Permit CITY TIGARD PLUMBING PERMIT
• DEVELOPMENT SERVICES PERMIT #: PLM2002 - 00214
�'' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 7/16/02
PARCEL: 1 S133AD - 02200
SITE ADDRESS: - ++
SUBDIVISION: / 073 1 ) /3.01-t- ZONING: R -
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: El FLOOR DRAINS; TRAPS:
STORIES: 2 WATER HEATERS: CATCH BASINS: 7
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: 100 ft
WATER CLOSETS: WATER LINE: 120 ft
DISHWASHERS: RAIN DRAIN: 950 ft
Remarks: Site utilities for new multi - purpose building.
FEES
Owner:
Type By Date Amount Receipt
WESTGATE BAPTIST CHURCH PLCK CTR 6/13/02 $197.95 27200200000
12930 SW SCHOLLS FERRY RD PRMT CTR 7/16/02 $791.80 27200200000
TIGARD, OR 97223 5PCT CTR 7/16/02 $63.34 27200200000
Phone 1: Total $1,053.09
Contractor:
WOLCOTT PLUMBING CONTRACTORS
PO BOX 2007
GRESHAM, OR 97030 REQUIRED INSPECTIONS
Phone 1: 667 -1781 Sewer Inspection
#: L IC 23847 Water Line Insp
Reg Rain Drain Insp
PLM 26 -208PB Rain Drain Insp
Rain Drain Insp
Rain Drain Insp
Final Inspection
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: r i1 Permittee Signature/
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
j � ~ P lumbing Permit Application , d
N
+ Date received: 6// °'x /4,: Permit no.: LFf !- 00,9..1
t p �> ;, City of Tigard ,. J
:� .- i ii• S ewer pe rmit no.I Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223 .. » _ 311 vi i
City of Tigard Phone: (503) 639 -4171 L -- ' - Project/appl..no.: ,. e date:
Fax: (503) 598 -1960 it, r. ;i nee g2 Ill e Receipt no.:
G l.1P 200 1 — 000 se fi le na:
., x-- Payment type:
Land use approval: �- �- � , 1� Y Ca „�,• n ati>zc�� �
; 1; , TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
' • • ,', J ; JOB`SITE INFORMATION -- - FEE SCHEDULE (for special inforn ation use checkl'st)
Job address: 1 2930 S%.r...1 SCI• ) FL1212Y Description Qty. Fee(ea.) Total
Bldg. no 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: Block: I Subdivision: SFR (2) bath
Project name: t 4 E S 6 At i .46. -PT (ST Gin 1120.4-1SFR (3) bath
City /county: rt C-a1A1Q� I ZIP: 9722 Each additional bath/kitchen
Description and location of work on premises: C-a e.. 11-161 , Siteutilities:
urn. k.1. - rr Catch basin/area drain
• ^) Est. date of completion/inspection: Drywells /leach line /trench drain
• Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR
Manufactured home utilities
Business name: Il ee Tr PGII - ;A/ t 3 O A-Ple 77 Manholes
Address: 44,60x o,0® ] Rain drain connector
City;,t-j f 4 ? -.� I State LIP: ,7Q; ��' Sanitary sewer (no. lin. ft.)
Phone ( p( /7 $/ Fax: I E -mail: u Storm sewer (no. lin. ft.) ;
CCB no 41 Plumb. bus. E re -gm. no: -.At Water service (no. lin. ft.)
3 g - � Fixture or item:
City /metro lic. no.:
Contractor's representative signature:!,- i Absorption valve
r , 't Back flow preventer
P name: f ate;
CONTACT Backwater valve -
. . I ' L R 1 Basins/lavatory
•
Name: rint N Ott- � 2J�J� O Clothes washer
• -Dishwasher
Address: ? OO t---I v�1 2-11 Drinking fountain(s)
j
.. �� City: NIL-L-8 r36�� I State6 2IP: ��) t 2.....4-• Ejectors/sump • Expansion tank
Phone: Fax ` ma il
`v im cg 4 � (MINER •
Off! (VhR Fixture/sewer cap
Name (print): Wes -c a &•'f 6 , -PT S'j CA-1t door drains /floor sinks/hub
g I 2930 . 5s V 5 Gt-10 Hose bibb
disposal
Mailing address: lA�� Hose bibb
City: 1 7 P._.--1> I State: 6121ZIP:99 2_52_,a Ice maker
Phone: ,2.4 3.5001 Fax: I E -mail: --1, . • Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation , Primer(s)
will be made by me or the maintenance d 'r made by my regular Roof drain (commercial)
e iig a ee on the_pr_o� u 19.wn e apter 447. Sink(s), basin(s), lays(s)
Owner's gnature: t Date: �i t t D Z Sump
Tubs /shower /shower pan -
Urinal
Name: D. L St, bt u G►'P�O U P
Water closet •
Address: 33 ht Ir4 Zit - -T6t2- 4L41/4e i • Water heater
City: 44-tu..S 1g:(352 -C I State :np I_ZIP: a- Other: •
Phone: 8,5 8 424 Fax: btts 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 ❑ MasterCard expires if a permit is not obtained
Credit card number: / i within 180 days after it has been State surcharge (8 %) .... $
Expires TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount
1/ Q 7 75--.- 440 -4616 (6/00/COM)
1
PLUMBING PERMIT FEES:
)lI
V
,> - ; ', ",'" °m"°- s; ;4 , r, ,`,z"?" v ,� ,r,N --W kI , arld`2= famil' SrOfI '�... ^o. �i`ad „� ?', `4' :ts',
` r. '> � � ° ` � � :��,...... PRICES~ - TOTAL e Y 9 Y� � A ,.� j
$ � . ' • � ,..�
FIXTURES";(mdividual) 5,, ' ' ` QTY, 4 ., "(ea)a,= mAMOUNI ;:(Includes a ll plumbing fixture in PRICE TOTAL
Sink 16.60 therdwellingnand 04:044;60 QTY :(ea) i' AMOUNT
Lavatory 16.60 = for ,each 'utility.connection) _ -a
_ - . , `- , - _ 4 Y'
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 '
TOTAL '
Garbage Disposal 16.60
Laundry Tray 16.60
Washing Machine 16.60 ..
Floor Drain /Floor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 " .
'" • . uantity'bj <Work`Pe formed
Gas piping requires a separate mechanical -:Fixture Type .' : ,, Moved ` Replaced °Removed/
permit. . , • . , Capped ' ,
MEG 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
_Urinal ,
Other Fixtures (Specify) 16.60 Dishwasher •
Garbage Disposal
17 !
O l_-`1' Laundry Room Tray -
Washing Machine -
- Floor Drain /Sink: 2"
Sewer - 1st 100' 72', 55.00 as 3 „
Sewer - each additional 100' 46.40 4" '
Water Service - 1st 100' 10 (if 55.00 .SS Water Heater
Water Service - each additional 200' IS I 46.40 �q OthFixtures
/ 55.00 b"5 (Sp eci fy) -
Storm & Rain Drain - 1st 100' 100 $g
Storm & Rain Drain - each additional 100' 1350 46.40 X417. b .
Commercial Back Flow Prevention Device ) . 46.40 •=16S0 .
Residential Backflow Prevention Device* _. • 27.55 •
Catch Basin 7 • 16.60 1 ( 6..Lt7 '
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections ' per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling i 65.25 '
Grease Traps i 16.60
QUANTITY TOTAL ' 7.9 8.0 •
Isometric or riser diagram is required if ;3 *,, I,':.''';'-, ;; ,
Quantity Total is > 9 ,a,. _` ,, r. - -
*SUBTOTAL %;':e..5,,,,,, ` ,Z,: - -7 80 .
8% STATE SURCHARGE ,, : ::,, ' "'r `_',' -`' (O- i.liift...
**PLAN REVIEW 25% OF SUBTOTAL v. " - 414 ` / " 9. C,
-
Required only if fixture qty. total is > 9 ,.. , .`; 4,', -,::,:',1 " , ' :' I �'
TOTAL _` �I 01/ .
* 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 2 sets of plans with isometric or riser
diagram for plan review.
•
is \dsts \forms \plm- fees.doc 12/26/01