Permit .. •
CITY OF TIGARD
Al PLUMBING PERMIT
J 4'b DEVELOPMENT SERVICES PERMIT #: PLM2005-00658
ISSUED: 11/29/2005
�` I , 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 - DATE
PARCEL: 2S 103RD -01500
SITE ADDRESS: 12025 SW CARMEN ST ZONING: R -4.5
SUBDIVISION: CARMEN PARK LOT: 016 JURISDICTION: TIG
Project Description: Line work and sewer connection. Decommission septic system.
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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
GENELLE ENGBLOM- TIEMAN Description Date Amount
12025 SW CARMAN ST
TIGARD, OR 97223 [PLUMB] Permit Fee 11/29/200f. $72.50
[TAX] 8% State Surchaq 11/29/200f $5.80
Phone : 503 -579 -4226 Total $78.30
Contractor:
A- AFFORDABLE SEPTIC SERVICE
PO BOX 1130 REQUIRED ITEMS AND REPORTS
WILSONVILLE, OR 97070
Phone : 503- 969 -9548
Reg #: LIC 158246
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law
requires you to follow rules adopted by the Oregon Utility Notification Center. Those ul:s are set forth in OAR
952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rul: o diriyof io s to OUNC by
calling 503 -246- 9 or 1- 800 - 332 -23 4.
Issued By: Permittee Signature: , ,
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Building Fixtures
Plumbing Permit AP
• ti CLVES) E • FOR OFF IC USE ONLY a
City of Tigard 11/9-4/0 6$ Permit NT/pi 20 -on 6,5 (
13125 SW Hall Blvd., Tigard, OR 97223 NOV 2 9 2005 Plan Review
Phone: 503.639.4171 Fax: 503.598. 60 / /n,: » rd , \ Dat B Other Permit No.: Y.
Inspection 24- HourIns Line: 503.639.41751 I Y OF TIGARD i'J .� j � . Date Date/ R
p �; e d/Met od: Supplemental See Page 2 for
Internet: www.ci.tigard.or.us BUILDING DIVISI Notified/Method: // Supplemental Information
TYPE OF WORK FEE* SCR ULE
❑ New construction ❑ Demolition For special information use checklist •
Description I Qty. I Ea. I Total
2 Addition /alteration/replacement ❑ Other: New 1 dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
El 1- and 2- family dwelling • ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00 •
El Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
' JOB SITE INFORMATION AND LOCATION , Site utilities
Job site address: /.2D25 .);!� ��i-i.re,7 s/ Catch basin or area drain 16.60
City /State /ZIP: 724.,2,,,,,,,../ ®, 7- Z...? Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no% 1 Project name: Footing drain (no. linear ft.: ) Page 2
Cross street /directions to job site: e / ``, / /� /S Manufactured home utilities 1 10.00
` dn� J Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: /6 Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: f Lot no.: Water service (no. linear ft.: ) Page 2
Tax map /parcel no.: Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK. Back flow preventer Page 2
/
'''/D,2.7. 3S /d>-r - ,,.I%/ ? /1/, ....,914G % / f Backwater valve 16.60
/��/7 c_ i ,% -PX G
/5T see
/ e. 4./m f Clothes washer 16.60
_ r Dishwasher 16.60
„afo /L2
I:1 PROPERTY OWNER ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: P�P 2--L Expansion tank 16.60
Address: 2.22 5- , C) K r� _5/' Fixture /sewer cap 16.60
City /State/ZIP: / d_ ®/e 7.223 Floor drain/floor sink/hub 16.60
Phone:( ) I Fax: ( )
Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
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:
( ) I Fax::( )
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
. CONTRACTOR / , . Water closet 16.60
Business name: 0 Q l� ; :72 � j6e //` Water heater 16.60
Address: 12 " /4 ! .� Other:
City/State/ZIP: l� / m y / 4 317e, 2 7e) Minimum / Minimum permit fee: $72.50
Phone: (sue) g12 - /9'... 9 Fax: ($25 ) 5 7') - d'7 77 Residential backflow minimum permit fee: $36.25
CCB Lic.: ,Sg. Plumbing Lic. no.: Plan review (25% of permit fee)
Authorized signature:
Amor'
r State surcharge (8% of permit fee)
•
l �l�� TOTAL PERMIT FEE
Print name: f.;""11.--,,/ r 0/74-.5 / Date: // �9 D5'" 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\PLMF- PennitApp.doc 06/05 440.46t6T(10 /02/COM/WEB)
. -
Plumbing Permit Application - City of Tigard ' '
Page 2 - Supplemental Information •
Fee Schedul :: Residential Fire Suppression Systems:
, Site Utilities Qty. - Fee (ea) • 'Total Sg iare: Footage: Permit °Fee :' , ' , '
Footing drain - 1" 100 55.00 0 to 2,000 $115.00
Footing drain - each ad. ional 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 1,0' 46.40 ;
Storm & Rain Drain - 1st 100' 55.00 valuation:.. , Permi Fee`: '
$1.00 to $5,000.00 Minimu fee $72.50
Storm & Rain Drain - each additional 00' 46.40 $5,001.00 to $10,000.00 $72.50 4 r the first $5,000.00 and $1.52 for each
.Fixture. or Item- Qty Fee (ea) Total additio al $100.00 or fraction thereof to and
inclu. ng $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $14:.50 for the first $10,000.00 and $1.54 for
Residential Back flow Prevention Device ea additional $100.00 or fraction thereof to
(minimum permit fee $36.25) 27.55 a.. 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 $50,000.00.
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work: 'Ian Review for Coniplex Structures, ' •
Are you capping, adding or replacing fixtures? If "yes", A "• 4mplex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to s .tem that meets any of the following criteria.
accurately report fixtures could result in increased sewer fees lease check all that apply.
Quantity by (Fixture) °Work Performed : ❑ Any new commercial building.
•
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
' ., Previous Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry/Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower • Medical gas and vacuum systems for health care facilities
- Jacuzzi/Whirlpool . oviding services to human beings.
Car Wash - Each Stall ❑ PI • bing installations, alterations or additions to food service
- Drive Thru facili . s where new plumbing fixtures, including interceptors,
Cuspidor/Water Aspirator are bein l 'nstalled for the food service area.
Dishwasher - Commercial El Any new re • sential building containing three (3) or more
- Domestic _ dwelling units.
Drinking Fountain ❑ Any NFPA 13 -D . tipurpose fire sprinkler system.
Eye Wash
Floor Drain /sink -2" Submit 2 sets of plan. 'th any of the above.
- -3"
Car Wash Drain Isometric or Riser I' ragzafi ,
Garbage - Domestic in Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) / Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/(/vatory
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
_ Water Extractor
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
• Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: plumbing permit can be issued.
i:\ Building \Peimits\PLM- PermitApp.doc 07/06/05
U - .
CITY OF TIGARD
BUILDING DIVISION .
PERMIT #: PLM2005-00658
13125 SW Hall Blvd., Tigard, OR 97223
DATE ISSUED: 11/29/2005
Phone: (503) 639-4171
Inspection Requests (24 Hrs.): (503) 639-4175
l
INSPECTION WORKSHEET FOR DATE: 1217/2005
TIME: " 7:00AM PAGE: 27
SITE ADDRESS: 12025 SW CARMEN ST CLASS OF WORK:
SUBDIVISION: CARMEN PARK LOT #: 016 TYPE OF USE:
PROJECT NAME: ENGBLOM
DESCRIPTION: Line work and sewer connection. Decommission septic system.
OWNER: ENGBLOM-TIEMAN, GENELLE PHONE #: 503-579.4226
CONTRACTOR: A-AFFORDABLE SEPTIC SERVICE PHONE #: 503-969-9548
Inspection Request Scheduled For: Date: 12/7/2005 Pour Time:
I
Code # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 023101-01 503-969-9548 Y
Corrections /Comments/ Instructions:
..,
V
..--
— ,---
6 1 ..... DASS El PARTIAL APPROVAL 7 CANCEL El NO ACCESS
FAIL 7 CALL FOR INSPECTION 7 ADDITIONAL FEES ASSESSED
Inspector: Date: gh______ Phone #: (503) 718-