Permit CITY TIGARD PLUMBING PERMIT
* 1 DEVELOPMENT SERVICES PERMIT #: PLM2000 -00434
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/29/00
SITE ADDRESS: 12475 SW 129TH AVE PARCEL: 2S104AA 11900
SUBDIVISION: BELLWOOD NO. 3 ZONING: R -4.5
BLOCK: LOT: 138 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of back flow preventer
FEES
Owner:
Type By Date Amount Receipt
SMITH, DORIS J TRUSTEE PRMT CTR 11/29/00 $36.25 27200000000
12475 SW 129TH AVE 5PCT CTR 11/29/00 $2.90 27200000000
TIGARD, OR 97223
Total $39.15
Phone 1:
Contractor:
REQUIRED INSPECTIONS
Phone 1: RP /Backflow Preventer
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 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued By: 7j2-1/1 , Permittee S i g n a t u r e
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Plumbing Permit Application
Date received: 1 \ \ , .1 . UV Permit no. :60000- DD 119
- h g y � ; City of Tigard
,41' ` J Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By: Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family l Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
` , JOB SITE INFORMATION FEE SCHEDULE (for special inforn ation use checklist)
Job address: \ Z+k7 S S‘J (J't a. A Description Qty. Fee(ea.) Total
Bldg. no.: I Suite no.: New 1- and 2 -family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: —�1 � p I ZIP: Each additional bath/kitchen
Description and location of work on premises: l I t C.1Ar1 haJ Site utilities:
1- zi' - (G T P. N\ Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: ) -z L Manholes
Address: Rain drain connector
City: I State: I ZIP: Sanitary sewer (no. lin. ft.)
Phone: I Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: I Plumb. bus. reg. no: Water service (no. lin. ft.)
City /metro lie. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer 1
Print name: Date: Backwater valve •
C'ONTAC'T PERSON Basins/lavatory
Name: Clothes washer
Address: Dishwasher
Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E-mail: Expansion tank
Fixture/sewer cap
Floor drains/floor sinks/hub
Name (print): 1)0(2./6 G214 V nt Garbage disposal
Mailing address: (7A'lS l.N) 'Vt A`<L Hose bibb
City: ' C) I State: Q4-1,ZIP: Ice maker
Phone: 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 Roof drain (commercial)
employee on the propert pe ORS C apter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: //- a- y 2 ` Sump
Tubs/shower /shower pan
Urinal
Name:
Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $
Notice: This permit application Plan review (at %) $
❑ Visa ID MasterCard expires if a permit is not obtained
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $
Expires TOTAL $ 3 9, >'
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6/00/COM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUN1 (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 _ SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 - TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 -
3" 16.60 PLEASE COMPLETE:
4~ 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory
•
Tub or Tub /Shower
Hose Bibs 16.60 _ Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Other Fixtures (Specify) 16.60 - Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
- - Washing Machine
Floor Drain /Sink: 2"
Sewer- 1st 100' • 5E.0t;
v „
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 - Water Heater
- Other Fixtures
Water Service - each additional 200' 46.40 (Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device* 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL ,
8% STATE SURCHARGE 9
* *PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty total is > 9
TOTAL i q 5'
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
* * All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
i s \dsts \forms \plm- fees.doc 10/10/00
CITY OF TIGARD BUILDING INSPECTION DIVISION
* 244-four Inspection Line: 639 -4175 Business Line: 639 -4171 MST
BUP
Date Requested / Z 1 AM PM BLD
Location / Z if 7.) /Z ar -r Suite MEC
Contact Person Ph 6 f Z 5 3-6 � PLM G,t/- a a y3 6(
Contractor Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab SIT
Post & Beam A
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall /
Fire Sprinkler j 1
Fire Alarm
Susp'd Ceiling
Roof
Misc:
Final
PASS PART FAIL
1 & Beam
Under Slab
Top Out Cf<Gcv
Water Service
Sanitary Sewer
Rain Drains
Fi I
S PART FAIL
ANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In •
UG /Slab
Low Voltage
9
Fire Alarm
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA
Approach /Sidewalk Date v ► Inspector Other D I t Ext
Final
PASS PART FAIL DO NOT - EMOVE this inspection record from the job site.
BUP - Building Permit ELC - Electrical Permit
4 Inspection Description Date Passed By 4 Inspection Description Date Passed By
Footing /Setback Underground cover
Foundation walls Wall cover
Footing drain Ceiling cover
Waterproof bsmt walls Electrical rough -in
Slab Electrical service
Crawl drain Electrical final
Underfloor insulation
Post/beam structural
Shear walls /anchors ELR - Restricted Energy Permit
Roof nailing J Inspection Description Date Passed By
Firewall Low voltage
Tilt -up panel Electrical fmal
Masonry /Reinforcement
Framing
MFG - Structure set -up MEC - Mechanical Permit
Insulation
Drywall nailing 4 Inspection Description Date Passed By • Post/beam mechanical
Suspended ceiling Gas line
Engineered soils Mechanical rough -in
Welding Lab Final Fire damper
Concrete Lab Final Duct work
Bolting Lab Final Smoke detector
Fireproofing Lab Final Mechanical final
Structural observation
Final inspection
PLM - Plumbing Permit
4 Inspection Description Date Passed By
BUP — Fire Protection System Permit Plumbing underslab
4 Inspection Description Date Passed By Crawl drain
Sprinkler underfloor /slab Post/beam plumbing
Sprinkler rough -in Plumbing top -out
Sprinkler final RP /backflow preventer
Fire alarm final Rain drain
Storm drain
Water service
SIT - Site Permit Sanitary sewer
J Inspection Description Date Passed By Culvert/catch basin
Footings Pump /fill septic tank c
Foundation walls Plumbing final / 2 ///w'T
Sprinkler supply lines
Sprinkler underfloor /slab
Catch basin/Manhole SWR - Sewer Permit
Engineered soils I Inspection Description Date Passed By
Engineering acceptance Sanitary sewer
Final inspection Final inspection
INSPECTION RECORD - BUP, PLM, SWR, ELC, ELR, MEC, SIT PERMITS
Atte CITY OF TIGARD PLUMBING PERMIT
li l t, DEVELOPMENT SERVICES PE
DEVELOPMENT PLM2000-00434
��'I� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/29/00
PARCEL: 2S104AA -11900
SITE ADDRESS: 12475 SW 129TH AVE
SUBDIVISION: BELLWOOD NO. 3 ZONING: R -4.5
BLOCK: LOT: 138 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of back flow preventer
FEES
Owner:
Type By Date Amount Receipt
SMITH, DORIS J TRUSTEE PRMT CTR 11/29/00 $36.25 27200000000
12475 SW 129TH AVE 5PCT CTR 11/29/00 $2.90 27200000000
TIGARD, OR 97223
Total $39.15
Phone 1:
Contractor:
REQUIRED INSPECTIONS
Phone 1: RP /Backflow Preventer
Reg #:
.0
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 6 8
Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued By: 75 , D Permittee Signatur• Call 03) 639 -4175 by 7:00 P.M. for an inspection needed the next business day