Permit }
CITY TIGARD PLUMBING PERMIT
6• DEVELOPMENT SERVICES PERMIT #: PLM2005-00158
DATE ISSUED: 4/25/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2 S 103RD -00406
SITE ADDRESS: 10915 SW FONNER ST ZONING: R -4.5
SUBDIVISION: LOT: 013 JURISDICTION: TIG
Project Description: 75 If. Line work for sewer connection to existing house. Septic system to to pumped and filled or
removed. Reimbursement District #21 PAID
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: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
ROUTON, CLYDE A Description Date Amount
ROUTON, ETTA M TRUSTEE
10915 SW FONNER [PLUMB] Permit Fee 4/25/2005 $72.50
TIGARD, OR 97223 [TAX] 8% State Surcharl 4/25/2005 $5.80
Phone : 503 639 - 3365 Total $78.30
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
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 -..99 or 1- 800 - 332 -2344.
Issued By: a / . - ,411 ' / Permittee Signature: Va4)4 g L
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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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P'rtumbing Permit A.p 11011 C .> r
- , FOR - OFFICE FUSE ONLY ;; � , t , , f .,
City of Tigard NPR 2 b t6 Received
c / Permit No.
13125 SW Hall Blvd , Tigard, OR 97223 �� Date/By �� / ���� �rj. (�
F 'r AGAR Plan Review
Phone 503.639.4171 Fax. 503598.1960CW( 1 }mo I DateBy: Other Permit N t�1.�
24- Hour Inspection Line: 503.639 4175 B LD G D�V z �,k Q • " l" ' "' 7
_W Date Ready /By Juns. El See Page 2 for
Internet www ci tigard or.us Notified/Method: — t IC) Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description l Qty I Ea. } 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
❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
El Accessory building El Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45 00
❑ Master builder ❑ Other
Fire sprinkler ( sq ft) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: �,Q 9 1 t j Q K) i.,12._ - Catch basin or area drain 16 60
City/State /ZIP• "1-1a,4 -2"t) O)---, q 7 a-a-?j Drywell, leach line, or trench drain 16.60
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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 dram connector 16 60
Sanitary sewer (no. linear ft • 5 Page 2 66. ov
Storm sewer (no linear ft : ) Page 2
Water service (no linear ft. ) Page 2
Subdivision. I Lot no.:
Fixture or item
Tax map /parcel no.
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
0 -4f)44. a e,:r` Tb tazi. ? Backwater valve 16.60
Clothes washer 16 60
Dishwasher 16 60
PROPERTY OWNER I ❑TENANT Dnnking fountain 16.60
' l
Ejectors/sump 16.60
Name: ��/ r ��d Expansion tank 16 60
Address. tOC'.� 1 5 s � _ �!!!10 &I L Fixture /sewer cap 16 60
City /State /ZIP: C ft', k 4.`i,, biz 4 7 a T 5 Floor drain /floor sink/hub 16 60
Phone- 5 0 3 ) ( ' _ .35 4 Fax ( ) Garbage disposal 16 60
111 APPLICANT Hose bib 16.60
❑ C ONTACT PERSON
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 dram (conuneicial) 16.60
Sink/basin/lavatory 16 60
Phone•( ) Fax:.( )
Tub /shower /shower pan 16.60
E-mail. Urinal 16.60
CONTRACTOR Water closet 16 60
Business name: 01)...`i fi— Water heater 16 60
Address Other.
City/State /ZIP Subtotal
Minimum permit fee' $72 50 +fi j)
Phone. ( ) Fax ( ) Residential backflow minimum permit fee $36.25 1 Ol • 5
CCB Lic.: Plumbing Lic no Plan review (25% of permit fee)
State surcharge (8% of permit fee) 5 . 11
Authorized signature X - d TOTAL PERMIT FEE 7 g . �
Print name G L ` f d: t 'i i f �- Date: '�� ' 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.
1 \Bu 1d,ug\PermIts\PLM- PenmtApp 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:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1s 100' 55.00 0 to 2,000 $115 00
2,001 to 3,600 $160.00
Footing drain - each additional 100' 46.40 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
Valuation: Permit Fee:
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
Fixture or Item Qty. Fee (ea) Total additional $100 00 or fraction thereof; to and
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
Inspection of existing plumbing or each additional $100 00 or fraction thereof, to
and including $50,000.00
specially requested inspections - per hour 72 50 $50,001.00 and up $742 00 for the first $50,000 00 and $1 20 for
Subtotal: each additional $100.00 or fraction thereof
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Fixture Work: 1 � tp--)
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 * .
Quantity by (Fixture) Work Performed
Fixture Type: Replace
New Moved Existing Capped 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 increase of sewer EDUs, a sewer permit will be issued and
Ice Mach./Refrig Drains
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 Isometric or riser diagram is required if fixture quantity
- Commercial
- Service
total is >9.
—
Swimming Pool Filter s&-rs
Washer - Clothes O�
Water Extractor Plan Review
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures
t \Butldtng\Permtts\PLM- PermttApp doc 3/03
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CITY OF TIGARD
BUILDING DIVISION
PERMIT #: PGKgoa"�x15
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 -- �u�a�� °�OII���rypiviyl��,,
Inspection Requests (24 Hrs.): (03) 6-417
39 5
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: A®9 b'8. --6 '`--- CLASS OF WORK:
SUBDIVISION: LOT #: ' TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: Pour Time:
C ode # Inspection Description Confirm # Contact # Message
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Co rectio s /Co ments /Instructions: �I
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)74 PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
p ii , , AIL n CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: Z a Phone #: (503) 718-
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