Permit DEVELOPMENT PLUMBING PERMIT
~=�~�u�u~~~x nwnm~n�o SERVICES PERMIT #...... PLM97-0298
� A CITY OF TIGARD.
l ���8N/�W8h�.��'�DR9Z�J��}G���7l DATE ISSUED: 07/28/97
PARCEL: 2S101DC-05300
SITE ADDRESS...: 13493 SW 75TH PL
SUBDIVISION....: PACIFIC RIDGE ~ ZONING: R-3.5
BLOCK~...... ^ LOT....... ...... :5&0 =� JURISDICTION: TIG
_ ____ _ ______
CLASS OF WORi<..:ALT GARBAGE DISPOSALS.: 0 MOBILE HOME SPACES.: 0
TYPE OF USE 'SF WASHING MACH ^ 0 BACKFLOW PREVNTRS..: 1
OCCUPANCY GRP..:R3 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: Installing a residential backflow prevention device
Owner: — ---- — FEES
DENNIS WORZNIAK type amount by date recpt
13493 SW 75TH PLACE PRMT $ 15.00 B 07/28/97 97-297631
TIGARD OR 97223 5PCT $ 0.75 B 07/28/97 97-297631
Phone #: 620-2225 •
Contractor ----- •
OWNER
Phone #: $ 15.75 TOTAL
Reg #..: 999999
REQUIRED INSPECTI
This permit is issued subject to the regulations contained in the RP/Backflow Prev ___
Tigard Municipal Code, State of Ore, Specialty Codes and all other Final Inspect ion ___
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 OR 9521001-0010 through OAR 952-0001-0080. You may _ ___
obtain copies of these rules or direct questions to OUNC by calling _____
(503)246-1987, _
, .
Issued By:
e ( ' «\�_��� �r �.�'L^� Permittee Signature :X����^"~~� w—w~ '
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Call 639-4175 by 6:00 p.m. for an inspection needed the next business day
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
11
CITY OF TIGARD Plumbing Application . Reed By f
13125 SW HALL BLVD. Commercial and Residential Date Recd - = "'
TIGARD OR 97223 Date to P.E.
. Date to DS { j ) � 1
(502)'639 -4171 Permit # f �Y/�" l"t /��/ - d 7�/�
l
Print or Type Related SWR #
Incomplete or illegible applications will not be accepted Called
' Name of Development/Project
\ 5 R '4' • FIX TURES '(indiyldual) t.3 ;;:,' . , ,?fylt� ° � : ,p , QTYS P 10E.? A _ .
Job t° NN1 hi 2 ��.���, ,t...�,.K �x �
Address Street Address y t Suite Sink 9.00 w
MT
13 93 (5C 0 p `
c te (1- Lavatory 9.00
Bldg # City/State Zip Tub or Tub /Shower Comb. 9.00
_ 7/7/4)/1/ OR 17t 2
Name • I Shower Only 9.00
7s pefy N (t Wo 2 . ry 1 a K Water Closet 9.00
Owner Mailing Address Suite Dishwasher r 9.00
Garbage Disposal 9.00
City /State Zip Phone Washing Machine 9.00
Name q � Floor Drain 2" 9.00
/, 3" 9.00
Occupant Mailing Address Suite 4" 9.00
CitylState Zip Phone Water Heater 0 conversion 0 like kind 9.00
Laundry Room Tray 9.00
I Name Urinal 9.00
v N <- Other Fixtures (Specify) 9.00
Contractor Mailing Address Suite
9.00
(Prior to issuance City/State Zip Phone 9.00
' applicant must 9.00
provide all Oregon Const. Cont. Board Lic.# Exp. Date 9.00
i contractors 9.00
1 license Plumbing Lic. # Exp. Date Sewer - 1st 100" 30.00
t information if
expired _ Sewer - each additional 100' 25.00
in COT COT Business Tax or Metro # Exp. Date Water Service - 1st 100' ' 30.00
database). Water Service - each additional 200' • 25.00
Name
Storm & 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 Zip Phone Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Device
Residential Backflow Prevention Device' ( 15.00
1
Describe work New 0 Addition 0 Alteration 7 Repair 0
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
sY 1•Q�xl s Sc.,- Insp. of Existing Plumbing 40.00
L i w "4) per/hr
Specially Requested Inspections 40.00
Existing use of 5' / per/hr
building or property , -.. / Y Rain Drain, single family dwelling 30.00
Proposed use of I • t Grease Traps 9.00
building or property
QUANTITY TOTAL
Isometric or riser diagram is required if Quanity Total is > 9 -
Are you capping , moving or replacing any fixtures? Yes ❑ No 0 *SUBTOTAL
(If yes see back of form) . , /5
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 t / 7 6 c
that plans submitted are in compliance with Oregon State Laws. PLAN REVIEW 25% OF SUBTOTAL
S {re' of Owner /Agen Date Required on if fixture
V eq N qty. total is > 9
j( -7'7 TOTAL (S^7c.--
Contact Person Name Phone 'Minimum permit fee is 525 + 5% surcharge, except Residential Backflow
I j „1 �1 7
t\d Prevention Device, which is 515 + 5% surcharge
stslplmapp.doc 5/97 t. l�tl !�
PLEASE COMPLETE AS APPROPRIATE TO PROJECT:
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: \dsts\plmapp.doc 5/97