Permit s
CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2005 -00334
��•���: DATE ISSUED: 7/27/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2S 103DA -01400
SITE ADDRESS: 10695 SW DERRY DELL CT ZONING: R -3.5
SUBDIVISION: DERRY DELL PLAT 2 LOT: 014 JURISDICTION: TIG
Project Description: New sewer connection.
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: 60 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
MOELLER, JOHN C + NANCY A Description Date Amount
10695 SW DERRY DELL CT
TIGARD, OR 97223 [PLUMB] Permit Fee 7/27/2005 $72.50
[TAX] 8% State Surcharl 7/27/2005 $5.80
Phone : Total $78.30
Contractor:
ARTS EXCAVATION LLC
4004 SE GRANT ST REQUIRED ITEMS AND REPORTS
PORTLAND, OR 97214
Phone : 503- 473 -1800
Reg #: LIC 156488
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. Thq rules are set forth in OAR
952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rule or direct questions to OUNC by
calling 503-246-66999. 1- 800 - 332 -2344.
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.
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City of Tigard Received Permit N \\\,,,
13125 SW Hall Blvd., Tigard, OR 97223 / C DateBy
P �� l0 3 ,7v
JU 2 ( 200
Phone: 503 639.4171 Fax: 503.598.1960 ls�n 11 ' 1 1 1i'f Plan Review
Date /By Other Permit No
24- Hour Inspection Line: 503 639.4175 1 Juns
CITY OF TIGIA. - Date H See Page 2 for
Internet: www.ci.tigard.or.us
BIUt�r nl� r,!\�tlell w Notified/Method % �r Supplemental Information
TYPE OF WORK v FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description Qty. I Ea. I Total
g 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
0 Commercial/industrial SFR (2) bath 350.00
1:1 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: 7 6t9 j s .,,- 10(,x/ r y V / C Catch basin or area drain • 16.60
City /State /ZIP: -/(3, Cy" r_ r Drywell, leach line, or trench drain 16 60
Suite/bldg. /apt. no.: Project name Footing drain (no. linear ft.: ) Page 2
Cross street /directions to job site (kic, ,, fy�� --/- r .1/ n .C / �� Manufactured home utilities 110 00
`` ! lr Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft. 4 6 ) 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 Page 2
S P�(A/ ,-- ,., (' y),,� y. A- t C - Backwater valve 16 60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16 60
❑; PROPERTY :OWNER ; Li TENANT
Ejectors /sump 16 60
Name: Expansion tank 16.60
Address: Fixture /sewer cap 16.60
City /State /ZIP: Floor drain/floor sink/hub 16.60
Phone. ( ) Fax ( ) Garbage disposal 16.60
Hose bib 16.60
L`APPLICANT • - _ - ° E l PERSON —
Ice maker 16.60
Business name: A r t rl t� (.. C-J Ge.-- -- 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 ci--"S f- k cc/ J Cti— ( j._ Water heater 16 60
Address: 2,106 0 e (/t/f.. !` / � A , Other:
(/ Subtotal
City /State /ZIP: 2,, t,, k kV., .,,j t• ( q U 1
Minimum permit fee • $72.50 d
Phone: ( $J) Z,� �J
0 / 7 7 r Fax: ( ) Residential backflow minimum permit fee. $36.25 ' %�
CCB Lic. 510 Plumbing Lic. no.. ' f� y LfG�/� Plan review (25% of permit fee)
State surcharge (8% of permit fee) �
Authorized signature: ,� . 6
. ._...i TOTAL PERMIT FEE
Print name: ft - p---Yh7- l(1 S-_, // j Date: 7...... z- _ 0, 5 -- 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.
t\ BuildingTennus \PLMF- PermuAppdoc 06105 440- 4616T(10 /02/COM/WEB)
CITY OF TIGARD
BUILDING DIVISION - PERMIT #: PLM200S -00334
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 7/27/2005
Phone: (503) 639 -4171 i "���' 1 °il���y�o�pl'
Inspection Requests (24 Hrs.): (503) 639 -4175 ,„t+k
INSPECTION WORKSHEET FOR DATE: 7/29/2005 TIME: 7 : 07AM PAGE: 6
SITE ADDRESS: 10695 SW DERRY DELL CT CLASS OF WORK:
SUBDIVISION: DERRY DELL PLAT 2 LOT #: 014 TYPE OF USE:
PROJECT NAME: MOELLER
DESCRIPTION: New sewer connection.
OWNER: MOELLER, JOHN C + NANCY A, PHONE #:
CONTRACTOR: ARTS EXCAVATION LLC PHONE #: 503- 473 -1800
Inspection Request Scheduled For: Date: 7/29/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 012462 -01 503- 473 -1800 Y
Corrections /Comments /Instructions:
6 - 75
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Nt_1:2ASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
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Inspector: V Date: if Phone #: (503) 718-
,