Permit C ITY OF TIGARD PLUMBING PERMIT
go, � DEVELOPMENT SERVICES PERMIT #: PLM2001 -00073
All „ I� 13125 SW Hall Blvd., T igard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/13/01
SITE ADDRESS: 12465 SW 72ND AVE PARCEL: 2S101A6 -01900
SUBDIVISION: HERMOSO PARK ZONING: MUE
BLOCK: LOT: 015 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks:
FEES
Owner:
Type By Date Amount Receipt
WHITETHORN, LLC PRMT CTR 3/13/01 $72.50 27200100000
12465 SW 72ND AVE 5PCT CTR 3/13/01 $5.80 27200100000
PORTLAND, OR 97223
Total $78.30
Phone 1:
Contractor:
JOHN E FRANK
7739 SW 171ST P LACE
ALOHA, OR 97007 REQUIRED INSPECTIONS
Phone 1: 503 - 259 -3021 Sewer Inspection
Reg #: LIC 62819
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 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 Signa e: �� 4
Call ( 03) 639 -4175 by 7:00 P.M. for an inspection needed the next ess day
r _ - _ . Plumbing Permit Application
, Date received: 3 //1/ l Perm no.: Peal oZ GiD / -OO
, j.:: • City of Tigard
..4' : ‘A I' b Sewer pemut no.;app/, 73. Building permit no.:
CifyojTigard Address: 13125 SW Hall Blvd, Tigard, OR 97223 Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By: I Receiptno.:
Land use approval: Case file no.: Payment type:
II PE OF PERMIT
)111 & 2 family dwelling or accessory 0 Commercial/industrial O Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Food service 0 Other.
.1013 SITE INFORMATION FEE SCI IFI)UI E (for special information use checklist)
Job address: /)q/(, S S. tJ • 7 n - AV E.-r uE Description Qty. Fee (ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
P/ R 5/S r7 3 3 S SFR () 100 ft. for each utility connection)
Tax ma tax lot/account no.:
Lot: / S' 'Block: 'Subdivision: Heti M o so PIA a t.- SFR (2) bath
Project name: SFR (3) bath
City/county: '7 ; Ghop D W iS H . I ZIP: `j rj 2_2_3 - 616,6s- S Each additional bath/kitchen
Description and location o € work on premises: ce.... r Er-7 Site utilities:
$ AN 1 v+∎' -/ SNT.A./.4 ER Catch basin/area drain
Est. date of completion/inspection: /'- Nay' c , t_4 / 5 . 7_.c. 0 1 Drywells/leach line/trench drain
PLUMBING CON7 RACTOR Footing drain (no. lin. ft.)
—
Manufactured home utilities
Business name: 'To1...1, -�1 F. FP ..1 I"( r cb q "1 b. c -S a %2 Manholes
Address: rl 3 S .1.,. . I rl 1 S-.\ PLA c \= Rain drain connector
City: A L G - »r I Staters \2 I ZIP: 9 r l 0 o 1 Sanitary sewer (no. lin. ft.) /O 0 /
Phone: S e 1 - 3 o -L.( I Fax: Z S9 - 3 N9 I I E -mail: Storm sewer (no. lin. ft.)
CCB no.: (, ..E;19 I Plumb. bus. reg. no: Water service (no. lin. ft.)
City/metro lic. no.: 'DE Q 3 (, S O.-- Fixture or item:
Absorption valve
Contractor's representative signature:
Back flow preventer
Print name: 0 - FR ,..,---, %-c Date: Backwater valve
Basins/lavatory
Name: Gl 4 \ Sx -- 1 t,.J 017 Clothes washer
Address: / Z y ( $" S 1--,...) '1 L v`—c=1 — Drinking ng fountains)
City: ---- G k.-ca. I State= I ZIP: C) r) 2.7...1
Ejectors/sump
Phone: rj (o 8,- 9 Zoo I Fax: c/(„& • 16 en E -mail: Expansion tank
Fixture/sewer cap
Name (print): \'.J-4 \ -1 E: \- 1 A c Fr .J , L L C. Floor drains/floor sinks/hub
Garbage disposal
Mailing address: / 2.- S . L . e 2 del -Jr Hose bibb
City: — C <a. I State:o e. I ZIP. c 1 LL 1 Ice maker
Phone: I Fax: 1E-mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
EN(; I N I. E R Tubs/shower /shower pan .
Urinal
Name: Water closet
Address: Water heater
City: 'State: I ZIP: Other.
Phone: 'Fax: 1E-mail: Total
Minimum fee $ 7 2.5 v
Not all jurisdictions accept «edit cards, please call jurisdiction for more information- Notice: This permit application
❑ Visa 0 MasterCard Plan review (at _ %) $
expires if a permit is not obtained Et v
Credit card number: / / within 180 days after it has been State surcharge (8%) .... $
Expires TOTAL $ r) & , 3
0
Name of cardholder as shown on credit card
accepted as complete.
Cardholder signature Amount 440 -4616 (6100/COM)
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 PLEASE COMPLETE:
3^ 16.60
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
MFG Home New San/Storm Sewer 46.40 Lavatory
Hose Bibs 16.60 Tub or Tub /Shower
- Combination •
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet ,
16.60 Urinal
Other Fixtures (Specify) Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain/Sink: 2"
Sewer - 1st 100' • 55.00 SS 00 3"
Sewer - each additional 100' ' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
( Speciy)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain 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 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL 7a g7
8% STATE SURCHARGE
3
*'PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $7b.3
X 'Minimum permit fee is $72.50 + 8% state surcharge. except Residential Backflow l
Prevention Device, which is $38.25 + 8% state surcharge. SE-60 e ,�, At / . 3 D D , v Tv
"NI New Commercial BuIIdings require plans with isometric or riser diagram and
plan review. /'v,s 2A/ 35, QZ)
,„1 � 335, DD
I: dsts\forms\plm- fees.doc 10/10/00
s.
% ,''*, L O .. A : AiTY ' SE r ..
P.O. Box 309, BANKS, OREGON 97106
644 -2797 648-6254 639-5188
NAME: //A a r,. illt04/ 1 G `C / .-O h IJ E -z,N,.
ADDRESS: t Z A ( e s - , 9 . 4 / - 7z ;A ie.
CITY: 464 0v L41,14 STATE: 0 z ZIP:C{1ZZ3
HOME: WORK: CELL:
JOB SITE: ( me /0 d u P.O. #:
PAID BY CHARGE ❑ 42//CHECK 6(3 CASH ❑ CREDIT CARD ❑
DATE OZ - 1 (j- ZO 0 1 1 DRIVER 66 11(--, 7da,g4 l ip' AMOUNT
17K ----
7 PUMP SEPTIC TANK TOO
❑ LINE OPENING
I
❑ INSPECTION FEE
❑ SERVICE CALL
❑ LABOR, LOCATING, DIGGING & BACKFILL
❑ MATERIAL I
yizixe 4
1
-- -THIS IS NOT A SEPTIC SYSTEM INSPECTION REPORT-- TOTAL 1 $ 3O4
✓// . -- REMARKS - -
TYPE OF TANK: STEEL ❑ CONCRETE ❑ PLASTIC ❑ HOMEMADE
HORIZONTAL ❑ V RTICAL ❑ RECTANGLE ❑ OTHER
SIZE OF TANK: 350 ❑ 500 ❑ 7• i ❑ 101 S ❑ 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑
LID LOCATION: INLET ❑ OU ' ET ❑ IDDLE ❑ ENTIRE TOP ❑
TANK CONDITION: GOOD ❑ AIR 11 POOR ❑
FITTINGS: BAFFLES ❑ ON - ETE ❑ CAST IRON ❑ PLASTIC ❑
NEEDS NEW LID? ❑ YES IZE
GROUND COVER OVER TANK
COMMENT ON CONDITION OF DRAINFIELD ETC.
SIGNED BY DATE
,CITY OF -TIGARD BUILDING INSPECTION DIVIS t^nsT
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
BUP ` A
Date Requested
(5-***-' J 2 AM PM BLD � '
Location ( (f G r Sci/ 7 2--1-s' /tvt Suite MEC
Contact Person ,ldi 7 rfra � Ph ; 7 ?v PLM / -6O oJ.
Contractor Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:, 1,11 J 01/41-11e N H`S FPS
Ftg Drain
Crawl Drain Inspection Notes: SGN
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler C v � ' / /�
Fire Alarm
Susp'd Ceiling
Roof
Misc:
Final !�
PASS PART FAIL
Post & Beam
Under Slab
Top Out
Water Service
ain Drains
Fi
ASS ART FAIL
MECHANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
Fire Supply Line
ADA
Approach /Sidewalk /
Other Date / - Ins Ext
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.