Permit CITY TIGARD PLUMBING PERMIT
AN WS i ; D EVELOPMENT SERVICES P ERMIT #: PL 15/200 -00265
-4 - f 13125 SW Hall Blvd., Tigard, O R 97223 (503) 639 -4171 DATE ISSUED: 6/15/2004
SITE ADDRESS: 11405 SW 95TH AVE PARCEL: 1S135CA -02200
SUBDIVISION: BOETCHERS ADDITION ZONING: R -4.5
BLOCK: LOT: 003 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: 1 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: Replace gas water heater with like kind.
FEES
Owner:
Description Date Amount
VICTORIA VILLARREAL
11405 SW 95TH [PLUMB] Permit Fee 6/15/2004 $72.50
TIGARD, OR 97223 [TAX] 8% State Surchari 6/15/2004 $5.80
Total $78.30
Phone : 503 620 - 6016
Contractor:
WORTHINGTON PLUMBING
3915 SE MONROE ST
MILWAUKIE, OR 97222 REQUIRED INSPECTIONS
Phone : 503 Rough -in Insp
Final Inspection
Reg #: LIC 153975
PLM 3 -489PB
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 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
246 -669 .
Issue B y: L i A Permittee Signature: „0 , � ,;/I is -�
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
FROM :WorthingtonPluming Inc FAX NO. :5036597747 Jun. 11 2004 02:54PM P1
Plumbin Per imit A. licatio
r()l: OI I l( I I �I 1)m
City of Tigard
Alk Rece ived �
13€25 SW Hail Blvd,, Tigard, OR 97223 i>afe/13 Q / permit No.: ./ t= " D S
Phone: 503.639.4171 Fax: 503.598 -1960 . v Review
24- Hour 1rt9pcction Line: 503.639.4175 t)atc/By: Other Permit No.:
Internet: www.ci,tigarrl.or.us r - - Date
r /By: tuna I See page 2f 01
Supplemental Information
r1j.1P
T1�
. 0 *0•A* .
❑ New construction ❑ Demolition For special atfornudto t use checklist
® Addition /alteration /replacement ❑ Other: I Qty I Ea T
Des cription
•
New 1- 2- family dwellings (includes 100 it for each utility connexion)
CAI CrORY,;OF . GQN
SIR (1) bath 24920
® 1 - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
111 Accessory building ❑Multi-family ,. — SFR (3) bath 399,00
Each additional bath/kitchen 45.00
❑ Master builder ❑Other:
.. ire a s9 ft) "' sprinkl r ( , ft. Page 2
A" `_. : , : ; 4 51ST : '1lN''1F'ORM41 O1 .TAND .LOCATION
,.. .... S n
lob site address: 1140S SW 95"h Ave _ Catch basin or area drain 16.60
City /State/ZIP: Tigard, Or _Drywell, leach line, or trench drain 16.60
Suite/bldgJapt- nn -: project name: Footing drain (no. ling ft.: Page 2
Cruet street /directions to job site: - Manufactured home utilitiCS 110.00
�• - Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear lt.: ) Page 2
Subdivision; I no.: Water service (no, linear ft.: ) Page 2
Tax ma / I
Fixture or item
map /parcel no_:
Absorption valve 16.60
t . - DF,SCRIPTI(al� O :CttQltl , T Beckflo_w prcvcntcr Page 2
Replace 40 Gallon gas water heater with new 40 gallon gas water heater Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
-
-. . `23IRei 4 141**- .':'' :'..`;,,.. �. 3iiiNAPIT! '
m
:' •:..' ;: : ' ,.. mg fountain 16.60
Bjecuxs/sump 16.60
Name: Vikki Viliesseal — Expansion tank 16.60
Address: 11405 SW 95 Ave i•
�., -- -- ...
Fixture/sewer cap 16.60
City /State/LIP: Tigard OR Floor drain/floor sink/hub 16.60
Phone: (503)620 Fax: ( ) Garbage disposal 16 -60
�I;; t►t'LI(l_r,11T ; CaNTAC F
Row bib 16,60
- .. lie maker 16.60
Business name: Worthington Plumbing Inc.
Interceptor/grease trap 16.60
Contact name: Tim Worthington _ medical gas (value: $ ) Page 2
Address: 3915 SE Monroe St, Primer 16.60
City /State/ZIP: Milwankie OR 97222 Roof drain (commercial) 16.60
Phone: (503) 522 -3908 I Fax: : (503) 659 -7747 Suitt/basin/lavatory .. • 16.60
E-mail: t.worthington(a,>eomcast.oct fib /shower /shower pan 16.60
Urinal 16.60
...... ,.., ,:i:.': ?; ':; ; >WVTRA;G`I'(1x >- ;` - , .. Water Inset 16,60
_
Buainnas name: Worthington Plumbing inc. Water heater ' 16.60 /6,66
Address: 3915 SE Monroe St. Other;
City/State/ZIP: Milwaukie OR 97222 Subtotal 4,.‘11
Minimum permit tee: $72.50
Phone: (503) 522 -3908 Fax: (503) 659 -7747 Residential backtlow minimum
permit fee: $36.25 - � Z is) v
CC :l3 lie.: 153975 /' - Plumbing Lie, no.: 3 - Pli Plan review (25% of permit fee)
/ - 4 / 0 S State s urcharge (8% of p ermi t fee) 5 , -t7'
Authorized signature: �t -- (� 'ill 3 3� —
��/ •� _ Terror. pERMTT FEE 7k 36
Print name: Tim Worthington 4 Date: 6-9-2004 I This permit application expires if a permit is not obtained within
-- 180 days after it bas been accepted as complete.
•Fcc mcthodo €oev set by Tri -County Building Industry Service Board.
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested / AM PM BUP
Location / / L/ O� S ` / 4-1 P -12 Suite MEC
Contact Person Ph ( ) Sv — . I `f PLM € 2U O 9 `OO4p? 6,5
Contractor Ph ( ) SWR
BUILDING Tenant/Owner !/ � -�-cp , V .,cQ�1/� -� ELC
Footing 6 O - Coo /6 ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: .. SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear /' 00 p, rD U
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler 6
Fire Alarm
Susp'd Ceiling
7-
Roof
Other:
Final
PASS P RT FAIL
MBI
Pos Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
OPART FAIL
0 • ■fir AL
Post & Beam
Rough -In
Gas Line
Sm • .e Dampers
in -)
PART FAIL
CTRICAL
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 E Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date J ■ Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL