Permit ..• PLUMBING PERMIT
CITY OF TIGARD
74 : COMMUNITY DEVELOPMENT Permit #: PLM2009 -00294
.TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/16/2009
Parcel: 25101 DA00104
Jurisdiction: Tigard
Site address: 13333 SW 68TH PKWY
Subdivision: FARMERS INSURANCE Lot: 0
Project: Triangle Pointe
Project Description: Install commercial backflow for landscape irrigation. Backflow assembly test report received with
application and is in file.
Owner: FEES
TRIANGLE POINTE LLC Quantity Description Date Amount
901 NE GLISAN ST #100
PORTLAND, OR 97232 1 ea Backflow Preventer 10/16/2009 $31.27
1 12% State Surcharge - 10/16/2009 $8.70
PHONE: Plumbing
41 ea Minimum Fee Adjustment - 10/16/2009 $41.23
Contractor: Plumbing
GREEN THUMB LANDSCAPE AND
MAINTENANCE
PO BOX 5172
PHONE: 503 - 362 -7327
FAX: 503 - 364 -6391
Type of Use: COM
Class of Work: OTR Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notif . - • - . Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or dire • uestions to OU ` b • • 03.246.6699 or 1.800.332.2344.
Iss - d B / I Permittee Signa • e: . j
By: rif
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.
' Plumbing Permit ApplicatilE
Building Fixtures
City of Tigard OCT 5 2009 Received 9 ,9k c / l ) 9 - Cl S!
g O C 1 Rec �D �S O Permit No.:
V 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.639.4171 Fax: 503.59 OF TIGARD Date /B y: Other Permit No.:
Inspection Line: 503.639.4175
''' " "t ° Internet: www.tigard-or.gov BUILDING DIVISION Date Ready /By: �' • El See Page 2 for
Notified/Method: , /!Ca Supplemental Information
TYPE OF WO RK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description 1 Qty. 1 Ea. 1 Total
0 Addition/alteration /replacement ❑ Other: New 1- 2 -family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
❑ 1- and 2- family dwelling ® Commercial/industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bath/Idtchen 25.02
❑ Master builder ❑ Other: Fire sprinlder (- sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 13333 SW 68 Parkway Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City/State/ZIP: Tigard, Oregon 97225
Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: Project name: Triangle Pointe Manufactured home utilities 50.03
Cross street/directions to job site: I -5 Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 1 31.27 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Install landscape Irrigation including backflow device
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: SD Deacon Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 901 NE Glisan St, Ste 100
Garbage disposal 25.02
City/ State/ZIP: Portland, Oregon 97232 Hose bib 25.02
Phone: (503)297 -8791 Fax: (503)297 -8997 Ice maker 12.51
0 APPLICANT 0 CONTACT PERSON Interceptor /grease trap 25.02
Business name: Green Thumb Landscape and Maintenance Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: Bonique Hollinrake or Damon Sump
Roof drain (commercial) 12.51
Address: PO Box 5172 Sink/basin/lavatory 25.02
City/State/ZIP: Salem, Oregon 97304 Solar units (potable water) 62.54
Phone: (503) 362 -7327 I Fax: : (503) 364 -6391 Tub /shower /shower pan 12.51
E -mail: bonique @greenthumblandscaping.net Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: Green Thumb Landscape and Maintenance Water piping/DWV 56.29
Address: PO Box 5172 Other. 25.02
City/ State/ZIP: Salem, Oregon 97304 Subtotal 31.27
Phone: (503) 362 -7327 Fax: (503) 364 -6391 5 /.5/ //G Minimum permit fee: 572.50 72.50
Plan review (25% of permit fee) 0.00
CCB Lic.: 131659 '' Plumbing Lic. no.: 7339 LCB State surcharge (12% of permit fee) 8.70
Authorized si :�1 • = IN) �_ TOTAL PERMIT FEE 81.20
Print name: B. Hollinrake ( Date: 10/13/2009
' "" r r' • T ' This permit applicatlon expires If a permit 1s not obtained within 180 days
_ after It has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\ Building \Permits\PLMU- PamitApp.doc 10 /01/09 440- 4616T(10 /02/COM/WEB)
9
® ‘18 NEW
PNWS-AWWA BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED
PROPERTY \ ❑ REPLACEMENT
OWNER: \ Cap.t1e per: 1 Q c•D . beer S A PHHONE:09) • g ?q 1
ADDRESS: I 2,i 3 5c( 1 �l Q a. r c,, 4 y
CITY reS.ANG v■ STATE Q T` zfPg7c O 1
ASSEMBLY
ADDRESS: / 1114.12....
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: 1 1 L 1.,5Q MAKE: . .st.lnGr •t MODEL: t'c"C=o
WATER SERIAL
PURVEYOR: c ,„,pQ NUMBER: 1 !law
ASSEMBLY
LOCATION: Yjb W ar.) S .�14 6 C 4 ,., i1....) ? 1i1.t )t� kO ,D�e .
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITI TEST
Ni CHECK 'DOUBLE: CHECK AIR CHECK PASSE
PRESS DROP (A l CH.QK #1 INLET FAILED ❑
INITIAL RELIEF VALVE
TEST OPENED AT (B)ITIG !LEAKED a. &:, OPENED AT: PRESS DROP DATE:
MIN 2 PSID LEAKED ❑ PSID
RESULTS BUFFER PSID PSID 101 q SIDq
A - B= I C CK #2
MIN 3 PSI
RELIEF VALVE (TIGHT DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ !LEAKED ❑ P D OPEN ❑ ❑ PSI T 5
COMMENTS
REPAIRS
AND /OR
PARTS
REDUCED PRESSURE ASSEMBLY P.V.B.A. /S.V.B.A. AFTER REPAIRS
#I CHECK > ' D:C.V A
TEST PRESS DROP (A) CHECK #I DATE:
RELIEF I OPENED AT PRESS DROP
AFTER OPENED (B) TIGHT ❑ PSID /
REPAIRS BUFFER .m+ MD ( CHECK #2 ❑
A B¢ 1011.33 (TIGHT ❑ PSID PSID PSID PASSED
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 CALIBRATI N DATE ETECTOR METER READING & `A
TESTER SIGNATURE r TJr.- 3 � 5-ER #
• Q r � 'SrY:::)"- (1 1 ISZ
TESTERS NAME PRINTS G UG #
�•o. ��c 5 L-�� ne1ce.N.�2 aZ N cmt. , 49
TESTERSADDRESS ( � PHONE #
COMPANY NAME
SERVICE RESTORED
REPORT RECEIVED BY (REPRESENTATIVE OF OWNER)
WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester Copy
n 13125 SW Hall Blvd.
1111 1 Tigard, OR 97223
c i Alt t) 503.639.
Inspection Requests 503.639.4175 .
Permit No • LM2009 -0 0294
Site Address 3333 SW 68TH PKWY
nstall commercial backilow for landscape
■ rrigation. Backflow assembly test report received
ascription
ith application and is in file.
ontractor
• hone No
1174 3133121111
ovember 03, 2010
our Time
nspection Code (99 Plumbing final
equest Comment 122206 -01 503- 362 -7327
• equestors Phone •03- 362 - 7327
Result Comments
NSTALLATION OF OBL CHECKS- OK
APPROVAL IS CONTINGENT UPON AN APPROVED BACK -FLOW
DEVICE TESTING REPORT(S),_
2.ONTRACTOR STATED THAT THE REPORTS WOULD BE FAXED ..
N AND_CONFIRMED THAT THEY WERE TESTED AND
APPROVED.
Results PASS - No C of 0
nspector Rick Bolen
Date November 03, 2010
Phone No ;503718 -2424