Permit CITY TIGARD PLUMBING PERMIT
I6\ DEVELOPMENT SERVICES PERMIT #: PLM2004 -00100
..I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/10/04
SITE ADDRESS: 11009 SW 110TH PL PARCEL: 1S134DB-05900
SUBDIVISION: JEFFREY ESTATES ZONING: R -4.5
BLOCK: LOT: 018 JURISDICTION: TIG
CLASS OF WORK: OTR 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: Backflow preventer install.
FEES
Owner:
Description Date Amount
CHRISTIAN, K GENE + MICHELE K
11009 SW 110TH PLACE [PLUMB] Permit Fee 3/10/04 $36.25
TIGARD, OR 97223 [TAX] 8% State Surcharl 3/10/04 $2.90
Total $39.15
Phone : 503 684 - 8381
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : RP /Backflow Preventer
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
Issued By Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Plumbing Permit Application A FOR OFFICE USE ONLY
City of Tigard
Date/By: d 3/1 /U`/ , J. Permit No.: /n dopy_ oa /(:?2
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
' Phone: 503.639.4171 Fax: 503.598.1960 //e � ipNl vq,,, ,\ Other Permit No.:
�
24- Hour Inspection Line: 503.639.4175 r • .1 DateBy:
Date Ready /By: f ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: �/ Supplemental Information
F � OF s f2IC � , '" FE *' SCHED E
�i iax. ^F` �.i , �_� �, . d` ..� .. _._ ,3:.n4 0 d3- 3i�'w. - . s*. � aro> " �. .��.,_ k•: >. y : � .
❑ New construction ❑ Demolition For special information use checklist.
Description Qty. I Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
il,ie2`.°?z s . `��tY2 ;' A** RYJCQ. 1 _,._ SFR (I) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
El Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
l F 6 ^ =� , ` t 4 7 , .. • _, .,, Site utilities
Job site address: t, \ v }-,,, 0 GI S (AJ 1 � 0 1 t' ) Catch basin or area drain 16.60
City/State /ZIP: - ri 9 C.0 red () f a - 7a- d3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: _) Page 2
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
Storm sewer (no. linear ft.: _) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: _) Page 2
Fixture or item
Tax map /parcel no
ors 1 4 Absorption valve 16.60
:; � . w t'� I ,, . . 5 ... _ Backflow preventer / Page 2
I A 0 it A 5 + /II . Backwater valve 16.60
/ 1 � 1 • e yard Clothes washer 16.60
I ', F + 1- o ' 1 + V , Dishwasher 16.60
Low Drinking fountain 16.60
j ) .}t s g �i . fir . , ; „',
Ejectors /sump 16.60
Name: ..e r\ e QVL r i C 1/ Expansion tank 16.60
Address: D� '` a 7 7 ' t) Fixture /sewer cap 16.60
City/State /ZIP: /I _ f- r / �� Floor drain/floor sink/hub 16.60
Phone: ( � ) r „ : = Fax: ( ) Garbage disposal 16.60
l!J
- •° -° :�: r „� ,. •.� � Hose bib 16.60
a A. Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
� � 7 N ,' i :,� R „,� ,. - Water closet 16.60
Business name: ) c,t/ N & ie- Water heater 16.60
Address: Other:
Subtotal
City/ State/ZIP:
Minimum permit fee: $72.50 S
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 3t ' .
CCB Lie.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee) C 0
Authorized signature' L��,() , A TOTAL PERMIT FEE
3°I t l 6
Print name YKI i / MI ` i Date: 6.,MMI This permit application expires if a permit is not obtained with
180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
i.\ Building \Permits\PLMF- PermitApp.doc 12/03 440- 4616T(l0 /02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information '
Fee Schedule: Residential Fire Suppression Systems:
a
$duareixFootage: Permit Fee:
Footing drain - 1 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 . ;..
Ntglit“
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
t�� oT additional $100.00 or fraction thereof, to and
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 .ermit 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
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
s.eciall re.uested ins.ections - .er hour 72.50 and including $50,000.00.
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and for
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 * .
a .. t iattti . W r e + e
74 CM-
P . .411:,r 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
Ice Mach. /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory
Quantity Total
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
Service total is >9.
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:
is\ Building \Permils\PLM- PermitApp.doc 3/03