Permit CITY TIGARDPLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2004 -00469
DATE ISSUED: 10/11/2004
• 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 10435 SW 66TH AVE PARCEL: 1S136AD -00603
SUBDIVISION: VILLA RIDGE NO. 2 ZONING: R -4.5
BLOCK: LOT: 004 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: 1 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
Remarks: Installation of new gas water heater.
FEES
Owner:
Description Date Amount
ROBERT ROUNDTREE [PLUMB] Permit Fee 1 0/11 /2004 $72.50
10435 TIGA RD, OR 9 7223 SW AVE [TAX] 8% State Surchari 1 0/11 /2004 $5.80
GA 97223
Total $78.30
Phone : 503 244 - 3271
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : Rough -in Insp
Final Inspection
Reg #:
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. • u may obtain copies of these rules or direct questions to OUNC by calling (503)
246699.
Is ued By: 1 410,1/ Permittee Signature
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Plumbing Permit Application FOR` USE ONLY
City of Tigard Received J ( ,
13125 SW Hall Blvd., Tigard, OR 97223
DateBy: / f Q, A' Permit No.: 6,,,, Phone: 503.639.4171 Fax: 503.598.1960 aa Plan Review
f I
4111‘ , Date/By Other Pe t No.:
24- Hour Inspection Line: 503.639.4175 E._ ��. Date Ready/By: furls:
8
�. y See Page 2 for
Internet www.ci.tigard.or.us Notified/Method: 01 Supplemental Information
:_ TYPE:O
❑ New construction ❑Demolition For special information use checklist.
Description Qty. Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
,, 'l, s " "CATEGORY OF' CONSTRUCTION - .w SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder ❑ Other: Each additional bath/kitchen 45.00
Fire sprinkler ( sq. ft.) Page 2
° JOB` SITE 'INFORMATION AND LOCATION r Site utilities
Job site address: /�y,rr �j � ® '�c, y ...% Catch basin or area drain 16.60
� e , i
City/State/ZIP: ! � x .07 972 D rywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name:� Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: 1 Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
- ' DESCRIPTION OF :WORK Absorption valve I .60
6
" _ _ ? Backflow preventer Page 2
Backwater valve 16.60
e g" � .j f L r4 ' Clothes washer 16.60
Dishwasher 16.60
❑ PROPER TYbOWNER Drinking fountain 16,60
'
�❑ TENANT
Ejectors /sump 16.60
Name: 765 J'�1/�d,r
w/+% Expansion tank 16.60
Address: /v4ej .�� ,, . Fixture /sewer cap 16.60
City/State/ZIP: 7/1, .), 9 Floor drain/floor sink/hub 16.60
Phone: aao gyy .9.7 / Fax: ( ) Garbage disposal 16.60
Hose bib 16.60
;:l.."''.!':''' ;
❑:; APPLICANT ❑ ; CO N TACT PERSON
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 16.60
Phone: ( ) Fax::( )
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
.CONTRACTOR :
° `� `' - ` Water closet 16.60
Business name: IC/(� ��./ ) -/ Water heater / 16.60
Address: Other:
/ ate /ZIP:
Subtotal
Minimum permit fee: $72.50 7� ,..50
P one: ) Fax: ( ) Residential backflow minimum permit fee: $36.25 -
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
„ eZ i_ er zi o
,I Authorized signature: State surcharge (8% of permit fee) , 86
TOTAL PERMIT FEE 7 8'. 3C)
Print name: 9 Date // . r 7 This permit application expires if a permit is not obtained within
r� ` 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
i:\ Building \Permits\PL.M- PemdtApp.doc 12/03 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities . Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1' 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
Sewer 3,601 to 7,200 $220.00
ewer - 1st 100' 55.00
7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item Qty. • Fee.(ea) ..Total additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
Inspection of existing plumbing or • each additional $100.00 or fraction thereof, to
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by (Fixture) Work Performed
•
Fixture Type: Replace
New Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor /Water Aspirator
Dishwasher - Commercial
- Domestic •
Drinking Fountain
Eye Wash
Floor Drain /sink - 2"
-3"
-4"
Car Wash Drain
Garbage - Domestic
Disposal Commercial *Note: If the fixture work under this permit results in an
- Industrial
Ice Mach. /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink -Bar /Lavatory
Quantity Total
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
- Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
•
i:\ Building \Permits\PLM- PermitApp.doc 3/03