Permit CITY TIGARD SEWER CONNECTION PERMIT
A DEVELOPMENT SERVICES PERMIT #: SWR2000 - 00122
Ai' 1 3125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 06/07/2000
SITE ADDRESS; 14485 SW 100TH AVE PARCEL: 2S111 BC -00400
SUBDIVISION: TIGARDVILLE HEIGHTS ZONING: R -3.5
BLOCK: LOT: 019 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Connection to sewer lateral as part of Reimbursement District #13. Reimbursement fee of
$8,000.00 paid on 6/7/00. Septic tank to be pumped, filled and capped or removed and inspected.
Owner:
FEES
UNTALAN, JOSE C + JUANITA F
TRUSTEES Type By Date Amount Receipt
14485 SW 100TH PRMT KJP 06/07/200C $2,300.00 0002765
TIGARD, OR 97224 INSP KJP 06/07/200C $35.00 0002765
Phone: Total $2,335.00
Contractor:
Phone: ORIGINAL
Reg #:
Required Inspections
Sewer Inspection
Septic Tank Filled
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires
180 days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not
guarantee the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer
shall prospect 3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and
Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted
by the Oregon Utility Notifi tion Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0080.
You may obtain copie f th e rules or direct questions to OUNC by calling (503) 246 -1987.
Issued by: Permittee Signature: �� /2 (I
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed th ext business day
CITY OF TIGARD Plumbing Permit Application Plan Check#
13125 SW HALL BLVD. Commercial and Residential Rec'd By
TIGARD, OR 97223 Date Rec'd
(503) 639 -4171 Date to P.E.
Print or Type Date to DST
Incomplete or illegible applications will not be accepted Permit #
Related SWR # S(,it 2- (Cr1 -CO J22.
Called
Name of Development/Project FIXTURES (individual) QTY PRICE AMT
Job Sink 11.50
Address Street Ad ress ' j _ Suite Lavatory 11.50
��� � � /rv Tub or Tub /Shower Comb. 11.50
Bldg # Ci/ ` I4- Z7 7 z 5"-i( Shower Only 11.50
N_.� Water Closet 11.50
.J es 5 C I,Ar -1A/ Urinal , 11.50
Owner Mailing Address Suite Dishwasher 11.50
/Y7g -s- $i) /& �& Garbage Disposal 11.50
Cit !S to Zip Prone
�- , � j � Laundry Tray 11.50
(/ y� �Z -`� a -3G G6
Name Washing Machine /Laundry Tray 11.50
' T C. LA/ 7 -LA-,1Y Floor Drain /Floor Sink 2" 11.50
Occupant Mailing Address ), Suite 3" 11.50
114.4"--- -6-'•1,/. r4rr9 4 4„ 11.50
Ci ! tate Z Phone
---/ �/f - `-cf .
` f q 7 ay , -24 G L Water Heater 0 conversion 0 like kind 11.50
Name " 7 �f � Gas piping requires a separate mechanical permit.
ngD g --� MEG Home New Water Service 32.00
Contractor Mailing Address Suite MFG Home New San /Storm Sewer 32.00
Hose Bibs 11.50
Prior to permit City /State Zip Phone Roof Drains 11.50
issuance, a copy q,1Y- .1, f
Drinking Fountain 11.50
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if Other Fixtures (Specify) 15.00
expired in COT Plumbing Lic. # Exp. Date
database
Name
Architect Sewer - 1st 100' 38.00
or Mailing Address Suite Sewer - each additional 100' 32.00
Water Service - 1st 100' 38.00
Engineer City /State Zip Phone
g Water Service - each additional 200' 32.00
Describe work to be done: Storm & Rain Drain - 1st 100' 38.00
New 0 Repair 0 Replace with like kind: Yes 0 No 0 Storm & Rain Drain - each additional 100' 32.00
Residential 0 Commercial 0 -
�lditional description of work: Commercial Back Flow Prevention Device 32.00
h , : �
a 0-¢F r /r Residential Backflow Prevention Device* 19.00
(�' Catch Basin 11.50
Are you capping, moving or replacing any fixtures? Insp. of Existing Plumbing or Specially Requested 50.00
Yes 0 No 0 Inspections per /hr
If yes, see back of form to indicate work performed by Rain Drain, single family dwelling 45.00
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Grease Traps 11.50
WORK COULD RESULT IN INCREASED SEWER FEES.
I hereby acknowledge that I have read this application, that the information QUANTITY TOTAL
given is correct, that I am the owner or authorized agent of the owner, and Isometric or riser diagram is required if Quantity Total is > 9
t t plans submitted are in compliance with Oregon State Laws.
nature of O `SUBTOTAL
L. _ ' A n� Dajg�7�
��* ( 8% SURCHARGE
ontact Person Name Phone
**PLAN REVIEW 25% OF SUBTOTAL
1 BATH HOUSE $178.00 Required only if fixture qty. total is > 9
2 BATH HOUSE $250.00 TOTAL
3 BATH HOUSE $285.00
(This fee includes all plumbing fixtures in the dwelling and the first 'Minimum permit fee is $50 + 8% surcharge, except Residential Backflow Prevention
100 feet of sanitary sewer storm sewer and water service) Device, which is $25 + 8% surcharge
"All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
I: \dsts \forms\plumapp.doc 11/18/99 x OLo 0
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
l \dsts\forms\plumapp . doc 11/18/99
CITY OF TIGARD BUILDING INSPECTION DIVISION MST
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
BUP
Date Requested (P/ c y 00 AM ,k PM BLD
Location (- g 1 Suite O / _ MEC r�
Contact Person Ph ql 3 l - •S �o pun 2 O ` 0010
Contractor Ph SWR Z000 - 001 22
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler � •
Fire Alarm , J j '
Susp'd Ceiling /�` - ; }'
Roof " i ,.t'
Misc:
Final
PASS PART FAIL
IL IUS)
Post & a
Under Slab •
Top Out
Wa - - ice
Rai, - 'rains
fir PART FAIL
ANICAL
r ,„/
Post & Beam % ir,•;
Rough Inr
Gas Line ii/p717.
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
Fire Supply Line
ADA
Approach/Sidewalk Date / I Inspector 12/9 Ext
Other r Final
PASS PART FAIL D • 'NOT REMOVE this inspection record from the job site.
06/09/2000 17:13 5032515428 STEVE MCBEE PAGE 01
Invoice
JAMES GRIF FITILS EXCAVATING, INC.
N �� _ L ' . Date _ [ , — - o
�� Phone 9_3P - e /..4
CRY — r i _ .� initial Terms On Acct.
state Zip code
Pilaf Amoum
eb.
I
AMMO
* NOT RESPONSIBLE FOR LANDSCAPING
l r
*A service ChArpa of 1 1126 per month will be charged on all past due accounts.
A fee of $10 ad will be charged on 311 returned checks. Not responsible for attorney's tees. ibt' C5 ,�---
Apprgval
Sys I�s. .,00111M.�
Customer :. nature
P.O. Sox 1136 • Canby, OR 97013
COB #104320 (503) 263 -8038 • Pager (503) 815 -9368 ?l ankyou