Permit CITY TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2007 -00574
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 12/31/2007
PARCEL: 2S103BC -02000
SITE ADDRESS: 12205 SW ALBERTA AVE ZONING: R -4.5
SUBDIVISION: CANOGA PARK LOT: 004 JURISDICTION: TIG
PROJECT: DAWES
Project Description: Connect existing house to sewer service. Septic tank is to be pumped, filled and iinspected.
Reimbursement District #30 fee paid this date.
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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner:
FEES
RICHARD & DAWES
12205 SW ALBERTA ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 12/31/2007 $72.50
[TAX] 8% State Surcha 12/31/2007 $5.80
Phone : 503 -579 -3386 Total $78.30
Contractor:
WESTSIDE UNDERGROUND UTILITIES INC
30585 NW EVERGREEN RD
HILLSBORO, OR 97124 -1855 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 969 -4631
Reg #: LIC 110690
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 -0100. You may obtain copies of
these rules o 'fee estions to OUNC by calling 503.246.6699 or 1.800.332.2344.
•
Issu d By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application ocv/L 7- 3
Building Fixtures , FOR OFFICE USE ONLY
City of Tigard Date/By: d Permit No.. � �- oos7
Receive
711 n 13125 SW Hall Blvd., Tigard, OR 97223
P hone: 503.639.4171 Fax: 503.598.1960 Plan Review O ther Permit No.:
Other
Inspection Line: 503.639.4175 Date Read B �'�' la See Page 2 for
Internet: www.ti
TIGARD and - or. ov Ready /By: / L� g
g g Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description Qty. Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2 - family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION 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
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: / c7od 5 S) a-l� d'l( �Sil Catch basin or area drain 16.60
/ !
City /State /ZIP: q a4 . f R q7� Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: /Q ) Page 2
Storm sewer (no. linear ft.: _ ) Page 2
Subdivision: Lot no.: Water service (no. linear ft.: _ ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
eL )f Ii n Q . cs /woe- t/ y (� Backwater valve 16.60
`7 Clothes washer 16.60
Dishwasher 16.60
PROPERTY OWNER ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: R / Ch a nel LIi5t „DO w S Expansion tank 16.60
Address: / as cull Fixture /sewer cap 16.60
City /State /ZIP: - T a4Qi U 97aa3 Floor drain /floor sink/hub 16.60
Phone: (5)3) 5-9._ 3 -4 Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON' ose bib 16.60
N
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
Sink/basin/lavatory 16.60
Phone: ( ) Fax::( )
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: tI) ' I (Q, [)r) C fi r'
OL! ! Water heater 16.60
Address: Other:
City /State /ZIP: A //shaky , (X_ Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
surcharge (8% of permit fee)
Authorized signature State surch
a TOTAL PERMIT FEE
Print name: Z/64 /4 na_G1l°,3 Date: h7 - 3/ 07 This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
I ABuitding\ Permits \PLMF- PermitApp.doc 12/27/06 440- 46t6T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
•
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total: Square Footage: . Permit Fee: .
Footing drain - 1S 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
Valuation: • • Permit Fee: •
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
Fixture or Item Qty. Fee (ea) Total 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
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or
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: Plan_Review for Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain • Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
- 4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory •
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i \Building\Permits\PLM- PermitApp.doc 12/27/06
FROM : LJESTSIDE UNDERGROUND FRX O. : Jan. 18 2888 01:20PM P2
AL•HA :FANMT Y SERVCE -
INVOICE NO .
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 8 7
503 - 644 -2797 • 503 -648 -6254 • 503 - 639 -5188
NAME: . ' ! r/ 5 !r' tip ), i J f i 3 1- Z14 I
ADDRESS:
CITY: STATE: _ ZIP: _
HOME: WORK: CELL:
Jos SITE: /1 d S y r ,9 ` J .,fi . /. P.O. #:
/
PAID BY CG E - 4 - �" CHECK ❑ CASH ❑ CREDIT CARD ❑
DATE / / i " ij DRIVER )1,9; 7 d ! AM,/O;; UNT
if PUMP SEPTIC TANK G-
❑ LINE OPENING
❑ INSPECTION FEE
❑ SERVICE CALL
❑ LABOR, LOCATING, DIGGING, BACKFILL
LI MATERIAL
r
- - THIS IS NOT A SEPTIC SYSTEM INSPECTIOW REPORT - -
TOTAL
- - REMARKS - -
TYPE OF TANK: STEEL LI CONCRETE LI PLASTIC ❑ HOMEMADE ❑
HORIZONTAL LI VERTICAL ❑ RECTANGLES 0113E»R =
SIZE OF TANK: 350 ❑ 500 ❑ 750 ❑ 1,1100 - x"250 ❑ 1 500 ❑ 2000 ❑ 3000 ❑
LID LOCATION: INLET Li ET LI MIDDLE ❑ ENTIRE TOP ❑
TANK CONDITION: GOOD,Q - FAIR ❑ POOR LI
FITTINGS: -BAFFLES LI CONCRETE ❑ CAST IRON ❑ PLASTIC ❑
NEEDS NEW Lib? YES ❑ SIZE .
GROUND COVER OVER TANK
COMMENTS ON CONDITION OF DRAINFIELD ETC.
SIGNED BY _ DATE /-..-A? r^�
CITY OF TIGARD „, -
BUILDING DIVISION PERMIT #: PLM2007- 00574
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12/31/2007
Phone: (503) 639 -4171 emu- u�'��WII�'�+
Inspection Requests (24 Hrs.): (503) 639 -4175 -__�
INSPECTION WORKSHEET FOR DATE: 1f72/2008 TIME: 7:01AM PAGE: 70
SITE ADDRESS: 12205 SW ALBERTA AVE CLASS OF WORK:
SUBDIVISION: CANOGA PARK LOT #: 004 TYPE OF USE:
PROJECT NAME: DAMS
DESCRIPTION: Connect existing house to sewer se'vice. Septic tank is to be pumped, filled and inspected.
Reimbursement District #30 fee paid this date.
OWNER: DAWES, RICHARD & LISA PHONE #: 503 -670 -3396
CONTRACTOR: VVESTSIDE UNDERGROUND UTILITIES INC PHONE #: 503-969-4631
Inspection Request Scheduled For: Date: Pour Time:
P q 'i /�.2/ �t300
Code # Inspection Description Confirm # Contact # Message
f'j05 Sanitaiy sAwer 063572 -01 503. 9694631 N
r1 1.
Corrections /Comments /Instructions: ` { e
PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: A\A 4-- Date: f 122,1 0 Phone #: (503) 718-
CITY OF TIGARD - . - .
BUILDING DIVISION PERMIT #: PLM2007- 006,74
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 1213°11`'007
Phone: (503) 639 -4171 A 11 111
Inspection Requests (24 Hrs.): (503) 639 -4175 "__..
INSPECTION WORKSHEET FOR DATE: 1/17/2008 TIME: 7:00AM PAGE: 15
SITE ADDRESS: 12205 SW ALBERTA AVF CLASS OF WORK:
SUBDIVISION: CANOGA PARK LOT #: 004 TYPE OF USE:
PROJECT NAME: DAWES
DESCRIPTION: Connect existing house to sewer service. Septic tank is to be pumped, filled and inspected.
Reimbursement District #30 fee paid this date.
OWNER: DAWFS, RICHARD & LISA PHONE #: 503- 179.3396
CONTRACTOR: WESTSIDE UNDERGROUND UTILITIES INC PHONE #: 503969.4531
Inspection Request Scheduled For: Date: 1/17/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
505 ;sanitary sewer 063435 -01 503 - 969.4631 Y
Corrections /Comments/ Instructions:
P ck, — e P, i 1 S-( � .,-A. 4- P;ti\tk_.. Cow Ou.: ,-1,-- cf\1lo7
PASS .X PARTIAL APPROVAL n CANCEL ❑ NO ACCESS
n FAIL n CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: \\ \ . ---- -- Date: I I I1' b Z Phone #: (503) 718-