Permit C ITY OF T I GA R D PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2005 -00012
— 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1(12/2005
SITE ADDRESS: 11835 SW 95TH AVE PARCEL: 1S135CD-02500
SUBDIVISION: BOETCHERS ADDITION ZONING: R -4.5
BLOCK: LOT: 007 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: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 120 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replace 120' of sewer line.
FEES
Owner:
Description Date Amount
CORYELL, JACK M AND ALICE 0
TRUSTEES [PLUMB] Permit Fee 1/12/2005 $101.40
9900 SW 92ND [TAX] 8% State Surchar1 1/12/2005 $8.12
PORTLAND, OR 97223 Total $109.52
Phone:
Contractor:
MR ROOTER OF PORTLAND
PORTLAND SERVICES INC
15033 SE MCLOUGHLIN BLVD #344 REQUIRED INSPECTIONS
MILWAUKIE, OR 97267
Phone : 503-653-5301 Sewer Inspection
Final Inspection
Reg #: LIC 138941
PLM 3 -434PB
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 -6699.
Issued By: / / Go Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
(
R RECEIVED
Plumbing Permit Application FOR OFFICE USE ONLY
City of Tigard I .{AN 12 2005 ' Receive / %Z -& 2 - Permit No.:� L�2cv� - � )
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review 4. r
Phone: 503.639.4171 Fax: 503.598.1X9 Q % ' I
I Date/BY: :
\ Other Permit No.:
24- Hour Inspection Line: 503.639.4174.1TY OF TIG : ∎ ' '
Internet: www.Ci.ri ard.or.us • - : + Date Ready/By: Juns: See Page 2 for
g . L NG DI Notified/Method: Supplemental Information
�. � .0 ,' .2. -. . _ `, , __, , . ,,.„ T., , � J .
p� r , �x v
❑ New construction ❑ Demolition For special information use checklist.
Description Qty. 1 Ea. I Total
ddition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
24.';',", p i : -s z : `� SFR (1) bath 249.20
...,.�. .rr._..,�z �,�.1 ' :.:: � �.i ;: s �:s ... .
E' - and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other:
Fires rinkler s . ft.
Pa e 2
g
, - I. '',::;.:.,',1`,:c,.:, w Y _ id Site utilities
Job site address: �r
t C i Catch basin or area drain 16.60
City/State/ZIP: ` \ c.-j 0 R ll 22_._2_. Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: 9....-O e\ 0_ Footing drain (no. linear ft.: Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
_ Manholes 16.60
X`- \ G I N rat -6 Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) I ) 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
-� ' f--n 4 i Absorption valve ] 6.60
,, s ' ii ^^ . ' .4 . n 4� 5` '9 a . 11 :..4 . -' -. Backflow preventer Page 2
R - -5(/C l v K Q O . Backwater valve 16.60
Iy'_ Clothes washer 16.60
Dishwasher 16.60
,: i a- t ., Drinking fountain 16.60
� - ._ _ate . __ - : a '' Ejectors /sump 16.60
Name: 1 C,V__ Expansion tank 16.60
Address: \ 1.6.. • ST Fixture /sewer cap 16.60
City/State/ZIP: T r c- O vz -1 Floor drain/floor sink/hub 16.60
Phone: (91 ) 1 f I' 0 • Fax ( )
Garbage disposal 16.60
. F ^ Hose bib 16.60
-- *r te Ice maker 16.60
Business name: , e_[, Interceptor /grease trap 16.60
Contact name: �� 3 v 1 Medical gas (value: $ ) Page 2
Address: \Y33 �E, N•C-. LOkA_G
„E '■.,., tn" 2 (j� . Primer 16.60
City/State /ZIP: IA L L r c , o c1 2' 7 i T Roof drain (commercial) 16.60
( � (a S 3 - -So I (. (053....s 3-7 Sink/basin / lavatory 16.60
Phone: Fax: : �jv3 ) (O
Tub /shower /shower pan 16.60
E-mail:
; �,. i :�� = „ l �' Urinal 16.60
.
a J �1 r. s : w ' I a Soak
� � ��,.' .� �� � . .� _ _ a �fi �`°= � � � 9 . . e.,,;,-., Water closet 16.60
Business name: Water heater 16.60
Address: Other:
City/ State/ZIP:
Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 l a/, g 6
N. "CB Lic.: t 1 Plumbing Lic. no.: 34 l `--1 c ? Plan review (25% of permit fee)
Authorized signature: (iihV State surcharge (8% of permit fee) 4,2_ r 1 t' TOTAL PERMIT FEE j (JL/ .) - Q 2 . _
Print name: t_ Lj f. / o g.T V Ns Date: ii i 2.1° 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\Pemtits\PLM- PermitApp.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:
Square root P ermit 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 Vali�a><ot: +t`m�t
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
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
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
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 * .
e i i V P • p p JA It � Peafarr �.
° � 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
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:
is\ Building \Permits\PLM- PermitApp.doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: , 03) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 - 4171 MST
Received Date Requested / — / 3 AM PM BUP
Location ) ? 3 ,� � ` r�-Q -� Su MEC
Contact Person 9,19/Le/yr 8, Ph ( ) F — Lf 4 p / A ' .
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
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
11
Roof
Other: •
Final
PASS PART FAIL
PLUMBING •
Post & Beam
Under Slab
Rough -In
Water Service i r e
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other
Fin
PART FAIL
ANICAL
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 in — no access
Fire Supply Line 1
ADA Approach/Sidewalk Date D Inspector 4/ Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL