit #: MST2009-00134
T IG ARD 13125 SW Hall Blvd., Tigard OR 97223 503.639,4171 Date Issued: 08/19/2009
Parcel: 2S112CC21700
Jurisdiction: Tigard
Site address: 15631 SW 81ST AVE
Subdivision: GAGE FOREST Lot: 24
Project: Gage Forest
Project Description: New SFR. .
BUILDING
Floor Areas Required Setbacks Required
Stories: 2 Bedrooms: 4 First: 973 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 24 Bathrooms: 3 Second: 1349 sf Garage: 408 sf Front: 15 Smoke
Dwelling Units: 1 Third: 0 sf Right: 5 Detectors: Yes
Total: sf Value: $252,888.78 Rear: 15
PLUMBING
Sinks: 1 Water Closets: 3 Washing Mach: 1 Laundry Trays: 1 Rain Drain: 1 Catch Basins: 0
Lavatories: 4 Dishwashers: 1 Floor Drains: 0 Sewer Lines. 100 SF Rain Other Fixtures: 0
Tubs /Showers: 3 Garbage Disc: 1 Water Heaters: 1 Water Lines: 100
Drains: 0
Bckflw Prevntr: 0
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 4 Clothes Dryers: 1
Natural Gas Heat Pump: N Hoods: 1 Other Units: 0
Furn <100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4
Furn > =100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp SrvclFeeders 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: 4 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: Y
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: $15,101.36
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. ' • • Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 -00 -0010 through /AR 95 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling .2 6.6699 or 1. 2.2344.
1
Issued = Permittee Signature:
•
,Building Permit Application
Residential RECEIVE a' FOR'OFFICE USE ONLY
City
Received permit No.: t
of Tigard JUN ►N 17 2009
d g Date /B : , \�.� V. 7 •
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review alla - //QQ •
I . Phone: 503.639.4171 Fax: 503.598.1960 CITY OF TIGAR t Date /B �����(� V Other Per ini , / , , ` ,l . • 414
Inspection Line: 503.639.4175 a te Read •/B Bl S ee Page 2 for
T.IGARD Internet: www.tigard-or.gov BUILDING DIVISIb l�otified /Method: • O1 , , Su pplemental Information
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.
Valuation: $ Q
® 1- and 2- family dwelling ❑Commercial /industrial C .
❑ 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: 15631 SW 81st New dwelling area: 2322 square feet
City /State /ZIP: Tigard, OR 97224 Garage /carport area: 408 square feet
Suite/bldgJapt. no.: Project name: Gage Forest Covered porch area: 0 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.: 24 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
Address: 12670 SW 68th Ave, Suite 300
(Please refer to fee schedule)
Structural plan review fee (or deposit): . 1•.
City /State /ZIP: Tigard, OR 97223
FLS plan review fee (if applicable):
Phone: (503) 620 -8860 Fax: (503) 598 -9081
CCB lic.: 141715 Total fees due upon application:
Amount received:
Authorized signatur : ^ This permit application expires if a permit is not obtained
f � J within 180 days after it has been accepted as complete.
Print name: Maureen enny Date: / (-- err * Fee methodology set by Tri- County_ Building Industry
{ Service Board.
I: \Building\Permits \BUP -RES PermitApp.doc 11/6/07 440 -4613T(11 /02/COM/WEB)
Plumbing Permit Application
Building Fixtures i FOR OFFICE 'USE ONLY ' • .
City of Tigard Received permit No.'
I I /
n 131 25 SW Hall Blvd., Tigard, OR 97223 Plan Re : r /�1 � '00 ��
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date /By: Other Permit No.:
T I GA R D, Inspection Line: 503.639.4175 Date Ready /By: Juris: ® See Page 2 for
i 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. I 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/industrial SFR (2) bath 350.00
El Accessory building ❑ Multi-family SFR (3) bath 399.00 '�'—
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 15631 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.: 24 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
Drinking - fountain 16:60
® PROPERTY OWNER 1:1 TENANT ,
. . _ _ _ . . _ 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 ❑ CONTACT PERSON Hose bib 16.60
Ice maker 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 Fax: : (503) 598-9081
Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail: maureen @Timberlandhomes.net Urinal 16.60
- CONTRACTOR Water closet 16.60
Business name: MEI Plumbing Water heater 16.60
Address: PO Box 207 Other:
City /State/ZIP: Banks, OR 97106 Subtotal �,OC)
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 � 1 y fee)
, _ State surcharge (12% of permit fee) A`7,
Authorized signature: /9it / 44 ge J TOTAL PERMIT FEE 44(, kp
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.
l:\ Building \Permits\J'LME- PermitApp.doc 12/27/06 440-0616T(l0/02/COM/WEB)
.P ,
.Electrical Permit.Application FOR OFFICE USE ONLY .
Received //Sc. 0 f D17/
City of Tigard Received Permit No.:
13125 SW W Hall Blvd., Tigard, OR 97223 Plan Review - - - -
g . :: Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Petmtt:
•
T I GA RD Inspection Line: 503.639.4175 Date Ready/By: lads: 0 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 of plans 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
CI Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", E ", "1 -2 , I -3 ",
Job no.: Job site address: 15631 SW 81 Ave IOOHP or more. upancy.
❑ Six or more:residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard, OR 97224 El 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.
F SC
Cross street/directions to job site: Hall to Langtree to 81st Description I Qty. I Fee. I Total
New residential single- or multi- family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 046.'1 4
Subdivision: Gage Forest Lot no.: 24 Ea. add'l 500 sq. ft. or portion 33.40 1; IS) I
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK • (with -above sq. ft.) 75.00 2
New single family residence Limited energy, multi- family
ew sin
75.00 2
g y residential (with above sq. ft.)
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
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
®• APPLICANT ❑ C ONTACT PERSON - above service or feeder fee, 6.65 2
each branch circuit
Business name: Timberland Homes, Inc. B. Fee for branch circuits
without service or feeder fee,
Contact name: Maureen Denny 46.85 2
first branch circuit
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
dwelling, 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
Signal circuit(s) or limited -
Business name: Lighthouse Electric 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 inspection 62.50
Phone: (503) 582 -9600 Fax: (503) 582 -8484 Investigation per hour (I hr min) 62.50
CCB Lic.: 154897 Electrical Lie.: Suprv. Lie.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: 27e ,'"7----
Print name: Mike Neel Date: Plan review (25% of permit fee):
` State surcharge (12% of permit fee):
Authorized signature: M [ v / TOTAL PERMIT FEE_ ( , Z o
This permit application expires if a permit is not obtained within 180
Print name: Date: days aftenit has been accepted as complete.
• Number of inspections allowed per permit. _
I:\ Building \Permits\ELC- PermitApp.doc 05/23/06 440- 4615T(t1 /05 /COM/WEB L \�T -
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. '
CC�Ic9)119C�l� �Crmit 1 ppliCs1�1091 ` , l.= : s " ., r ; OR OFsFIC E I S . u w `, �„,t .,L-'
�
4 � 4 City of Tigard Dateei3ed — – P No
f ''gy 131;:5 5 W Hall Bivd.. fi,xtd, t)R. 9j223 Plan R,.; ., ����� � .... /3
3 �honc. III b ��� ' 17 i Fn l J 45(1
f ,,rhr :1
y 'T j. D ate �t�l
AIGARD I1 sp ti n Line 503.639 (i f 'Date Read B See Pagt 7 fu `-- -
. +,crs
. t•> Internet e4 w' ttaatd ter. tsos ttotiriedqvi-:titiiti I
1 Nupplemenrul ,,alive
❑New construction Li Addition /alteration /replacement
f`•:`e:_hanicai permit lees` are based on the value c:r th.e `cork
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: I mechanical materials, equipment, labor, overhead. and profit.
CATEGORY OF CONSTRUCTION I Value: $
RESIDENTIAL EQUIPMENT I SYSTEMS FEES*
1 - and 2 family dwelling ❑ Commercial /industrial ❑ Accessory' building - - - --
For spec•url Infer in C a i 017 use checklist.
❑ Multi - family ❑ Master builder ❑ Other: i - —
Description Qty. E i Total
JOB SITE LNFORNLATION AND LOCATION Heating /cooling
Air conditioning or heat pump � T_ ----,
Job site address: (requires site plan showing placement) I [ 14.00
City /State /ZIP: - ( 1 2-Zif Furnace 100,000 BTU (ducts /vents) ! t 14.00
Furnace 100,000+ BTU (ducts/vents) 17.90 _ {
Suite /bldg. /apt. no.: Project name: Ct P,f,� Gas heat pump 1 L
Cross street/directions to job site: Duct work ; 14.00
Hydronic hot water system Th 14.00
Residential boiler (radiator or , I
hydronic) I 14.00
Unit heaters (fuel -type, not electric),
in-wall, in -duct, susrended, etc. 10.00
Flue /vent for any of above 10.00
Subdivision: 1 Lot no.: Zy j Other: — L . 1 0.00
Tax map /parcel no.: / Other fuel a r iliances
DESCRIPTION OF WORK LWater heater j k � 10.00
Gas fireplace -I- i 10.00
I ;
Flue vent for water heater or gas I �-
�
y I fireplace 10.00
. ja( ., S t Al Cs C- K t 6- P.-Cc -C f t'} . Ct,a N E C 4- ...__ '(C C,, — —
Log lighter (gas) _ 1 10.00
I I I Wood /pellet stove I 10.00 1
Wood fireplace /insen 10.00
Chimney /liner /flue /vent I 10.00 I
[PROPERTY OWNER ❑ TENANT
Other: 10.00
Name: ( ,_ p,E,2- e_,46._L ' '-'- s (!L(C • Environmental exhaust and ventilation
Range hood /other kitchen pp
Address: ('L(. 8 S �• 6c8 �V equ I 10.00
City /State /ZIP: T'((. ,4 ( c"/L_ 4 1.1 2-2-3 Clothes dryer exhaust — I 10.00
Single -duct exhaust (bathrooms, t
Phone: (S453 ) G?. • B 9(00 Fax: (P 3 ) S 4B • ct° S ( toilet compartments, utility rooms) • Q 6.80
[j ❑ CONTACT PERSON Attic /crawlspace fans 1 10.00
Other: 1 10.00 1
Business name: Fuel piping
((( p g
Contact name: r $5.40 for first four; $1.00 for each additional
Address: ` If Furnace, etc. 1
Gas heat pump .
City /State /ZIP: Wall /suspended/unit heater _
Fax:: 1
Phone:( ) ( ) Water heater
Fireplace I'
E - mail: Range (
CONTRACTOR Barbecue
Business name: CCZ7_�Pt -C_ p, Clothes dryer (gas)
Other:
Address: ? (j %6K 33 MECHANICAL PERMIT FEES*
City /State /ZIP: CL.A ( &A et - 1O($ Subtotal 6G ke0
Minimum permit fee ($72.50)
Phone: ( "3) ( 1 q . ' l Og Fax: ( ) Plan review (25% of permit fee)
CCB lie.: ; _ / State surcharge n of permit fee) (Cr 1 _
J�
k" TOTAL PERMIT FEE t q t
Authorized signature: �(/ This p ermit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: hji t ¢ i Date: ' Fee methodology set by Tri- County Building Indust service Board
I `,Biuldina'Permiu''�.StEC- Permit pp.dcc 04106/1)6 C i - 140 - 4617T (i I!o2!C0Vt.WEt31
11- 05 -09; 03: 05PM; i ( 7 7 3 ` SIN 5 tS . 1 - / l y e J AG 120 ; # 1 / 1
Brown Label-E3077
Banging Insulation with ECOSE Technology 1 1 CTII 1
Attic Card
Wien fnslidled in nccoraanc4) won ma manufaeturos's Thermal Performance (Attic Application)
roconmondal(ons, Knauf butts and blankets will provide nut elated thermal resistance (R- veluo) is provided by Installing in acwrdenee wl(h tno manufacturer's Instructions,
the fnii R481ue. the required number of bags per 1,000 sq. ft. of not area, Mend less 01311 rite labelod minimum thickness. Feflute 10
Inslell both the required number of bags and at leant the minimum thl kness will result in lower insulation R•value.
t...., i. fl minimum ,, Initi01 , 111 nUm
kV Tfilskrc5s :, Iingsi 11 rlaxi 1 r nitnh4 _ In 1111c11 bottled ;
TdoDOelnen •instailnaInsulairon •. Va16n' 1,000,SF, COvo"r5(t .-- ,...- Vrt.ly11 t,_ , - 711 1Ckp1Sti _7hi6kn
'•• ipit :llhutlY$11:130'; '' • Ehabld eat bn • • • : •; :• ltInnlamer.ofbaiai •.' .. TMANeoW(ifof' ' • ' '
(i ;Vet
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rmutit11p114 a - ,YaabI 6gtba - .aaebld net Eever ialitildna l* • •iltidolenoCbs Ikea net . .
R•38 12.0 (R:Valaakott•.: ...-_aauuisnt ewe • srhen • ' bit then; lentltere •
R40HD : 26' R.60 42.3 I 23.0 SF 1.311 lbs. 1 27.50' j 27.50'
R - --•-- 10.0' - -- R.49 -_ 33.7 - - _I . 29.6 S -�„ 1 A46 ib9. � 23.00" _ 23,00'
- - R•22 - - Ads•-- •-°- -- R•44 30.2 _ 3 33.2 SF _ ,935!be. - 21.00' . 21.00'
R•21HD g 5 R•38 , . M. . - 25,8 - 8.7 SF .801 lbs. - 18.50' 18.50'
R•19 7 y ° " R•30 V ~ 20,1 T 40 -7 SF_ I_ .624 @a. 15.00' 15.00
R•15HD 3,r -- R 20 - �� 11.0 y S0.7 SF 1 .528 ihs, --� 13,00° - 13,00'
- f - - - - - i 1.25
-_ ...__ 14.4 T � - � T
R•13 3.5' R -22 14
69.3 SF .447 IDS. 11,25'
a 3.5" 11.19 12.0 78.2 SF 392 tbg� I 90.00" .. . .. . 10.00 -
_ i .., .�, 7aio ._ 7.00
•2_-• -- -- R.1 3 8.5 117.5 SF 1 .264 Ibs. _ . - - __
--
cedema,bnsTrecalsaoaRr rmswdlltatwrl v ,4axta R1i ""' .' --' - -. - -- -
7.2 1389SF 2231bs, 6,00' 6.00
• R' r. �mv ,sructdauxtoMNllme.TMtic•SVVw*was), eta yeah"
the n cula9np pexa.htt yew paw foe Oa IM et al to lLv+4as. - -- .
'4L idle a SW tab!. tai NM Vadate -liae4W 71 16x.. Roam JOlbt,
4428 a'L1MSW4aon tit%*0 MSVearwd Yin? a VNmMano s b ntr iene In dad Des pelt 17' eateeptnig, 7,Or44'• raises MI
l 1013' I'nfNMtedato1a new
• 'If m n: to W can to herd r - , x. tx ,lielaaa*R•r::lo. g pews.To yt hemaaufReabt,,pae ddfneteal
Framing Adjustment mddslaallwlf vilad prapsik. u,a,dedyo,nnu, be1c o and tl mawncanfuiltbeittandudo ,1n50011aNO141ppyap.
To compensate for inning nm7mberc. number of 'T ob Itdre PonyRtaadaratelitdefr,1 proecwetariareatrmra2- yanomlttiAltAJMr1palt'onl(V 'at . 1) Al itY%aY,f¢t • ;foa u
bogs per 1,000 ft. of area to bo incuiatftd should bo benol l b"ta'aant' Madam. Ma mcli d mJ adaad dedlanceeaueb adyPoe Cm
as shown below.
Builder's Insulation Statement
'wary i'tfSF 8AR.1G}SF Baits andfof blankets hove been instated in conformance with the above recomrnendedons to provide a thermal
Joler 1E n(:• GC, ; resistance of...
R AllltaIElo IrmnGI(ii ; rranhI 2
M 41.9 42,0 ..� .
, .. _ R- Value•' . " Thtcfmasa
R'60 24 41.6 41,8 Allcken - R. QS at / Inchon
2x8 41.3 41.7 ••
2x4 33.3 33,5 ftopodCeilings R. 30 01 /0 Inches
R.40 24 33.0 33.3 Walls R- 2.1 at 5 t� inches
24 2x4 3 2 6 24,8 Floors (over an unheated crew t space) R- ,6) yy LL` at . � -.- !(} Inches
Rya 2x6 20.4 20. • C Space Poiimeter R. el Inches
- _ - - ---- -
2�18 _ .,? 20.4
._ 2x4 ••-- 26 4 a.. 25A Dbto Installod,...__ - L3/ _ 6 `7 _^
R -38 _ _ 2 x6 r_ ,,,_3' ,, 254 Blown Insulation hag been Inatallod tit conformance with the abovo recommendntions to
2x8 44.4 - 2S.2 provide an R -votuo of: R. 4S using _ ( _____ bugs of thla Insulation to cover
NA 10.7 19.8 Y y
R•30 2x6 10.4 - v - •�• senora foot of araa at a minimum thickness of Z inches.
2x8 ' _ 19.2 t . _ .s...._.._.:_ . _ -- - - -
�, •,•,,,,,," sedan.. conUactm (a '
'fir i6.6 16.7 , !
R-26 _ 1x6 16.4 10.0 _
2z8 18.1 16.4 company owe
i 2x4 14A 14.1 ..............__..,..,,..
'isms (Nolen wanolta.) -- -
12.22 2x6 13.8 14.0
2x8 13.5 13,8 _.-.----- ...------ ----- -- --.. .�, - -. -
III 2r4 ' 12.2 12,4 CDmpanY .. „�.... Data
2x8 12.0 12.2
2x8 11.7 1Z.0 ECOSE" Tacbnology iy a revefurienary new stntalnabfa binder boicd on
2x4 8.1 82 ropidfy- ronowabfa b!o-brasod materials instead of permleum •based chemicals.
2x6 7.9 _ 8.1 • Up to 70% foss embudrod onwpy rhmt our rroditionol binder.
- 2z8 • 7.7 7,9 - with COSE • Converts bio•based, ropldfy rcnnwab)o marariois into on inert
20 6.8 G.4 su mo paflmlar for superior anvironmonratnimIofnobr7ly.
203 6.6 OA . Does not contain hm formaldeb
p oi, ydq acrylics or arri(ltfa! colors.
- 173 - 8.4 6.0
www.Knauftnculatlon.us Knauf Insulation GmbH One Knauf Drive. Shelbyville, 114 46176 Tel: (809) 020.4434 ext.8300 FAX: (317) 308.3675
MN-Ai-19h' 10 09 02009 KROUffnsukhfion GmbH.
PACIFIC LUMBER CO.
5974 JEAN ROAD
LAKE OSWEGO, OR 97035
PH 503 - 858 -9663 FAX 503 - 636 -2502
N® _ 2 2 1 3 5 9 7 2 NV() 2 CE R 10/15/09 08:01 01I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST LB 230 S 2
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE CB 230 P5210
TIGARD OR 97223 TIGARD, OR DB 219 A 203
TK 14 W 203
C 3
P 3
CUST #: 8060.0540 DEL DATE:09 /15/09 TERMS: 1% 10TH FROM: 0 4283036
503 - 620 -8860
L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT
1D RUNO4 SECOND LOAD - BY 10AM
2D LOADO6 FIRST FLOOR WALLS
3D TYPEO2 HALF LOAD
4D
5 14 TDX8 SILVER HOLD DOWN HD8A SIMP 270261600 14 13.75 EA 192.50
SILVER TDX8 SIMPSON HD8A
6 42 785HB 7/8X5 HEX BOLT ZP 41365132A 42 1.49 EA 62.58
7 56 78HN 7/8 HEX NUTS 43105570A 56 .29 EA 16.24
8 42 78W 7/8 WASHERS [50# 325PC IND] 43106471A 42 .28 EA 11.76
9 10 MSTA30 1 1/4" X 30" STRAP TIE 27082152A 10 1.63 EA 16.30
SILVER MSTA30 SIMPSON MSTA30
10
11 78 2X4 -104 5/8 GDF STUDS 110210450 468 240.00MBF 112.32
12 244 2X6 -104 5/8" STUD GR S -GRN DF 120220570 2196 225.00MBF 494.10
13 600 2X4 -RL STD & BTR GRN DF 10416000 400.02 190.00MBF 76.00
36/16 3/ 8
14 896 2X6 -RL #2 & BTR S -GRN DF 20618000 896 225.00MBF 201.60
32/12 32/16
15 88 2X6 -RL #2 & BTR S -GRN DF 20618000 88 225.00MBF 19.80
1/ 8 8/10
16 160 4X 6 -RL #2 & BTR S -GRN D/F 60652000 320 350.00MBF 112.00
16/10
17 36 4X12 -RL #2 & BTR S -GRN D/F 61255000 144 350.00MBF 50.40
3/12
18 8 4X12 -RL #2 & BTR S -GRN D/F 61255000 32 350.00MBF 11.20
1/ 8
19 80 6X 6 -RL #2 & BTR S -GRN D/F 70661000 240 495.00MBF 118.80
8/10
20 20 6X 8 -RL #2 & BTR S -GRN D/F 70862000 80 495.00MBF 39.60
2/10
CONTINUED TO NEXT PAGE
PACIFIC LUMBER CO
5974 JEAN ROAD
LAKE OSWEGO, OR 97035
PH 503 - 858 -9663 FAX 503 - 636 -2502
NO _ 227.3597 7C1STV02CE .3v e R. 4 ' 10/15/09 08:01 02I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST LB 230 S 2
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE CB 230 P5210
TIGARD OR 97223 TIGARD, OR DB 219 A 203
TK 14 W 203
C 3
P 3
CUST #: 8060.0540 DEL DATE:09 /15/09 TERMS: 1% 10TH FROM: 0 4283036
503 - 620 -8860
L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT
21 12 6X12 -RL #2 & BTR S -GRN D/F 71264000 72 350.00MBF 25.20
1/12
22 24 6X 6 -RL P.T. #2 /HF S4S ACQ.60_ 96656000 72 1150.00MBF 82.80
2/12
23
24 48 7/16 - 4X8 WAFERBOARD 24/16 241020350 1536 225.00MSF 345.60
25
26 4 5 -1/4" X 11 -7/8" RIGIDLAM_2.0E 151306100 4 11.25 LF 45.00
1/ 4
27 21 5 -1 /8X13- 1 /2XRL GLULAM ARC AITC 160415500 21 8.65 LF 181.65
1/21
SUBTOTAL 2215.45
D THANKYOU!!! .00
TOTAL 2215.45
PLEASE PAY
THIS AMOUNT: 2215.45
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 1 3 7 3 DL 2 N\TO I CE R 10/19/09 08:50 01I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST LB 202 S 2
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE CB 202 P5210
TIGARD OR 97223 TIGARD, OR DB 17 A 203
MISC: UPPER LEVEL FLOOR TK 33 W 203
C 3
P 3
CUST #: 8060.0540 DEL DATE:10 /19/09 TERMS: 1% 10TH FROM: 0 4283103
503 - 620 -8860
L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT
1D RUNO4 SECOND LOAD - BY 10AM
2D LOADO7 SECOND FLOOR I -JOIST
3D TYPEO2 HALF LOAD
4D
5 30 ITT11.88 HANGER, TJI SIMPSON 271006110 30 1.95 EA 58.50
6 30 11 -7/8" TOP MT I -JOIST HANGER 270622520 30 2.15 EA 64.50
SIMP.ITT2.06 /11.88 SIL.TH020118
7 5 4X12 HVY 14GA SILVER HANGER 270441600 5 6.75 EA 33.75
SIMPSON HU412/ SILVER HD412
8
9 FROM IWP PO# 3228616
10 21 7 "X14" 2.0E STRUCLAM LVL SO 151405200 21 24.75 LF 519.75
1/21
11
12 488 1 -3/4" X 11 -7/8" RFPI -20 150105900 488 1.25 LF 610.00
3/20 2/18 3/16 24/10 9/ 6 8/ 4
6/ 3
13 638 2- 1/16 "X11 -7/8" RFPI -400 150307100 638 1.45 LF 925.10
9/22 22/20
14 16 1 -1/8" X 11 -7/8" X 12' RIGIDRIM 150806100 192 1.75 LF 336.00
15 80 1 -1/2" X 11 -7/8" LVL RIM RD 150805150 80 2.75 LF 220.00
4/20
16 10 1 -3/4" X 11 -7/8" RIGIDLAM 150706100 10 2.95 LF 29.50
1 /10
17 114 3 -1/2" X 11 -7/8" RIGIDLAM 2.0E 151206100 114 7.25 LF 826.50
1/26 1/22 3/12 1 /10 1/ 8 3/ 4
18 10 5 -1/4" X 11 -7/8" RIGIDLAM_2.0E 151306100 10 11.25 LF 112.50
1 /10
19
20 64 2X8 #2 & BTR DRY DF 214020000 85.33 275.00MBF 23.47
CONTINUED TO NEXT PAGE
PACIFIC LUMBER CO.
5974 JEAN ROAD
LAKE OSWEGO, OR 97035
PH 503 - 858 -9663 FAX 503 - 636 -2502
I■YO _ 2213731 X ■1\T0 ICE R 10/19/09 08:50 02I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST LB 202 S 2
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE CB 202 P5210
TIGARD OR 97223 TIGARD, OR DB 17 A 203
MISC: UPPER LEVEL FLOOR TK 33 W 203
C 3
P 3
CUST #: 8060.0540 DEL DATE:10 /19/09 TERMS: 1% 10TH FROM: 0 4283103
503 - 620 -8860
L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT
4/16
21 54 2X12 #2 & BTR DRY DF 214024000 108 350.00MBF 37.80
3/18
22 5 1 "X 11 -1 /2 "X 12'OSB STEPPING 232255250 60 1200.00MBF 72.00
23 48 3/4 -4X8 T &G WAFERBOARD (23/32) 240850480 1536 395.00MSF 606.72
SUBTOTAL 4476.09
D THANKYOU!!! .00
TOTAL 4476.09
PLEASE PAY
THIS AMOUNT: 4476.09
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 7 6 6 2 MVO 2 CE ve R lir 10/20/09 07:57 01I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST LB 230 S 2
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE CB 230 P5210
TIGARD OR 97223 TIGARD, OR DB 219 A 203
MISC: UPPER LEVEL WALL TK 14 W 203
C 3
P 3
CUST #: 8060.0540 DEL DATE:10 /20/09 TERMS: 1% 10TH FROM: 0 4283104
503 - 620 -8860
L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT
1D RUNO6 EARLY PM - NOON TO 2PM
2D LOAD09 2ND FLOOR WALLS
3D TYPEO3 QUARTER LOAD
4D
5 250 2X4 -92 5/8 GDF STUD GRADE 110210350 1333.33 200.00MBF 266.67
6 172 2X6 -92 5/8 STUD GRADE S -GRN DF 120220350 1376 175.00MBF 240.80
7 1132 2X4 -RL STD & BTR GRN DF 10416000 754.70 190.00MBF 143.39
1/12 70/16
8 1068 2X6 -RL #2 & BTR S -GRN DF 20618000 1068 225.00MBF 240.30
6/10 4/12 32/14 32/16
9 148 2X6 -RL #2 & BTR S -GRN DF 20618000 148 225.00MBF 33.30
10 /10 4/12
10 30 4X12 -RL #2 & BTR S -GRN D/F 61255000 120 350.00MBF 42.00
1/14 1/16
11 12 4X12 -RL #2 & BTR S -GRN D/F 61255000 48 350.00MBF 16.80
1/12
12 12 6X12 -RL #2 & BTR S -GRN D/F 71264000 72 495.00MBF 35.64
1/12
13 49 7/16 - 4X8 WAFERBOARD 24/16 241020350 1568 225.00MSF 352.80
SUBTOTAL 1371.70
D THANKYOU!!! .00
TOTAL 1371.70
PLEASE PAY
THIS AMOUNT: 1371.70
RECEIVED
BY: X
SIGNATURE:
PACIFIC LUMBER CO
5974 JEAN ROAD
LAKE OSWEGO, OR 97035
PH 503 - 858 -9663 FAX 503 - 636 -2502
Nr• _ 2 2 1 3 9 1 0 I ■VO I CE R 10/22/09 12:45 01I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST S 2
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE P5210
TIGARD OR 97223 TIGARD, OR A 203
MISC: ROOF LOAD W 203
C 3
P 3
CUST #: 8060.0540 DEL DATE:10 /22/09 TERMS: 1% 10TH FROM: 0 4283105
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
6 240 2X4 -RL STD & BTR GRN DF 10416000 160.01 190.00MBF 30.40
15/16
7 96 2X6 -RL #2 & BTR S -GRN DF 20618000 96 225.00MBF 21.60
6/16
8 36 2X8 #2 & BTR DRY DF 214020000 48 275.00MBF 13.20
1/ 8 2/14
9
10 140 2X8 PRIMED WHITE WOOD 176710140 186.66 750.00MBF 140.00
7/20
11 100 1X3 PRIMED WHITE WOOD TRIM 176710050 25 925.00MBF 23.13
5/20
12
13 20 1/2 -4X8 CCX PTS 5PLY (15/32) 240630250 640 660.00MSF 422.40
14 60 7/16 - 4X8 WAFERBOARD 24/16 241020350 1920 225.00MSF 432.00
SUBTOTAL 1082.73
D THANKYOU!!! .00
TOTAL 1082.73
PLEASE PAY
THIS AMOUNT: 1082.73
RECEIVED
BY: X
SIGNATURE:
PACIFIC LUMBER CO. TRUSS
5895 JEAN ROAD
LAKE OSWEGO, OR 97035
PH 503 - 858 -9663 FAX 503 - 636 -2502
NO _ 2211212115 2 MVO 2 CE R* 10/23/09 05:30 01I
SOLD TIMBERLAND HOMES, INC. SHIP LOT 24 GAGE FOREST S 3
TO: 12670 SW 68TH AVENUE #300 TO: 15631 SW 81ST AVE P5210
TIGARD OR 97223 TIGARD, OR A 203
W 310
C 3
OUR PO: 11134 P 3
CUST #: 8060.0540 DEL DATE:10 /23/09 TERMS: 1% 10TH
503 - 620 -8860
L# QTY DESCRIPTION ITEM # UNITS PRICE AMOUNT
1 1 ROOF TRUSS PACKAGE 37000301E 1 2247.00 EA 2247.00
SUBTOTAL 2247.00
D THANKYOU!!! .00
TOTAL 2247.00
PLEASE PAY
THIS AMOUNT: 2247.00
RBCBIVBD
BY: X
SIGNATQRR:
1, (11 ( -7t
ES IN
12670 S.W. 68"' A\ /ENIJ[, SUITE 300, TIGARD, OR 97223
(503) 620 -8860 • FAX (503) 598 - 9081 • CCB 141715
Mark Van Domelen
Building Official
City of Tigard
13125 SW Hall Blvd
Tigard, OR 97223
RE: MST2009 -00134
15631 SW 81 Ave
Gage Forest #24
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 left side of the family room window
header as indicated by blue tape placed by contractor and agreed by all present.
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
pr.. -cts in the City o Tigard.
•er ly,
S ': rown
Tim.- land Homes, c.
I
M. rk Stewart
Ma k Stewart Home Design
tri5
STREET TREE CERTIFICATION
I, Ac., wA■ ,.P , Owner /Agent for 72m 64 Idvd /4/i1-..s L
(PLEASE PRINT) (PEI= HOLDER)
ti
Do hereby certify that the following location meets
City of Tigard land use and development standards
for street tree installation.
ADDRESS:
SUBDIVISION: �Y��� -- LOT:
..1
SIGNATURE: DATE: VAgh �
(Ol LINER /AGE1[T)
RECEIVED BY: DATE:
(CM" OF TIGARD)
I: \Building \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: 15631 SW 81 Ave.
City: Tigard
Permit #: MST2009 -00134
Subdivision/Lot #: Gage Forest #24
and/or
Map and Tax Lot #:
To conform with the 2008 Oregon Residential Specialty Code (ORSC), Section R318.2 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.
— / - 7 4 Xfam k i
/Zt c n /c 73/Zioutl, vP
Signature: Date: s , r
General Contractor or Owner- Builder �/ ,�
(:\Building\ Form\RES - MoistureSensitiveWood.doc 09/25/08
Oregon Residential Specialty Code N1107.2
HIGH- EFFICIENCY INTERIOR LIGHTING SYSTEMS
Permit No.: MST 2009 -00134 Jurisdiction: Tigard
Site Address: 15631 SW 81 Ave. Tigard, OR 97224
Subdivision/Lot #: Gage Forest #24
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)
?7/llx ib z✓ c
/P1 ' i7 X owa, r P
Signature: , Date: 4/26/10
Owne /Genera a l 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.
I:\Building\ Forms \RES- HighEfficiencyLighting.doc 07/01/08
Apr 05 10 09:07a Redwood Lane 5036783252 p.2
1058762
(Er EW p v6 1 .7 - 10 o - / 5(i
PNWS-AWWA BACKFLOW ASSEMBLY TEST REPORT 0 REMOVED
: ) 0 REPLACEMENT
PROPERTY 0 I / . 4 1 ,_f , . A, _.
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OWNER: ' f."164E,A) PHONE:___..._-..---_,
MAILING (,)
ADDRESS: '.) :I- ;i- .7.j i; 4
ST ATE..: ZIP ----
CITY------14 ' 4 "
ASSEMBLY
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ADDRES STREET
OR.P.B.A. ErD.C.V.A. 0 R.P.D.A. 0o.c.p.A. a P.V.B.A 0 S.V.B.A. D A.V.B. OR OAP 5
SIZE: 1.....LLI....t.-1 MAKE: 1/1,____?!-L.I.i-f----. 4______ MODEL:
WATER -. - SERIAL 1
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ASSEMBLY i ( l ::, <•-' I 63 I
PURVEYOR: il,;__..__;-.::.-:---'--------'--, NUMBER: _-:.__...-.:—=-----------.
----- . . .
LOCATION: ' ? (2 ./..". 7 \ /" i , t )./ /./1. /.. ■ I - r" i i i I 7: , r i
•
REDUCED PRESSURE ASSEMBLY INITIAL TEST
• CHECK 111 on ..bs ,Eall CHECK PASSED Ea"
PRESS DROP ......._.-..--S2
A I CHECK #11 FAILED 0
INITIAL p.E.IF (13)1T1GHT il-.. •i...) OPENED AT. PRESS DROP DATE:
TE.ST 7-'-"-.'
IAN 2 P D LEAKED 0 "
RESULTS BUFFER --- -- .7_2_11 '
PSID PS10
A - El = ----- I CHECK #2,
MIN 3 PSI
RELIEF VALVE ITIGHT tri..c DID NOT FAILED SYSTEM
r -, psio OFEN 0 0 PSI
PASS 0 FAIL 0 LEAKED L-.1
— - — - ----------------- — -
COMM REPAIRS
AND/OR
PARTS
-- — --_--_ —_— _ , —
REDUCED PRESSUR.E
IN CHECK ASSrMIALM"-ABLY l'F'IlDgM112112516M AFT DAT E E REPAIRS
PRESS DROP (A)
----- CHECK #1
TEST RELIEF I ---.--- OPENED AT PRESS DROP
AFTER oPswEo (11) TIGHT 0 Psi D
wiwIpcs.
REPAIRS BUFFER CHECK #2 PASSED
A - 13 .. .....".......1 P13 TIGHT a nip 1.
IN COMPLETING AND suesernb* nos TEST REPORT. THE TESTER CERTIFIES THAT TNE
ASSEMBLY HAS BEEN TESTED AND /A/UNTAMED IN ACCORDANCE WITH ALL APPLICABLE.
RULES AND REGULAIDNS 3£ THE WATER SYSTEM. AND STATE FtEGULATIONS
GAUGE CALIBRATION,DATE -L..:-■1-.-L--ID,ETECTOR METER READING ...........--,-,.---
'e• , %...../ . /'
,.../ `.--./ L--C..,/ V _....--:" , e: i i . i.-- - N s- CD , •
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its-rEpt stGNATuRE . 1 ... .. --1 -- T 4-- .1 ---- i i e :....-
.-, ..,., ,, PHONE 6
CICII*Arri AM E ' 0.-SERV ICE RESTORED
PLEPORT RECEIVED BY (REPRESENTT
AIVE OF OvrNES)
WHITE - Water System Copy PINK - Customer Copy YELLOW - Tata Copy