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Permit CITY TIGARD PLUMBING PERMIT T r DEVELOPMENT SERVICES PERMIT #: PLM2005 -00657 II 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 11/29/2005 - PARCEL: 2S103BD -01700 SITE ADDRESS: 11945 SW CARMEN ST ZONING: R -4.5 SUBDIVISION: LOT: 014 JURISDICTION: TIG Project Description: Line work and connect to lateral. Decomission 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: 80 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS: RAIN DRAIN: ft Owner: FEES MARGARET JOHNSON Description Date Amount 11945 SW CARMEN ST TIGARD, OR 97223 [PLUMB] Permit Fee 11/29/200E $72.50 [TAX] 8% State Surchan 11/29/200E $5.80 Phone : 503 690 - 3705 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 rules are set fort in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rules o dire ;,a •�itUNC by calling 503 -246 -6 9 or 1- 800 -332 -2 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 t t , � � � ® ' a. Plumbing Permit A •' aQ . FFOR OFFICE uUSE. ONLy ` ; City of Tigard Received / e15 131 SW Hall Blvd., Tigard, OR 97223 NOV 200" Date/ y: e� 646 Permit NoL� � -p v �- Phone: 503.639.4171 Fax: 503.598.196 R Una h1i.. „y : \ �ueBy e Other Permit No.: 24 -Hour Inspection Line: 503.639A175 ��TY OF T IGA 'I �� UILDING DIVIS� ` Date e Ready/By: ' ° " ® See Page 2for Internet: www.ci.tigard.or.us Notified/Method: 71 Supplemental Information TYPE OF WORK FEE* SCHEDULE ❑ 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 ® I- and 2- family dwelling ❑'Commercial /industrial SFR (2) bath 350.00 CI Accessory building ❑ Multi- family SFR (3) bath 399.00 ❑ 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: // 9 .... c $ a . Czri,.-7 eh SPA Catch basin or area drain 16.60 City /State /ZIP: /' Ci/ © 7 7.223 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: ��s71- ��� _5;--zi /..2, Sy Manufactured home utilities 110.00 Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: 2eL) Page 2 • Storm sewer (no. linear ft.: ) Page 2 Subdivision: I 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 ,P,e'0/h <sS/a� P.r4s P7 ,�/ - fit f l ©wee/ Backwater valve 16.60 4 S•t✓ _ Clothes washer 16.60 Dishwasher ' 16.60 • _ El PROPERTY • OWNER CI TENANT Drinking fountain 16.60 ` Ejectors/sump 16.60 Wd Name: re7 Expansion tank 16.60 Address: ///7"9.5.- Q 4 /1.54/? } /a p e'a S1. Fixture /sewer cap 16.60 City /State /ZIP: T „/ /Pie. 9722.3 Floor drain/floor sink/hub 16.60 Phone: ( ) / , / 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 Phone: ( ) Fax:: ( ) Sink/basin/lavatory 16.60 Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet 16.60 Business name:A_ Z j /CC 1`t Water heater 16.60 Address: Ra gex // Other: / Subtota City /State /ZIP: � /,�yylU, Z / p 70 74 Minimum permit fee: $72.50 Phone: (Q)3 ) 4f2 /9'2 7 Fax: (5223) S70 _ (} 79 Residential backflow minimum permit fee: $36.25 CCB Lic.: /S$ t, Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (8% of permit fee) Authorized signature: TOTAL PERMIT FEE 7T., 31 Print name: ,,,e.. SAS Date/2 (J5 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. is \Building\ Permits\ PLMF- PennitApp.doc 06/05 440-4616T( I0 /02/COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Sc edule: Residential Fire Suppression Systems: Site Ut>l iitiies Qty. j Fee (ear Total S'quare•Footages. , .,Permit Fee: ` � ' Footing drain 1 100' 55.00 0 to 2,000 $115.00 Footing drain - . ch additional 100' 46.40 2,001 to 3,600 $160.00 3,601 to 7,200 $220.00 Sewer - I st 100' 55.00 7,201 and greater $309.00 Sewer - each additi ,• al 100' 46.40 Water Service - 1st III 55.00 Medical Gas Systems: Water Service - each ad s: tional 100' 46.40 Valuation: .Permit= Fee: Storm & Rain Drain - 1st 10' 55.00 $1.00 to $5,000.00 Minimum f- $72.50 Storm & Rain Drain - each a • • itional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for he first $5,000.00 and $1.52 for each .Fixture or Item Qty. Fee (ea) Total addition. $100.00 or fraction thereof, to and includi $10,000.00. Commercial Back Flow Preventio l evice 46.40 $10,001.00 to $25,000.00 $148. i for the first $10,000.00 and $1.54 for Residential Backflow Prevention De .• e each . dditional $100.00 or fraction thereof to (minimum permit fee $36.25) 27.55 and eluding $25,000.00. Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $3 9.50 for the first $25,000.00 and $1.45 for Inspection of existing plumbing or .ch additional $100.00 or fraction thereof, to • specially requested inspections - per hour 72.50 nd including $50,000.00. 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 Complex Structures Are you capping, adding or replacing fixtures? If "ye ", complex structure" is defined as an installation of a plumbing please indicate work performed by fixture. Failure to system that meets any of the following criteria. accurately report fixtures could result in increased sewer • • s *. Please check all that apply. Quantitxby (Fixture). Work Performed El Any new commercial building. Fixture Type: Replace ❑ Any new exterior plumbing site utilities. - Previous Capped Added Existin ❑ 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 •roviding services to human beings. Car Wash -Each Stall ❑ robing installations, alterations or additions to food service -Drive Thru fact ' ies where new plumbing fixtures, including interceptors, Cuspidor/Water Aspirator are be • installed for the food service area. Dishwasher -Commercial ❑ Any new - sidential building containing three (3) or more - Domestic dwelling un . . Drinking Fountain Eye Wash ❑ Any NFPA 13- ■ multipurpose fire sprinkler system. Floor Drain /sink 2" Submit 2 sets o lans with any of the above. -3 -4 „ Car Wash grain Isometric or ' _'ser Diagram .` ` Garbage -Dome in Isometric or riser diagram is : • uired for new buildings Disposal - Commercial three (3) or more stories in heigh - Industrial Ice Mach. /Refilg. Drains Oil Separator (Gas Station) Comments regarding fixture work: Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - 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: 1 plumbing permit can be issued. • is \Building\Perrnits\PLM- PermitApp.doc 07/06/05 i , i" , , r ,;(,, ,i1 . , ( e \ y i ' ' am ZL,J C EEMICE. . ` . , P.O BOX 1130 \ ‘'' 9 L C WLiE, OR 97070 (503) G= G=ag= t-AX EainsD mitaaffom' septi rc c am CUSTOMER'S ORDER NO. PHONE I DATE NAME 5 At e j 04 ,../_ce9.04 ADDRESS S I / 99S -- _,S`; �/l ; ,, ,j s,/ SOLD BY CA C.O.D. CHARGE ON!ACCT. MDSE. RET'D. PAID OUT - QTY. " DESCRIPTION PRICE AMOUNT , I ` e GcE)#v /J% , ) � � • .. • TAX ' RECEIVED BY -" — TOTAL All claims and returned goods MUST be accompanied by this bill. - " JAJ To Reorder: THANK YOU -- . 8O0=4?„5 -6380 Cr m.,ba.com y CITY OF TIGARD , . BUILDING DIVISION PERMIT #: PLIVI2005-00657 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: — 1112912005 Phone: (503) 639-4171 ' 4 : 1 0 1 1111 • Inspection Requests (24 Hrs.): (503) 639-4175 - -=-• INSPECTION WORKSHEET FOR DATE: 12/6/2005 TIME: 7:02AM PAGE: 19 SITE ADDRESS: 11945 SW CARMEN ST CLASS OF WORK: SUBDIVISION: LOT #: 014 TYPE OF USE: PROJECT NAME: JOHNSON DESCRIPTION: Line work and connect to lateral. Decomission septic system. JOHNSON, MARGARET 503-690 OWNER: PHONE #: CONTRACTOR: A-AFFORDABLE SEPTIC SERVICE PHONE #: 503-969-9548 Inspection Request Scheduled For: Date: 12/6/2006 Pour Time: Code # Inspection Description Confirm # t ct # Message 505 Sanitary sewer 023005 503-969-9548 Y Corrections/Comments/Instructions: , s . / ..„ _AND ' lir / -...4 ' r -r ( Ar# P/ ' ,' • OPIP" - r Ir .I. ''-- "" 21■P S I I PARTIAL APPROVAL 0 CANCEL III NO ACCESS EI FAIL I I CALL FOR INSPECTION 0 ADDITIONAL FEES ASSESSED Inspector: Th7- Date: L' ---1 Phone #: (503) 718-