Permit • 1
a CITY OF TIGARD PLUMBING PERMIT
14 S ; ' COMMUNITY DEVELOPMENT Permit #: PLM2009 -00149
-1-f G A g O 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/15/2009
Parcel: 2S103CD04500
Jurisdiction: TIG
Site address: 13500 SW 121ST AVE
Subdivision: Lot:
Project: TINDALL PARTITION
Project Description: Connect existing house to newly installed sewer service. Septic tank is to be pumped and filled.
Owner: FEES
SHARON ULLRICH Quantity Description Date Amount
13500 SW 121ST AVE 66 If Sewer Service 06/15/2009 $55.00
TIGARD, OR 97223
PHONE: 1 12% State Surcharge - 06/15/2009 $8.70
Plumbing
18 ea Minimum Fee Adjustment - 06/15/2009 $17.50
Contractor: Plumbing
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: Permittee Signature: ��
Call 503.639.4175 by 7:00 a.m. for an inspection that business d. �!
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
Building Fixtures i '' „i FOR OFFICE USE ONLY
Tigard of Ti Received
City � 9
1111 `'r g � I ' DDate/By: � � he" d CJ Permit No.: �� QQl[ /
- a 13125 SW Hall Blvd., Tigard, OR 97223 /
Phone: 503.639.4171 Fax: 503.598.1 N 1 2009 Plan Review �/
Date/By: Other Permit No. 0/2.O ^ a ! C floe' �T
Inspection Line: 503.639.4175 ` 7
T I G A R D
Internet www.ti azd - or. ov Date Ready/By: y WI See Page 2 for
g g CITY Notified/Method: ' / Supplemental Information
TYPE OF WORK; :, FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
Accessory building SFR (3) bath 399.00
❑ ry g ❑ Multi - family
❑ Master builder ❑Other: Each additional bath/kitchen 45.00
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND ^ LOCATION Site utilities
Job site address: 1 ;Spa SL 2 l 9 /'r te. Catch basin or area drain 16.60
City/State /ZIP: s- ;5,,,,-.A.1 D 2 q' 77.23 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: LAN S o ,_ P 1_,- Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) 6b) Page 2 100
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: , ) Page 2
Tax map /parcel no.: Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
14 0) , C , v4 :'S 1-; r..g ...,S,e {- 5'.e w S/ S tit. vr.._ Backwater valve _ 16.60
Clothes washer 16.60
Dishwasher 16.60
I4ROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: 'W A 4_ Law o••
Expansion tank 16.60
Address: i 3s-e, ID S V 12. l 5..4.:- A-t� Fixture/sewer cap 16.60
City /State /ZIP: * t . 5 �J , a 2 c / 2 '2. Floor drain/floor sink/hub 16.60
Phone: ( ) ?e _ 7 ? Fax: ( ) Garbage disposal 16.60
Er ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: .`,` G.,s ezirat Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 16.60
Phone:
( ) I Fax:: ( )
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: 0114./t„ jl �; I l co - � / / - - / Water heater 16.60
Address: Other:
City/State/ZIP: Subtotal
Minimum permit fee: $72.50 4r0,01
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumb' Lic. no.: Plan review (25% of permit fee)
Authorized signature: State surcharge (8% of permit fee) 70
����/ TOTAL PERMIT FEE fr //
Print name: , Date: This permit application expires if a permit is not obtaineg*ithin
180 days after it has been accepted as complete.
0 W, *Fee methodology set by Tri -County Building Industry Service Board.
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1:\Building\Permits\PLM - PermitApp.doc 12/27/06 440- 4616T(10 /02/COM/WEB)
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Plumbing Permit Application - City of Tigard 40 /_ o �' / , 4/d A„..,..
Page 2 - Supplemental Information r 9- • / 7
Fee Schedule: Residential Fire Suppression • Sys . � "ie d /35
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - ls 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' _ 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
VAT r S rvice - 1St tee 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
Valuation: Permit Fee:
Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
•
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
_ (minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped, by licensed
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain/sink - 2" that meet the qualifications above.
-3"
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i.\ Building \Permits\PLM- PermitApp.doc 12/27/06
EXISTING SYSTEM DECOMMISSIONING
SEPTIC PERMIT NUMBER: ST 0
T. S.; R. E.; Sec. ; Tax Lot
The street address for the property is ( S 5b 0 S W I I a t __
By my signature, I ce ify that the existing (select one or more of the following)
eptic tank [ ] Seepage Pit [ ] Cesspool
was decommissioned in accordance with established standards of the Department of
Environmental Quality (DEQ). The DEQ standards require the selected items to be:
A) pumped by a licensed sewage disposal pumping service to remove all septage;
B) filled with reject sand, bar run gravel or other material acceptable to the County, OR
the tank must be removed and properly disposed.
The septage was pumped by Se-t2C
(C omp me o t septage pu ping business)
Signature: Date: _ 9
• Attach a copy of the pumping receipt.
• Remit completed form to:
Clackamas County
Water Environment Services -- -Soils
9101 S.E. Sunnybrook Blvd.
Clackamas, Oregon 97015
Or, submit via FAX: (503) 353-4565
503.663.2807 * 7 Days a Week Emergency Service
Job Name: ,
.,� Date:_
Location:./
Phone # • , Alt:
Mailing Address:
Description of Work Amount
„ Yom.
Thank you. We Apprciate your business 'TOTAL DUE
Payment: _ o Check # ,%
❑ Visa /MC # Exp Date:
Customer Signature: •
I hereby acknowledge the completion of the above work. I do not hold Speedy Septic & Rooter Service
liable for any /and all pre- existing conditions or damage to landscape due to the above described work.
PO Box 1260 Boring, OR 97009 *Fax 503.663.9712
www.speedysepticservice.com
CITY OF TIGARD
BUILDING DIVISION PERMIT #: Pi-Pi '20vq - C0
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 41 71'''tlIN 1 it
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: G j1 ti/09 TIME: PAGE:
SITE ADDRESS: 135 SW tai 5 CLASS OF WORK: Al._
SUBDIVISION: LOT #: TYPE OF USE: 5
PROJECT NAME: - 5 , s ^1APoI ?A 4T = -rx4
DESCRIPTION: s fA awivEcrs�,
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: 6//q/ Pour Time:
Code # Inspection Description Confirm # Contact # Message 00) . 7 - 01
. -1j "606 7 555 O
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Corrections /Comments /Instructions: ASAP n y -_r
2 0 .krir Ar f 7 - L _ c
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ASS n PARTIAL APPROVAL n CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
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Inspector: Date: , i /.; Phone #: (503) 718-