Permit CITY TIGARD PLUMBING PERMIT
.,I DEVELOPMENT SERVICES PERMIT #: PLM2005 -00004
'�' c 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/5/2005
SITE ADDRESS: 14360 SW 80TH PL PARCEL: 2S112BA 01100
SUBDIVISION: WAVERLY MEADOWS ZONING: R -7
BLOCK: LOT: 041 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: R3 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: ft
Remarks: Installation of residential backflow prevention device.
FEES
Owner:
Description Date Amount
HELFENSTEIN, HARVEY A + MARY E
14360 SW 80TH PL [PLUMB] Permit Fee 1/5/2005 $36.25
TIGARD, OR 97224 [TAX] 8% State Surcharl 1/5/2005 $2.90
Total $39.15
Phone:
Contractor:
SIMON & SIMON & ASSOCIATES INC
6322 SW PONY ST
WEST LINN, OR 97068 REQUIRED INSPECTIONS
P RP /Backflow Preventer
Phone : 503 656 8864
Final Inspection
Reg #: L1C 6674
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 -00 -I II. You may obtain copies of these rules or direct questions to OUNC by calling (503)
24 - 699.
I ued By: A , Permittee Signature: 1 _ � _�
Call (50 39 -4175 by 7:00 P.M. for an inspection needed the next II. i e• s szy
Plumbing Permit Application 17o12 OFFICE USE ONLY -
City of Tigard Received
/ 1 M
Date/B . i Permit No.: !
13125 SW Hall Blvd., Tigard, OR 97223
Plan Review Other Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 / /ai,r,l1�Di�y4•I' ac�^ Date/By.
24- Hour Inspection Line: 503.639.4175 . LA Date ReadyBy: ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: 1� Supplemental information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description 1 Qty. 1 Ea. 1 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 ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
' JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: l f ' , C 1t` SO" P k . Catch basin or area drain 16.60
City /State /ZIP: T`� ' \r Ov' - m.2....--k. Drywell, leach line, or trench drain 16.60
j Suite/bldg. /apt. no.: ( Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street /directions to job site:
G Manholes 16.60
f
`W s C tiO ' \v■-\lv').e_CIV, -^ TD..∎...■.Q 6e, %k V A . Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer 9 Page 2
1 tA\ j �- k-tan W2.... 1 <,ovx "`442, Backwater valve 16.60
5j15� -.. Clothes washer 16.60
Dishwasher 16.60
lip PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
' 1 � Ejectors/sump 16.60
j
Name: ,-e� d - �I\/v � \., �re ...5''�`� Expansion tank 16.60
Address: "` 14%0 S , $0 ? Fixture /sewer cap 16.60
City /State /ZIP: 'r \6 `Or ci i 2 2' Floor drain/floor sink/hub 16.60
Phone: (5t)3) b .. o 33 t Fax: ( ) Garbage disposal 16.60
. S] APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: G kww„■ 4 7,r„`.,,` S0CA- 5, t t' Interceptor/grease p
tra 16.60
Contact name: je_EF G? \ p..� Medical gas (value: $ ) Page 2
Address: (p . 2 7 PQ h■.. ( -. Primer 16.60
ck "lob
y w t°.rS� L\ �.� (Cc Roof drain (commercial 16.60
City/State/ZIP:
( 933 b � - I ( ) Sink/basin/lavatory 16.60
Phone: Fax: :
Tub /shower /shower pan 16.60
E -mail: 5 5‘w.a, Q. Low,. ce.„S . , vVe,21
Urinal 16.60
. CONTRACTOR Water closet 16.60
Business name: hA,,,A,e G.5 G.%j p v Water heater - 16.60
Address: Other:
Subtotal
City /State /ZIP:
t Minimum permit fee: $72.50 get), a6-
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 0!
CCB Lic.: \C'
D Plumbing Lic. no.: Q5 \b Plan review (25 %ofpermit fee)
Authorized si ature: State surcharge (8% of permit fee) 6(• 5
-"� TOTAL PERMIT FEE 59 . /5
Print name: � - e - rc ‘ ‘j‘ v ,„,,, p.. Date: \ 15 ( r) This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
i:\ Building \Permits\PLM- PermitApp.doc 12/03 4404616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: ' Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage : - Permit Fee•
Footing drain - 1 100' 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
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas S
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
Qty. 'Fee (ea) Total additional $100.00 or fraction thereof; to and
'Fixture or Item 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:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
• Quantity by (Fixture) Work. Performed ,
Fixture Type: Replace
New Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall •
-Drive Thru
Cuspidor /Water Aspirator
Dishwasher - Commercial
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
-3 „
-4
Car Wash Drain
Garbage - Domestic
Disposal -Commercial *Note: If the fixture work under, this permit results in an
Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice Mach. /Refrig. Drains + P
oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing•permit can be issued:
Shower -Gang
-Stall
Sink - Bar /Lavatory
Bradley Quantity Total
Commercial Isometric or riser diagram is required if fixture quantity
Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Uririal. . •
Other Fixtures:
i:\ Building \Permits\PLM- PerrnitApp.doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION - Business Line: (303) 639 -4171 MST
Received Date Requested AM 9 / PM BUP
Location / T 3 ( 6 FL-- Suite MEC
Contact Person Ph ( ) (0 -'� �fS f LM' 465---00so o t
Contractor. Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
ELC
Foundation
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath /Shear / f r � /� 'S S� /? p L /; 6
Framing }` t/" f' "`�
Insulation /
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
• Susp'd Ceiling
Roof
Other:
Final
PASS • - T FAIL
V aiwor
Bea
Under Slab
Rough -In •
Water Service -
Sanitary Sewer
Rain Drains a _
Catch Basin / Manhole''
Storm Drain
Shower Pan /� s
ther: /�
PART FAIL
HANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRIC AL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final 111 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE El Please call for reinspection RE: Unable to inspect - no access
Fire Supply Line / L i?
ADA t/ ( Inspector \/(2,i,
- Ext
Approach/Sidewalk Date
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL