Permit CITY OF TIGARD
i;� DEVELOPMENT SERVICES PLUMBING PERMIT
Y .
, PERMIT # PLM97 -0371
° '� I.. 13125 SW HaII Blvd., Tigard, OR 97223 (503) 6394171 DATE ISSUED: 09/09/97
PARCEL: 2S101AA -09800
SITE ADDRESS...: 12570 SW 69TH AVE
SUBDIVISION • MLP95 -0013 ZONING: MUE
BLOCK : LOT •001 JURISDICTION: TIG
CLASS OF WORK..:NEW GARBAGE DISPOSALS.: 0 MOBILE HOME SPACES.: 0
TYPE OF USE •COM WASHING MACH • 0 BACKFLOW PREVNTRS..: 0
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
J T ROTH JR type amount by date recpt
12540 SW 68TH AVENUE #B PRMT $ 25.00 DRA 09/09/97 97- 299066
TIGARD OR 97223 5PCT $ 1.25 DRA 09/09/97 97- 299066
Phone #:
Contractor
ACI MECHANICAL
12300 SW 69TH AVE
TIGARD OR 97223
Phone #: 598 -4798 $ 26.25 TOTAL
Reg #..: 006833
REQUIRED INSPECTIONS
This peruit 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 per.it will expire if work is not started
within 180 days of issuance, or if work is suspended for lore
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 952-0001-0810 through OAR 952-0081-0080. You ay
obtain copies of these rules or direct questions to OUNC by calling
(503)246 -1987.
•
Issued Y : k • 4 f 4 Permittee Signature:
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
Call 639 -4175 by 6:00 p.m. for an inspection needed the next business day
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
CITY OF TIGARD tic Plumbing Application Rec'd B _ .. ! AP/
1 Date Recd A• AI
13125 SW MALL BLVD. Commercial and Residential
TIGARD, OR 97223 Date to P.E.
Date to D
(503) 639 -4171 / t'r Permit # - 7
y Print or Type Related SWR #
Incomplete or illegible applications not be accepted call
Name of Development/Project ' ' �� I
Job J , I P .FIXTURES "(Indlytdual) " ' ' .'..'.4 ?5`'..;y.,k : QTY_ ;::;, 'PRICE • -A_ MT:;
Address Street Address I Suite Sink 9.00
1 a 5 - }O SW (09. Lavatory . 9.00
Bldg # City /State Zip Tub or Tub/Shower Comb. 9.00
f l C ar A, O C 't a a-- Shower Only 9.00
Name n
1. Tt R_OT- Water Closet 9.00
Owner Mailing Address Suite Dishwasher 9.00
► a teO6 Sw'4 Dr' #0.1 ,,..5 e ao Garbage Disposal 9.00
City /State Zip Phone Washing Machine 9.00 '
'T' c� arc,� i a1� q (03Q-a[339 Floor Drain r , 9.00
Na
3• 9.00
Occupant Mailing Address Suite 4• 9.00
Water Heater 0 conversion 0 like kind 9.00
City/State Zip Phone Laundry Room Tray 9.00 ,
Name Urinal 9.00
A -a • Z , M t= C F4-AV / e./1k Other Fixtures (Specify) 9.00
Contractor Mailing Address Suite
9.00
1 200 S W (0 PUt. 9.00 •
(Prior to issuance City/State , Phone
applicant must -tit-00 Or c q i•3 6 - q713 9.00
provide all Orego bonst. ant. Board Lic.# Exp. Date 9.00
contractors p $ ?) Fr 8-a.-q8
license Plumbing Uc. # Exp. Date 9.. 0
information if
3 - a4 3Qg ++ Sewer -1st 100• 30.00
expired t (- 3o -a j- Sewer -each additional 100' 25.00
in COT COT Business Tax or Metro* Exp. Date Water Service - 1st 100' 30.00.
database). /4, 7_ , 5/ /ioIO g - k_ 5a Water Service - each additional 200' • 25.00
Name
Store & Rain Drain - 1st 100' 30.00
Architect Storm & Rain Drain - each additional 100' 25.00
or Mailing Address Suite
Mobile Home Space 25.00
Engineer City /State Ztp Phone Commercial Back Flow Prevention Device or Anti- 1 25.00 � a C)
Pollution Device
Describe work New 0 Addition 0 - Alteration 0 Repair 0 Residential Backflow Prevention Device* 15.00
•
to be done: Residential 0 Non - residential O Any Trap or Waste Not Connected to a Fixture 9.00
Additional description of work Catch Basin 9.00
Insp. of Existing Plumbing 40.00
per/hr
Specially Requested Inspections 40.00
Existing use of per/hr
building or property • Rain Drain. single family dwelling 30.00
Proposed use of
Grease Traps 9.00
building or property
QUANTITY TOTAL
Isometric or riser diagram is required if Ouanity Total is > 9
Are you capping . moving or replacing any fixtures? Yes 0 No ❑ *SUBTOTAL )6-
(If yes see back of form) .
I hereby acknowledge that I have read this application, that the information 5% SURCHARGE • • given is correct, that I am the owner or authorized agent of the owner, and 1 , J` S
that plans submitted are in compliance with Oregon State Laws.
S i nature of Owner/Agent ent Date PLAN REVIEW 5 OF SUBTOTAL
9 9 Required only it fixture qty. total is > 9 9
I C� , a -"ill c ` ! g/q TOTAL W /. ��
Contact Person Nam Phone *Minimum permit fee is S25 + 5% surcharge. except Residential Backflow '
M °/ l L &o 69g - L/7. r Prevention Devi which is S15 + 5% surcharge
6 �
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PLEAS COMPLETE AS APPROPRIATE TO PROJECT:
ti
Fixtures to be capped, moved or replaced Qty
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet .
Dishwasher
Garbage Disposal .
Washing Machine
Floor Drain 2"
3"
4 "
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify) .
COMMENTS REGARDING ABOVE:
I: Wstslplmapp.doe 5197