Permit C ITY OF TIGARD PLUMBING PERMIT
P42 DEVELOPMENT SERVICES PERMIT #: PLM2004 -00035
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/26/04
SITE ADDRESS: 12845 SW 121ST AVE PARCEL: 2S103BC -01600
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: 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: 40 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replace 40' of water service
FEES
Owner:
Description Date Amount
TERRY WORRELL
11782 SW SWENDON LP [PLUMB] Permit Fee 1/26/04 $72.50
TIGARD, OR 97223 [TAX] 8% State Surchan 1/26/04 $5.80
Total $78.30
Phone : 503 - 524 - 0824
Contractor:
POWER PLUMBING CO
PO BOX 19418
PORTLAND, OR 97280
REQUIRED INSPECTIONS
Phone : 503 244 - 1900 Water Service Insp
Reg #: LIC 52378
PLM 34 -150PB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Issued By: Permittee Signature: /r/
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Jan 26 2004 7 : 43FIM HP LASERJET 3200 p . 1
" Plumbing' Permit Application
Permit no-et/Imo/ - ob 0 3
., , City e .
t t- . , . (h ig laeravito 1 .,7 e g 1`%;,-.4'Wmfalia.: Building permit no.:
,,.. ,,,,,.. Addkaa: 13125SW Ball - 1
C (3-1 ' agar " A - Plion6: (03) t539-4171 - • '- 4 " ' . ''' ' . — - — - Project/aPPI-no-: Expire date:
- ' -- .1/ 4 011X: (503) 598-1960 ! JAttz; 1 )04 -- - Dille issued: By f Receipt no.:
- Lan , ,....:::41)1,
use approval: C.ase ille no.: I I Payment type:
-------4 - " 2 1416 1,:t.$ ;ID • - .. --- - • • .--- .... -• -, .".. --- . -..• -a .
; 1 r" . 01 1'1 It1111
-0-1-4 V*** 7 rellialStaVitrettildeSMAIATIchistisi__ 4 :1P3r". 'fflit 'T, n . , Gi prove:neat
U NciTiallis.,,e4oil ' - ':":". 4-4 - .7" ' :-:- El Addition/alteratioruire,.. 1 . ',..,..:Fi, : .:::: i .5
.10104111 1 '\l 0101 .1 U)\ I I I s( III 1)1 Ii (1(.1 .p...1:11 infolni.ition ii.....•.1ictl, ist)
lob address: . • 7 la I S7 , ,, Total
' New 1- and 2-foun!ly Asp only:
Bldg. no.: Suite no.: ' -
(liselikles flf.for each utility connection)
Tax map/tax lot/account no.:
' SFR (1) bath - "'' -- -- --- --
Block I Subdivision: - SFR (2) bath '- .
Project mune: jire-w
_ SF bath
CitYkountY: / id944-A LoeSPI ZIP: 4:P q 7) Each additional bath/kitchen
• .. talon . • location of work on . - . ' Site utilities:
A / . , • i .. / A ' e .-0' WI. .raNir, 2 Catch basin/area drain
Est. date of cornpletion/inspecticrn: . ._.- - Drywells/leach line/trench drain
,
Footin : drain (no. lin. ft.)
I'l 1 II It1 NG ( ON I R X( 1011 ____
Manufactured home utilities
Business name: ' DLOILic ' 1 .1A ' .fr-q _la Manholes
Address: p 0 4k. 1 0 I. i / ,
Rain drain connector
City: PbYi I State:(5 I ZIP: q 7, Sanitary sewer (no. lin. ft.)
Phone: _ - 9 C)) Fax: , -f5 E-mail: . Storm sewer (no. lin. ft.)
CCB no.: ,5D Plumb. bus. reg. no: --i 6b ° Water service (no. lin. ft.) A I'
flatm-e or item
Oty/metro tic. no.: /4(p2_
Absorption valve
Contractor's representative signature:
,,.-At - 4 -!--■-■--- 4 ;---- 111 -A- ' Back flow preventer
Print name: JP rgriem-in Date: - dr iP 1.4) ."'" - Backwater valve -
I ON1 t( 1 PI R‘4(1\ Basins/lavatory
Narne: - - il. 4 - - Clcdiell . ' r
Dishwasher
Address: , II . ' 41.4 . ' _ / , --
Drinking fountain(s)
City: fey jr / / S ZIP: I 7 ,_1. \___Ejectors/sump
Phone: .1. - I-4- ci Cl) Fax: • .. E-mail: Expansion tank
OVV\ I R Fixture/sewer cap
Name (prim): ctie tc) i i , Floor drains/floor sinks/hub
Garbage disposal
Mailing address: / f fink . :VIV:ie"..,l _i , 1 Hose bibb
CRY: Lq f, State: of ZIP: Cil a 3 Ice maker .---
Phone: 5...). Li - 082(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 R d ( 000nnero i a i)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s). lays(s)
Owner's signature: -- - - . . Date: Sum,
,.._._—
LN(.111 FR Tabs/shower/shower pan
Name: _
Water closet .
Address:
Water heater ,I• .. .
City: [State: ZIP: (Xher: .
Phone: I Fax: I E-mail:
S $ q 2. SO
' In .19ribl at climii camig. 'gall` M
can imucficti°° rcir C" MfaCM"MM Notice: permit Plan review (at %) $
CI Matt 0 MasterCard
expires if a permit is not obtaiaed
CUKfit cacti musks: / 1 within ISO days after it has been State surcharge (8%) .... $
Espies
- TOTAL $
accepted as complete.
Name oi casholder as Awn as credit crd
. . $
Candbokier apnea Madera
. i 44D-4616 (6.01C061)
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received )72-4 J Date Requested / 3.0 AM PM BUP
Location 1e . - s / Z-1 S7` Suite MEC
Contact Person Ph ( 2//e/-1906 1:q 5
Contractor P ) SWR
BUILDING Tenant/Owner \ q [iul JUJ �T'� �-� ELC
Footing
ELC
Foundation
Ftg Drain Access: ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
P ASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
ater Service
ewer
Rain Drains
Catch Basin / Manhole
Storm Drain
S hower Pan
S PART FAIL
CHANICAL
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 Li Please call for reinspection RE: L Unable to inspect — no access
Fire Supply Line �t ,/ �
DAoachlSidewalk Date // V i Inspector 1 f!/ Ext
Approach/Sidewalk
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL