Permit s a
A CITY OF TIGARD PLUMBING PERMIT
.
P ERMIT #: PLM2000 -00294
,, DEVELOPMENT SERVICES DATE ISSUED:
13125 SW Hall B lvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 14790 SW 104TH AVE PARCEL: 2S111 CB -01301
SUBDIVISION: DEL MONTE SUBDIVISION NO.2 ZONING: R -3.5
BLOCK: LOT: 021 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: 112 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Reimbursement District #16
FEES
Owner:
Type By Date Amount Receipt
BANFORD, ROBERT D PRMT RCP 8/9/00 $70.00 0004378
BETTY R 5PCT RCP 8/9/00 $5.60 0004378
14790 SW 104TH
TIGARD, OR 97223 Total $75.60
Phone 1:
Contractor:
PHIL PAULSON EXCAVATION
1939 SE BROOKWOOD AVE
HILLSBORO, OR 97123 REQUIRED INSPECTIONS
Phone 1: 693 -6610 Sewer Inspection
Reg #: LIC 141383
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 may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
_ f ,
Issued By: ! (e , 'Q Permittee Signature: _Q
Call (5 ) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Ct rY 011r TIGARD Plumbing Permit Application Plan Check#
13125 SW HALL BLVD. 'Commercial and Residential Rec'd Byyn)
TIGARD, OR 97223 Date Rec'd s` -- 00
(503) 639 - 44'71 Date to P.E.
Print or Type Date to DST
Incomplete or illegible applications will not be accepted Permit #
Related SWR # 6 234
Called
Name of Development/Project FIXTURES (individual) QTY PRICE AMT
Job / //79c , /t). /C4/4 Sink 11.50
Address Street Address Suite Lavatory 11.50
Tub or Tub /Shower Comb. 11.50
Bldg # City /State Zip Shower Only 11.50
% <A - .O ; D. 97,2.
Water Closet 11.50
e g, r %-: 6 46/1. C Urinal 11.50
Owner Mailing Address 9 �� Suite Dishwasher 11.50
/I71rn .5• Ai, i�* Garbage Disposal 11.50
City /State Zip / Phone
/6A Dt. g7„7.?I- � off, 3 Laundry Tray 11.50
Name Washing Machine /Laundry Tray 11.50
jJ/y74 Floor Drain /Floor Sink 2" 11.50
Occupant Mailing Address Suite 3" 11.50
4" 11.50
City /State Zip Phone
Water Heater 0 conversion 0 like kind 11.50
Name Gas piping requires a separate mechanical permit.
/-y IL A4 a o4.) F XC4 0177ti/- MFG Home New Water Service 32.00
Contractor Mailing Address Suite MFG Home New San /Storm Sewer 32.00
/939 ,5F64oexid 4vr Hose Bibs 11.50
Prior to permit City /State Zip , Roof Drains 11.50
issuance, a copy ,' /(.L 3 C � , 9 2� 79 /Vi Drinking Fountain 11.50
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if /q'/ 3 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
Water Service - each additional 200' 32.00
Describe work to be done: Storm & Rain Drain - 1st 100' 38.00
New, Repair 0 Replace with like kind: Yes 0 No 0 Storm & Rain Drain - each additional 100' 32.00
Residential 6 Commercial 0
Additional description of work: Commercial Back Flow Prevention Device 32.00
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. QUANTITY TOTAL �/ j
I hereby acknowledge that I have read this application, that the information Isometric or riser diagram is required if Quantity Total is > s I t-`'
given is correct, that I am the owner or authorized agent of the owner, and *SUBTOTAL
that plans submitted are in compliance with Oregon State Laws.
Ny Sign t of Own r /Age t Date 8% ture �S CG���}�_ ' .rI eS 8/a SURCHARGE 5 tt; / (-
Conta , RR o Name J 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
gr
3 BATH HOUSE $285.00 7
(This fee includes all plumbing fixtures in the dwelling and the first *Minimum permit fee is $50 + 8% surcharge, except Residential Backflow Preventi A 5' LC
100 feet of sanitarysewer 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
•
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:
I:ldsts\formstplumapp.doc 11/18/99
CITY OF TIGARD BUILDING INSPECTION DIVISION
24 -Hour Inspection Line: 639 -4175 • Business Line: 639 -4171 MST
BUP
Date Requested r- AM PM BLD
Location /(1 7 Q 0 _54,4/iv( t Suite MEG
Contact Person Ph _,? 3 U- Z Z y' WO( 7 v•1s4.. / - de 2 9 y
Contractor eI f 1b S,/ OG,,& J Ph / vSWR 2e(4) r' b 2 3 y
BUILDING Tenan r / h /it /v> s�,p ELC
Retaining Wall EL'R
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
Stisp'd Ceiling
Roof
Misc:
Fihal
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Top Out
Water Service
C' Sallii221E21 1 11
Rain Drains i
F w
PASS PART FAIL \
MECHANICAL '��
Post & Beam
Rough In
Gas Line
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
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA
Approach /Sidewalk Date — / ( — ate
Q a Inspector — - — ; Ext
Other
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.