Permit CITY TIGARD PLUMBING PERMIT
ji DEVELOPMENT SERVICES PERMIT #: PLM2003 -00114
. 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/31/03
SITE ADDRESS: 12040 SW 116TH AVE PARCEL: 2S103BA -00125
SUBDIVISION: LERON HEIGHTS NO. 2 ZONING: R -4.5
BLOCK: LOT: 039 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: Installation of irrigation backflow prevention device.
FEES
Owner:
Description Date Amount
HUTCHINSON, TERRENCE E +
CAROL V [PLUMB] Permit Fee 3/31/03 $36.25
12040 SW 116TH AVE [TAX] 8% State Tax 3/31/03 $2.90
TIGARD, OR 97223 Total $39.15
Phone :
Contractor:
PROFESSIONAL GROUNDS MGT INC
PO BOX 667
CORNELIUS, OR 97113
REQUIRED INSPECTIONS
Phone : 503 - 740 - 6333 RP /Backflow Preventer
Final Inspection
Reg #: LIC 6832
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
/
Issued By:
Z„ek
Permittee Signature: a ., ,4 ,A
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the ne bu ess d -y
Building Fixtures ��II..���
iM 051:Wi
PluIII$ Pe Received FOR OFFICE USE ONLY � Plumbing
DateBy�/. Ca 4441--- Permit No.:� ZAOS O// y
City of Tigard MAR 3 1 2003 Planning pp val
Date Se Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 CITY OF TIG Date/By: Permit No.: icinN
Phone: 503- 639 -4171 F -1 ! -9 601' -. ' Post-Review Land Use
A Date/By: Case No.:
Internet: www.ci.tigard.or.us „ eh ( Contact .. ® See Page 2 for
24 - hour Inspection Request: 503 639 - 4175 W Name/Method: /6 Supplemental Information.
TYPE OF ` , � E* SCHEDULE (for^,special Inf o r m at ion use checkl si)
R New construction ❑ Demolition Description I Qty. Fee(ea.) I Total
w NOI 1 & family wellings, K ,
Addition/alteration/replacement [=] Other: � ���� , ucudeslloo�;oreach 411111Y ("61144141")
,Y CATEGORY OF (ION�UQ!N. _' 4 = . SFR (1) bath 249.20
1 & 2- Family dwelling ❑ Commercial/Industrial SFR (2) bath 350.00
Accessory Building ❑ Multi- Family SFR (3) bath 399.00
• Master Builder • Other: Each additional bath/kitchen 45.00
='a j t': s 111,1FORMA IQ: n' '' or 07, .. " , Fir s,rinkler ft Pa e
��yy $
Job site address: / ZO 'LO S t4-) -F r1 ci - _ 4 iltttes . . w' g : „4,
Suite #: 1 Bid . /Apt. #: Catch basin/area drain 16.60
N Drywell/leach line/trench drain. 16.60
Project Name: - re tr N 10 r 11 1 k �ti Footing drain (no. linear ft.) Page 2
Cross street/Directions to site: Manufactured home utilities 110.00
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.) Page 2
Subdivision: I Lot #: Storm sewer (no. linear ft.) Page 2
Tax ma • / • arcel #:
Water service no. 5 linear ft. Pa:e 2
Absorption valve 16.60
Backflow preventer / Page 2 , „25
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
i �, z ;i i ° Ejectors/sump 16.60 • Name: e r i^ 1 14-4 #( t vL (. o .-1 Expansion tank 16.60
Address: j Z olio S • (----) • I ( to Tk rt t) a Fixture/sewer cap 16.60
City : Otle �T i a z Floor drain/floor sink/hub 16.60
y p ! 4 ✓ Garbage disposal 16.60
Phone: So 5 - - . Fax: 52 1-' 1Z. 3 Z Hose bib 16.60
nn ..?" : - fir• „ i _ 4 ;, Ice maker 16.60
Name: k r Air Interceptor /grease trap 16.60
Address: PC) 7( 6 ( gyp 7 Medical gas - value: $ Page 2
Primer 16.60
City /State /Zip: Co • r K ‘ u 01. Roof drain (commercial) 16.60
Phone: 6 Z9Z1 i7 I Fax: Sink/basin/lavatory 16.60
E- mail: -....-- Tub /shower /shower pan 16.60
Urinal 16.60
Business Name: Pro ws.,; pmt I G v to . S Water closet 16.60
Water heater 16.60
Address: f. 0 , / < 406 7 Other:
City /State /Zip: C pi r (A% Qe other
Phone:So3' 4?. 012 - 7 Fax :5 3 97Z` (7677 '1 t k r 1 t':A, ., 4 .:
a Subtotal $
GCB Lie. #: 67 $ 3 a b. Lic. #: Minimum Permit Fee $72.50 $
Authorized 3 3) 03 Residential Backflow Minimum Fee $36.25 ,_...?6,_, . 2......‹. Signa e: n J �: Date: J • 37 Plan Review (25% of Permit Fee) $
3
r “ tr I- SNI 1 -it% State Surcharge (8% of Permit Fee) $ . 9 0
(Please print name) TOTAL PERMIT FEE $ 3 4 , /S"
Notice: This permit application expires if a permit is not o . tailed within MI new commercial buildings require 2 sets of plans with isometric or
180 days after it has been accepted as complete. riser diagram for plan review.
6 *Fee methodology set by Tri -County Building Industry Service Board.
i:\Dsts\Permit Forms\PlmPermitApp.doc 01/03
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information a *' r►
Fee Schedule: Residential Fire Suppression Systems:
.`: «.. 1 44 1Tr '. ¢ ::', ...tee ea E ¶ ota1 Square Footage: Permit Fee:
Footing drain - l" 100' 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 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 Valuation: Permit Fee:
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
additional $100.00 or fraction thereof, to and
_.. r�.s R ;�� 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 permit 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
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: 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
•
accuratel re . ort fixtures could result in increased sewer fees *. Comments regarding fixture work:
1� a t c F a a
U,77, 'AIIPV*Xj
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 *Note: If the fixture work under this permit results in an
Garbage - Domestic
Disposal - Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice Mach./Refrig. Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
is \Dsts \Permit Forms\PlmPermitAppPg2.doc 01/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested 2.7. AM PM BUP
Location 1')- a TO - Suite MEC
Contact Person / (fti 1 .��1/� -� Ph ( ) 5a�I' -/ °Z3a P ) M J= °L
Contractor 0 Ph ( ) 4 3 o d it
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain � ELR
Crawl Drain
Slab Inspe.,e• J otes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm � 41"
Susp'd Ceiling /—
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
.1c 1t(
' Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan 1 3 , r r s
Other:
Fin -
PART FAIL
ANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please cal for reinspection RE: ❑ Unable to inspect - no access
Fire Supply Line 7)
ADA
Approach/Sidewalk Date - i A Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL