Permit OF -TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2007 - 00258
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 6/19/2007
PARCEL: 2S103BD - 03500
SITE ADDRESS: 12970 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
PROJECT: KIRCHER
Project Description: Connect existing house to sewer service, approximately 100'. Septic tank is to be pumped and
filled.
CLASS OF WORK: ALT 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
Owner: FEES
ROBERT B. KIRCHER
12970 SW 121ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 6/19/2007 $72.50
[TAX] 8% State Surcha 6/19/2007 $5.80
Phone : 503 -590 -3327 Total $78.30
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # :
Reg #:
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 • - t questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issu: d By: ` j /� y Permittee Signature
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Plumbing Permit Application
Building Fixtures
FOR !IFFICE USE ONLY
IN City Of Tigard
Date/By: Received ��� Permit No , j07� Bob j
q 1312 SW Fall Blvd., Ti OR 972 y C
_ Phone: 503.639.4171 Fax: 503.598.1960 Date Beview Other Permit No.:50 -1 7 - ODC4/
y:
TI G A RD Inspection Line: 503.639.4175 Date Ready /By: r ' n 65 See Page 2 for
w
- Internet: ww.tigard or.gov Notified/Method: ( i(? Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description Qty. I Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
CI Accessory building CI Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
• Job site address: /Z 7 SGc] /2/ Sr Catch basin or area drain 16.60
City /State /ZIP: 774/ / Oz._ 97223 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: , // /eCNE2 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 55°a
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
� 0E r c1111.)& c77 p,J Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I - El TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: /20 6 ,S, ``r2C# Expansion tank 16.60
Address: / 2977 � /2/ 5T Fixture/sewer cap 16.60
7761
City /State /ZIP: 9 / QI ?c? 97 Floor drain/floor sink/hub 16 60
Phone: (� J '9 3 Z Fax: ( ) Garbage disposal 16.60
CI APPLICANT CI 'CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 16.60
Phone: ( ) Fax::( )
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR . Water closet 16.60
Business name: ()/"j / e________ Water heater 16.60
Address: Other:
•
City /State /ZIP: Subtotal
Minimum permit fee: $72.50 .-9
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 /
Plan review (25% of permit fee)
CCB Lic.: �� Plumbing Lic. nod Plan O
State surcharge (8% of permit fee)
Authorized signature: /v/ ./ *C- ' - TOTAL PERMIT FEE 70
Print name: .45E Cfc-� Date: V / y 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.
L\Building\Permits \PLMF- PermitApp doc 12/27/06 440- 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 - 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
Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit. Fee:
$1.00 to $5,000.00 Minimum fee $72.50
Stone & 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: Q ty. Fee (ea) Total additional $100.00 or fraction thereof, to and
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
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50 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 Plumbing Installations .
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
- 4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall -
Sink - Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a 'sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
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INVOICE # 175
GRIFF'S SEPTIC SERVICE
Phone 503-263-2087 /Fax 503-663-2840
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Name Dt0 VI r( kc. r Date ..
Address A-10 5k,k) ti 1 st Phone 5C:1D
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NOT RESPONSIBLE FOR DAMAGES
A service charge of 1.5% will be applied on all past due accounts
Returned check fee is $25.00
In case suit, action or arbortration ispstituted by either party breach or to enforce any provisions herein, the court .
Shall award reasonable attorney's,fees and actuar costs to the prevailing party at trial or arbitration, or upon any appeal taken therefrom.
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CUSTOMER APPROVAL )
- THANK YOU! COB # 126930 DEQ # 37194
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CERTIFICATION OF EXISTING SYSTEM
ABANDONMENT
SEPTIC PERMIT NO..
T ` S,R ILA ,SECTION O3I L , TAX LOT. O?1
I certify the existi , SEPTIC TANK —, DRYWELL CESSPOOL (circle one)
was properly abandoned to State standards. The sewage contents were
removed by C?ficf P -
(COMPANY NAME )
a licensed sewage disposal pumping service. The unit was then backfi with
rock or sand, and the building sewer pro • fitly capped or removed.
-C7
Signature Date .
•
• Attach a copy of the pumping receipt.
• Remit completed form to: .
•
S: soils\certification existing system abandonmentdoc
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CITY OF TIGARD
BUILDING DIVISION PERMIT #: PLM2007- 00268
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 6/19/2007
Phone: (503) 639 -4171 "tit
Inspection Requests (24 Hrs.): (503) 639 -4175 _ L `__..
INSPECTION WORKSHEET FOR DATE: 7/5/2007 TIME: 7:03AM PAGE: 43
SITE ADDRESS: 12970 SW 121ST AVE CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: KIRCHER
DESCRIPTION: Connect existing house to sewer service, approximately 100'. Septic tank is to be pumped and filled.
OWNER: KIRCHER, ROBERT PHONE #: 603 -630 -3327
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 7/5/2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
506 Sanitary sewer 0514001 503 - 590.3327 Y
Corrections /Comments/ Instructions:
co,„„ FV --• L c -1Z)
r r K ✓J ✓4 AC._ Ca t . O f— f (A.^ f at/ �� c �S 1.t
PASS n PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
'54 FAIL ❑ CALL FOR INSPECTION I I ADDITIONAL FEES ASSESSED
Inspector: Date: 7 MK)? Phone #: (503) 718 -
CITY OF TIGARD _
BUILDING DIVISION PERMIT #: PLM2007 -00258
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 6/19/2007
Phone: (503) 639 - 4171 ■■''
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 7/6/2007 TIME: 7:06AIVI PAGE: 10
SITE ADDRESS: 12970 SW 121ST AVE CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: KIRCHER
DESCRIPTION: Connect existing house to sewer service, approximately 100'. Septic tank is to be pumped and filled.
OWNER: KIRCHER, ROBERT PHONE #: 503. 590 -3327
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 7/6/2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 051557 -02 503-590-3327 N
Corrections/Comments/Instructions:
C ,w b , III r4 t Cot -fr -c a ae, ' fr o V.. f ✓H c+ t T6 h/eti. S..a,,,,
e, 1 1 k e,le YS At_ Co
S A A pv- f-ul 1 c_ e_ i s ✓ C
PASS IKS PARTIAL APPROVAL I I CANCEL n NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: CR, i t > ► Date: — 21 (, J 07 Phone #: (503) 718-
.
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•
CITY OF TIGARD
BUILDING DIVISION PERMIT #: PLM2007- 00258
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 6/19/2007
Phone: (503) 639 -4171 Inspect ion Requests (24 Hrs.): (503) 639 -4175 Jr% .
INSPECTION WORKSHEET FOR DATE: 8/3/2007 TIME: 7:03AM PAGE: 16
SITE ADDRESS: 12970 SW 121ST AVE CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: KIRCHER
DESCRIPTION: Connect existing house to sewer service, approximately 100'. Septic tank is to be pumped and filled.
OWNER: KIRCHER, ROBERT PHONE #: 503-590-3327
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 8/3 /2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
399 Plumbing final 053393.01 503- 590.3327 N
Corrections /Comments /Instructions:
PASS I I PARTIAL APPROVAL n CANCEL ❑ NO ACCESS
I I FAIL n CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector; Date: $`13 10) Phone #: (503) 718-