Permit ' CITY OF TIGARD PLUMBING PERMIT
�i DEVELOPMENT SERVICES PERMIT #: PLM2004 -00289
e ' II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/24/2004
SITE ADDRESS: 12120 SW ALBERTA AVE PARCEL: 2S103BC -02700
SUBDIVISION: CANOGA PARK ZONING: R -4.5
BLOCK: LOT: 001 JURISDICTION: TIG
CLASS OF WORK: OTR 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: ft
WATER CLOSETS: WATER LINE: 55 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replace approximately 55' of water service.
FEES
Owner:
Description Date Amount
KYLE BUCHHOLZ
12120 SW ALBERTA ST [PLUMB] Permit Fee 6/24/2004 $72.50
TIGARD, OR 97223 [TAX] 8% State Surchari 6/24/2004 $5.80
Total $78.30
Phone : 503 - 521 - 9061
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : Water Service Insp
Final Inspection
Reg #:
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR
952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
24 699.
1 _ -. , /
Is ued By: �l�>?i� , i �; Permittee Signature: , :I 1/ A
Call (51 - 639 -4175 by 7:00 P.M. for an inspection needed the next busi s day
Building Fixtures
Plumbing Permit Application .FOR o FILE usE oNLY
City Of Tigard Received /_ � Permit No : /a��_ �}�-89
13125 SW Hall Blvd., Tigard, OR 97223 Date/By: (,f
Plan Review /C.( Phone: 503.639.4171 Fax: 503.598.1960 /�tailli e l ts Date/By: Other Permi N o.:
24- Hour Inspection Line: 503.639.4175 -41,L, I Date Ready/By: ru'i H See Page 2 for
www.ci.tigard.or.us g Notified/Method: Supplemental Information
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❑ New construction ❑ Demolition For special information use checklist.
Description 1 Qty. 1 Ea. Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
� =' 3°.'i$' � "S .r`g iP::�" =§:' :a'1';v n�ax»:..s;'.x'- :s#?aF2� ,? .��..cz.r... .- s;�kSi?.ES�"F
` ' �1 �� C'ATFGQRY:�OFiirONSTRT�CTION i 1 �� 'WIZ Z •a 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:
A g Fire sprinkler (- sq. ft.) Page 2
t i er JOB ai IN!k'O TIatm za is ; I'
. F:. s , ,2,, _. . - :1 1- a� s .,: i V . : Site utilities
Job site address: /21 2 0 r j AA �( S C Catch basin or area drain 16.60
City/State/ZIP: T NG, = 0 Q 9 `' ' 2 2" Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: /i ) tip .V\/\Ol 2 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.: ) Page 2
Storm sewer (no. linear ft.: ,._�) Page 2
:e�
Subdivision: I Lot no.: Water service (no. linear ft. S) -� Page 2
Fixture or item
Tax map /parcel no.:
a ; s, . e E,r: ;x;..', Absorption valve 16.60
.",� >l x :,� ." a' F � 4 DESCRIPTION e413Ri �," 4.`4
..g ,w4.. a,, , . .•k • ,"., `, Backflow preventer Page 2
P -- , Qk 3C a f C S2 C -,.( J _c___ Backwater valve 16.60
Clothes washer 16.60
Dishwasher 1 6.60
, : ';t�F .s,�:�kit t: , .. ,>,,, < ,z; �; r ..,,..,..:. ,.,.,., , 0• Drinking fountain 16.60
%..'ri'PItOP„.;,, WNER .,., _. ( 0 t�.. c. >�T r .
° "'° N ¢'- -' � �`'° Ejectors /sump 16.60
Name: 1 f e 2 `Z Expansion tank 16.60
Address: 12 t '2. 0 S lam/ A._ n < 4,0. Fixture /sewer cap . 16.60
City/State /ZIP: `-, 0 ,&c. C�.-(2 C `7 9 2 Floor drain/floor sink/hub 16.60
Phone: ( )3 5? ( Y Garbage disposal 16.60
9 , 0 -, / Fax: ( )
Y.I � u��;r:.�:;.:�:.a - : �`?r3 , �£ .,,, ear:> .,�, „e..,:� " „x Hose bib 16.60
• E; , ,,,,', ®APPLIC�IN� y ; , : G ON7' CT :,•• •- 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
Phone: ( ) Fax:: ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
': : ;= . ` , ,,,, , • r � ?
C ONTRA(:. bRlsm : : ,,,, > ,i e t � ° Water closet 16.60
��e.� .. �" �t° � '�� il`. .ar':•.•,r ���. -s�. ,;;x,�,:ai`.. , . ,,. �';; §;" __..��;�'�. +��u?���
Business name: O &JOU E ^ Water heater 16.60
Address: Other:
•
Subtotal
City/State /ZIP:
Minimum permit fee: $72.50 �y�
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 7e<' �
CCB Lie.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee) 5. gc2
Authorized signature: , 7 G y )
TOTAL PERMIT FEE o LJ
Print name: j/, /�� 1 tj l\ ( A ? Date: c- 2 Y O c( This permit application expires if a permit is not obtained within
7 V 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
i:\Building\Permits\PLMF- PermitApp.doc 12/03 440- 4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
-
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Str Utllttles ` a Q eei t ea i li."614' "` ..
. <... Square Footage, a _. ,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,
na"Iuation 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
t , , Y. �� 1 , ; .el° .: additional $100.00 or fraction thereof, to and
Fitill,e,O1'zj eTTl .�, u Q ..,s ., r. ore.4 .,; 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: = -
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 * .
•
r , Quanfiliw Frxtok iy-Ao eiformiea ;
YP - ; Replace
ture� e 3 ..
w ° �� f-°:1.f!!t1 ayx lin Cap � 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 increase of sewer EDUs, a sewer permit will be issued and
Ice Mach. /Refrig. Drains
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 \Pemtits\PLM- PermitApp.doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION . - Business Line: (503) 639 -4171 MST
BUP
Received Date Requested ' -2 -8 AM PM BUP
Location l ? — a Suite MEC
Contact Person 16-6/62 Ph ( ) 5? 1 — 90 C r Km OO H 2 4
Contractor J Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling . ..„.../fr _ .
Roof
Other: '
Final
r �'
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
inalk:
PART FAIL
�. • ` ANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
• PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final E Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE • Illi Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line i / /f �
Approach/Sidewalk Date i Inspector 9")/7 Ext
Other:
Final DO N I REMOVE this inspection record from the Job site.
PASS PART FAIL