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Permit S A: CITY OF TIGARD PLUMBING PERMIT DEVELOPMENT SERVICES PERMIT #: PLM2003 -00583 GII 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/12/03 SITE ADDRESS: 12540 SW 121ST AVE PARCEL: 2S103BD -00901 SUBDIVISION: ZONING: R -4.5 BLOCK: LOT: JURISDICTION: TIG CLASS OF WORK: NEW 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: 85 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS: RAIN DRAIN: ft Remarks: Connect existing house to newly installed sewer service. Septic tank is to be pumped, filled & inspected. Reimbursement District fee paid. FEES Owner: Description Date Amount ALLEN, STEVEN P + ELIZABETH A 12540 SW 121ST AVE [PLUMB] Permit Fee 11/12/03 $72.50 TIGARD, OR 97223 [TAX] 8% State Surchari 11/12/03 $5.80 Total $78.30 Phone : Contractor: KEVIN COOPER EXCAVATING 158 SE 22ND BORING, OR 97009 REQUIRED INSPECTIONS Sewer Inspection Phone : 503 849 - 4735 Insp existing /capped fixtures Reg #: LIC 103803 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 Issu By: ��� A, � � / � Permittee Signature: - Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day Isuiliuing r fixtures Plumbing Permit Application • - FOR OFFICE USE ONLY N Received Plumbing / Date/By: !a /A /5 Permit No.: u7 X 58 3 City g of Tigard Planning Approval Date/By: Sewer Permit No.: U � 3 r ��3g 7 13125 SW Hall Blvd. Plan Review Other Tigard, Oregon 97223 DateBy: Permit No.: Phone: 503 - 639 -4171 Fax: 503 - 598 -1960 i i , ` Post - Review Land Use B : case No.: Internet: www.ci.tigard.or.us JJ _ . ' Ii� A Contact Jurjs_ � See Page 2 for 24 -hour Inspection Request: 503- 639 -4175 Name/Method: ✓1 / 0 , Supplemental Information. s ,1 ` TYPE OF WORK TEE ° ;' .y'' ,} ' , �,.e � information use checklist ❑ New construction ❑ Demolition Desert .tion - Qty Fee(ea.) Total • Addltlon/alteratlon/re . lacement 111 Other: i [ " F °e ` - '-, 11 " h: :'6 ' +') - , , ,,t':) , ',::°:. , veriON • 1 & 2-Family dwelling • Commercial/Industrial SFR bath ■ 350.00 y g l/I 2 SFR 2 bath ■ 350.00 DAccessory Building ❑ Multi- Family SFR 3 bath ■ 399.00 ❑ Master Builder ❑ Other: Each additional bath/kitchen ■ 45.00 °;'' Fire s.rinkler •. ft.: Pa:e 2 JOB SITE INFORMATION' � �_s a �2L0N �,. -, � ■ Job site address: 125z►o sw 12.0 Ay ° ;173 ' Suite #: I Bldg. /Apt. #: Catch basin/area drain ■ 16.60 Project Name: D ell/leach line /trench drain ■ 16.60 Footin• drain no. linear ft. ■ Pa:e 2 Cross street/Directions to job site: Manufactured home utilities ■ 110.00 Manholes ■ 16.60 Rain drain connector ■ 16.60 Sanit. sewer no. linear ft. ■ Pa:e 2 1.� Subdivision: I Lot #: Storm sewer no linear ft.) ■ Pa:e 2 Tax map /parcel #: f I 4)Ial v 2 , , . e v o linear *Item . Water service ft Pa:e ° � ' `� � ° � � k ' ' Abso tion vale ■ 16.60 Sewer Cor. e.c., ton i St t■c DG- Connmt65:on Backflow .reventer ■ Pa:e 2 Backwater valve ■ 16.60 Clothes washer ■ 16.60 Dishwasher ■ 16.60 Drinkin • fountain ■ 16.60 - : t ' ,., E'ectors/sum. ■ 16.60 Name: 54 -cJc-r\ P. allcr, Ex.ansiontank ■ 16.60 3u iZ .. P.vr• Fixture /sewer ca. ■ 16.60 Address: 125y p Floor drain/floor sink/hub ■ 16.60 City /State /Zip: T;s Rrd m Ore* g7z23 Garba:e dis.osal ■ 16.60 Phone: sos - sqo - 36't i Fax: sv3 -'.se0 - 3(r"1L Hose bib ■ 16.60 U APPLICANT " "_ , _` ,, , ''' . , ,' Ice maker ■ 16.60 Name: Interce.tor /• ease trap ■ 16.60 Address: Medical :as - value: $ ■ Pa :e 2 Primer 16.60 City /State /Zip: ■ Roof drain commercial ■ 16.60 Phone: I Fax: Sink/basin/lavato ■ 16.60 E -mail: Tub /shower /shower .an ■ 16.60 CONTRACTOR 41 ' , Urinal ■ 16.60 Business Name: Coo per Excu ,)a -V;n Water closet ■ 16.60 g Water heater ■ 16.60 Address: t64 s E $ 22rc Other: ■ -- City /State /Zip: B or■nci 1 OeeSor. Q1oO1 Other: f"\ Phone: 5v3.v- - 4135 Fax: `f:MiV:!2 r�l;iri nil ialYg1 : ?t:4.„...- ,•i! €l,a `� CCB Lic. #: 1 o2 So 3 Plumb. Lic. #: Subtotal $ Minimum Permit Fee $72.55 0 $ � �-� Authorized �jf� / Residential Backflow Minimum Fee $36.25 Signature: ��� ��X,r -r Date: a Plan Review 25% of Permit Fee $ State Surchar • e 8% of Permit Fee EMINMINNII (Please print name) TOTAL PERMIT FEE EMWANII Notice: This permit application expires if a permit is not obtained within All 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. *Fee methodology set by Tri- County Building Industry Service Board. i:\Dsts\Permit Forms\PimPermitApp.doc 01/03 Plumbing Permit Application - City of Tigard • Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: to Yrtili ies Qty. " Fee (ea) Total Square Footage: Permit Fee: Footing drain - 1" 100' 55.00 0 to 7;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 additional $100.00 or fraction thereof, to and Fixture or Item Qty. 1e : (ea) Total 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 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: 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 *. Quantity by (Fixture) Wor'erforined Comments regarding fixture work: g Te - Replace: New ?,Moved Existing- 'Capped, 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: i: \Dsts\Permit Forms \PlmPermitAppPg2.doc 01/03 ORVALL T. CADE JOB INVOICE BYER'S SEPTIC TANK SERVICE, INC. Wants After 10: AM P.O. BOX 549 OREGON CITY, OREGON 97045 CUSTOMERS ORDER NO. DATE ORDERED (503) 656 -3326 11 -14- 03 ORDER TAKEN BY DAT PRO�n D ❑ A.M. Grace 1 1 - l ❑ P.M. BILL TO PHONE Kevin Cooper Exc. ADDRESS MECHANIC CITY JOB NAME AND LOCATION 12540 SW 121st. / & Walnut / Tig. ❑ DAY WORK DESCRIPTION OF WORK ❑ CONTRACT ❑ EXTRA _ I QUART. DESCRIPTION OF MATERIA USED PRICE AMOUNT > L Tank pumping HOURS LABOR AMOUNT TOTAL MECHANICS MATERIALS HELPERS © TOTAL LABOR I hereby acknowledge the satisfactory TOTAL LABOR TAX completion of the above described work. SIGNATURE DATE COMPLETED TOTAL / / CITY OF TIGARD 24 -Hour BUILDING Inspection`Line: • (503) 639 - 4175 INSPECTION DIVISION Business Line: (503) 639 - 4171 MST BUP Received Received Date Requested / 1 "� t 7 AM PM ✓ BUP Location taffEET - - !— A. ite MEC Contact Person .�- J Ph ( ) 84<9 — X735 PLM 3 —.DOS—E3 Contractor Ph ( ) SWR BUILDING Tenant/Owner ELC Footing ELC Foundation Access: Ftg Drain ELR Crawl Drain Slab Inspection Notes: SIT Post & Beam Shear Anchors Ext Sheath/Shear Int Sheath/Shear Framing Insulation Drywall Nailing Firewall c � a J � rr` Fire Sprinkler - — ��� Fire Alarm Susp'd Ceiling Roof Other: Final PASS PART FAIL PLUMBING Post & Beam Under Slab Rough -In Water Service ,anitary sewer, Rain Drains Catch Basin / Manhole Storm Drain Shower Pan Other: Fin -I 'ART 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 call for reinspection RE: ❑ Unable to inspect — no access Fire Supply Line ADA Approach/Sidewalk Date 2 Inspector Ext Other: Final DO NOT REMOVE this inspection record from the Job site. PASS PART FAIL