Permit CITY OF TIGARD PLUMBING PERMIT
e • COMMUNITY DEVELOPMENT Permit #: PLM2010 -00199
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/26/2010
Parcel: 2S114AA00500
Jurisdiction: Tigard
Site address: 16375 SW 85TH AVE
Subdivision: Lot: 0
Project: Clean Water Services
Project Description: Site utilities related to Headworks addition and improvements.
Owner: FEES
CLEAN WATER SERVICES Quantity Description Date Amount
2550 SW HILLSBORO HWY
HILLSBORO, OR 97123 2 ea Catch Basin or Area Drain 08/26/2010 $37.52
PHONE: 503-547-8177 4 ea Manholes 08/26/2010 $75.04
2 ea Rain Drain Connector 08/26/2010 $37.52
525 If Sewer Service 08/26/2010 $250.14
Contractor: 55 If Storm and Rain Drain 08/26/2010 $62.54
HARBOR PACIFIC CONTRACTORS INC 1 12% State Surcharge - 08/26/2010 $55.53
19628 144TH AVE NE - STE A Plumbing
WOODINVILLE, WA 98072
PHONE: 425 - 488 -7131
FAX:
Type of Use: COM
Class of Work: ADD Type of Const:
Occupancy Grp:
Stories:
Total $518.29
Required Items and Reports (Conditions)
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
issu• • , or i wor ' . spended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
ity Notification Center. • •se rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct questions to OUNC bA. • .0 .246.6699 or 1.800.332.2344.
� r
Issued By: , re Permitt Sig nature:
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.
S Plumbing Permit Application nC C Q C 9 9- JGC 5 •
Site Utilities Y V.D FOR ( > 1 . 1 , 1 C . : I A S I' o'' i .1
City of Tigard JUN 1 2010 D'eaciar �0 it I " k T-' Permh No-: "LN,o?Ol0
13125 SW Hall Blvd, Tigard, OR 9 Plan Review
` Phone 503.639.4171 Fax: 503 ; • 1,y}, 0P7' . Other Permit No.:
r } r i n }f ( ) Inspection Lino: 503.639.4175 % U 1LD1NG DI D ate Readyley: sari,• RI See Page 2 for
Internet: www,tigard - or.gov v1.II0N Notift O � SupplementalInformatlon
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, New construction El Demolition For speda llafornration use checklist •
Description 1 Qty. 1 Ea. 1 Total
❑ Addition/alteration/replacement . ❑ Other: New 1- 2 -famly dwellings (includes 100 ft. for each utility connection) I
312.70
'3:zi,,, ' i«U..4 x :� # ;. •!.: " r tl% ±' . ' ..' •; ,yr,' 4. c_} .K. .... SFR (1) ba
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: ?si; ss� N � 1 ;; �, w ;�S:. .F . � �d . Y �� bi� :k.� • `7X� ��s .:.: �:• - .�:` �: � _
❑ 1 • and 2- family dwelling • . CoimnerciaUtndustrial SFR (2) ball; 437.78
(3 Accessory building
13 Mult[•lhmily SFR (3) bath 500.32
Q 7 � •
Each additional bath/Idtchen 25.02
❑ Master builder / J ❑ Other. Fire sprinkler ( , sty ft.) Page 2
. y'.4° y '_t .;..,• i' _: as M 001 ., .1 ,� i ? � , `
.i:z. ,��'� <`':� �'1;:.. r :..,.�:`;i? SltetrfllHid:
m nrr+l�i Catch basin or area drain . e , • : 18.76 3 7 51,
Job site address: l: r• '7„ fr. ` . ' ' • . s W $S t �vtz. Drywall, leach line, or trench drain 18.76 •
City/steterzlP: ,, 4 / 1 7 a Footing drain (no. linear ft.: Page 2
Sulte/bldg.lapt. no.: Project name: Pitt J/frvit✓'r f'-!'
I t: 513/ �., /'l svow >} .r INartufacnned home utilities 50.03
Cross street/directionsto Job site: Q� Manholes • ..q. • 18.76 7$. o y
Se y Is1 oil AI t I' B I v/ Gt &'.$3 /t r X14.7 �r�J / Rain drain connector ,2, 18.76 3 62
w elt - ' / g �� /'� v r`< _ Sanitary sewer (no. linear ft.: _,_) S2.1 Page 2 / A. !4
S /Ae d Storm sewer (no. linear ft.: _) . 55 Page 2 64, 5
Water servtce (no. linear ft.: _) Page 2
Subdivision: I Lot no.: Fixture or item: •
Tax map/parcel no.: Backflow prvventer • 31.27
. v . •,. ... �.. ,+. +.. . <:- ..„ } r, -. , ,�' r . ' .yi •� °. .: ..: Backwater "Iv! 12.51
� .;7 ".a':t ' aNr ,jl.. °,71,0 }'4• f.:" ► .Y� :bid � l..J
nl :' ::.• ?axii / I Iy�OI ,,>:i'.'':.'a' � } ` 1 .3 / .�. t, . Clothes washer • 25.02
. Sf e Ve tr s•�fe ' . / s t / /' / (.,.." " f; a er, / Yl eyi Dishwasher. '• 25.02
660 '3 D -1 • Destr p t/ eh d W o /� /r , '/ Drinking fountain 25.02 • . P�ectors/sump 25.02
K ` ` * ex anaion tank
_ -..).: ' •.'4 st ir. tits' : ii i `(i 'is+ 'i- yy, - /•' Fa'` ''r 12.51
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-� i•.r�i;J tr ^j } :i 'K . 1 ; V � " L I ' b ; ` p .
=‘1..-_4'.:,!;'-:..• a1a ��/� L' ,y
Fixture/sewer 25 •
ti �� 9•! r7!4' fe'r •. t Floor drain/floor sink/hub 25.02
Address: 1404 s itii/ 6,..5 Y e. Garbage disposal 25.02
� ity /State/ZIP: f l , / Coq 7a. &/ Hose btb 25.02
Phone: (sd,3 ,Sll - g / 7 r wc (sa3 ) f y ,- $ 7.6 Ice maker 12.51
.}. t•� 1:1v_.ti -iitd c: � � S7 r i. i t v 1. � ;
�"'` : - r. �Y r F�t•' : :�(; t ... , OlVti �• Iltterceptm/g[easse trap 23 .02 j^ 2:,{lifli�.i)1� %�'vi'�id:sM*i �- -`.'` "':f ' •t,° ett .," i•�ow,. �, �''•.. ,,.W. ja
Business name: e!j• Int4 i t „ Ser ve r 'e S Medical gas (value: $ ) Page 2
B ore 1 Prhaer 1251
Contact name: Z7, .r c Roof drain (Commercial) 12.51
Address: 1 6 6 W g✓r' �Y� _Siak/ 25.02 •
, ` ,
City/StatefZIP f .3 , ,4 ) /1 9 7 2 2 7 Solar units (potable water) 62.54
Phone: (.� 5-y7- 1 7 7 I Fa>c : (93) r 7- 8/ ! 1 Tu bhhower /shower p an 12.51
E -mail: b O rb 4 its,/ /e Q c !e' ' h, tv ttr s�'r✓,` P1'. d r urinal 25.02
i -'- . „ - , � ,... A; r } r , ,, 1
,.7. t water closet 25.02
t i.lia_,ja'stit , 1 ` 7�: :�: "Fti^.;i . +L ;i ^ . f' wt yl 1 \ f ! 4!' %i "�'�
: !....:.;..;:'t'.. ' : .<.he .► . ..• :'i. e 3;?"t,r'...r;r._:.,1 fie ;V' Waterheater 37.52
Business name: _�� �•�R : Wate ngfDWV 56.29
Address: , too ..• a Other: 25.02 •
City/State/21P: . �i oe:1z it i d („4,e_ 7,d? 9' Subtotal &p ,2• °
Phone:.( f!,• felt • 713/. Fax: ( )
Minimum permit fee $72.50
CCB Lio.: II/ 3! ;' P : f vl9 j n ,. , Plan review (25% of permit fee) 6. • 'tr yr " State surcharge (12%ofpermit fee) . 56.5".'; Authorized signature: x ! . � TOTAL PERMIT FEE S $, ?9 i
• / 'This permit appliealion expire if a permit Is not obtained withia 13O days ///���,
Print name: X G ; fit/ N �Q;, 1 Datex BA 4 /p 1 after 1t has been accepted as complete.
•Fee methodology set by Tri•Comtty Building Industry Service Board
LABadini maits>er.aty -t tkpydoe 10/01/09 0444616 0/021COINWen) 'PD. 1
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r . a € °' ❑ EXISTING
PNWS AWWA
> . - BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED
�, ❑ REPLACEMENT
a PROPERTY
OWNER: C1-PAN AT _ ER .S V/C e PHONE: 6P. .3'66
MAILING /6. 75
ADDRESS: - # -S . E
W d .� 7/tj/ A V q /,
CITY / / &/ppmil K n D STATE d R ZIP 1.7 T
ASSEMBLY,
r '
ADDRESS: , D , TAA•E-
STREET
, ® R.P.B. A. ❑ D.C.V.A. ❑ R.P.D.A. ❑ D.C.D.A. ❑ P.V.B.A. ❑ S.V,B.A. ❑ A.V.B. ❑ AIR GAP
SIZE: �.I- 4 V/A MODEL: C2D C1
WATER SERIAL /
' • PURVEYOR:_ C / T 40 P T/ ( -,4R to NUMBER: ) 4 / 5 .6 7
, 'ASSEMBLY I /V
1 , LOCATION: H4:: oR K_ .S A 1)? HA NO ' / / y-
/
65 Lit) / 0
',;. Roon-) S1D U rig W . LL. N "AI? H0T `Ali/'' ;
R EDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST
NI CHECK = DQUBI:EF�CHEGK AIR CHECK PASSED -23'. PRESS DROP (A) CHECK #1 INLET FAILED ❑
• INITIAL RELIEF VALVE /r- r �B) TIGHT ❑ OPENED AT: PRESS DROP
TEST OPENED AT Y ,
DATE: j.
MIN 2 PSID LEAKED ❑ PSID • . 7
RESULTS BUFFER I PSID PSID j 1e-ii/ /
A - B = I CHECK #2
MIN 3 PSI
TIGHT ❑ DID NOT FAILED SYSTEM
RELIEF VALVE PSID OPEN ❑ ❑ PSI M .
PASS ® FAIL ❑ I LEAKED ❑
If'.
COMMENTS
1-, REPAIRS
AND /OR
,. *- . PARTS
:t
REDUCED PRESSURE ASSEMBLY P.V.B.A. /S.V.B.A. AFTER REPAIRS
El CHECK � ' D.0 ViA,zs ss
f - PRESS DROP (A) _i.,�.;'.,. DATE:
TEST RELIEF I CHECK #1 OPENED AT PRESS DROP
AFTER OPENED (B) TIGHT ❑ PSID - - / / •
REPAIRS BUFFER I CHECK #2
A - B PASSED ❑
. ❑ .1m. I TIGHT PSID
PSID PSID
7.
• IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS
GAUGE ALIB! • ION D / R // °DETECTOR METER READING -
� _ '` X749
£ TESTE SIGN i f / ^f �D�'� /?6.7.. L' -- l /1 /� ? ,x;
r _
�' TESTERS ; NAME PRINTED
A G a P .
�i �"�1 � sr i
-" TESTERS ADDRESS A/.
/ 1 '7-F t) . R c. e . c PH a n. '
'(. ""•- Z` 69,4_40
a SERVICE RESTORED
, RECEIVED BY. . /(REPRESENTATIVE OF OWNER) '
\ WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester Copy