Permit CITY OF TIGARD
PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2004 -00133
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/1/04
SITE ADDRESS: 12950 SW 129TH PL PARCEL: 2S104AD 03301
SUBDIVISION: ZONING: R -7
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT 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: 270 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Install 270' line work to connect to residence to sewer. Septic system to be pumped and filled or removed.
FEES
Owner:
Description Date Amount
LORENCE, WALTER P + DEBI D
12950 SW 129TH PLACE [PLUMB] Permit Fee 4/1/04 $147.80
TIGARD, OR 97223 [TAX] 8% State Surchari 4/1/04 $11.83
Total $159.63
Phone : 503 - 524 -5410
Contractor:
OWNER
•
REQUIRED INSPECTIONS
Sewer Inspection
Phone : 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
Issued By. Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Pfunlbing Permit Application FOR OFFICE USE ONLY -
City of Tigard Received " / / Permit No ?mop AF _
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 /4441 �Vi I + + °� Date/By: Other permit No! j��pr� ^ .Co / 05? 24- Hour Inspection Line: 503.639.4175 e' II Date Ready/By: s 0 See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: 1 Ida' Supplemental Information
7 1
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TY WORK, . .,.� � s FEE , SC
e .. ..ova .x ar�=A� _,..x ,.a =..ate _�." °'..�'�..�r &y.�, ��. �.• E' -as „ <aka�:::...^�':.w.`•�c. .. �.�.'F:, .:�a«". :«, _ .
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
',c:.. , r,i7 °ter - ,,3 •�. .°.. ”° . .- • <s::
r ” 12 `�a, C ATE W - O = `= M u s' «;..�::s ` ,�:. SFR 1 bath 249.20
- •- :i'r��a�, "n ,�s� =s -; ..� .�•^.�,v -- .�.:=�t� =• �.. , c.�arx €�;6+:�a =- �;,€�i,,. °'.r. �? „��,.e= •� -ez:: �zA:l:�?;Y, ( )
❑ 1- and 2- family 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:
;r;. 4,::, �._: ,.:.._aP.:;;; a_ ; , r ,•,,s ., Fire sprinkler ( sq. ft.) Page 2
JOB STI'E''wINFO I,O - kip ,
'f _. * ,,,12. >_� : k , .,,,..k_., v �: ,.. ,..- ` .o c.. Site utilities
Job site address: I44 57) 5 ,1— C placL ' Catch basin or area drain 16.60
City/ State/ZIP: ' \ r 0 e___ (i a-- � Y Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name:
Footing drain (no. linear ft.: ) Page 2
Manufactured_ home utilities 1 10.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: L� Page 2 /0/.4/0
Storm sewer (no. linear ft.: Q 2) /Page 2
Subdivision: 1 Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
=•; , ^ , r.=.ar., . ; ,<.•,. , .1, Absorption valve 16.60
� " „ i `„�r�, -p�;` ; .'�', ��: � ;,�� , =5 v a. ;a;�;;.� �; �� ;ay.. .r ,.�: w•”` fir;
>;q,,F' `t. - ,,, _. y , DESGRIPT ON OAF W ® RK t , ”) w " R= Backflow preventer Page 2
_ 1. (Jy y{, , � Backwater valve 16.60
�ll�� Clothes washer 16.60
Dishwasher 16.60
•ao ; ems-, - a .' Drinking fountain 16.60
_
'• : ;.. rPR ERTX "OWNER - Amy ,.., TENAN " '
�z���� ��x�>'=�Sw�xs�k�,,.as�:x d,:� i ,.�?„�.�+. �a, �.r.�. �T �.< „ m,t.a. , Ejectors /sump _ 16.60
Name: l ._.c. r e._( t.J f '€_f Expansion tank 16.60
Address: 5 Ct,/ Fixture /sewer cap 16.60
City/State /ZIP: 7 — ,/-�/ o O, ) d-d 3 Floor drain /floor sink/hub 16.60
2' 7 t}
Phone: ( -60 Cf Fax: ( ) Garbage disposal 16.60
a . � 4a: = s tar—vm F ,,,,,, 7 , a + x,11- si,: h x;. g i �w == =.;. y.; a Hose bib 16.60
Nom_. „_ �� 0 .*APP : s ; � - ; i Cp NTAC P ERSON
� - n�� �;.��.c ,a,�_° < s � ' �� � .: - �, ®._�� - w, � • 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) ..61 )4
Phone: ( ) Fax: : ( ) Sink/basin/lavatory I 6 .,. i (l , g a
Tub /shower /shower pan 1...0 d
E -mail:
�� a= k „ � �, �r �� � Urinal ;Ar � g � y „,6 m R /AC�IOR x - , =s ` ;r" . ; C J�`T I ��_H .. y a.,;.x:va - - r-. .- 41R&Mel ernikW - Water closet 0� . Business name: U " i / '� t✓ 0 g— /) . e owN Water heater .60
Address: /) I. O f 14 ,�•LiC,,.l�,? 6/ .1 Other: /
Subtotal //. g3
City/ State/ZIP: �-.'�� C IY
Minimum permit fee: $72.50 �/
Phone: ( //C Fax: ( ) — Residential backflow minimum permit fee: $36.25 �� Yv
CCB L : " -- Plumbing Lic. no.: Plan review (25% of permit fee)
�) State surcharge (8% of permit fee) . / 9
Authorized signature: ? j/ � e TOTAL PERMIT FEE / .5" '
Print name: '.) Date: This permit application expires if a permit is not obt the w '
180 days after it has been accepted as complete. ; /; t ,. -• ,
Ik . - Y / �' � (J _ *Fee set by Tn-- Coounntty Induuustry Service oard --;:;;,f_.-!
• :,
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i:\ Building \Petits\PLMF- PermitApp.doe 12/03 2 440- 4616T(I 0 /02 /COM/WEB) n _ A ( )`^•^ ' �O' ` I //
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utal qu
Pee (ea) afar " „Sare oota a Permit =
Footing drain - 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 �5 -ce 7,201 and greater $309.00
Sewer - each additional 100' 01 46.40 C)a,gp
Water Service - 1st 100' - Medical ca Gas Systems:
Water Service - each additional 100' 4F ^ 7 e7
N7A,u '< Perm t F ee;°
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
additional $100.00 or fraction thereof, to and
- te.. ' ,a °
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 first 0.00.
(� $50,001.00 and up $742.00 for the e first $50,000.00 and $1.20 for
Subtotal:
�(./7 id 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 * .
, . Qua�ttty�',b� (Fturej,Wbrl�Performed
F ixture .�, � � � Type 1 i Replace �.
� �, �l o �ea , �c p d 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
Ice Mach. /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
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 •
Bradley • Quantity Total
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- PemtitApp doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
L/1-,R BUP
Received Date Requested 7 AM PM BUP
Location (r 9S /422, WI et._ Suite MEC
Contact Person wC2-1 ) Ph ( ) /,3a - lo O /1- PLM 1 7 1 - Do /3 3
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
ELC
Foundation Access: '�
Ftg Drain ' ELR
Crawl Drain , ' �� �/�
Slab Inspecti rotes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler /
Fire Alarm
Susp'd Ceiling
Roof
Other: L ; _� _
Final / l
PASS PART FAIL / _ ' /I
Post & Beam
Under Slab
Rough -In
Water Service
'am IP rains
Catch Basin / Manhole
Storm Drain
Shower,Pan
Other:
Fr P RT FAIL
• CHA AL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRIC AL
Service •
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hail, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date ig-7/ 6 t Inspector /' Ext
Other:
Final DO NOT REMOVE this inspection r cord from the Job site.
PASS PART FAIL
ALOHA SANITARY SERVICE INVOICE NO.
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 84
503 - 644 -2797 i 503 - 648 -6254 * 503 - 639 -5188
NAME: k d�? � " f ' /7;1, A C ; . . a
ADDRESS: 1 :4 f 111(+7
-
CITY: i .✓ 4' 7 2v ;, STATE: ZIP:
HOME: WORK: -7
ORK: CELL: j k✓ - 1.1.' u .� a 1
•i
r"
JOB SITE: f4Y" r "`;4j 4 t i '3 , P.O. #:
s'
1 r 11 \
PAID BY CHARGE ❑ ; �j Y CHECK ® CASH CI CREDIT CARD ❑
V a / I r>! '---.- te‘
, I i .
DATE 1 k ; LI ''' ";da ,A t i 1 DRIVER � , �) ii� () 7 / AMOUNT
• PUMP SEPTIC TANK 2' 0 j , -
❑ LINE OPENING I
❑ INSPECTION FEE I
❑ SERVICE CALL
❑ LABOR, LOCATING, DIGGING, BACKFILL I
❑ MATERIAL i
�' ' TOTAL $ . _'l' O0 9:1-..
- - THIS IS NOT A SEPTIC SYSTEM INSPECTION REPORT - -
r ' ] '' REMARKS
TYPE OF TANK: / STEEL ❑ CONCRETE ❑ PLASTIC ❑ HOMEMADE ❑
HORIZONTAL ❑ VERTICAL ❑ RECTANGLE ❑ ❑ OTHER
SIZE OF TANK: 350 ❑ 500 ❑ 750 ❑ 1000 ❑ 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑
LID LOCATION: INLET ❑ OUTLET ❑ MIDDLE ❑ ENTIRE TOP ❑
TANK CONDITION: GOOD ❑ FAIR ❑ POOR ❑
FITTINGS: BAFFLES ❑ CONCRETE ❑ CAST IRON ❑ PLASTIC ❑
NEEDS NEW LID? YES ❑ SIZE
GROUND COVER OVER TANK
COMMENTS ON CONDITION OF DRAINFIELD ETC.
SIGNED BY DATE
•