Permit CITY TIGARD PLUMBING PERMIT
�., DEVELOPMENT SERVICES PERMIT #: PLM2005 -00125
41i DATE ISSUED: 3/28/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 2S103BD 03700
SITE ADDRESS: 11905 SW FONNER ST ZONING: R - 4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: 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: 50 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
BRUMMETT, JUSTIN Description Date Amount
11905 SW FONNER
TIGARD, OR 97223 [PLUMB] Permit Fee 3/28/2005 $72.50
[TAX] 8% State Surchan 3/28/2005 $5.80
Phone : 503- 624 -0301 Total $78.30
Contractor:
•
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 t. OUNC by
calling 503 - 246 -6699 or 1- 800 - 332 -2344. •�
Issued By: D „ ,/„ ` Permittee Signature: 41484 ►_.. ./
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.
• Plumbing Permit _ 0 t ` ., P
.a FOR OFFIC USE,-.0,, NLY' ` ¢ • Y
Received 3_ -.1 \��oLO ev/
City of Tigard Permit No
Date/By.
13125 SW Hall Blvd , Tigard, OR 97223A 8 20�
�t � � � Plan Review �n �`' l � �� �-
Phone 503 639 4171 Fax: 503.598.1960 / psN 1, vl Date/By Other Permit No �) GOI �'
24- Hour Inspection Line. 503.639 41 5 TIGAR 'I w
�jITY OF 1.1 Date Ready/13y Juns / H See Page 2 for
Internet• www ci.tigard.or us _ ' ��V�S�i v Notified/Method !U Supplemental Information
T�PE ° WORK FEE* SCHEDULE
For special information use checklist.
❑ New construction ❑ Demolition
- Description I Qty I Ea I Total
V C] Addition /alteration/replacement ❑ Other. New 1- 2- family dwellings (includes 100 ft for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
N 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ 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 I 1 05 .t f oN,.iFe S r Catch basin or area drain 16.60
City/State /ZIP j; (?Gei, p q 77_ Z 3 D ry well, leach line, or trench drain 16.60
�
Suite/bldg. /apt. no . I Project name. Footing drain (no linear ft. ) Page 2
Manufactured home utilities 110 00
Cross street/directions to job site: I ST / Sc ---- iF
Manholes 16.60
Rain drain connector 16 60
Sanitary sewer (no. linear ft.. 7(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
Backwater valve 16 60
Clothes washer 16.60
Dishwasher 16 60
® PROPERTY OWNER El TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: ��.s1 - :ERv N I-7— Expansion tank 16 60
Address: , / C > — S > ,i, 2 Fixture /sewer cap 16.60
City/State /ZIP• 1. . �� d-2 9 7 ZZ 3 Floor dram/floor sink/hub 16 60
Garbage disposal . 16.60
Phone (cpj) G2 ,4 - b I Fax: ( ) Hose bib 16 60
E APPLICANT ❑ CONTACT 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 (conunercial) 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: n Co owl Water heater 16.60
Address Other.
Subtotal
City/State /ZIP:
Minimum permit fee $72 50
Phone (50> ) 62c( 0 I o ( Fax: ( ) Residential backflow minimum permit fee: $36.25 7 U ` )
CCB Lic : Plumbing Lie. no : Plan review (25% of permit fee)
State surcharge (8% of permit fee) , j4)
Authorized signature. �p Q
TOTAL PERMIT FEE !`
Print name 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
■ \Bwldmg\Permits\PLM- PerrnnApp dos 12/03 440- 4616T(i0 /02 /COM/WEII)
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 - l t 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
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
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
$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.
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 * .
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./Refng. 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 total is >9.
- Service —
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:
\Bmidmg\Penmts\PLM- PemntApp doc 3/03
I
Sched4 ed 04/04/05 Date °03 /28/05
• Work Order # W024688
River City Environmental, Inc. Complete Industrial
P.O. Box 30087 503- 252 -6144 Waste Removal
Portland, Oregon Septic Tank Cleaning
97294 Sump
PO# Line Cleaning
Brenda:Josepli r()-nr \ i Site Information
11905 SW Fonner St"
Tigard, OR 97223 Brenda Brummett
11905 SW Fonner St
503 - 624 - 0301 Tigard, OR 97223
503 - 624 -0301
Description Units s` Amount
e
Septic Service 1.000 @ 275.00 275.00 /"-'
Septage Overage 2 @ 0.25., :) so - - ,'").13-)
Locate &Dig @ . 70.00
Instructions: Driver Notes • -- .
Brenda LeX4TP/' DI A9. if t A'S
503 624 -0301
WK 503 548 -6284 aLR rig A-) 67_ ,.
Is being hooke up to sewer, wants tank filled with
'sand or rock. . PoM PEA 12.o0 G - S
^. t raA i Q, � ' M� lJp-'w �s ^ /I�' a F s rfpn c q Z - i v 1z_ -
tik JJJ
River City Environmental, Inc. is in no way esponsible for damage to the septic tank or lids on the system.
Terms: Net 10 days. 1.5% per month will be charged on past due accounts. (18% per annum).
Terms and Conditions The Right to Lien
The customer agrees to pay all invoices arising out of pumping services, and any other special services herein within 10 days.
• The customer agrees to pay such extra and overtime charges as may be invoiced from time to time for services rendered, over and above the
normal servicing schedule, on behalf of the customer.
The customer agrees to assume responsibility damage to customer's real or personal property arising from pumping services which take place
ry `� on customer's premises, where the drivers and vehicles of River City Environmental have been instructed to enter.
. %' This includes, but is not limited to driveways, trees, power lines or poles and building structures ,
- • ^ a If River City Environmental, Inc. finds it necessary to add liquid to the tank on jobsite, customer will be charged for the additional gallonage resulting
from these condidtions.
Customer agrees to reimburse River City Environmental, Inc. for all reasonable attorney's fees court costs and other expense incurred by said
company to enforce collection or to serve their rights under this agreement.
Customer agrees to the above conditions. Redeemable in Multnomah County -
Work Authorized by Date 4 / l /i P A l
Driver Signature 40, -, 4,1 6-," Date '4 /7 / Os Time 12 • c17 ,;
i t gl 's". 476 ;Pi, .._ , , ,
,fr,*,;.,„... r :,-,- 4-- ', 'it - O p .,, , OI L: '!! z a -"-;:i.iiii.f4":- -,40F.*:..,..- .--!=,
CITY OF TIGARD
BUILDING DIVISION PERMIT #: RLM2006 -00125
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 3/2B/2005
Phone: (503) 639-4171 A �y��VB 11
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 5/6/2005 TIME: 7:10AM PAGE: 5
SITE ADDRESS: 11905 SW FONNER ST CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: BRUMMETT
DESCRIPTION: Sewer connection.
OWNER: SRUMML.I I , JUSTIN, PHONE #: 5503 -624 -0301
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 5/6/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
505 Sanitary sewer 006299-01 503 - 6240301 N
1
Corrections /Comments /Instructions:
- 1 , , --- --. ; --7. 1°'
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ApC.P .
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PASS ❑ PARTIAL APPROVAL ❑ CANCEL n NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: 0 7 Date: _ _ Phone #: (503) 718 -
ii