Permit A --- CITY OF TIGARD PLUMBING PERMIT
l koNs1r6 DEVELOPMENT SERVICES PERMIT #: PLM2002 -00362
' I " 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/18/03
SITE ADDRESS: 10998 SW 68TH PKWY PARCEL: IS136AD -06505
SUBDIVISION: WAY LEE ZONING: C -G
BLOCK: LOT: 003 JURISDICTION: TIG
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: B FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS: 4
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 100 ft
WATER CLOSETS: WATER LINE: 15 ft
DISHWASHERS: RAIN DRAIN: 300 ft
Remarks: S
FEES
Owner:
Description Date Amount
BANK OF SALEM
PO BOX 847 [PLUMB] Permit Fee 2/18/03 $370.06
SALEM, OR 97308 [PLMPLN] Plan Review 2/18/03 $92.52
[TAX] 8% State Tax 2/18/03 $29.61
Phone : 503 - 585 - 5290 Total $492.19
Contractor:
PLUMBERS NORTHWEST INC
PO BOX 7217
SALEM, OR 97303 REQUIRED INSPECTIONS
Phone : 503 - 364 - 2896 Sewer Inspection
Water Line Insp
Reg #: LIC 81100 Rain Drain Insp
PLM 24 - 209PB Rain Drain Insp
RP /Backflow Preventer
Final Inspection
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
Issued By: k ; ! : 44
,. , , / / Permittee Signature:
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the next business day
i i € C -(T L/ // ES
il
A P lumbing Permit Application
Date received: 9 // DI Permit no.: f � ja �� j(
A'al_,,, City of Tigard
b Sewer permit no.: Building permit no.:
L Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl.no.: edate:
Fax: (503) 598 -1960 Date issued: Receipt Receipt no.:
Land use approval: Q-` 9 —C6° T Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCIIEDtil.E (for special information use check ist)
Job address: `o 1)(3 (6 5%4 re VI --- H���jk A Descri i tion Qty. Fee(ea. Total
Suite no.: New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: I Block: J Subdivision: SFR (2) bath
Project name: " , <., ( \ 11 J V ') SFR (3) bath
City /county: I ZIP: Each additional bath(kitchen ,
Description and location of work on premises: At., Site utilities:
\t`, Lj■ NI (r' ( D t ) t3 ) Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: , tai t /Z.f btl tfv M
Address: /7( 7A/7 Rain drain connector
Cty: j� I State7L, I ZIP: 97g e5 Sanitary sewer (no. lin. ft.)
Phoneme -1/0q ,�g9(e I Fax: I E -mail: � Storm sewer (no. lin. ft.)
CCB no.: $ll� I Plumb. bus. reg. no: et�,e Water service (no. lin. ft.
—
City /metro lic. no.: 5• 531-453 Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve
�
_,, Basins/lavatory
Name: - 1 � t�'�51' l0, Cf 1tl�N A ta'1ei7Atc Clothes washer
Address: Dishwasher
��e0 (,f��+�DN ° Drinking fountain(s)
City: AVCA/1 1 State: aQ . I ZIP: 01 30 b Ejectors/sump
Phone Fax
I E -mail: Expansion tank
Fixture/sewer cap
(p i 0 N Floor drains/floor sinks/hub
Name rmt): Garbage disposal
Mailing address: ' 't 0 t 0. • Hose bibb
City: ■ State: A! ZIP: 21 Ice maker
Phone: I, ,�iLISr E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
Tubs/shower /shower pan -
Urinal
Name: Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information Notice: This permit application Minimum fee $
Plan review (at _ %) $
CI Visa 0 MasterCard expires if a permit is not obtained
Credit card number: / / within 180 days after it has been State surcharge (8%) .... $
Expires TOTAL $
Name of cardholder as shown on credit cars accepted as complete.
$
Cardholder signature Amount 440-4616 (6/00/COM)
,\
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PLUMBING PERMIT FEES:
- PRICE TOTAL New 1 and 2- family dwellings only: `
FIXTURES (individual) - QTY ' (ea) • AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY .(ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
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Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" 16.60
3" 16.60 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San/Storm Sewer 46.40 Lavatory
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Urinal
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' / 55.00 SS cro 3"
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 SSdO Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' / 55.00 5K-50
Storm & Rain Drain - each additional 100' a 46.40 92
Commercial Back Flow Prevention Device / 46.40 4'114
Residential Backflow Prevention Device* 27.55
Catch Basin (q) 16.60 4, , 5 /0
Inspection of Existing Plumbing or Specially . 62.50 •
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
**PLAN REVIEW 25% OF SUBTOTAL 92•5 Afeale 2 de �0/' ‘tiO vi eS
Required only if fixture qty. total is > 9
TOTAL $ //Ate' vn S/Yk�re
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow � �
Prevention Device, which is $36.25 + 8% state surcharge.
** AII New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
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