Permit CITY TIGARD PLUMBING PERMIT
I A , DEVELOPMENT SERVICES PERMIT #: PLM2004 -00209
j• ' I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/12/2004
SITE ADDRESS: 14175 SW 103RD AVE PARCEL: 2S111 BB -02000
SUBDIVISION: TIGARDVILLE HEIGHTS ZONING: R -3.5
BLOCK: LOT: 002 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: ft
WATER CLOSETS: WATER LINE: 190 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replace 190' of water service.
FEES
Owner:
Description Date Amount
KEN &JL CROSS
14175 SW W 103RD RD [PLUMB] Permit Fee 5/12/2004 $101.40
TIGARD, OR 97224 [TAX] 8% State Surchari 5/12/2004 $8.12
Total $109.52
Phone : 503 624 - 1659
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : Water Service Insp
Final Inspection
Reg #:
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 -4 e e -: !S. You may obtain copies of these rules or direct questions to OUNC by calling (503)
• 6 -6699. f / '
Issued By: . / .i � ' J :� Permittee Signatur �l •
Call (503) • 9 -4175 by 7:00 P.M. for an inspection needed1'next business day
Building Fixtures
Plumbing Permit Application FOR OFFICE USE ONLY �/y���}
Received / C97'- ti--49.)1
Pemut No.: mo
City of Tigard Rec \ J
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 / - 'c.11l:�„' i i Date/By: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 1 'f 1 Date Ready/By: Allis ; ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Supplemental Information
x + 4 FEE* SCHEDULE
' x i z _ . 1 H'Y' OF WORT ,
❑ Demolition For special information use checklist.
El New construction Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1 2 family dwellings (includes 100 ft. for each utility connection)
���� , „ � .'.. . SFR (1) bath 24920
❑ 1 and 2 family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
SFR (3) bath 399.00
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
t
,i Job site address: t t - I . e , , "' ` ` Site utilities
y
/ 75 ,5 ,
`� �� Catch basin or area drain 16.60
l ✓ '47. � 7 7.7-e.-`7/ Drywell, leach line, or trench drain 16.60
City/ State/ZIP: 1 r
/� Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: / PProect name:
Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ______) Page 2
C
Storm sewer (no. linear ft.: ) Page 2
_
--) Water service (no. linear ft. Page 2 /Q /, 40
Subdivision: Lot no.:
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
A AF %'i l f.. TirtN OF WORK - ,, fi :k
W 11-,,..-.0,- ,rr - ' 13=1c preventer Page 2
U V 0'66°4 g' ���� Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
t y i Drinking fountain
` 16.60
�a , i m ,,u r ��- ,.. Ejectors /sump 16.60
Name: €/ q' Gr '1/ g ez Expansion tank 16.60
Address: /9775. 4.;!Q Fixture /sewer cap 16.60
City/State/ZIP: T - ,Y f/� 7 ZC Floor drain /floor sink/hub 16.60
/� / Fax: Garbage disposal 16.60
Phone: `6 O (O !�/ ( )
-, t-; Hose bib
R . _
g: m ,, ii: 4 s' a ., Ice maker 16.60
f mom. a"a.c+ `
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address:
Primer 16.60
Roof drain (commercial) 16.60
City/State /ZIP:
Sink/basin /lavatory 16.60
Phone: ( ) I Fax:: ( )
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
� ..; -
' _ :c' �, � _ - . 1
., �. Water closet 16.60 ar
udf2tes5 nathe: 3��� Water heater 16.60
f� it
Other:
Address: Subtotal
City/ State/ZIP: Minimum permit fee: $72.50 U �
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 (
Plumbing Lic. no.: Plan review (25% of permit fee)
CCB Lic.: g t
State surcharge (8% of permit fee) $, /
Authorized si_ C �, C%' L / � a2O TOTAL PERMIT FEE JO 9 rs�
v
Print na s / / /91. a�0ss Date: _ 02 /Q� This permit application expires if a permit is not obtained within
/ 180 days after it has been accepted as complete.
*Fee methodology set by Tn Building Industry Serv Board.
440- 4616T(10 /02/COM/WEB)
i:\Building\P /LMF- PermitApp.doc 12/03
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. 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
Valuation: Permit Fee:
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
® , . ota additional $100.00 or fraction thereof, to and
- d =., r a v� . �� � Y .,. 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 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: 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 ('Fl±ture) Woek Performed
FuturelyPe« I{eplace
Nev Moved Extshag 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 „ -
- 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 fees assessed for the sewer increase must be paid before the
Oil Separator (Gas Station)
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 total is >9.
- Service
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:
i:\ Bui lding\Pennits\PLM- PermitAPP.doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 - 4175
INSPEtsTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested _ T AM PM BUP
Location Suite MEC
Contact Person / /� Ph ( ) 6
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
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
/414o7)&01--- Fire Sprinkler UU Fire Alarm et L
Susp'd Ceiling /
Roof ‘nt C, ' //e •
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Ro
,
Sanitary Sewer
Rain Drains A /1
Catch Basin / Manhole ,
Storm Drain
Shower Pan
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 E Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE ❑ Please call f• reins. -ction RE: �� nable to inspect — no access
Fire Supply Line / � � )(Z�
ADA
Approach/Sidewalk Date Inspector � Ext -
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL