Permit CITY TIGARD 4)� PLUMBING PERMIT
4 DEVELOPMENT SERVICES PERMIT #: PLM2000 -00110
Ai- 4 �' I ° 13125 SW Hall Blvd., Tigard, O 97223 (503) 639 -4171 DATE ISSUED: 4/7/00
SITE ADDRESS: 10751 SW 130TH AVE 4/ PARCEL: 1S133AC-08001
SUBDIVISION: KNOWLEDGE BEGINNINGS DAYCARE C ZONING: R -25 •
BLOCK: LOT: 001 J b IRISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 1 l og OCCUPANCY GRP: E3 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 commercial backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
KNOWLEDGE BEGINNINGS PRMT DEB 4/7/00 $50.00 0001258
10751 SW 130TH AVE 5PCT DEB 4/7/00 $4.00 0001258
TIGARD, OR 97223
Total $54.00
Phone 1:
Contractor:
ANCTIL PLUMBING INC
16900 SW MERLO RD
BEAVERTON, OR 97008 REQUIRED INSPECTIONS
Phone 1: 503 - 642 -7323 RP /Backflow Preventer
Reg #: LIC 00000241 Final Inspection
PLM 26 -162PB
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 y: ,. , / 4 „ , � Permittee Signature :,, / d joi6
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the next business day
■
CITY OF TIGARD Plumbing Permit Application Plan Check
13125 SW HALL BLVD. Commercial and Residential Rec'd By
TIGARD, OR 97223 Date Recd _ O
(503) 639 -4171 (N3WdO13A3C1 AlINf1WW03 Date to P.E. `
-°
) , I Print or Type Date to DS
Incomp o i lre g iible applications will not be accepted Permit# `M rIJ-t /,'
Related SWR #
(331\130 A�Pr1�9 -d03 (1 Called
AV Clige
Name / of Developme t / Project FIXTURES (individual) QTY PRICE AMT
Job ei t) ,i 1- & gdi i I fw s Sink 11.50
Address Street Address Suite Lavatory 11.50
/O? S!Ai 1-5 Ar Tub or Tub /Shower Comb. 11.50
Bldg # City /State Zip
.?' /A 4.0 q ?ZZ3 Shower Only 11.50
Name / / Water Closet 11.50
Si In 6 Dishwasher 11.50
Owner Mailing Address Suite Garbage Disposal 11.50
Washing Machine 11.50
City /State Zip Phone Floor Drain /Floor Sink 2" 11.50
Name 3" 11.50
, rtYfiC 4" 11.50
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 11.50
Gas piping requires a separate mechanical permit.
City /State Zip Phone Laundry Room Tray 11.50
Urinal 11.50
Na Other Fixtures (Specify) 15.00
h eI c/ rn 6 all .z'ivc. Contractor M /-frfC
ddress Suite
/ Oa Sw / n Cr6e go,
Prior to permit City /State Zip Phone 7 Sewer - 1st 100' 38.00
issuance, a copy ‘1 4 wZ - � - 3 L3
Sewer - each additional 100' 32.00
of all licenses are Oregon Const. Cont. Board Licit Date
required if f 2 -di Water Service - 1st 100' 38.00
expired in COT Plumbing Lic. # D Exp. Date Water Service - each additional 200' 32.00
database Z 6 - / (p 2 ,PO &_ 3c, - CO Storm & Rain Drain - 1st 100' 38.00
Name Storm & Rain Drain - each additional 100' 32.00
Architect Mobile Home Space 32.00
or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- , •J 32.00 Q � ,OG
Pollution Device
Engineer City /State Zip Phone Residential Backflow Prevention Device* 19.00
(Irrigation timing devices require a separate
Describe work to be done: restricted energy permit.)
New 0 Repair 0 Replace with like kind: Yes 0 No 0 Any Trap or Waste Not Connected to a Fixture 11.50
Residential 0 Commercial 0 Catch Basin 11.50
Additional description of work:
'j y� ,{ / V '► /�t Insp. of Existing Plumbing 50.00
,// 6i6 C ` /( /6Z 1 i/ per /hr
50.00
Are you capping, moving or replacing any fixtures? Specially Requested Inspections per/hr
Yes 0 N9,..0"-- 45.00
Rain Drain, single family dwelling 45.00
If yes, see back of form to indicate work performed by Grease Traps 11.50
fixture. FAILURE TO ACCURATELY REPORT FIXTURE
WORK COULD RESULT IN INCREASED SEWER FEES. QUANTITY TOTAL
I hereby knowledge that I have read this application, that the information Isometric or riser diagram is required if Quantity Total is > 9
given is rrect, that I am the owner or authorized agent of the owner, and *SUBTOTAL
't .
that pl s submitted are in co ibnce with /Oregon State Laws.
Si a reof Owner /e�nt D e
,4A --� (.2t- / 'U L 3 �U 5�o SURCHARGE € ±d -' C- 41. .-
Contact - • o Name • o . * *PLAN REVIEW 25% OF SUBTOTAL
, Z, 4 Ai - �2 f Z3 Required only if fixture qty. total is > 9
Ill:MTH Hi USE $178.00 TOTAL � //CO r
2 BATH HOUSE $250.00 '5 ,, - `?
3 BATH HOUSE $285,00 - ., --'''',:':•: - : "" *Minimum permit fee is $50 + 5% surcharge, except Residential Back .w..
(This fee includes all plumbing fixtures in the dwelling and the first = Prevention Device, which is $25 + 5% surcharge
s ° Buildings re
100 feet of sanitary sewer storm sower and water service) .. • * *All New Commercial Buildin g require plans with isometric or rise die• am
and plan review ,
I: \dsts \formsi.plumapp.doc 6/2199
a9- oO
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PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain /Floor Sink 2"
3
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
r e, fia Ft / /�` ✓�l6 C e TC i'i ( it.„ /Yr% y'tj 6 S .
I \dstsltormsl plum app .doc 6/2/99
04/28/2000 Activities for Case #: PLM2000 -00110
8:46:59 AM
Assigned Hold Updated
Activity Description Date 1 Date 2 Date 3 To Done By Disp. Level By Updated Notes
PLMC003 Application received 04/04/2000 DEB MAIL No Hold DEB 04/07/2000
PLMC005 Permit Created 04/07/2000 DEB DONE No Hold DEB 04/07/2000 Applicant did not submit
enough money for permit.
Additional fees received on this
date.
PLMC750 RP /Backflow Preventer No Hold DEB 04/07/2000
PLMC799 Final Inspection 04/26/2000 MRS DONE No Hold MRS 04/26/2000
PLMCO50 (F) Issue permit 04/07/2000 DEB DONE No Hold DEB 04/07/2000
PLMC800 Case Fineled 04/26/2000 MRS DONE No Hold MRS 04/26/2000
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