Permit CITY TIGARD PLUMBING PERMIT
$ ;�1 i DE VELOPMENT SERVICES PERMIT #: PLM2005 -00131
DATE ISSUED: 3/31/2005
13125 SW Hall Blvd., Tigard, OR 97223 503- 639 -4171
PARCEL: 25111 BA -09800
SITE ADDRESS: 09519 SW BROOKLYN LN ZONING: R -4.5
SUBDIVISION: SHANNON MEADOWS aftimakalligitOT: 003 JURISDICTION: TIG
Project Description: Backflow device.
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
PAN, CHEN
9519 SW BROOKLYN LN Description Date Amount
TIGARD, OR 97224 [PLUMB] Permit Fee 3/31/2005 $36.25
[TAX] 8% State Surcha 3/31/2005 $2.90
Phone : 503- 639 -1706 Total $39.15
Contractor:
NORTH STAR PLUMBING
1445 SE OREGON STREET
SHERWOOD, OR 97140 REQUIRED ITEMS AND REPORTS
Phone : 625 - 2679
Reg #: LIC 00090697
PLM 34 -255PB
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 - 246 -6699 or 1- 800 - 332 -2344.
Issued By: ) c1 Permittee Signature:
Call 503 - 639 -4175 by 7:00 a.m. for an inspection th business d Y•
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.
P lum b i n P ermit Application `FOR :OFFICE ' USE , ONLY: ,
City of Tigard Received Permit No.:
13125 SW Hall Blvd., Tigard, OR 97223 y ' 5 ` � / ~ v, �
Date/By: 77 \` �� 1m5)
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 y///aoop ' Date/By: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 c all j.' t Date Ready/By: Suris. El See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: j ( Supplemental Information
TYPE OF WORK FEE* SCHEDULE
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)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
X 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
•
11] Accessory building El 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: 9 s / 9 , y ,e ' 0/(G, y /A) - Catch basin or area drain 16.60
City/State /ZIP: 7' C,4 I'l 7 - c .., !!��'"' ' -a2;2 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: / Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site: ,0( Avii.A,G
/ Manholes 16.60
Rain drain connector 16.60
•
Sanitary sewer (no. linear ft.: ) 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 X Page 2
L?.40c/Ow Backwater valve / , 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: CA/0Q /AA; . Expansion tank 16.60
Address: 9s i 9 5 el40 C�' (1v Fixture /sewer cap 16.60
City/State /ZIP: 7-/ , 0 % 2 7 2 y Floor drain /floor sink/hub 16.60
Garbage disposal . 16.60
Phone: (5 639 - /7 6 Fax: ( ) Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON
Ice maker 16.60
Business name: A l( , r 4, 4 S %A/' „07/ eir 1e /-u,.
Interceptor /grease trap 16.60
Contact name: fcs3� _ Medical gas (value: $ ) Page 2
Address: j 9 ye s S e ,.' S 7_ Primer 16.60
City/State /ZIP: gIf' C,C fu0e2 c' 27/ Ye • Roof drain (commercial) 16.60
�� /' �Q Fax: Sink/basin/lavatory 16.60
Phone:
(SO)) %�" ` ` ( ) Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: c) 773. sj�l,, I `UT/4 /,4/st, Water heater 16.60
Address: / .V v C v/eg - ‘2,-. ‘2,-. a ,, S 7r„ _ Other:
Subtotal
City/State /ZIP: 15..L� 1 c:y o, 9' 1 / y:
_ Minimum permit fee: $72.50
Phone: ( d.I) U, _ -- r2 6 2 9- Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lie.: 90 6 9 7 Plumbing Lie. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee)
Authorized signature:
TOTAL PERMIT FEE
Print name: t/(( CA /"'G Date: 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:\ Building \Permits\PLM- PermitApp.doc 12/03 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard 0,- d
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: •
Footing drain - 1 100' 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 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: 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 * .
Quantity by (Fixture) Work Performed
Fixture Type: Replace
New Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi /Whirlpool
Car Wash -Each Stall
-Drive Thai
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 Quantity Total
- Bradley Isometric or riser diagram is required if fixture quantity
- Commercial total is >9.
- Service -
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- PermitApp.doc 3/03
CITY OF TIGARD lir
BUILDING DIVISION PERMIT #: PLM2005 -00131
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/31121106
Phone: (503) 639 -4171 :viol ll¢I'\
Inspection Requests (24 Hrs.): (503) 639 -4175 J - --.
INSPECTION WORKSHEET FOR DATE: 4/1/2005 TIME: 7:10AM PAGE: 90
SITE ADDRESS: 09519 SW BROOKLYN LN CLASS OF WORK:
SUBDIVISION: SHANNON MEADOWS LOT #: 003 TYPE OF USE:
PROJECT NAME: PAN
DESCRIPTION: Backflow device.
OWNER: PAN, CHEN, PHONE #: 603 -639 -1706
CONTRACTOR: NORTH STAR PLUMBING PHONE #: 625-2679
Inspection Request Scheduled For: Date: 4/1/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
325 RP /backflow preventer 003467 -01 503-672-9324 Y
Corrections /Comments /Instructions:
- Z-
/ .
• //� "ice — / / ,. r " ��� '
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'PASS n PARTIAL APPROVAL _ CANCEL Ill NO ACCESS
❑ FAIL fl CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: 07 2, Date: 1 / / v Phone #: (503) 718-