Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2006 - 00314
DATE ISSUED: 6/23/2006
MI 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 2S103BA 00900
SITE ADDRESS: 12330 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Plumbing reversal.
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
Owner: FEES
MARY ANNE/ ANDERSON
12330 SW 121ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 6/23/2006 $72.50
[TAX] 8% State Surcha 6/23/2006 $5.80
Phone : 503- 984 -4882 Total $78.30
Contractor:
MCROOTER DRAIN SEWER & PLBG SVC
PO BOX 301415
PORTLAND, OR 97294 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 632 -8211
FAX 503- 939 -3246
Reg #: LIC 103682
PLM 26 -724PB
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 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued By: Pe rmittee Signature:
f �/
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Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business • ay.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Building Fixtures
Plumbing Permit Applicatibli- ' FOR 01+14 I: t St; 0M.1
City of Tigard
Received 2 2006 Date/By.. / ,. AO - / i Permit No. i 1� • 41 , 0 0 /
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie Other Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 r v T f r Date/By:
24- Hour Inspection Line: 503.639.4175 -- d k � .
Internet: www.ci.tigard.or.us BUILDING DIVI - Date ediMet o Supplemental See Penet Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
Addition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 249.20
1- and 2 -family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
1:3 Accessory building 12 Multi-family SFR (3) bath 399.00
1:1 Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 4g 33 i.e../ <6P/ 'l' Catch basin or area drain 16.60
City /State /ZIP: 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.: Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
42,a yf(/o 6 2 5,E C , Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER 1 ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: Expansion tank 16.60
Address: Fixture /sewer cap 16.60
City /State/ZIP: Floor drain/floor sink/hub 16.60
Phone: ( ) I Fax: ( )
Garbage disposal 16.60
❑ APPLICANT .CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: a C i Z o07 t D ' i � ) p e � g i � / Interceptor /grease trap 16.60
Contact name: /�� ! °�
/ q 5 J t J
P /J() Medical gas (value: $ ) Page 2
Address: AiZ`I . n /.
) 6t370-'7-"Z) Primer 16.60
City /State /ZIP: ( to c' -,14 sp d�J Roof drain (commercial) 16.60
(93) ?W o ? J 3 I Fax: 4c33) P 7- .Z 1 ) Tub/shower/shower Sink/basin/lavatory 16.60
Phone:
/ �"� Tub /shower /shower pan 16.60
E -mail: A A ds t ///1.* (4 � 4 /�. itli Urinal 16.60
Y �/ � " /` �� ` CONTRACTOR /'17/ Water closet 16.60
Business name: / v, ' l 0 � ] �l ( f�v�� v/ f Water heater heater 16.60
i"
Address: d /54)t 34 4 ( s' Other: g" ' "
City / State/ZIP: CJ � � S ubto t al
!-� � 4) j 6 - 7:57 7, �� Minimum permit fee: $72.50
Phone: l�J ) --(e3,0 Fax: ) Residential backflow minimum permit fee: $36.25
CCB Li O3 6 2...-
j umbing Lic. no d& / v7 61 Plan review (25% of permit fee)
Authorized signature:/ surcharge (8% of permit fee)
'/ /�� ` U��/ TOTAL PERMIT FEE i . 30
Print name:11iW eel /r Dates -', ,'}- This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
is \ Building \ Permits \ PLMF- PermitApp.doc 06/05 440.4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information -
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1' 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' 55.00 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
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
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof to and
Commercial Back Flow Prevention Device 46.40 including
148. i0g for the first $
$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
Inspection of existing plumbing or each additional $100.00 or fraction thereof to
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Complex Structures
Are you capping, adding or replacing fixtures? If "yes", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria
accurately report fixtures could result in increased sewer fees *. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building.
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool providing services to human beings.
Car Wash - Each Stall ❑ Plumbing installations, alterations or additions to food service
- Drive Thru facilities where new plumbing fixtures, including interceptors,
Cuspidor/Water Aspirator are being installed for the food service area.
Dishwasher - Commercial ❑ Any new residential building containing three (3) or more
- Domestic
Drinking Fountain dwelling units.
Eye Wash ❑ Any NFPA 13 - D multipurpose fire sprinkler system. •
Floor Drain /sink 2" Submit 2 sets of plans with any of the above.
-3"
-4"
Car Wash Drain Isometric or Riser Diagram
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor p
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: plumbing permit can be issued.
i:\ BuildingTermits \PLM- PennitApp.doc 07/06/05
Case Activity Listing 7/24/2006
10:27:46AM
TIDEMARK Case #: PLM2006 - 00314
COMPUTER SYSTEMS, INC.
Assigned Done Updated
Activity Description . Date I Date - Date 3 Hold Disp To By By Notes
PLM1740 Case finaled 6/27/2006 None DONE RB 6/28/2006
RB
PLM2320 Plumbing rough -in 6/27/2006 None PASS RB 6/28/2006
RB
PLM2399 Plumbing final 6/27/2006 None PASS RB 6/28/2006
RB
PLM1020 Permit created 6/23/2006 None DONE BB 6/23/2006
BB
PLM1010 Application received 6/23/2006 None RECD BB 6/23/2006
BB
PLM1030 Check for parcel tags 6/23/2006 None DONE BB 6/23/2006
BB
PLM1280 Issue permit 6/23/2006 None DONE BB 6/23/2006
BB
Page 1 of 1 CaseActivity..rpt