Permit ~ CITY OF TIGARD
PLUMBING PERMIT
c 1 +� DEVELOPMENT SERVICES PERMIT #: PLM2005 -00089
E ��I DATE ISSUED: 3/11/2005
mair ' - 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
PARCEL: 2 S 103 DA -03100
SITE ADDRESS: 10610 SW DERRY DELL CT
SUBDIVISION: DERRY DELL PLAT 2 ZONING: R -3.5
BLOCK: LOT: 033 JURISDICTION: TIG
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: 75 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Sewer connection.
Owner: FEES
HANSEN, HARRIS H SARA J
10610 SW DERRY DELL Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 3/11/2005 $72.50
[TAX] 8% State Surcha 3/11/2005 $5.80
Phone : 203- 639 -6515 Total $78.30
Contractor:
THEODORE D. MCBEE
13691 SE WILLINGHAM CT
CLACKAMAS, OR 97015 - 7253 REQUIRED ITEMS AND REPORTS
Phone : 503- 239 -2707
Reg #: LIC 75513
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.
< p
Issued By: r Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection the next 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 Application' ' k OFFICE USE ONLY:'`
City of Tigard 1--- Received 2 Permit No. : -�,y� Q
13125 SW Hall Blvd., Tigard, OR 97223 ° t RG� DateBy — �� 7j5 �`� o'ti�/ G O� /
U Plan Review
Phone 503 639.4171 Fax 503 598.1960 \ 1 / W arl�lNl i t n� t Date/By. Other Permit No
24- Hour Inspection Line: 503 639.4175 r .` I
Internet: www ci tigard.or.us G V' W' Date Ready /By i0 f 1 5 H See Page 2 for
— - QC �, Notified/Method - T 1 V Supplemental Information
f ,e'; 3 =x�< �.r�,.. , yr� -�z :fit - �'wa «.- .g - e„'° " : � *. »; -. .�':�, � i;� "y.. �.� =„' ��r�-- ;:%- � -;�; - c,:. a ° s��.F r qe
qtr- s "'c � ;-; ` °sa5 ' R.F , +;: :. :.,•• .�::. >.:re.. f . ,,� � i' S�ry° a:i�''�`�'9°a t, . °,y.,, „ ';:� ,t ,, ,, -- ' .
".•£,. F.n, <Ar 4 t#' :;'t L - <N,,, Pte: O ., °v, ., 4'= ,. z. ":.;• ' :!,` : : ;'RV' r.x v <,".. . TEE, S CI3E Di ,, ,•
u.' . -,H�, Y:.�r.+�`natn�. ,:`�,�^�. ��wi:' � ��u� .R�',` = %r»"'<�'+`as3 zr�so - �c „u.. ,' a'� �, .�._,. .H: e`�;?�,:'�:�, ,.,,�. -:i: �zx-'�:A... � >n „y ^...,e .+a ,N
111 construction ® ❑Demolition For special information use checklist
Description Qty Ea j Total
Addition/alteration/replacement ❑Other New 1- 2- family dwellings (includes 100 ft for each utility connection)
- � :�¢�;vd:'� ' Mks ,�'��;:F��aa > �` . • a �'i�?�< , S�r% sa” `�'� ".° :�:z =s t= ,�?'ar.�,e3v�w�,q �;,•
... ,s -r : . - -
c�
;'t= , °,'
,,1 i s , ; GATEGOIi , O : 0 x , ,.: - <43 :' ` SFR bath 249 20
, ��, �?`d. "= .mot' =- ,;��..:�a,r t max.. „�,n,'rs- s��a .,, <._ <r "• , u°� :rte � s s �:. , a,: ,v ��'..:
1- and 2- family dwelling ❑ Commercial /mdustnal SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399 00
El Master builder Each additional bath/kitchen 45.00
❑ Other:
„..., K: , - - . , . - ; a _::. r.E >,,.i. Fire spnnlcler ( sq ft.) Page 2
JOB S,...„.:„..k,...,,,,,,,•'.0
lIN eithvIT =IONS` "Alb • °®CATION ° ,.,' .x t
4 .
-ar 3 th,,, -. ,a,!..,-16.,„.a. „,-. ,- ,.x^+14, w�_ 11ao Site utilities
Job site address: 166 16 Derr / 1 C'"� � Catch basin or area drain 16 60
(
City/State /ZIP. Drywell, leach line, or trench drain 16 60
Suite/bldg. /apt. no.: 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 h, / 16.60
Sanitary sewer (no. linear ft /,7) 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.:
M' ., r =x” = , :^ . « n i �,z >: .- Absoiption valve 16 60
,, „ ;'= t ;� * °' DBSGI IPIa: Sisal e •'.;,, � ' ", , ;,. , . >, ,,
`.F�•- • �.'r, ' , s „i,: a ,-,,. .,'.;' �9't,t'� .o, � „' t1 als ,.;, t, Backflow preventer Page 2
er 4Pl`v(L.P. CW /4 ie ct/Ova . Backwater valve 16.60
Clothes washer 16 60
Dishwasher 16 60
r - ,, fi wM ,.. i , °. -: r- �v r.4,} Drinking fountain 16.60
4V .., ° ` � ,,,'t ;, -, , s
ry „ ;: O rnF'NEI2 ' - 'l' * I, t ; •F' °” " TENAN 0, - ,,, .,0
.,,., - ; z •• . s:. IiO ; , rr %, ,PlccS ;. ,. :i Imo` , N'...�,.�xu. . °° ' .II „.r 4t -� �, , _
Ejectors /sump 16 60
Name: Ha r-ri $ 'l i !i . An Expansion tank 16.60
Address: ) 0 G ( d • 'let
, 7) I r CI. Fixture /sewer cap 16 60
City/State /ZIP: T 0 r 2 . Floor drain /floor sink/hub 16.60
Phone: (Z3 11 £ .. 6,5 / J L Fax: ( ) Garbage disposal 16.60
y' ° s4L,, :a ° .y,w- t,. :tea - , ,7.�•. + r , Hose bib 16 60
�i„ ` " ;ACT P � R O
fit A 1 IA t,; - • x CO i , -' S N. :, -i/t: h j
��"". 5��.�- ._rt � ' -,��. vr�s?r�.:.;.�. _3 A ,�� � „�. .a� •fit .a,�� < - i � •M, 4, Ice maker 16 60
• �°' � // " �� ' �� ��
Business name: c'��Oe Interceptor /grease trap 16 60
Contact name: D � I„ - / (c kto<efri Medical gas (value $ ) Page 2
Address: ^ •� � � � Primer 16 60
City/State /ZIP: P'a f" etti [' , OR 9'7236 Roof drain (commercial) 16 60
Phone: 5 `e ) , �J 9 _ 2_7 7 Fax: : (� —st� 1 2 ) n 7o Sink/ basin /lavatory 16.60
�(J Tub /shower /shower pan 16 60
E -mail:
Urinal 16 60
Ter:: 1 ,4 ° . ' tf tsgi :'_ , ; x.;. -; FONT =- > ,-, 4 , i� " <M :' -a:; a: °” ;, ::°°l ,. ,' .: ,.. ;;, =si
_. -�, � �������. �,,�"�� 5.•� ��z•°x ��� � a.�M �• ;��`. ;' lin;, �:•;'a' . W ater closet 16.60
Business name: Water heater 16 60
Address: Other:
City/State /ZIP:
Subtotal
Minimum permit fee' $72.50
Phone. ( ) Fax. ( ) Residential backflow minimum permit fee. $36 25 71
CCB Lie.: 5-5-8 ' - . . Plumbing Lie. no.: Plan review (25% of permit fee)
Authorized signature: C� State surcharge (8% of permit fee) J•
l � '� TOTAL PERMIT FEE 1 �%, .7 0
Print name: r)D 1N / Lk /,i4 5 G IA Date: /' -e f This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tn -County Building Industry Service Board
I \ Building\Permiis\PLMF- PerautApp doc 12/03 440- 4616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information •i
Fee Schedule: Residential Fire Suppression Systems:
`Site Ttities• <_- ,.,: :, :: u3ar Foota .e, - .:,_ PeriutFee,
Footing drain - 1s 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
72- Pe
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 $1 52 for each
`✓` °'' ' `$ M <,, t '_'; <s` wQ,iy;'. kee(ea);'` Total' ` additional $100.00 or fraction thereof, to and
FYxtureNor item ; ' .... $,
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
Fixture; =3 Pe ;. Ot ° Replaces ,
0,1 . < { 4 ' ` .° :` a N ` =t v o £ X,st� ca 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 \BmidmglPermttstPLM- PertmtApp doc 3/03
CITY OF TIGARD
BUILDING DIVISION PERMIT #: / O�
13125 SW Hall Blvd., Tigard, OR 97223 D ATE ISSUED:
Phone: (503) 639 -4171 4mae 1-
Inspection Requests (24 Hrs.): (503) 639 -4175 ' f I.
INSPECTION WORKSHEET FOR DATE: 3/ii /dc TIME: PAGE:
SITE ADDRESS: / 0 co / O /12-04e /)_ CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: 7--(1 PHONE #: c l
33 al 76 7
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: Pour Time:
Code # Inspection Description Confirm # Contact # Message
Cell �,„€__c(--vV'
Corrections /Comm) is /Instructions:
(/6.0k/q74
R t/i-t . ' / 7-e ( c-7 / 4"))1-1- - ; e_=-X,../7 - 2// C:>( (---
�/. 6 d S —
e int- / cf - / Ge
1 1° j ial Cill#7. "1
2 PASS I I PARTIAL APPROVAL ❑ CANCEL n NO ACCESS
FAIL CALL FOR INSPECTION ❑ ADDITIONAL FE ASSESSED
Inspector: id t'_ Date: Phone #: (503) 718