Permit .
CI TY OF TIGARD PLUMBING PERMIT
100 DEVELOPMENT SERVICES PERMIT #: PLM2001 -00404
44.
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/29/01
SITE ADDRESS: 11670 SW 98TH AVE PARCEL: 1S135CD -01800
SUBDIVISION: GREENBURG HEIGHTS 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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Connect existing house to newly installed sewer.
FEES
Owner:
Type By Date Amount Receipt
VISTA NORTHWEST PRMT CTR 8/29/01 $72.50 27200100000
PO BOX 91459 5PCT CTR 8/29/01 $5.80 27200100000
PORTLAND, OR 97291
Total $78.30
Phone 1: 503 - 531 -0505
Contractor:
VISTA NORTHWEST
P.O. BOX 91459
PORTLAND„ OR 97291 REQUIRED INSPECTIONS
Phone 1: 503 - 531 -0505 Sewer Inspection
R Final Inspection
Reg #: LIC 75507
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 - ::.'• copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issu • • By: / . /i 1 j -! .. Permittee Signature: \
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
, ,20'o0t — eto.,?Y'j
Plumbing Permit Application
Date received: d e y Permit no.: WAVY / --1 OX
M City g of Tigard
- . a 1' Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By: Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special inforn ation use checklist)
Job address: // 7 ' SL?:_j l Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: 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: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: - 7 - 2, 4 ,... 2 ,<>2) I ZIP: 5'>' Each additional bath/kitchen
Description and location of work on premises; ST)�, Site utilities:
,,le:=0"r-><Z../ Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line /trench drain
Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR
Manufactured home utilities
Business name: (��� Manholes
Address: p ' ?( ei I y5 Rain drain connector
City: p- 1 State:CLI ZIP: 9' 79-91 Sanitary sewer (no. lin. ft.) /aD '
Phone: 53o O Si, 5' I Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: 7 6-5 7 0/A.-Plumb. bus. reg. no: Water service (no. lin. ft.)
City /metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print): r �� c° �J— rc Floor drains/floor sinks/hub
Garbage disposal
Mailing address: 9IyS Hose bibb
City: 4' -;,,e7G�t/ Stated 3 ZII Jam , "7_ . / Ice maker
Phone 53/ z 01. 1 l r'ax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the mainten. r - . and L,;... 'r made by my regular Roof drain (commercial)
employee on the prope .,�• y • • � y �'haxt -• . Sink(s), basin(s), lays(s)
Owner's signature: /ems i • • % __Ai'"i Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name:
Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: Fax: 1E-mail: Total �� 6-1::. rm
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ . �,_ d j � �� ,
Notice: This permit application
la Visa review (at %) $ _ Visa ❑ MasterCard expires if a permit is not obtained TO
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $
Expires TOTAL $ 7C • 3
Name of cardholder as shown on credit card accepted as complete
Cardholder signature $ Amount � 3 � • � 440 -4616 (6/00 /COM)
�LI J3 -3�
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
16.60 for each utility connection)
Lavatory 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 •
Urinal 16.60 8% STATE SURCHARGE ,
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL .
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity b Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
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
Other Fixtures
Water Service - each additional 200' 46.40 (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 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25 -
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
* SUBTOTAL
8% STATE SURCHARGE -
* *PLAN REVIEW 25% OF SUBTOTAL
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 plans with isometric or riser diagram and
plan review.
is \dsts \forms \plm- fees.doc 10/10/00