Permit fw ,
CITY TIGARD PLUMBING PERMIT
ar I DEVELOPMENT SERVICES PERMIT #: PLM2005 -00503
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 9129/2005
II
PARCEL: 2S103BC -00100
SITE ADDRESS: 12525 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Connect existing house to sewer lateral. Reimbursement District 18 fee paid this date.
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: 90 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
MIKE & LIN STEVENS Description Date Amount
PO BOX 3527
WILSONVILLE, OR 97070 [PLUMB] Permit Fee 9/29/2005 $72.50
[TAX] 8% State Surcharl 9/29/2005 $5.80
Phone : 503 925 - 9100 Total $78.30
Contractor:
BRIAN CLOPTON EXCAVATING INC •
PO BOX 509 REQUIRED ITEMS AND REPORTS
WILSONVILLE, OR 97070
Phone : 503 682 - 0420
Reg #: LIC 50337
PLM 3 - 517PB
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 -• I 0 through OAR 952 - 0001 -0100. You may obtain copies of these rules or direc questions to OUNC by
calling
:21::9 � /� L • Permittee Signature: ir
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.
• Building Fixtures
Plun%b ng Permit Application FOR ' OFFICE USE ONLY
City of Tigard Received G, 8.q U ( P No.: •,`1"',9065 � ryS 6 b
13125 SW Hall Blvd., Tigard, OR 97223
Plan P R y. / V "
Plan Review Other ermit No.:
• Phone: 503.639.4171 Fax: 503.598.1960 i/� /av ll �� e� Date/By.
24 -Hour Inspection Line: 503.639.4175 -Law �•'_ Date Ready/By: t s: ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: J Supplemental Information
• TYPE OF WORK - FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. j Ea. I Total
El Addition /alteration/replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
[A 1- and 2 -famiy dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building El 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: / 25 7 c r f f\ ) ' a ) . C A v e_ Catch basin or area drain 16.60
. City /State /ZIP: fi b Or 7 3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Pr ject name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street /directions to job site: Manholes 16.60
, U rikA ) \) I&.-- >( ) 1 -L 4t C - Rain drain connector 16.60
xe Sanitary sewer (no. linear ft.: 6 10 ) I Page 2 55 x.
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.: 00100
Water service (no. linear ft.: _) Page 2
Fixture or item
Tax map /parcel no.: 2 5 i r O b I OD Absorption valve 16.60 .
DESCRIPTION OF WORK Backflow preventer Page 2
5j= (A) ER [ I N F i NooK u P Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
® P OWNER = ❑ TENANT Drinking fountain 16.60
_ Ejectors/sump 16.60
Name: 1 g j e f Acii Cf--. L r `a A E %)5 Expansion tank 16.60
Address: f 04 g50/ 3 5: 7 Fixture /sewer cap 16.60
I
City /State /ZIP: W • 1 DNA, V,' ) l e 0 ,^ L - -7-0 7 0 Floor drain /floor sink/hub 16.60
Phone: ( g G , ,s _ 9 I 0 C) Fax: (SO 0 `� "' ) 3 fy Garbage disposal 16.60
i Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON .
Ice maker 16.60
Business name:
1 Interceptor /grease trap - 16.60
Contact name: , Medical gas (value: $ ) Page 2
Address: w Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
•
•
Phone: ( ) Fax:: ( )
Sink/basin/lavatory 16.60
Tub /shower /shower pan r6.60
E -mail: Urinal 16.60
• ``,, CONTRACTOR_ Water closet 16.60
Business n 44 1 a ptai EX GA VA- 7 7 ° N Water heater 16.60
Address: O Lox &-OC / Other:
City /State /ZIP: W l LS a-w I/ IL(. c 0-K , Ct ' - Subtotal
b Minimum permit fee: $72.50 79 S d
Phone: (S ) ( S 2-. - Oj ZD Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plum g Lic. Plan review (25% of permit fee)
SD A
Authorized signature: State surcharge (8% of permit fee) 5• g0
TOTAL PERMIT FEE 7 s , 50 •
Pr in t name /M Date: 6--,--_, / .0 -- 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.
i:\ 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 - I 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
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: ° Plan Review for Complex Struct • ,
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 (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 dwelling units.
Drinking Fountain
❑ Any NFPA 13 -D multipurpose fire sprinkler system.
Eye Wash
Floor Drain /sink 2" Submit 2 sets of plans with any of the above.
-3"
-4"
Car Wash Drain Isometric. orRiser 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
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:\ Building \Permits\PLM - PermitApp.doc 07/06/05
- CITY OF TIGARD
BUILDING DIVISION PERMIT #: PLIv12005-00503
1 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 9/29/2005
Phone: (503) 639-4171 efaryinmOi
Inspection Requests (24 Hrs.): (503) 639-4175 ' J1.
INSPECTION WORKSHEET FOR DATE: 10/7/2005 TIME: 7:05AM PAGE: 21
SITE ADDRESS: 12525 SW 121ST AVE CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: STEVENS
DESCRIPTION: Connect existing house to sewer lateral. Reimbursement District 18 fee paid this date.
OWNER: STEVENS, MIKE & LINDA PHONE #: 503-925-9100
CONTRACTOR: BRIAN CLOPTON EXCAVATING INC PHONE #: 503
Inspection Request Scheduled For: Date: 1017/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 017749-01 503-784-3850 V
Corrections/Comments/Instructions:
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PASS 0 PARTIAL APPROVAL fl CANCEL 0 NO ACCESS
FAIL n CALL FOR INSPECTION fl ADDITIONAL FEES ASSESSED
Inspector: ' Date: • 1. Phone #: (503) 718
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_ CITY OF ~,
��nm m ��m TIGARD `� .
1 BUILDING DIVISION
~�~,"~~~~.""~= ~°"°"~~"~~.~ PERMIT #: PLhd200E-00503
| 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 8/29/2005
Phone: (503) 639-4171
Inspection Requests (24 Hrs.): (503) 639-4175 ^�4 AL
INSPECTION WORKSHEET FOR DATE: 10/7/2006 TIME: 7:05AM PAGE: 21
SITE ADDRESS: 126255W121STAVE CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: STEVENS
DESCRIPTION: Connect existing house to sewer lateral. Reimbursement District 18 fee paid this date.
OWNER: STEVENS, MIKE & LINDA PHONE #: 6O3-925-9100
CONTRACTOR: BRIAN CLOPTON EXCAVATING INC PHONE #: 503-602-0420
Inspection Request Scheduled For: Date: 10/7/2006 Pour Time:
{}ode # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 017749-01 603-7843050 Y
Corrections/Comments/Instructions:
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Inspector: iTK) .�D' Oa�m� • Jt Phone #: ` ��O3) 718'
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