Permit C ITY OF TIGARD PLUMBING PERMIT
���,,�. I DEVELOPMENT SERVICES PERMIT #: PLM2005 -00418 •
`^��' ��II 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 8/31/2005
PARCEL: 2S103BB -07400
SITE ADDRESS: 12522 SW 123RD AVE ZONING: R -4.5
SUBDIVISION: LAKE TERRACE LOT: 002 JURISDICTION: TIG
Project Description: Replace water service.
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: 80 ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
DAN SIMMONS
12522 SW 123RD Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 8/31/2005 $72.50
[TAX] 8% State Surcha 8/31/2005 $5.80
Phone : 503 -590 -9330 Total $78.30
Contractor:
BRUNER PLUMBING
PO BOX 23985
TIGARD, OR 97281 REQUIRED ITEMS AND REPORTS
Phone : 503- 624 -4880
Reg #: LIC 81837
PLM 26 -445PB
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: Permittee Signature:
e
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
Plumbing Permit Application, '�_` , FOR OFFICE USE ONLY
CI Of Tigard U E ( /En/E�� Received ?/ -0-1w, �A)-5'
131 fi
g SW Flail Blvd., Tigard, OR 97223 Date/By J / Permit No7l\ WY
31 2U �
Plan Review
• Phone: 503.639.4171 Fax: 503.598.1960 AUG ��� *ak , y �igj�l�: Date /By. Other Permit No.:
24- Hour Inspection Line: 503.639.4175 f �_ Date Ready/fly: Juris: RI See Page 2 for
Internet: www.ci.tigard.or.us CITY ^...±- T Notified/Method: - 1' ( / Supplemental Information
• l Urtrj
' TYPEE E'N K DrinsiriN .FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. 1 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
. )kl- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ 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: / 0 25 ' /03/4 Catch basin or area drain 16.60
City /State /ZIP: ' 77 () re_ t; Q Drywell, leach line, or trench drain 16.60
•
Suite/bldg./apt. no.: Project name: C � { Footing drain (no. linear ft.: ) Page 2
� _ ` ( Manufactured home utilities 110.00
I �
Cross street /directions to job site: ► V / / /--
v b v j Manholes 16.60
• Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: . Lot no.: Water service (no. linear ft.:_) Page 2 00
Tax map /parcel no.: • Fixture or item
Absorption valve 16.60
DESCRIPTION OF 'WORK Backflow preventer Page 2
-0 1 j aAAri Backwater valve 16.60
V� t� Clothes washer 16.60
' Dishwasher 16.60
• Drinking fountain 16.60
PROPERTY OWNER ( . ❑ TENANT '. -
Ejectors/sump 16.60
Name: ' n 'rjnn /n /��►
•� � V',t.. ���4 trl' I NL�u v cs Expansion tank 16.60
Address: 7t I Q Fixture /sewer cap 16.60 •
City /State /ZIP: Floor drain/floor sink/hub 16.60
Phone: ( ) J 9 4 -I J ? ,Y( Fax: ( ) Garbage disposal 16.60
- .1:3 APPLICANT ' ❑ CONTACT PERSON Hose bib 16.60
• � �
Ice maker 16.60
�^�
Business name: (, I(�`r /\ � V ' , Interceptor /grease trap 16.60
I
Contact name: 1/ s 7: - rV h-el--. Medical gas (value: $ ) Page 2
Address: -0 . I Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
, , 1 Sink /basin/lavatory 16.60
• Phone;03 C CI 27v Fax: : (�3 c _0.1,7 Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: 13 r u m e it - e Lu i - ; i i ✓I 10 � Water heater 16.60
Address: p, O , e c 3 X Z 1 e S Other:
--7730,,,_,4 Subtotal . nr
City /State /ZIP: 0 °(� 2 ? Min ,
j Minimum permit fee: $72.50 //1 �y�
Phone: (C 03 y 5L C f v Fax: (S p3) ,, �V - a i - 7 3 Residential backflow minimum permit fee: $36.25 7c t w
CCB Lic.: g7 6 3 7 Plumbing Lic. no.: Zb_ Y YS er, Plan review (25% of permit fee)
_� State surcharge (8% of permit fee) . 5 t
Authorized signature: ,, TOTAL PERMIT FEE ' , 30.
. Print name: 4 /4, et/'✓ e / - �'j 7 Date: ' This permit application expires if a permit is not obtained within
Syr 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
i:\ Building \Pernits\PLMF- PermitApp.doc 06/05 440.4616T(I0 /02ICOM/WEB)
•
Plumbing Permit Application - City of Tigard .
Page 2 - Supplemental Information `
Fee Schedule: - Residential Fire Suppression Systems:
S te.,t7tilities Qty.. Fee;(ea) ; Total ' Square Footage' - . _Permit Fee:. ,
Footing drain - l 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
1 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 f or 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 (Eiztbre)`Work`Perfo`rmed ❑ 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 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 under permit results in an
Water Extractor ure wor uner t 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:\ Buildin \Permits\PLM- PermitApp.doc 07/06/05
CITY OF TIGARD
.
BUILDING DIVISION PERMIT #: PL M2005-00418
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 8/31/2005
Phone: (503) 639 -4171 ,, y ' a lI u y� I l i
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 9/1/2005 TIME: 7:14AM PAGE: 25
SITE ADDRESS: 12522 SW 123RD AVE CLASS OF WORK:
SUBDIVISION: LAKE TERRACE LOT #: 002 TYPE OF USE:
PROJECT NAME: SIMMONS
DESCRIPTION: Replace water service. •
OWNER: SIMMONS, DAN. PHONE #: 503 - 580 -9330
CONTRACTOR: BRUNER PLUMBING PHONE #: 503- 624 -4880
Inspection Request Scheduled For: Date: 9/1/2005 Pour Time: , a
Code # Inspection Description Confirm # Contact # Message
330 Water service 014776.01 503 -624 -4880 V
Corrections /Comments /Instructions:
ecti- fl‘ p
•
tx PASS I PARTIAL APPROVAL ❑ CANCEL n NO ACCESS
n FAIL ❑ CALL FOR INSPECTION n ADDITIONAL FEES ASSESSED
Inspector: `, �+/ ►' rs -A—i '/ " , Date: c l . 1 I`larL Phone #: (503) 718-