Permit C ITY OF T I GA R D PLUMBING PERMIT
r�
DEVELOPMENT SERVICES PERMIT #: PLM2002 -00031
. �I :. 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/4/02 •
SITE ADDRESS: 15862 SW 72ND AVE 200 PARCEL: 2S112DD -00200
SUBDIVISION: OREGON BUSINESS PARK III ZONING: I -P
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: OTR 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: 1 URINALS: 1 GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 4 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Moving (2) water closets, replacing (1) urinal, capping (1) sink and (2) water closets. No addition EDU's.
FEES
Owner:
Type By Date Amount Receipt
PACIFIC REALTY ASSOCIATES PRMT CTR 2/4/02 $99.60 27200200000
15350 SW SEQUOIA PKWY #300 -WMI 5PCT CTR 2/4/02 $7.97 27200200000
PORTLAND, OR 97224
Total $107.57
Phone 1:
Contractor:
DEAN WARREN PLUMBING
3111 SE 13TH
PORTLAND, OR 97202 REQUIRED INSPECTIONS
Rough -in Insp
Phone 1: 236 -4152
Reg #: 23 2 Insp existing /capped fixtures
PLM 26 -83P6 Finallnspection
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 • - s stain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
"g7 TN g ' Permittee Signature: Ai
- Call (503) 6 175 by 7:00 P.M. for an inspection needed the next business day
A. Plumbing Permit Application /�
• Dafereceived: /Z A� Permit no.:
-- 4.1,�' Of Ti Sewerpermitno.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City c Phone: (503) 639 -4171 Project/appl.no.: no.: Expire date:
Fax: (503) 598 -1960 Date issued: By: Receipt no.:
Land use approval: Case file no.: Payment type:
111'1 OF 1'1121111
0 1 & 2 family dwelling or accessory Commerciallmdustrial 0 Multi- family 0 Tenant improvement
0 New construction Addition/altemtion/replacement 0 Food service O Other.
.1011 SI I F INFOR11 ION FEE 5(' III :1)I :1 "I: (for special information iisechccklist)
Job address: /5'86g. G w a on Qty. Fee(ea.) Total
Bldg. no.: I Suite no.: ack, New 1- and 2- family dwellings only:
Tax map/tax lot/account no.: (ice 100 0. for each Witty correction)
Block: Subdivision: SFR (1) bath
) bath
Lot
I I SFR (2)
Project name: Mg I GA L 5,4Ee 1,4La'i ,mac SFR (3) bath
City/cotmty: 72 ( q , I ZIP: 9'7 k " .4, c{ Each additional bath/kitchen
Description and location of work on premises: C. A. u21`n jP Site utilities:
A L4<E 1C. C' x.V1. te.1�S Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
1'LU1113INC CONTRAC 1 ()It Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: LEAto I A / .A 1 Q' E ,,..., 11_6 6-1 Manholes
Address: . 11 \ 3 E 1 3 Rain drain connector
City: Pp eyj.a I Stater 4 ZIP: CL? oa Sanitary sewer (no. lin. ft.)
Phone: a 3 (o 4 i 5 Fax :o" (- i - i 1 E-mail: Storm sewer (no. lin. ft.)
CCB no.: O / 7 a I Plumb. bus. reg. no: 9,( R 3 PB Water service (no. lin. ft.)
City/metro lic. no.: l 4 g- j Fixture or item:
Contractor's representative signature: . 7,1,12_, ?775� . Back flow k fl ow valve
Print name: LF n� e► - r c41 Date: - • - Back preventer
Backwater valve
CON FACT PI ItSON Basins/lavatory
Name: co..(,E,iv N r ri-...L 0 ca.-35 Clothes washer
Address: Dishwasher -'
•
City: I State: I ZIP:
Drinking fountain(s)
Ejectors/sump
Phone: Fax: E -mail: Expansion tank
OWN Fixture/sewer cap
Name (print): PA. G T/ . Vl. ST S .17L Floor drains/floor sinks/hub
31:0 Garbage disposal
Mailing address: �/ 3 50 SW SECZAd t PKy Hose bibb
City: 7)6-AAA A A I StZ2JZIP: 4 7 a.a. L( Ice maker
Phone: &al.{ c 00I Fax: I E -mail: Interceptor /grease trap
Owner installatian/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) 1
Owner's signature: Date: Sum.
I. NC IN L I: II Tubs/shower /shower pan
Name: Urinal
Address: Water closet 4
Water heater
City: I State: I ZIP: Other.
Phone: I Fax: I E -mail: Total
inf
p
mud
jmiseetions accept (di c s, lease call jwisd on ror mere «mancIL Minimum fee $ � Q rO
(Not all O Visa 0 MasterCard Notice: This permit is not application Plan review (at _ %) $
` c wt era ® / / expires if a perot oai State strr e (8 %) .... $ 7 Cigi
Expires W 18 days after it has been TOTAL k Name of cardholder as shown an coedit care accepted as complete.
$ /07 ✓ `'7
Cardholder signature Amount 44o -4616 (MJQ OM)
•
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 i 16.60 J,O 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 2-4 16.60 64 N2_ SUBTOTAL
Urinal I 16.60 J (p . . 1 -- 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 • i
MFG Home New San/Storm Sewer ' 46.40 Lavatory
• Tub or Tub /Shower
Hose Bibs 16.60 Combination
' Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet V VS
16.60 Urinal
Other Fixtures (Specify) 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
( 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 Specialty 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 8 '
Quantity Total is > 9
*SUBTOTAL 99 60
8% STATE SURCHARGE Cr
1 '7
'*PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total Is > 9
TOTAL $ O "1
* Minimum penult fee is $72.50.8% state surcharge. except Residential Backflow
Prevention Device, which is $36.25. 8% state surcharge.
** All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
i:\dstsforms\plm- fees.doc 10/10/00
Accumulative Sewer Tally
Tenant Name: Medical Specialties This SWR# N/A
Site Address: 15862 SW 72nd Ave #200 This PLM# 2002 -00031 ,
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count: off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi/Whirlpool 4 0 _ 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 ■ 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 48 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 , 0 0 0 0
- Bradley - - 5 0 1 0 0 0 0
- Commercial 3 0 1 3 0 -1 -3
- Service 3 0 _ 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 2 12 0 -2 -12
Urinal 6 0 0 0 0 0
Previous EDU Count 13 208 208
Capped EDU Credit 0
TOTALS 0 208 3 15 0 0 -3 193
Current Fixture Value 193 divided by 16 = 12.1 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 208 divided by 16 = 13.0 Previous EDU
Change -15 divided by 16 = -0.9 over (under) $ (2,070.00)
Enter EDU Change Here =t2 'e',9.ls r q.:',rr ' ^ " •
HISTORY ..
Notes: PLM# 2001 -00436 EDU# 13 SWR# N/A
PLM# 2001 -00078 EDU# 12.8 SWR# N/A
# 99 -00009 EDU# 13 SWR# 99 -00013
me: _k_ adZ&LL Date: jp/ l a
Signature of person that calculated this tally sheet and date perfromed is required
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received_ - _ - bate Requested -' / 3_ AM • PM BUP
Location / s & 2- Suite 2- 0 0 MEC;
Contact Person Ph ( ) 2 - 3 ( '(/ PLM 0,02 D AD 3j
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
—
Framing
Insulation ' _----
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm &IQ S —)
Susp'd Ceiling
Roof
Other:
Final
S PAR FAIL
- LUMBING
ost m
Un88r61ab_ _
Rough -In
Water Service
Sanitary Sewer
Rain-Drains
Catch Basin / Manhole
Storm Drain
Shower Pan r'
Other:
• PASS PART FAIL
M C NICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE D Please call for reinspection RE: 0 Unable to inspect – no access
Fire Supply Line
Approach/Sidewalk Date / -� / lalnspector Cyr- �' l Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL