Permit •
CITY TIGARD PLUMBING PERMIT
I I DEVELOPMENT SERVICES PERMIT #: PLM2004 -00347
' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 7/26/2004
SITE ADDRESS: 13650 SW 124TH AVE PARCEL: 2S103CC -07100
SUBDIVISION: WHISTLER'S WALK ZONING: R -4.5
BLOCK: LOT: 018 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of residential backflow prevention device.
FEES
Owner:
Description Date Amount
LEX DAM IS
13650 SW 124TH AVE [PLUMB] Permit Fee 7/26/2004 $36.25
TIGARD, OR 97224 [TAX] 8% State Surchan 7/26/2004 $2.90
Total $39.15
Phone : 503 - 524 - 6773
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : RP /Backflow Preventer
Final Inspection
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 -0i • ! 00. You may obtain copies of these rules or direct questions to OUNC by calling (503)
246 .699.
Issu B r / Permittee Signature: G
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the ne • usiness day
Buildin; Fixtures
Plumbing Permit Application ! FOR OFFICE USE ONLY
City Of Tigard DateB Received 7 don ..,_ e Q Permit Ii ►/ 4A�3g
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review CN i
Phone: 503.639.4171 Fax: 503.598.1960 //"iii /,Nl� (,i ll; Date/By: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 �„ ,.• 1 ra
Internet: www.ci.ri ard.Or.us W Date ed /Me y: H See Page 2 for
g Notified/Method: Supplemental Information
" ? . ,:, - rl i1 � r vm ` FEE *` SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
r r t i ,+ if- fik �F1SI/ 161.!) 4 SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler (_ sq. ft.) Page 2
9 e * 4 "" �, t e " ,. #.. ?.` S . .. _ _,, _ Site utilities
i lob site address: ) - SO $' L,'. /2 y 7 " Catch basin or area drain 16.60
City/State /ZIP: 77 , d /e q? 2,23 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name: Footing drain (no. linear ft.: ) Page 2
Cross street/directions to job site: /2 / 3 6 4'' y �! / •--- �,�/ S � , I ' Manufactured home utilities 110.00
l!`/ t� ''`� - Manholes 16.60
4 Pi 611 - 7..5 )l) / 2 Li fi Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
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
4 , Absorption valve 16.60
. .. .fit z- i I > i , s t Backflow preventer 1 Page 2
/I- �law / V i ' �� y Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
1 k ,,g rr r 3 Drinking fountain 16.60
;
'` " :4 4 - - ": Ejectors /sump 16.60
-Name: - x 1)4141/ S Expansion tank 16.60
,/Address: /3 t5 6se S 4? 12 y A Fixture /sewer cap 16.60
.-eity/State/ZIP: 7-/`S ,,-c l ( / 2_2_3 Floor drain/floor sink/hub 16.60
.Phone: (Sam , . 5 f c '73 Fax: ( ) Garbage disposal 16.60
;z g: a r t ' �� d .�. a , Hose bib 16.60
a '''' 44 ' 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
Phone: ( ) I Fax:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
,,,, . _ -:,.•-401.:;`'''' `l ,t , ,� sot Oh z g "`" l " , ' ; z F "'
, . ,,,, � , T ar _ t �,7 i s ' ;,. ,:A ) ,, 1; . Water closet 16.60
Business name: 16 7 - Water heater 16.60
Address: Other:
City/State /ZIP: Subtotal
Minimum permit fee: $72.50 Q / ? S
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 0
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
authorized signature: A� State surcharge (8% of permit fee) pt , 9 v
TOTAL PERMIT FEE I
Print name: X ` 2 I » / t Date: This permit application expires if a permit is not obtain ithin
180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
is\ Building \Pem¢ts\PLMF- PermitApp.doc 12/03 440- 4616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
9 e�.- Q�ye (ea} Total0. Siluare Footage;. 1,Perinit ,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
Medical Gas Systems
Water Service - each additional 100' 46.40
Storm & Rain Drain - 1st 100' 55.00
A414.-W, ,
$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
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: $50,001.00 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 * .
, p t 1 � = Comments regarding fixture work:
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
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
-Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar /Lavatory
Quantity Total
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
Service total is >9.
Swimming Pool Filter
Washer - Clothes
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
i:\ Building \Permits\PLM- PemvtApp.doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested T 2 AM PM BUP
Location / 3 Ca 5 — ` Suite MEC J ��
Contact Person Ph ( ) PLM �O – U 3 (C1
Contractor Ph ( ) SWR
BUILDING Tenant/0 42) ZA . ELC
Footing 5 7 c ` 9 ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain /
Slab Inspection Notes: SIT / �
Post & Beam
Ai vw
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation — PO-0 \.1 1G)11— pk f 12011 AC.GE35
Drywall Nailing �[.-�!
Firewall 617 C 1071
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan 3
Other: rC%
PART 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: El Unable to inspect — no access
Fire Supply Line
ADA t-�
Approach/Sidewalk Date ! 2 Inspector 6Q-
�r ] Ext
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL