Permit CIT OF TIGARD PLUMBING PERMIT
lli DEVELOPMENT SERVICES DATE ISSUED: 4/9 p2 02 -00114
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 PERMIT #:
SITE ADDRESS: 12855 SW 113TH PL PARCEL: 2S103AC -06600
SUBDIVISION: FONNER WOODS ZONING: R -4.5
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: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of backflow prevention device for irrigation.
FEES
Owner:
Type By Date Amount Receipt
CHUCK FORDE
PRMT CTR 4/9/02 $36.25 27200200000
113T
12855 SW 113TH PL 5PCT CTR 4/9/02 $2.90 27200200000
TIGARD, OR 97223
Total $39.15
Phone 1: 503 - 670 -0168
Contractor:
NATURAL TOUCH LANDSCAPING INC
22505 BENTS RD NE
AURORA, OR 97002 REQUIRED INSPECTIONS
Phone 1: 503 - 678 -1328 RP /Backflow Preventer
Final Inspection
Reg #: LIC 6811
PLM 10773
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 v - copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
sued By: � • P ream £ 4_ _4 , Permittee Signature: A i' - f f � , �
Call (51 •39 -4175 by 7:00 P.M. for an inspection needed tr . next business day
Plumbing Permit Application
� `J b
Date received: 9 p 2-- Permit no.: a49e2V _eew •,
,, , City of Tigard
� Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Projeet/appl. no.: xpir- , ate:
Fax: (503) 598 -1960 Date issued: B , 10 • eceipt no.:
Land use approval: Case file no.: - ayment type:
TYPE OF PERMIT
❑ I & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
LI New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: i 2_g s S S i j I / `3 -f.-i. PL, Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax map /tax lot/account no.: (includes 100 ft. for each utility connection)
SFR (1) bath
Lot: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: 6 4 /t0 I ZIP: 9 '•) 22 3 Each additional bath/kitchen
Descriptioj location of work on premises: Site utilities:
YJ•4e -I & -Blow $ p A., .t K ) e i - c Catch basin/area drain
Est. date of completion/inspection: v Drywells/leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: A/A-•}u ye ,_ L Jvu c.}l L.4 n 0s c4/7 1 o) Manholes
Address: 22 5'o S � en.Y S P-.4 N Rain drain connector
City: 4- l r o 2 i4- I State: OR, I ZIPS') C p-Z Sanitary sewer (no. lin. ft.)
Phone: 9.3_. ,0 fi 1 , 2 8I FaxsF s eg I E -mail: _Storm sewer (no. lin. ft.)
CCB no.: C g j 1 / / Pl bus. reg. no: Water service (no. lin. ft.)
City /metro lic. no.: 3/A/ 1 /0 �j Fixture or item:
Contractor's representative signature: G Absorption valve
Back flow preventer
Print name: - \.h W\ r2 o)+L C M vU \ k Date: 3 g v Z Backwater valve 7
Basins/lavatory
Name: J l <M 20 1-{ v - \-j w \ b -P o__
Clothes washer
Dishwasher
Address: 2 2. 5 o s Tp f yt-k) R-JI iv "c Drinking fountain(s)
City: f} ( ,t Ac 2 Pti I State: c2 f, I ZIP: Q ? o o "'Z Ejectors/sump
Phone: SM3 (07?? I 2.0 Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print): C f -�- �.( Toe. 0 Floor drains/floor sinks/hub
address: Garbage disposal
Mailing / S' 5 / j - S tH PL. Hose bibb
City: Ti e ,4 t iz t9 I State:0 2 I ZIP: q 7 2 2 3 Ice maker
Phone: 5'6 — lob b U 1 I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: 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. Minimum fee $ O T C P • '-5- Notice: This permit application Plan review (at _ %) $
❑ Visa ❑ MasterCard expires if a permit is not obtained
Credit card number: / / State surcharge (8 %) .... $
Expires within 180 days after it has been TOTAL $ 3 q r
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6,p0 /COM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Urinal
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3"
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Other Fixtures
Water Service - each additional 200' 46.40 (Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device* 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections per /hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
* *PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
** All New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
is \dsts \forms \plm- fees.doc 12/26/01