Permit ... CITY OF TIGARD
. . l e v 1 ,,, DEVELOPMENT LOPM�EN R SERVICES s CE5 PERMI 'LUMBING PERM ILM98 -0104
�i DATE ISSUED: 04/22/98
PARCEL: 1S136DA -00100
SITE ADDRESS...: 11308 SW 68TH PKWY
SUBDIVISION . ZONING: MUE
BLOCK • LOT • JURISDICTION: TIG
CLASS OF WORK. .:OTR 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: Installation of commercial backflow prevention device.
Owner: FEES
PROVICENCE HEALTH SYSTEMS type amount by date recpt
4805 NE GLISAN PRMT $ 25.00 DEB 04 /22/98 98- 305154
PORTLAND OR SPCT $ 1.25 DEB 04/22/98 98- 305154
Phone #:
Contractor
FULLMAN SERVICE CO LLC
5805 SW HOOD AVE
PORTLAND OR 97201
Phone #: 224 -5221 $ 26.25 TOTAL
Reg #..: 122310
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 Final 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 sore
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 -M1-0010 through OAR 952-0001-080. You say
obtain copies of these rules or direct questions to OUNC by calling
(5031246 -1987.
Issued By: Permittee Signature: � 7 /�h „ r
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + ++ + + ++
Call 639 -4175 by 7:00 p.m. for an inspection needed the next business day
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
1
CITY OF TIGARD Plumbing Permit Application Recd By C t' �F Date Recd y -c�a- c
13125 SW HALL BLVD. Commercial and Residential �,` „ � , .
TIGARD, OR 97223 l Date t o P.E.
�� c �I Date to DST
(503) 639 -4171 ■ t Permit* PLM 9k-o /O V
Print or Type Related SWR #
Incomplete or illegible applications will not be accepted Called
Name of Development/Project On back Indicate Work Performed by fixture.
Job Prn v , GI.0 (n u r 1 , I k 7 FIXTURES (Individual) QTY PRICE AMT
Address Streee , (� ) S uite Sink 9.00
I ,C ,S A j L O T l lcb ,) � Lavatory 9.00
Eldg # y CState • Q � Tub or Tub/Shower Comb. 9,00
Wm l 1 1 �� // � l � / V� y Shower Only 9.00
V v ' di ,V I t ,I , k-- 11 .c t )1 Jt 1111.. Water Closet 9.00
Owner Mailing Address I Sui Dishwasher 9,00
(IP) c fl. 6 l 1 ch A Garbage Disposal 9.00
City/State tp Phone Washing Machine 9.00
Name Floor Drain 2' 9.00
3' 9.00
Occ upant Mailing Address Suite 4' 9.00
City /State Zip Phone Water Heater 0 conversion 0 like kind 9.00
Laundry Room Tray 9.00
Name Urinal 9.00
I n n i t V ) c■ct kW( CA viAp '1 Other Fixtures (Spey) 9.00
Contractor Mailing Address Suite Y
/ 9.00
,grr7)5 ciAj i U1- 9.00
Prior to permit /State � Zi Phone
issuance, a copy ' 1' �/ l,�(l t\ q7 2 0 1 9.00
of all licenses are Oregon Const. Cont. Board Licit Exp. Date 9.00
required if 7, 2 � j ( 911/ k Sewer - 1st 100' 30.00
expired in COT Plumbing Uc. # Exp. Sewer - each additional 100' ate
database l - L,I '> ,P)D erl 25.00
Name Water Service - 1st 100' 30.00
Architect f ' ) Water Service - each additional 200' 25.00
Or Mailing Address Suite Storm & Rain Drain - 1st 100' 30.00
Storm & Rain Drain - each additional 100' 25.00
Engineer City /State Zip Phone Mobile Home Space 25.00
CommerciatBadrFrow Devic r Anti- 25.00
Describe work New 0 Addition 91 Alteration 0 Repair 0 Pollution Device I �.
to be done: Residential 0 Non-residential 93 Residential Backflow Prevention Device* 15.00
Additional description of work: Any Trap or Waste Not Connected to a Focture 9.00
Catch Basin 9.00
G11, _j.,� 1 / In / i j 1 0 (� / i / � Insp. of Existing Plumbing perm
r/ �' /l J� (r vi 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 9.00
building or property
I hereby acknowledge that I have read this application, that the information QUANTITY TOTAL .
given is correct, that I am the owner or authorized agent of the owner, and Isometric or riser diagram b required if Quanity Total Is > 9 t - * ,l
that plans submitted are in compliance with Oregon State Laws. 'SUBTOTAL
Slgnature_of Owner/Agent Date 5% SURCHARGE . _
//,)6 X11//6/ A i // 7/
PL
Co tact Peme hone AN REVIEW 25% OF SUBTOTAL - -
/�j �i Required only if torture qty-. total is > 9
tl,I of 1 / Pl.( ei/1rq 'Gi2ZI ( V 205" 76� / My, TOTAL /),4
'Minimum permit fee is $25 + 5% surcharge, except Residential Backflow
Prevention Device, which is $15 + 5% surcharge
I:ldststphnapp.doe 5197
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved Replaced Removed /Capped
Sink
_avatory
- rub or Tub /Shower Combination
ihower Only
'later Closet
)ishwasher
3arbage Disposal
Washing Machine
Floor Drain 2"
3 "
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
1.klats plmapp.doc 5/97