Permit v CITY OF TIGARD PLUMBING PERMIT
a i DEVELOPMENT SERVICES PERMIT #: PLM2005 -00064
��JII DATE ISSUED: 2/18/2005
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 11865 SW CARMEN ST PARCEL: 2S103BD 01900
SUBDIVISION: CARMEN PARK ZONING: R -4.5
BLOCK: LOT: 012 JURISDICTION: TIG
CLASS OF WORK: NEW 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
Remarks: Connect existing house to newly installed sewer lateral, 100 feet of service. Septic tank is to be pumped, filled
and inspected. Reimbursement District # 25 fees paid.
FEES
Owner:
Description Date Amount
IADANZA, NICHOLAS E AND
MARGRET A [PLUMB] Permit Fee 2/18/2005 $72.50
11865 SW CARMEN ST [TAX] 8% State Surcharl 2/18/2005 $5.80
TIGARD, OR 97223 Total $78.30
Phone : 503 - 590 - 5239
Contractor:
GREG SCHROEDER ENTERPRISES INC
9812 SE WICHITA AVE REQUIRED ITEMS AND REPORTS
MILWAUKIE, OR 97222
Phone : 503 654 - 4734
Reg #: LIC 99733
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those,rules are set forth in OAR 952 - 0001 -0010 through OAR
952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503)
24...99.
Iss ed By: L I 4 , Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
•
Building F'ixt
Plumbing Permit Application F OF FICE USE ONLY • � : . ' . `
City of Tigard R Date ecei B /$ 0 v , rfflork- <05"
/
,
13125 SW Hal] Blvd., Tigard, OR 97223
A.
„,'��� Plan Review 60
Phone: 503.639.4171 Fax: 503.598.1960 OYnu,Nil1 Abp 1 Date/By: Other Permit N J C �r V 6
O4 Y
24- Hour Inspection Line: 503.639.4175 '" Date Ready/By: ' S. El See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Ka; Supplemental Information
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❑ 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)
f b , - ? A , , p t tYI/O�S rr nt AAIK II ";
.� y � �w �' -,.�, .. raa �,.�.,. �r.r�`a�:.�sa�s;�s• _.- �.*;�: �:� a„ ,..•. ,: •�sa,� -.em=u SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
El Accessory building • ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00 1
❑ Oth
a Fire sprinkler ( sq. ft.) Page 2
. s . '4�.a r .4=.;..e ass ,.,3---- •,: -_-. .-§,. d ,ta tea. . g x :r ww ' ,. Site utilities
Job site address: / / b (� S SW C (-4\J Catch basin or area drain 16.60
City/State /ZIP: . � Ci (Ny�� \ C.)1 GO 223 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: 1 7 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.:` 1/20 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 Y WORK k I M
,, x�, •. ,' ., ,.._ ,. -.,.x �..,q..,,:ow•,... a ,, a.,^ , ��., -a ,r .. t, Backflow preventer Page 2
-- .: - .1.11..)%\p.\\ ^��� \. \ ►,3 Q Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
a R ,,_: Drinking fountain 16.60 • E ROA.., . . AV... 14w TEN N,iT ` .,.. `> Ejectors /sump 16.60
Name: K) ,Np - 1 . 1 , 3 -�
Expansion tank 16.60
Address: \\(;66s--- C. `NLs -, S\ Fixture /sewer cap 16.60
City/State /ZIP: "' ' . A,kX , 0 `� A TI 22.-1 Floor drain /floor sink/hub 16.60
Phone: ( 501 S c 0 - 5 r) Fax: ( ) Garbage disposal 16.60
jz .. iii41 <,,n �,=-at : °�a .'74N-W4 .. ,.�r �z ;_, Hose bib 16.60
f - ®A, ,t ; *' C , ` '74 ®� ON Lfin IrER, ON " .
,�,+» _# s:�x .`. a Psv,. �� �• � �� e� � ��� F � �_�.�_ Ice maker • 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: N Ct.\j,,O\ A, j'"?../.... Medical gas (value: $ ) Page 2
Address: \\ ( s Sks C��M Primer 16.60
City/State/ZIP: - f 0 f� (\1 223 Roof drain (commercial) 16.60
Phone: (S-0S s 5 2 3 ck Fax:: ( ) Sink basin /lavatory 16.60
Tub /shower /shower pan 16.60
E- mail:1M la , \nd4W.A∎ �- Ca
. /Lk Urinal 16.60
ia ,t GON RACTOR' Y - , M
'k �mr�^;;�,'' , �� :,.:tt�:�?�a4� �... ,�`.�.:. s�"�; s.� , a ... .t' Water closet 16.60
Business name: C�,k:eS `t_� P,,A Ea e �.eS LjC Water heater 16.60
Address: C\Qj r Se_ W ` 6A( a Other:
City/State /ZIP: �\\Wh)� e �k. ��ZZZ Subtotal
t Minimum permit fee: $72.50
Phone: (� c5N ( 4 n r Fax: (,j ci (�S. 2 23'I 3 Residential backflow minimum permit fee: $36.25 7 , co
CCB Lic.: 1 qs 3 CQ1),L,, S Plumbing Lic. no.: Plan review (25% of permit fee)
` (((( '+C State surcharge (8% of permit fee) c $ ii
Authorized signature: -4 TOTAL PERMIT FEE q g . ?...,0
Print name: dAakK S �A ,j-z Date: O Vji2/ S 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 \Pernits\PLMF- Per,nitApp.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:
$a e� 7tilit<es Avur, it i ee ( e a),. $ won Square Footage r Per><rut 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
Sewer - 1st 100' 55.00 3,601 to 7,200 $220.00 •
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
Vsa`Yizka °t?o= .w;w.' Permit Fee,-:u
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
xtu ::' ' _ Q;fy. Fee (ea), tom& additional $100.00 or fraction thereof, to and
rFixtureo o ai
��� 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 * .
41 moo." ; 4 N451 f5,b 'orl iWitor
Ftxfnre ype :i XZ ria- ` s
; AA ii $ V t w : N� ove r ili P a 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
Ice Mach. /Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
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
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:\ Buitding \Permits\PLM- PermitApp.doc 3/03
JOB INVOICE
•
BYER'S SEPTIC TANK SERVICE, INC.
C �1 P.O. BOX 549 p, q
OREGON CITY, OREGON 97045 CUSTOMERS ORDER NO. DATE ORDERED
(503) 656 -3326 - 2— t S^ v ›'
OR ER TAKEN BY DATE PROMISED :❑ A.M.
2 - 2 'S ❑ P.M.
BILL TO 1, cc // - q - /' ++ PHONE
ADDRESS MECHANIC
CITY li[[F ER
� ,,`• JOB NAME AND LOCATION •i . `
,,/ n ',• []
!I r t �G� .,� - n� DAY WORK
.
_ ❑ CONTRACT
DESCRIPTION OF WORK
1 1 V W ` ��\ ❑ EXTRA
•
QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT
•
•
24/0 o
•
,,r
T
•
.- .\ _ ' • `
HOURS LABOR AMOUNT
- TOTAL
MECHANICS Q M ATERIALS
HELPERS @ TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR TAX •
completion of the above described work.
SIGNATURE, • DATE COMPLETED
• TOTAL
CITY OF TIGA RD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
r BUP
Received Date 'equested - Z8 PM BUP
Location f l � � �' ' -k�1X j Suite MEC — Contact Person Ph ( ) 73 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation Access: ELC
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
Roof
Other: j' - ice%
Anal
PASS PART FAIL
PLUMBING •
Post & Beam
Under Slab
Rough -In
Water Service — --
- ' rains
f / CiG C� J / /
Catch Basin / Manhole
Storm Drain
Shower Pan r _
Other: j-
F'
AS PART FAIL
M HANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final a Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinspection RE: ❑ Unable to inspect – no access
Fire Supply Line
ADA Date • �"�
Approach /Sidewalk Ext
Inspector
Other: '
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL