Permit CITY OF TIGARD PLUMBING PERMIT
ry DEVELOPMENT SERVICES PERMIT #: PLM2002 -00071
- `�' 13125 S Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/27/02
SITE ADDRESS: 15862 SW 72ND AVE PARCEL: 2S112DD -00200
SUBDIVISION: OREGON BUSINESS PARK III ZONING: I -P
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: B 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: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: 260 ft
Remarks: Install 260 ft. storm drain line work.
FEES
Owner:
Type By Date Amount Receipt
PACIFIC REALTY ASSOCIATES PRMT CTR 2/27/02 $147.80 27200200000
15350 SW SEQUOIA PKWY #300 -WMI SPOT CTR 2/27/02 $11.82 27200200000
PORTLAND, OR 97224
Total $159.62
Phone 1:
Contractor:
H.L.GREEN
15350 SW SEQUOIA
TIGARD, OR 97224 REQUIRED INSPECTIONS
Phone 1: 503 - 624 -7717 Rain Drain Insp
Reg #: LIC 41328 Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans.
This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more
than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility
Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued By: /` , a Ab ir jaff, ♦ Permittee Signature: • Jao
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next ,•twness day
- , - 000
.-. • PlumbingPermit Application
Date received/ /> -• Permit no.: .LM a p G I -0 :7
—$,1( City o f Ti and
I g Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Bl Tigard, OR 97223
City ofTigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By.b 1 Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMEr
❑ 1 & 2 family dwelling or accessory '- Comme ' -. • trial ❑ Multi - family 0 Tenant improvement
❑ New construction ❑ Additi. alteration/ .. placement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
2S Job address: l S• t o D- S(,J r)a-Nb Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax ma /tax lot/account no.: (includes 100 ft. for each utility connection)
P SFR (1) bath
Lot: 'Block: Subdivision: SFR (2) bath
Project name: O►2ec,o A 'UsSi o f i' ile- III SFR (3) bath
City /county: 1 ZIP: Each additional bath/kitchen
X( Description and location of work on premises: Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench dram
1'LU11131NG CONTRACTOR Manufactured drain (no. lin. ft.)
Manufactured home utilities
Business name: 14 L. G.R�--B Manholes
Address: S 3 SO , I.J SE U O / A s LVD Rain drain connector
City: 7 State: OIL ZIP: Sanitary sewer (no. lin. ft.) ,
Phone: 6911 - 77 / 7 1 Fax: 1E-mail: Storm sewer (no. lin. ft.)
CCB no.: /_// � J p 1 Plumb. bus. reg. no: ,V iii_ Water service (no. lin. ft.)
City/metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve
P g at /� - - - '" ` '� Back flow preventer
Backwater valve
Print name: " Date:
CON "CAC "1' PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: 1 State: 1 ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print): pp, 1 G1C 1� �7°rl _ -,.,SOC_
Floor drains/floor sinks/hub
Mailing address: Garbage disposal
g Hose bibb
City: State: ZIP: Ice maker
Phone: Fax: E -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
ENGINI'I:R Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater '
City: 1 State: 1 ZIP: Other.
Phone: 1 Fax: 1E-mail: Total
Not all jurisdictions accept audit cads, please call jurisdiction for more information Minimum fee $ ��{ �•
Notice: This permit application Plan review (at _ %) $
❑ Visa ❑ MasterCard expires if a permit is not obtained
Expires credit a State number: within 180 days after it has been TOTAL surcharge (8%) .... $ v
Name of cardholder as shown on credit used 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 elf plumbing fixtures In PRICE TOTAL
Sink '`� 16.60 the dwelling and the first100 f. 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
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
Other Fixtures (Specify) 16.60 Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer -1st 100' 55.00 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
(Specify)
x Storm & Rain Drain - 1st 100' / 55.00 • /K
f � 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 62.50
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 rr 1, Yv
8% STATE SURCHARGE / / $? •
**PLAN REVIEW 25% OF SUBTOTAL •
Required only if fixture qty. total is > 9
TOTAL $/6' -1,)-
* Minimum permit fee is $72.50 + 8% state surcharge. except Residential Backflow
Prevention Device, which is $38.25•+ 8% state surcharge.
** M New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
IAdstsVorms\plm- fees.doc 12/26/01
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