Permit CITY TIGARD PLUMBING PERMIT
di I DEVELOPMENT SERVICES PERMIT #: PLM2000 -00331
l 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 09/07/2000
SITE ADDRESS: 15200 SW 81ST AVE PARCEL: 2S112C6 00403
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT 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:
Type By Date Amount Receipt
JANES, KEN & LYNETTE PRMT CTR 09/07/200C $36.25 27200000000
15200 SW 81ST AVE 5PCT CTR 09/07/200C $2.90 27200000000
TIGARD, OR 97223
Total $39.15
Phone 1: 620 -1112
Contractor:
MODERN PLUMBING
11120 SW INDUSTRIAL WAY
TUALATIN, OR 97062 REQUIRED INSPECTIONS
Phone 1: 691 -6166 RP /Backflow Preventer
Reg #: LIC 87906
PLM 34 -250PB
EXPIRED
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.
Signature: • OA
Si i
9414..w, Permttee / . 70/2/ &977O7\. Issued By: la Jr, g
Ca I (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day •
CITY OF TIGARD o Plumbing Permit Application Plan Check#
13125 BLVD. Commercial and Residential Rec'd By .22) 4#
TIGARD, OR 97223 Date Rec'd 9//
(503) 639 -4171 �� Date to P.E.
Print or Type Date to DST
Incomplete or illegible applications will not be accepted Permit #/ -Zo - 69 33/
Related SWR #
Called
• Name off !FIXTURES (infd vttl uaI) T i QTY 1 PRICE ;AMT
dV
Job iS 5(0 gr. -r kit , Sink 9.00
Address Street Address Suite Lavatory 9.00
Tub or Tub /Shower Comb. 9.00
Bldg # City /State / Zip Shower Only 9.00
Name /,‘,//\_,1471.-- � I ( - Water Closet 9.00
) ,yt 5 Dishwasher 9.00
•
Owner Mailing Address , Ave., Suite Garbage Disposal 9.00
(Sabo o bo si. B A Washing Machine 9.00
Cit / State Zi Phone
l a J D r, q1-0-`1 D -Pict, Floor Drain /Floor Sink 2" 9.00
Na �A�hJI 3" 9.00
J ck l 4" 9.00
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 9.00
Gas piping requires a separate mechanical permit.
City /State Zip Phone Laundry Room Tray 9.00
Urinal 9.00
• Nar rt O � irh n 6 Other Fixtures (Specify) 9.00
Contractor Mailing Address �/ Suite 9.00
1 t L a 050,IInrtus dal I 9.00
Prior to permit Cit / to 'e • Zip Phone Sewer - 1st 100' • 30.00
issuance, a copy Gyt Or c{'i3O6,9-
Sewer - each additional 100' 25.00
of all licenses are Oregon Const. Cont. Board Licit Exp. Date
required if r i i 01/ • - Water Service - 1st 100' 30.00
expired in COT PlynpiP Li # Exp. Date Water Service - each additional 200' 25.00
database 5I - J3 0 Storm & Rain Drain - 1st 100' 30.00
Name Storm & Rain Drain - each additional 100' 25.00
Architect Mobile Home Space 25.00 .
. or Mailing Address • Suite . Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Device
Engineer City /State. Zip Phone Residential Backflow Prevention Device* 15.00
(Irrigation timing devices require a separate j
Describe_ work to be done: - restricted energy permit.)
New 0 Repair 0 Replace with like kind: Yes 0 No 0 Any Trap or Waste Not Connected to a Fixture 9.00
Residential 0 Commercial O Catch Basin 9.00.
Additional description of work: Insp. of Existing Plumbing 40.00
per /hr
Specially Requested Inspections 40.00
per /hr
• Rain Drain, i le family dwelling 30.00 •
Are you capping moving or replacing any fixtures? Grease Tr l� �RE® 9.00
Yes 0 No 0
If yes, see back of form to indicate work performed by QUANTITY TOTAL >_
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Isometric or riser diagram is required if Quantity Total is > 9 ' , :
WORK COULD RESULT IN INCREASED SEWER FEES. *SUBTOTAL y 't FijmN
I hereby acknowledge that I have read this application, that the information gig& f ;1
given is correct, that I am the owner or authorized agent of the owner, and 5% SURCHARGE r�' -
that plans submitted are in compliance with Oregon State Laws.
Signature of Owner /Agent Date **PLAN REVIEW 25% OF SUBTOTAL miOit a
• 6G c
Required only if fixture qty total is > 9 ,� &.
l ( Lt TOTAL . 7 ri
Contact Perso N M ame Phone , ,
*Minimum permit fee is $25 + 5% surcharge, except Residential Backflow
p Prevention Device, which is $15 + 5% surcharge
�� /Q � , s' / * *All New Commercial Buildings require plans with isometric or riser diagram
and plan review
1: \dsts\plumapp.doc 7/2/98 .36 , ZS
/7,,,,,O r 7 4 74
a.
PLEASE COMPLETE:
Fixture Type Quantity by Work Perl~orr�ed
New Moved Replaced Removed /Capped':
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain /Floor Sink 2"
3"
4 "
Water Heater
. Laundry Room Tray _
-
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
•
•
I: \dsts\plumapp.doc 7/7/98