Permit A C ITY OF TIGARD PLUMBING PERMIT
il DEVELOPMENT SERVICES PERMIT #: P 28/02 00262
x � Jll 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/28/02
SITE ADDRESS: 11675 SW 91ST AVE PARCEL: 1S1 35DC 07000
SUBDIVISION: CHARBEN ZONING: R - 4.5
BLOCK: LOT: 8 - JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
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: 100 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Install of 100' of water service. This permit replaces PLM2000 -00371
FEES
Owner:
Type By Date Amount Receipt
JOHN W. DRENNAN PRMT CTR 6/28/02 $72.50 27200200000
11675 SW 91ST 5PCT CTR 6/28/02 $5.80 27200200000
TIGARD, OR 97223
Total $78.30
Phone 1:
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone 1: Water Service Insp
Final Inspection
Reg #:
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.
Issued By; _ �G� _./ •� / � i_ Permittee Signature: f W { (
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the ext business day
Building Fixtures
Y OFFICE USE ONLY
Plumb Permit Application
Date received -c - -Og Permit no: La) o4J& -- 00 • .
City of Tigard tM��Jh 3' g Sewer perm no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223-11 C
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 '� Date issued: Receipt no.:
Land use approval:
17.( --NA
?-000 —003 '1 ( Case file no.: Payment type:
',. ER
" , ,. .TYPE �; „� � YP,E' >OF� MITE. , - '
❑ 1 & 2 family dwelling or accessory ❑ Commercial /industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition /alteration/replacement ❑ Food service ❑ Other:
..., ;. ,.: sir JOB "SITE INFORMATION= ,`'. ,FEE• SCHEDULE (for sp'ecial`information use checklist) '.
Job address: //6 75- S,W, q 5T_ 4- Description Qty. Fee (ea.) Total
Bldg. no.: Suite no.: 1 New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: Block: Subdivision: SFR (2) bath _
Project name: SFR (3) bath -
City /county: ZIP: Each additional bath/kitchen MI
Description and location of work on premises: / 101/ct] Gt AT ,ii i Site utilities: ■ -.
Pao" 6R Nc3t26 RD 7 q % 5 A--d. Catch basin/area drain
Est date of completion/inspection: Drywells /leach line /trench drain _
' PLUMBING ,CONTRACTOR : Footing drain (no. lin. ft.) MI
;." , , l, Manufactured home utilities -
Business name: r jaMill1111 Manholes _
Address: Rain drain connector _
City: State: ZIP: Sanitary sewer (no. lin. ft.) -
Phone: Fax: E -mail: Storm sewer (no. lin. ft.) -
CCB no.: Plumb. bus. reg. no: Water service (no. lin. ft.) /DO
City /metro lic. no.: Fixture or item: ■-
Contractor's representative signature: Absorption valve
Back flow preventer _
Print name: Date: Backwater valve _
t , + :I, 1 t ',, E , >,, , ",;, CONTACT PERSON,4,, Basins /lavatory MI
Name: Clothes washer -_-
Address: Dishwasher _
Drinking fountain(s) -
City: State: ZIP: Ejectors /sump -
Phone: Fax: E-mail: Expansion tank _ -
` .;; ". >.t ` ,t { ' ^:.,OWNER ,;' `: ° ;;:s.• . .,.:„,;, . ' v t 1 Fixture /sewer cap _ MI
Na Name rent (print): 1 Floor drains /floor sinks/hub
(P ) J O I [ti . ✓�C /Vf� /v Garbage disposal MI
Mailing address: P D, 0 2 6 03 Hose bibb
City: j 1 A l€ t State:O11 ZIP: '72 9 / Ice maker _
Phone:511)3 - 3q - Fax: E -mail: Interceptor /grease trap _
Owner installation/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 progrty sminn as . - r ORS Chapter 447. Sink(s), basin(s), lays(s) -
Owner's signature. .6 U/ I L__ui <,_ Date: k -2 8 - 0 2. Sump -
', r : ENGINEER i . , Tubs /shower /shower pan _
/ Urinal 1
Name Water closet
Address: Water heater -
City: State: ZIP: Other:
Phone: Fax: E -mail: Total _ _ _ n- ,l
Not all jurisdictions accept t credit cards, please call jurisdiction for more information.
Minimum fee $ / a • CO
a p Notice: This permit application Plan review (at %) $
❑ Visa 0 MasterCard expires if a permit is not obtained
Credit card number: Expir / within 180 days after it has been State surcharge (8% ) .... $ .. -
Name of cardholder as shown on credit card
accepted as complete. TOTAL $
$
Cardholder signature Amount 440 -4616 (6 /00 /COM)
PLUMBING PERMIT FEES: 4 r'
1 , , , s . : - _ .> I E" TOTAL, -. "`
- New 1 and 2=`family dwellings'o' "nly ' „
* {FIXTURES, .(indi vidual) ,, , .x, P(ea' , g '. A MOUNT, . (includes all plumb ng t'i�turesn PR E ` e TOTAL ,
the
.;, =QTLY °__ � _ _
Sink 16.60 dwelling and thhe rs't100 ft „ QTY (e AMOUNT
- for each utilit connectionyA , e_ - s; v R =
Lavatory 16.60 . ,
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 16.60 SUBTOTAL z, E, '' " ",'; >" '^
Urinal 16.60 8% STATE SURCHARGE "5 „';,;." ` < ,'_
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL " z, ,°: • ,, t1
Garbage Disposal 16.60 TOTAL ; '°..u,` :. -" ;'!,';: ''
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 ' Quantlty`by,Wo�KP.erforrned "`
Gas piping requires a separate mechanical " Type 1. New Moved," IReplaced1 : "Remov ed /`
permit.
ow •• a ` ,.. ., , >, s : 4 .,: C app e d, µ
MFG Home New Water Service 46.40 Sink
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
Urinal
Other Fixtures (Specify) 16.60 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
(Specify)
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 Specially 62.50
Requested Inspections per /hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL =e," : ' ; " t. l' ° ;
Isometric or riser diagram is required if 4 , z °.iw
Quantity Total is >9 ^� . =N• ° , ! „�
*SUBTOTAL 7 4t
'';;; `
8% STATE SURCHARGE '' `'3`r
* *PLAN REVIEW 25% OF SUBTOTAL °4 i " '' ` : ;i :"
Required only if fixture qty. total is > 9 : --, -,, ""
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge. .
* * All New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
is \dsts \forms \plm- fees.doc 12/26/01 •
•
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION r : � � Business Line: (503) 639 -4171 MST
� BUP
Received Date Requested 7 ( AM PM BUP
l
Location 1( 1 n / • Suite MEC
Contact Person 9411/x) Ph ( ) 3q —S —S 7'J;2 PLM 2 6 --
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
ELC
Foundation
Ftg Drain Access: ELR
Crawl Drain . / /``"'
Slab I nspecti •'r r otes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing •
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm ,! -
Susp'd Ceiling
Roof r`,
Other: ,'
Final
P; • - T FAIL
li
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
F
dir PART FAIL
HANICAL
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 ❑ Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL