Permit , CITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2002 -00428
A �! 13125 SW Hall Blvd., Tigard, OR 9 7 2 23 (50 6 39 -4171 DATE ISSUED: 1/2/03
SITE ADDRESS: 12750 SW 68TH AVE PARCEL: 2S101AD -01300
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT: 033 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: 1 BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: B FLOOR DRAINS; 2 TRAPS:
STORIES: WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 13 URINALS: GREASE TRAPS:
LAVATORIES: 4 OTHER FIXTURES: 3
TUB /SHOWERS: 1 SEWER LINE: ft
WATER CLOSETS: 4 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: TI fixtures.
FEES
Owner:
Description Date Amount
HAMPTON BUILDING, THE LLC
6803 SW WHEATLAND RUN [PLUMB] Permit Fee 1/2/03 $527.80
WILSONVILLE, OR 97070 [TAX] 8% State Tax 1/2/03 $42.23
[PLMPLN] Plan Review 1/2/03 $131.95
Phone : Total $701.98
Contractor:
NORTHWEST CENTRAL PLUMBING
2870 SW 221ST
HILLSBORO, OR 97123 REQUIRED INSPECTIONS
Phone : 642 2067 Water Service Insp
Top -out Insp
Reg #: MET 00001690 RP /Backflow Preventer
LIC 72253 Final Inspection
PLM 34 -197PB
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
ed By: / I _ t ? / _ 44 ,1 Permiftee Signature: (A GEC
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the next business day
• awe•ema -., ,
O • P lumbing Permit Application OFFICE USE ONLY
Date received:1 1 - 9 - t.) Permit no.: i3ly (2:1 -; , - e
->� City of Tigar
� Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 --!t, cogl arip it : Date issued: ByZ13 Receipt no.:
Case tile no.: Payment type:
Land use approval: NOV Q 7 2002
a
!'YP!? OF PERi191T )-
- ,
-- .5. ❑ I & 2 family dwelling or accessory allilaNeillYIVISION ❑ Multi- family Tenant improvement New construction ❑ Addition /alteration /replacement ❑ Food service ❑ Other: 4J1
.10B SITE INFORMATION FEE SCHEDULE (for special information use checklist)
g
Job address: 12150 5 W G S4•t. Description Qty. Fee(ea.) Total r .•
Bldg. no.: I 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: Block: I Subdivision: SFR (2) bath
Project name: S FR 3
j pL� '�Et,i 1 Nt T17uTd (3) bath
s. City /county: -f c *a. b I ZIP: - Each additional bath/kitchen
Description and location of work on premises: TecAlittt.t•• /g140v. Site utilities:
Catch basin /area drain -
It ; Est. date of completion /inspection: Drywells /leach line /trench drain
6 PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
t,. Business name: _ t - t -_ ---.:_•1 Manholes
c . Address: Po to* I Rain drain connector
City: WI SOlag` 3 State: p ft. ZIP: q 7 0 70 Sanitary sewer (no. lin. ft.)
Ni Phone: 67a . 9 6 - F' . E -mail: Storm sewer (no. lin. ft.)
CCB no.: 7 8 3 : - ., Plumb. bus. reg. •. .2.6,4N- ea I Water service (no. lin. ft.) -- -
City/metro l' • .: 22.4 '2.. 6; -13o _ >� Fixture or item: rj
t. Contractor's representative signature: Absorption valve -r
1
Back flow preventer ` %• I/6,
Print name: Date: Backwater valve
CONTACT !'CRSON Basins /lavatory 4
Name: AltICl.► 0 t..4 Clothes washer I'
Address: pp go _ 7 1 Dishwasher ��
City: tLA 0.,3 V 11 L I State:04 I ZIP: et 7 7 O Drinking fountain(s)
Ejectors /sump
Phone: ZG . • 4 Fax: E -mail: Expansion tank CL:i
OWNER Fixture /sewer cap
Name (print): mot AAA tYD' J au • L at 44 , (.1.4j. Gl arrb b g disposal
sinks /hub —_2, Mailing address: 0 l0K 4 4 Gage e disposal
�•� Hose bibb
City: CAMP f Hi &+44 I State: 0 RI ZIP: q 7730 Ice maker 1
Phone:54i •24951 Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s) 1%
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employe the property 1 own as per ORS Chapter 447. Sink(s), basin(s), lays(s) 13
Owner's signature: Date: Sump E
Tubs /shower /shower pan (-
Name: Urinal
ta► '"
u, r closet ¢ r ,
Address: V- ii.. heater .t '
City: I State: I ZIP: j;iicr A Phone: Fax: E -mail: Total .-et 7 ,0 v
Not all jurisdictions accept credit cards. please call jurisdiction for more information. Minimum fee $ `4J'
Notice: This permit application a
❑ Visa ❑ MasterCard expires if a permit is not obtained Plan review (� %) $ /.3 / 9 ��
Credit card number: / / within 180 days after it has been State surcharge (8%) $ ._ R __
Expires TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
. Cardholder signature Amount 601 440 -4616 (6/00 /COM)
L/..2 d
•
• 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
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 y/ 13 /1. -
MFG Home New San /Storm Sewer 46.40 Lavatory ,/ 4 /3
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only r - /1'
Drinking Fountain 16.60 Water Closet L/4. /3
Other Fixtures (Specify) 16.60 Urinal .
Dishwasher Ni 1 • -1 I
Garbage Disposal
Laundry Room Tray / ,
Washing Machine ✓ 1 .'
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3" ✓ a, d 3 4 1
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater 1 1
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00 (LL HIl(L4D 1
Storm & Rath Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device" 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50 L�
Requested Inspections per /hr COMMENTS REGARDING A BOVE:
Rain Drain, single family dwelling 65.25 21
Grease Traps 16.60
QUANTITY TOTAL:
Isometric or riser diagram is required if
Quantity Total is > 9 i��
*SUBTOTAL:
8% STATE SURCHARGE:
* *PLAN REVIEW 25% OF •
SUBTOTAL: '
Required only if fixture qty. total is > 9
f TOTAL PERMIT FEE: $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% stale surcharge. R
* * All New Commercial Buildings require 2 sets of plans with isometric or riser N E CEI VE D O 7 1002
diagram for plan review.
CI TY
BUI OF
EKIN TIGARD
D IV ISION
is \dsts \forms \plm- fees.doc 02/05/02