Permit CITYOFTIGARD ,
� DEVELOPMENT SERVICES PLUMBING PERMIT
SI ■ PERMIT #
=8-0430
'!� °= 1 3125 SW HaII Blvd., Tigard, OR 97223 (503) 639-0171 DATE I SSUED : 11 /
PARCEL: 1S136AD -01300
SITE ADDRESS...: 10470 SW 69TH AVE
SUBDIVISION • VILLA RIDGE ZONING: R -4.5
BLOCK • LOT •001 JURISDICTION: TIG
CLASS OF WORK..:OTR GARBAGE DISPOSALS.: 0 MOBILE HOME SPACES.: 0
TYPE OF USE :SF WASHING MACH • 0 BACKFLOW PREVNTRS..: 0
OCCUPANCY GRP..:R3 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) ...: 50
WATER CLOSETS.: 0 WATER LINE (ft)...: 0
DISHWASHERS • 0 RAIN DRAIN (ft)...: 0
Remarks: Sewer connection. Spetic tank must be pumped /filled and capped, or
removed.
Owner: FEES
ROSS MONROE type amount by date recpt
10470 SW 69TH PRMT $ 30.00 GEO 11/19/98 98- 310956
TIGARD OR 97223 SPCT $ 1.50 GEO 11/19/98 98- 310956
Phone #:
Contractor
SHOEMAKER'S PLUMBING
PO BOX 250
ESTACADA OR 97023
Phone #: 630 -7728 $ 31.50 TOTAL
Reg #..: 000561
REQUIRED INSPECTIONS
This permit is issued subject to the regulations contained in the I n s p exist i n g / ca
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 more
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 952-0001 -0010 through OAR 952-0001 -0080. You may
obtain copies of these rules or direct questions to OUNC by calling
(503)246 -1987.
Issued By �/� Permittee Signature: of
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
Call 639 -4175 by 7:00 p.m. for an inspection needed the next business day
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
CITY OF TIGARD Plumbing Permit Application Plan Check#
13125 5 HALL BLVD. Commercial and Residential Rec'd By
TIGARD, OR 97223 Date Rec'd
(503) 639 -4171 Date to P.E.
Print or Type - Date to DST
Incomplete or illegible applications will not be accepted Relat w R Q33
)7r74-- Called
Name of Development/Project FIXTURE S (Individual) , .. QTY;`' PRICE AMT
Job 10 4-7o w 6444 44 sink 9.00
Address Street Address Suite Lavatory 9.00
Tub or Tub /Shower Comb. 9.00
Bldg # C' /State Zip p Shower Only 9.00
�� �r �� D 1 ZZ 3 Water Closet 9.00
Name }.,
11055 M 011 f o-e Dishwasher 9.00
Owner Mailing Address Suite Garbage Disposal 9.00
SC 1G1-e Washing Machine 9.00
City /State Zip Phone Floor Drain/Floor Sink 2" 9.00
Name 3" 9.00
5 a (/►l•Q, - 4" 9.00
- Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 9.00
Gas piping requires a separate mechanical permit.
• City /State Zip Phone Laundry Room Tray -- •- 9.00
- __ Urinal . 9.00
Name
5 Aoeo totf f. e, fnn/ 'IVYYIl//OI✓
h Other Fixtures (Specify) 9.00
Contractor Mailing Address Suite 9.00
PO 30%6 Z$ 9.00 .
Prior to permit City /State Zip Phone Sewer - 1st 100' ( 30.00
issuance, a copy FS 6c4d4, 0K. '7707_3 630 - -7Z£f
Sewer - each additional 100' 25.00
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date .
required if 56 13 S - Water Service - 1st 100' 30.00
expired in COT Plumbing Uc. # Exp. Date Water Service - each additional 200' • 25.00 -
database 3 - 2-4- P 1 Storm & Rain Drain - 1st 100' 30.00
Name Storm & Rain Drain - each additional 100' 25.00
Architect Mobile Home Space . 25.00
Or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Device
Engineer City/State Zip Phone Residential Backflow Prevention Device* 15.00
(Irrigation timing devices require a separate
Describe work to be done: restricted energy permit.)
New 0 Repair 0 Replace with like kind: Yes O No O Any Trap or Waste Not Connected to a Fixture 9.00
Residential Commercial 0 • Catch Basin 9.00
Additional description of work:
n `/ - Insp. of Existing Plumbing 40.00
f m
her-, 5P5P40 g per/ hr
S G � r+ AP T eo
Specially Requested Inspections 40.00
per/hr
Rain Drain, single family dwelling 30.00
Are you capping, moving or replacing any fixtures?
Yes O No O Grease Traps 9.00
If yes, see back of form to indicate work performed by QUANTITY TOTAL
. fixture. FAILURE TO ACCURATELY REPORT FIXTURE Isometric or riser diagram Is required it Quantity Total is > 9
WORK COULD RESULT IN INCREASED SEWER .FEES. *SUBTOTAL .
1 hereby acknowledge that I have read this application, that the information
given is correct, that I am the owner or authorized agent of the owner, and 5% SURCHARGE
that plans submitted are in compliance with Oregon State Laws.
Signature of Owner /Agent Date "*PLAN REVIEW 25% OF SUBTOTAL .
`4teehat) B. �/► 'r'a.. t" Q ��,� _ "w (° e•' 1 /c ep Required only it fixture qty. total is > 9
TOTAL
Contact Person Name Phone •
1)4 ve � G Z
OZ *Minimum permit fee is $25 + 5% surcharge, except Residential Backflow 1 �^5 n s "' j� a Prevention Device, which is $15 + 5% surcharge
'*All New Commercial Buildings require plans with isometric or riser diagram
and plan review
I:ldststplumapp.doc 7/2/98
PLEASE COMPLETE:
FiXture Type Quantity by Work Performed .
New Replac emoved /Capped .>
,R
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
I: ldsts\plumapp.doc 7/7/98