Permit CITY TIGARD PLUMBING PERMIT
A DEVELOPMENT SERVICES PERMIT #: PLM2004 -00409
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 9/8/2004
SITE ADDRESS: 14825 SW 92ND AVE PARCEL: 2S111AC KP001
SUBDIVISION: KELLEHER PARTITION ZONING: R -4.5
BLOCK: LOT: 001 JURISDICTION: TIG
CLASS OF WORK: NEW 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: 80 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Connect existing house to newly installed sewer lateral, approximately 80' . Septic tank is to be pumped and
filled.
FEES
Owner:
Description Date Amount
PHILLIP KELLEHER
PO BOX 23023 [PLUMB] Permit Fee 9/8/2004 $72.50
TIGARD, OR 97223 [TAX] 8% State Surcharl 9/8/2004 $5.80
Total $78.30
Phone : 503 936 - 7366
Contractor:
HOLLENBACH + HURD INC
3000 SW 174TH AVE
ALOHA, OR 97006 REQUIRED INSPECTIONS
Sewer Inspection
Phone : 591
lnsp existing /capped fixtures
Reg #: MET 4926 Final Inspection
LIC 121807
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 -000 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
-6699.
I ued By: = j A ;,� ,4L P ermittee Signature: A . D / ". ` � I
Call (50 639 -4175 by 7:00 P.M. for an inspection needed the next business day
BR:M.1 4g Fixtures
Plumbing Permit Application .. FOR OFFICE USE ONLY
City of Tigard Received 0 Date/By: 7 Dti Permit No.: A w ,
13125 SW Hall Blvd., Tigard, OR 97223
Plan Review - / �Q�` 4
Phone: 503.639.4171 Fax: 503.598.1960 Gy�NI � � + Other Permit No. t � 5/
24- Hour Inspection Line: 503.639.4175 + 6 -7/ i DateBy: tur
c Date Ready/By: RI See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method:
l Supplemental Information
£ `Yi*:?HI'S •i.- .- °mi�...a� am'.. '' �^, T "` "&aEi i�' �Arawv �,: >'; -34: i �,:ax_ . -„, w ",ty °�� -
' 4r- � ., , :. g WORK , y;,' .ar;..., :a `nc tQ.._, '> "� �r� 5 , , . SCAE D TLE
��. P x..o:�..„m `.�,., ��:�;; t 3: ,' , .3; X�`�aT9,a,;.�c :_,,,
..0 . .. &?;-���.g:��,,aw.:d� -:. ;,ter% ",�k�.;. 19���. h ' �. 5�' �?e. S., �� .... , k gn•::J3;s.a „e.a, :s?r•- -, _
❑ New construction ❑ Demolition For special information use checklist.
Description 1 Qty. Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
77; c�.. - r.� .� �s »�aax: , ..€; =.:z. xss� .°br�-�R� �a4':%;tt��^€ .� G r� a�..,�
GAT, e0. O C C TION r , ;°
y ` :, - , SFR I bath 249.20
�r��::' ;a,., .1 �e�i�'%a'�.'�F;., °�. �s�- ��� .:5.;'s��c�.,".c;a�s Mme, ' ( )
s. ❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
El Accessory building ❑ Multi- family SFR (3) bath 399.00
• Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
r u ; +K .y,s .F: x ION r: w,ti N :. €. .„,,, Fire sprinkler ( sq. ft.) Page 2
i t t , ,V JOB STIIE aaiiim AND eo ATION -. , t om. _ Site utilities
Job site address: \ C_( LS S.(�, (� 2 Catch basin or area drain 16.60
City/State/ZIP: -- tekt , C9N•-z-e_SoN.---- Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name: �� lt���� 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.: ) CJ Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: 1 Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
c ., ,te = ,: - ;7 rr :; W, aer Absorption valve 16.60
:� y &6, -4 t DESCRIPT ION OF WORK , .
- ,�.����.•� ��� ^.�.,, �.;:a,s, �:K*�. �,�:�- �,�,��t��- 6 -.. �`_, Backflow preventer Page 2
Co Kr. ec -t-- '\L) C .t-,x,-- Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
IV . . p :. �M ;n , � re Drinking fountain • 16 °60
i' ._,t � '4 T Y p ::, 4 +3 I-,. ' �.,,,, t TE lI - . 'i
ti � Ejectors /sump 16.60
Name: (:).6. . I \<:q 4 F� ^' \C�� Expansion tank 16.60
Address: Q �C 0 T 0 2_3 Fixture /sewer cap 16.60
City/State /ZIP: ir".D ' `e� CS t -t '� Z z Floor drain floor sink/hub 16.60
-
Phone: (573'3) q3 Fax: ( a3) (p2 0 _q" c(Z6 Garbage disposal 16.60
1,111‘-' xA:= t <> : °;:a, ., t.m; ;max^ r ms ..; , , Hose bib 16.60
§ . � ",; . _ i t:. ° GON ` ,
tea F °. h a a<r a. :;�xah >,: se.
Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax: : ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
I .- °�# v - ' r i «a-� s� + s ''s' 3 '' "= rSe'`>
° .., , , ,"a ,. �'� . r _: r GON � ... � eziv ; Kle F r�: W ater c 16.60
Business name: u �ka_ (1. t 1_-�-�A Water heater 16.60
Address: 1 `` Other:
City/State/ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lie.: / p..4 X6O 7 4. 1t 164' Plumbing Lic. no.: Plan review (25% of permit fee)
Authorized signature: l P \ f surcharge (8% of permit fee)
�-�( r 1 " ti TOTAL PERMIT FEE
Print name: ?h I 1 ti M t � <4- Dater (1 f Q g This permit application expires if a permit is not obtained within
111 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
is\ Building \Permits\PLMF- PernutApp.doc 12/03 440- 4616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
a1 Squai Foot, 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 Systems:
Water Service - each additional 100' 46.40
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
r-T4 fan 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:
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
W kQuantity by
fr AVOite $P3A0-4114,Air
Comments regarding fixture work:
Baptistry/Font
Bath -Tub/Shower
-Jacuzzi/Whirlpool
Car Wash -Each Stall •
•
•
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher -Commercial
-Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
Car Wash Drain
Garbage -Domestic
Disposal -Commercial *Note: If the fixture work under this permit results in an
-Industrial
increase of sewer EDUs, a sewer permit will be issued and
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang •
-Stall
Sink -Bar/Lavatory Quantity Total
-Bradley
Isometric or riser diagram is required if fixture quantity
-Commercial
-Service total is >9.
Swimming Pool Filter
Washer - Clothes
-.-
Water Extractor Plan Review •
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal -
Other Fixtures:
•
•
\Building\Permits \PLM-PennitApp.doc 3/03
FROM :HK;LLENBACH & HURD Inc FAX NO. : 583 848 6832 Sep. 10 2004 11:23AM P2
.— ...... _ .. - '• .C' te,.
r- "---- „ ....- +° - -- -
'worms.
CITY OF TIGARD 244Hour
BUILDING , Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line; (503) 639 -4171, MST
BUP
Received Date Requested AM pM /-a BUP
Location / L ,,�. .. '
[ . . t'r Suite
1 — MEC
Contact Person ,,. . rz., Ph ( r” ) / ., LM �,.
( I . _ E _ , .p r•_f c, 7 (:), t. ,
Contractor `
Ph ( ) SWR
_aUII:DING .- Tenant/Owner ELC
Footing
Foundation ELC
i � . , � i 71 ' z44 • ? �. Y'' 0.ti aka A 1,,"7 Z.Yf ° t k ., �
Ftg Drain re v- . ' ' ;', .. � ., F � ' 1„:"..,-,$, ' 1 � - r A r �� � , L„ ;� ` ',r � , • A .
Crawl Drain - 4 ti + ', , uR , ? w # .; t 9 1 ...3 1 4 - 1 -f. E LR
Sl .r.t . '•r,. „ _ � ":i •f� r r ' .. 1n2'i�M'��.,r ,y S:'�3. •4
Inspectio otes: SIT
Post & Beam (i
Shear Anchors ”
Ext Sheath /Shear
Int Sheath/Shear
Framing. .
Insulation
Drywall Nailing - j % `f
„v., ' , -,,,,, •
Flre Sprinkler 7 d ,,� , "%• .e. i
Fire Alarm ' :r
e ,
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL - - > , `
lEi ° UMMBIN /,
Post & Beam
Under Slab _...• ....
Rough-In
Water Service '- /3
" it iii ewer.
Rain Drains — -
Catch Basin / Manhole '
Storm Drain
Shower Pan
Other:
Fin1.
A $8 PART FAIL
HANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers -
Final
PASS PART FAIL
ELEc.TRicAL ..:
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final 0 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE .. ; ❑ Please call for reinspection RE: . fl Unable to inspect - no access
Flre Supply Line , t
ADA Q . ; 9 , - j ) I' i �r� " 5 '� .� , .. ` '
Approach /Sidewalk Date l f ' / 4/ Inspector -
Other: /
Final DO NOT REMOVE thla Inspection record from the Job site.
PASS PART FAIL
FROM :HOLLENBRCH 8 HURD Inc FAX NO. :503 848 6832 Sep. 10 2004 11:23AM P4
.
ALOHA SANITARY SERVICE ..
INVOICE NO.
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 8 8 7 0
503 -644 -2797 * 503- 648 -6254 i 503;639 -5188
' ..._.
NAME: '9'. i/ - .. ►r 1 4 +.. , 4 ,t /
ADDRESS: (�L -- a r, ,/(9/' Gam_
CITY: ,. a2 4 ., STATE: (7(. .... ZIP: 673 ' 6 ,..,
HOME: , f-: 7 77 - f 7" 75/ `"` _.. ORK: CELL:
JOB SITE: /2ST� .;f.,(/, f -,,- ' 1 , � ..r ' ,P0 •
i
PAID BY CHARG CHECK ❑ CASH LI CREDIT CARD ❑ _
DATE .'"?..-e? .. cl ei DRIVER 1 74aak iimg/ AMOUNT
C `.N PUMP SEPTIC TANK 7. 40
❑ INSPECTION FEE r
❑ SERVICE CALL ((
❑ LABOR, LOCATING, DIGGING, BACKFILL i
- - THIS Is NOT A SE IC SYSTEM INSPECTION REPORT - - TOTAL - $ �
-
/ - - REMARKS - -
TYPE OF TANK: /STEEL ❑ CbM BETE ❑ PLASTIC ❑ a;' HOMEMADE LI
HORIZONTAL ❑ VERTI@ L ❑ RECTANGLE» ❑ OTHER
SIZE OF TANK: 350 CI 500 Il 750 1000 0 / 1 2 50 ❑ 1500 ❑ 2000 ❑ 3000 ❑
Lio LOCATION: INLET ❑ OUTLET MIDD' ❑ ENTIRE TOP LI TANK CONDITION: GOOD ❑ kAIR ❑ P R ❑
FITTINGS: BAFFLES LI CONCRETE ❑ AST IRON LI PLASTIC II
NEEDS NEW LID? YES LI SIZE
GROUND COVER OVER TANK i
COMMENTS ON CONDITION OF DRAINFIEP. / 1
. ��
-
, ,... .
St• • BY J DATE t"7)o_(,,
A.
■ /
M
FROM ,: HOLLNBACH a HURD Inc FAX NO. :503 848 6832 Sep. 10 2004 11:23AM P3
3430-A S.W. 209th Ave., EXCAYATING AND UTILITIES Office (503) 591-5987
Aloha , OR. 97007-1073 OCCS #121807 Fax (503) 848-68
Email: handh2O@Juno.com
ON SITE SEWAGE DISPOSAL SYSTEM
AS-BUILT
Inspection Date: C LI.9nilding Permit # Septic Permit # zcp(1_,Qogo9
Building Contractor:
Tank Type: _it r41 Tank Size:
Drain Field Footage: /63 Drain Field
1 4)(4
`"
S6
\l/
i c/o
zit(
*4 46
FROM : HOLII & HURD Inc FRX NO. :503 848 6832 Sep. 10 2004 11:22AM P1
I-
Hodenbach & Hurd - inc. .
3430-A S.W. 2091.11 Ave„ EXC4V4riNG AND UTILITIES Office (503) 591-5987
Aloha , OR,. 97007-1073 OCC'R #121807 Fax (503) 848-6832
Email: handh20(4Jurio.com
FAX TRANSMITTAL
DATE . q 0 If FAX # ... 5 3-4.19 -36,1
7
PAGE j OF . 4 /
TO .-,
.., it d . ..
ATTN
ftLiees,6
41/4:e
L
FROM it-t..4-4 - •
Urgent Reply ASAP Please Comment Please Review
•
a l t )L or aAltoz-' h' .-- ife'")/(24414°
, j udt* 0 ' 0
Atearr
pa, d,looti - 0 0 ° 9
. •
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•
•
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested Ff - AM PM BUP
Location 1 Li 1� n -z S Suite MEC
Contact Person p ` � . � Ph ( /() 3 ( S 7 3 PLM d (- b0 4- 7 1 6
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
l Ftg Drain
Drain
• ELR
Crawl Drain �,,�
Slab Inspecti • �; otes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall 77.
Fire Sprinkler .s
P (Vflr7 / 1 �
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
ewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Fina
ar PART FAIL
CHANICAL
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 0 Please call for reinspection RE: 0 Unable to inspect — no access
Fire Supply Line
ADA
Date Approach /Sidewalk /17245
Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL