Permit CITY TIGARD PLUMBING PERMIT
aim I
DEVELOPMENT SERVICES PERMIT #: PLM2005 -00149
�.� 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 4/14/2005
PARCEL: 2S111 BD -00407
SITE ADDRESS: 14940 SW 96TH AVE ZONING: R -3.5
SUBDIVISION: DARMEL NO. 3 LOT: 017 JURISDICTION: TIG
Project Description: Sewer connection.
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: 60 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
POEHLER, EDWARD CARL
MYRTLE J Description Date Amount
14940 SW 96TH AVE [PLUMB] Permit Fee 4/14/2005 $72.50
TIGARD, OR 97223 [TAX] 8% State Surchari 4/14/2005 $5.80
Phone : Total $78.30
Contractor:
A- AFFORDABLE SEPTIC SERVICE
PO BOX 1130 REQUIRED ITEMS AND REPORTS
WILSONVILLE, OR 97070
Phone : 503 969 - 9548
Reg #: LIC 158246
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 e •ire't • - .•ns to ON C by
calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued By: � ��l Permittee Signature:
—
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
t- , ) di 5in r �^
Plumbing Permit Applic `-' + I EIVEH '. FOR OFFICE USE ONLY
City of Tigard APR 1 4 200, D te/By /y - � Permit No.r3 W ,65 G0 j yy
13125 SW Hall Blvd., Tigard, OR 97223
Plan Revi
Phone: 503.639.4171 Fax: 503.598.1960 /vr »a:4 Al I h Date/By eW Other Permit No..
SUSI iyo J2;6
24 -Hour Inspection Line: 503.639.4175 CITY OF TIGA'..-4' -'� I ,. Date Ready/By: J ri s: ® See Page 2 for
Internet: www.ci.tigard.or.us BUILDING DIVIRInni Notified/Method: f / Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition /alteration/replacement ❑ Other: New 1 dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION - SFR (1) bath 249.20
a 1- and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
El Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION' AND LOCATION Site utilities
Job site address: / 7 ? _) S .96Az Catch basin or area drain 16.60
City /State /ZIP: T- �(/ (0/ c ? 7.22
� �/ Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
/ Manufactured home utilities 110.00
c : /-
Cross street /directions to job site: 4( 9l AL
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.:6) ) 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.: Absorption valve 16.60
DESCRIPTION ff OF WORK // Backflow preventer Page 2
/'
D/7/72G/7 <�� Yv �i/�j � A__ /�zT Backwater valve 16.60
G eVQ / '..51(1)---/ 1 / / -AO C ! ,�_ j--12 j Clothes washer I 16.60
/� Dishwasher 16.60
/� PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
�j� / / Ejectors sump 16.60
Name: ,/f 1jr�'T /C
O e f1 /�
Expansion tank 16.60
L
Address: j4" 7 _____‹66.), 9'� Fixture /sewer cap 16.60
City /State /ZIP: 72,- ®Z G' 7 - 22 5/ Floor drain/floor sink/hub 16.60
Phone: (spy) (7_ s".:26 (.: Fax: ( )
Garbage disposal 16.60
Hose bib 16.60
APPLICANT , ❑ CONTACT PERSON
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: ( I Fax: : ( )
Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
•
. CONTRACTOR Water closet 16.60
Business name: 1 L /���� / e //(, Water heater 16.60
Address: 9,7"c9, R�X r / / 430 ! Other:
� 9 Subtotal
l�r/
City /State /ZIP: . / rJ . / A, (3 7
/ 9 7 Minimum permit fee: $72.50
Phone: (5 ) 919 - _s--e_//g' Fax: (563 5 70 - es 7 7 C7 Residential backflow minimum permit fee: $36.25 /
/s- p ,21
/� Plan review (25% of permit fee)
CCB Lic.: / !� 7 Plumbing Lic. no.:
Authorized signature: �- / State surcharge (8% of permit fee) J-7.1,0 %C -iGiL ///4,5"."- PERMIT FEE .3 e
Print name: ZC1 �2rf} 5 Date: 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 \Permits\PLM- PennitApp.doc 12/03 440-4616T(l 0 /02/COM/WEB)
Plumbing Permit Application - City of Tigard r - .,
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities • Qtr. Fee (ea) Total Square. Footage: 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 Valuation: Permit Fee: '
$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
Fixture or Item. Qty. . ".Fee (ea) Total 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
Inspection of existing plumbing or each additional $100.00 or fraction thereof; to •
specially requested inspections - per hour 72.50 and including $50,000.00.
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 * .
Quantity by,(Fixture) Work Performed
Fixture. Type: . Replace
New Moved" Existing Capped 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"
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
Commercial Isometric or riser diagram is required if fixture quantity
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 ,.)
BUILDING DIVISION PERMIT #: PLM2005 00149
13125 SW Hall Blvd., Tigard, OR 97223 D ATE ISSUED: 4/1412005
Phone: (503) 639 -4171 i° ��°mlpuypi�61�i
Inspection Requests (24 Hrs.): (503) 639 -4175 :..'
INSPECTION WORKSHEET FOR DATE: 4/20/2006 TIME: 7:11AM PAGE: 11
SITE ADDRESS: 14940 SW 96TH AVE CLASS OF WORK:
SUBDIVISION: DARMEL NC). 3 LOT #: 017 TYPE OF USE:
PROJECT NAME: POEHLER •
DESCRIPTION: Sewer connection.
OWNER: POEHLER, EDWARD CARL, / / #:
CONTRACTOR: A- AFFORDABLE SEPTIC SERVICE /� PHONE #: 503 - 969 -9548
Inspection Request Scheduled For: Date: 4/20/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 004961.01 603.969.9548 N
Corrections /Comments /Instructions:
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C PASS ❑ PARTIAL APPROVAL ❑ CANCEL
n NO ACCESS
AIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: 1- 77?, Date: , G Phone #: (503) 718- /
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SEPTIC SERVICE
P.O BOX 1130
�. UbIISONVfiLLE, OA 97070
. (503) 682.1929 FAX (503) 570.0779
CUSTOMERS ORDER NO, PHONE DATE
( ; °)) G
ADDRESS
//9 ,y. 6) m v
SOLD BY CASH C.O.D. CHARGE ON ACCT, MDSE. RET'D. PAID OUT
CITY. DESCRIPTION PRICE AMOUNT
77 Foi'{ Mona? / 5.4fe w !
TAX
RECEIVED BY
TOTAL
All claims and returned goods MUST be accompanied by this bill.
!/ ToRc arctar: THANK YOU
800 - 225.8380 or noln.corra /.