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Permit CITY TIGARD PLUMBING PERMIT 1 1 DEVELOPMENT SERVICES PERMIT #: PLM2001 -00075 s '�'I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/14/01 SITE ADDRESS: 11510 SW 115TH AVE PARCEL: 1S134DB 01800 SUBDIVISION: ZONING: R -4.5 BLOCK: LOT: 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: 100 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS: RAIN DRAIN: ft Remarks: Plumbing permit for line work to connect existing house to sewer lateral. No reverse plumbing. Septic tank must be pumped, filled and inspected. FEES Owner: Type By Date Amount Receipt KALSCH, LAWRENCE P PRMT CTR 3/14/01 $55.00 27200100000 4441 SE WITCH HAZEL RD SPOT CTR 3/14/01 $4.40 27200100000 HILLSBORO, OR 97123 Total $59.40 Phone 1: Contractor: HOLLENBACH + HURD INC 3000 SW 174TH AVE ALOHA, OR 97006 REQUIRED INSPECTIONS Sewer Inspection Phone 1: 591-5987 Misc. Inspection Reg #: LIC 121807 Final Inspection 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: -62 Permittee Signature: Call (503) 39 -4175 by 7:00 P.M. for an inspection needed the next business day Plumbing Permit Application Date received: 3b Lilo / Permit no.: ;1 G 0 / - Oo 07 y °a - City of Tigard t . 41' Sewer prmit no.pe o f_ eve Building permit no.: 1 " -" Address: 13125 SW Hall Blvd, Tigard, OR 97223 City of Tigard Phone: (503) 639 -4171 Project/appl.no.: Expire date: Fax: (503) 598 -1960 Date issued: By: I Receipt no.: Land use approval: Case file no.: Payment type: TYPE OF P :RAIIT U 1 & 2 family dwelling or accessory U Commercial/industrial U Multi - family U Tenant improvement U New construction U Addition/alteration/replacement U Food service U Other: JOB SITE INFORMATION FEE S('IIEDI'LE (for special inforn ation use checklist) Job address: / /S7 e S eel.' /'45' /¢Lt Description Qty. Fee (ea.) Total Bldg. no.: I Suite no.: New 1- and 2- family dwellings only: Tax map /tax lot/account no.: (includes 100 . for each connection) ft. Lot: I Block: I Subdivision: SFR (2) bath Project name: SFR (3) bath City /county: 7—, ;ie.Cl /41,45LZIP: Each additional bath/kitchen Description and location of work on premises: 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: Q j -6 ' / ,r- ,i Manholes Address: 3 D )O .5 /7 V ' E Rain drain connector City: / �State:©�I ZIP: 97l' p da Sanitary sewer (no. lin. ft.) /00 Phone:,. 5 /.$' $ 7 I Fax:ts' S) mail: Storm sewer (no. lin. ft.) CCB no.: / 7 I Plumb. bus. reg. no: Water service (no. lin. ft.) City/metro lic. no.: Fixture or item: Contractor's representative Si: . ,' u _Absorption valve Back flow preventer Print name: . 4 ,,. L9 Date: -- - C?/ Backwater valve • CON I A('1 PERSON Basins/lavatory Name:�J1s ' 11.L/4 Clothes washer Dishwasher Address: 26)00 .S. y / T A As) C Drinking fountain(s) City: •4 /cI A I State: ZIP: T 7 d Ejectors/sump Phone: 59 /.j 1 Fax: 13 4 1669 ail: Expansion tank Fixture/sewer cap Floor drains/floor sinks/hub Name (print): L j//e 5C.1+ Garbage disposal Mailing address: Hose bibb City: I State: I ZIP: Ice maker Phone: I Fax: 1 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. Notice: This permit application Minimum fee $ _515 ` ❑ Visa O MasterCard expires if a permit is not obtained Plan review (at %) $ Credit card number / / within 180 days after it has been State surcharge (8%) $ Expires TOTAL $ Ve Name of cardholder as shown on credit card accepted as complete. $ Cardholder signature Amount 440 -4616 (6/00/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 16.60 Urinal Other Fixtures (Specify) 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 72.50 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 plans with isometric or riser diagram and plan review. is \dsts \forms \plm- fees.doc 10/10/00