Permit As' k CITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2001 -00347
1111 13125 SW Hall B lvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 08/15/2001
SITE ADDRESS: 15210 SW 107TH TERR PARCEL: 2S110DA 06700
SUBDIVISION: ERICKSON HEIGHTS ZONING: R -3.5
BLOCK: LOT: 028 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Irrigation backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
RENAISSANCE DEVELOPMENT PRMT CTR 08/15/2001 $36.25 27200100000
1672 WILLAMETTE FALLS DR 5PCT CTR 08/15/2001 $2.90 27200100000
WEST LINN, OR 97068
Total $39.15
Phone 1: 557 -8000
Contractor:
MOODY ENTERPRISES INC
PO BOX 713
ESTACADA, OR 97023 REQUIRED INSPECTIONS
Phone 1: 503 - 630 -5532 Final Inspection
Reg #: LIC 5973
PLM 11717
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.
Issued By: 47 ��� Permittee Signature: } 1 �/
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
. . /(s7 coo -ao /4 2
Plumbing Permit Application
Date received: A. D / Permit no. :fi fioN4D 3Y7
-,,, City of
� �> , Citf Tigard
• "! I Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City ofTigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By:/3, Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
& 2 family dwelling or accessory ❑ Commercial /industrial ❑ Multi - family O Tenant improvement
air New construction ❑ Addition/alteration/replacement O Food service O Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: /5 / 0" C, k.' , / C 7 f ti TeR4 , 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: 28 IBlock: I Subdivision: SFR (2) bath
Project name: /t r 4 'II so.v //ri,. <�f SFR (3) bath
City /county: 7; y q�zd '(ZIP: 77 2 Z3 Each additional bath/kitchen
Description and location of work on premises: Spit t4 7t'n j Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name:
0 d U , Z- //il i c s. _rm. :, Manholes
Address: Po, 7 / 3 1 Rain drain connector
City: FSfaer N I State:0 iCZ I ZIP: 770 2.3 Sanitary sewer (no. lin. ft.)
Phone:§'d.7- 630 -3'C? 2 I Fax:fq.41G I E -mail: Storm sewer (no. lin. ft.)
CCB no.: 1/7/7 I Plumb. bus. reg. no: 5 3 Water service (no. lin. ft.)
City /metro lic. no.: Fixture or item:
w - —/ Absorption valve
Contractor's representative signature: 19, e ��
Back flow preventer l
Print name: f) , e/, , :✓ e /Pi Date: 7 I o/ Backwater valve
CONTACI PERSON Basins/lavatory
Name: ,_ washer
` R` � � U c Gr Dishwasher
Address: f ; p r 8 ' 7 { 3
Drinking fountain(s)
City: r-57ire, I StatefiiiZ I ZIP: 77023 Ejectors/sump
Phone: f 277 -CJG "6", . Fax: Sei.. E - mail: Expansion tank
OWNER Fixture/sewer cap
Name (print): Q,WP (2 4 J(F �� 1,6' Floor drains/floor sinks/hub
g 111L &4 ak%f1L M14 • Garbage disposal
Mailin address: Hose bibb
City: W T U N/ . I State: ZIP: 0110 Ice maker
Phone S4 . 000Q I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me o e . and repair made by my regular Roof drain (commercial)
employee on the p a I , wn as per ORS Chapter 447. I Sink(s), basin(s), lays(s)
Owner's signature: a Date: 4 SP / if / Sump
Tubs/shower /shower pan
Name:
Urinal
Address: Water closet
Water heater
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $ .24 i ZS
rm
CI Visa 0 MasterCard Plan rev (at _ %) $
expires if a permit is not obtained
Credit card number: / within 180 days after it has been State surcharge (8%) .... $ v2 , 9�
Expires $ _31 , /5
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount
440-4616 (6/00/COM)