Permit PLUr•iD I N3 P E R; S I T
PERMIT #....... : PLM96- -0273
.£ OF TIGARD DATE ISSUED: 09/18/96
COMMUNITY DEVELOPMENT DEPARTMENT PARCEL: 2S 101 AA -09001
S I T 11.3128 s if Sakd..Tigard, Dii iich E97E23 8 196 11431503)1839E4171
SUBDIVISION....: WEST PORTLAND HEIGHTS ZONING: C - -P
BLOCK........... LOT ............. :29 2 .1..T.F<C- 8 s(---i A-v-c__.
CLASS OF WORK..:ADD GARBAGE DISPOSALS.: 0 MOBILE HOME SPACES.: 0
TYPE OF USE....:COM WASHING MACH......: 0 BACKFLOW PREVNTRS..: 1
OCCUPANCY GRP..:B FLOOR DRAINS 0 TRAPS • 0
STORIES • 0 WATER HEATERS • 0 CATCH BASINS.......: 0
FIXTURES LAUNDRY TRAYS 0 SF RAIN DRAINS • 0
SINKS • 0 URINALS...........: 0 GREASE TRAPS • 0
LAVATORIES.....: 0 OTHER FIXTURES . 0
TUB /SHOWERS....: 0 SEWER LINE (ft) ...: 0
WATER CLOSETS..: 0 WATER LINE (ft) ... : 0
DISHWASHERS • 0 RAIN DRAIN (ft)...: 0 .
Remarks: Installing a commercial backflow prevention device
Owner: FEES
J T ROTH CONST INC type amount by date recpt
12540 SW 68TH PARKWAY, SUITE B PRMT $ 25.00 lx 09/18/96 96- -284084
5PCT $ 1.25 P 09/18/96 96- 284084
TIGARD OR 97223
Phone #: 639 -2639
Contractor: •-
ACI MECHANICAL
12300 SW 69TH
TIGARD OR 97223 -- - --
Phone #: 503- 598 -4798 $ 26.25 TOTAL
Reg #... 68338
REQUIRED INSPECTIONS - - -- - --
This permit is issued subject to the regulations contained in the RP /Backflow Prev _____
Tigard Municipal Code, State of Ore. Specialty Codes and all other F i n a l Inspection __ �_______
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. y __ ____ _______
Permittee Signature: p hhALaOi4) o_.
__._
Issued B y : ? ✓ i. l . ' , ^. - -- .� _ . _ _
Call for inspection - 639 -4175
CITY OF TIGARD Plumbing Application Recd By es-
Date Rec'd 'I''' 16 - N o
13126 S1 I HALL BLVD. Commercial and Residential Date to P.E.
TIGARD, OR 97223 Date to DST
(503) 639 -4171 Permit# PL4& 1(,, -62:73
Print or Type Related SWR #
Incomplete or illegible applications will not be accepted Called
Name of Devlopment/project ' • . ' New Slpgle Family Residerfoes Oniy , :. • • "
Job . 04 BATH HOUSE $140.00 .. - 0 :2 BATH I )USE $195.00
Address Street Address Suite .'. ' • p 3 BA TH Ii0USE3225.0 : -
iaSeS 5 u 6d' igue Fee Gtdudes ap plumbing lixtures the d wegtng' And li fret 100 f e e t of • •
Bldg it City /State Zip Water.senrice, sanitary sewer and storm sewer. See.fees below.
_ Tip-,.d 0< 9 2.2 .2..3 . .
Name [� FIXTURES (individual) QTY PRICE AMT
T. T. ke 't\ Sink 9.00
Owner Mailing Address Suite Lavatory 9.00
/aSyo s 68 Acre B
' City /State Zip Phone Tub or Tub /Shower Comb. 9.00
Tv-..8 O K P7.2.2,7 0/-07(039 Shower Only 9.00
Naiiie Water Closet 9.00
Dishwater 9.00
Occupant Mailing Address Suite Garbage Disposal 9.00
Washing Machine 9.00
City /State Zip Phone Floor Drain 2' 9.00
3' 9.00
Name ( n
A c-2 M c ck pl ( C A- 4 " 9.00
Contractor Mailing Address 4 � Suite Water Heater 9.00
1 Q3 o0 ,5c..) ,5c..) (' l e Laundry Room Tray 9.00
City /State Zip Phone v
U. ?)04-.1.. s - Y? �I 0 Urinal 9.00
Oreg Const. Cont. Board Lic.# Exp. Date Other Fixtures (Specify) 9.00
Attach Copy of (p 833 F r- a - ?? 9.00
Current Plumbing Lic. # Exp. Date
//-
License 3 - .793 PS v -9 ' 9.00
3 Sewer -1st 100' 9.00
COT Business Tax or Metro # Exp. Date Sewer - each additional 100' 30.00
/!e /0
Name Water Service - 1st 100' 25.00
Water Service - each additional 200' 30.00
Architect Mailing Address Suite Storm &Rain Drain - 1st 100' 25.00
or
Storm & Rain Drain - each additional 100' 30.00
Engineer City /State Zip Phone Mobile Home Space 25.00
9 Commercial Back Flow Prevention Device or Anti- ( 25.00
Describe work New It"- Addition 0 Alteration 0 Repair O Pollution Device Z
to be done: Residential 0 Non - residential O Residential Backflow Prevention Device' 15.00
Additional description of work Any Trap or Waste Not Connected to a Fixture 9.00
Catch Basin 9.00
Insp. of Existing Plumbing 40.00
per hr
Existing use of Specially Requested Inspections 40.00
building or property per hr
Rain Drain, single family dwelling 30.00
Proposed use of Grease Traps
building or property P 9.00
•
Are you capping any fixtures? Yes ❑ No QUANTITY TOTAL _
Isometric or riser diagram is required if Quanity Total is > 9
I hereby acknowledge that I have read this application, that the information 'SUBTOTAL j
given is correct. that I am the owner or authorized agent of the owner. and �y 0
that plans submitted are in compliance with Oregon State Laws. 5 %SURCHARGE p ,, r ✓
Sig • ature of ner /A ent Date ,- _ , • 1 v"�j
l � o /Ff -f j'o PLAN REVIEW 25% OF SUBTOTAL
ct Person Name Phone Required only if fixture qty. total is > 9
TOTAL ' -
? I • 5 55 - `n 9 t *Minimum permit fee is $25 + 5% surcharge, except Residential Backflow
hdstslplmapp.doc
Prevention Device, which is $15 + 5% surcharge