Permit C ITY OF TIGARD PLUMBING PERMIT
DEV ELOPMENT SERVICES PERMIT #: PLM2004 -00499
r� �1 DATE ISSUED: 11/2/2004
• `--' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 11480 SW FONNER ST PARCEL: 2S103AC -02300
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: 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: 40 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Connect existing house to new sewer lateral, approximately 40'. Septic tank is to be pumped, filled and
inspected.
FEES
Owner:
Description Date Amount
KENNETH GERTZ
19200 SW 46TH AVE [TAX] 8% State Surchan 11/2/2004 $5.80
TUALATIN, OR 97062 [PLUMB] Permit Fee 11/2/2004 $72.50
Total $78.30
Phone : 503 692 - 3390
Contractor:
MELBERG ENTERPRISES LTD
PO BOX 324
NEWBERG, OR 97132 REQUIRED INSPECTIONS
Sewer Inspection
Phone : 503
Insp existing /capped fixtures
Reg #: LIC 148515 Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR
952 - 0001- 01.00. You may obtain copies of these rules or direct questions to OUNC by calling (503)
246 -6699.
•N r e 0,
Issued By: tx"._14 Permittee Signature: -
4 _ _
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
4 -' 1 F;: - (
Plumbing Permit Application FOR OFFICE USE ONLY
' 31 y Tig ard
of Ti d Received J fi � . ) U D , / 9 N
Date/By. ( + Permit No (,_ d G
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone 503.639.4171 Fax. 503.598.196000IN0/ i + Date/By Other PermitNo4 - e�'3$
24- Hour Inspection Line 503.639 4175 ,1. li. Date Ready/By luii /1 a See Page 2 for
Internet www ci.tigard or us Notified/Method. plc • Supplemental information
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❑ New construction ❑ Demolition For special information use checklist.
Descnphon Qty Ea 1 Total
❑ Addition/alteration/replacement ❑ Other: New 1 - 2- family dwellings.(includes 100 ft. for each utility connection)
@AtfEG'OI2� ' -®ks.:CONSTRUGTlOi`I °� �x „ . i - , S FR (1) bath 249.20
I, 1. Fe. > t ».,:., ,., r" ;. :. - , ., a _
:: �., � "Nnlr0.@�r °t ^\:2"� w- '�.�'�u�i`�`4.n v. y°is %:rr c.`��"�zT
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350 00
El Accessory building El Multi-family SFR (3) bath 399 00
❑Master builder Ell Other: Each additional bath/latchen 45.00
_. ,, , . . ,. - = :> _ °�•w'� ,EA "•m Fire spnnkler ( sq. ft.) Page 2
; �z , . 4 l' J O B `,..t.,' 4 SiTE N O .l. , A TIQ . ' ∎ ` 'LOCATION _ .;a-- ' : 'v ,, ; ,
� , -�� -' .�sK��.�_���.. ,: Site utilities
Job site address: s / Y r 5 c_ , „� � Catch basin or area dram 16 60
City/State /ZIP: T cQ oar Drywell, leach line, or trench dram 16 60
Suite/bldg. /apt. no.: Project name: C-9 tai_- - Z____ Footing dram (no linear ft ) Page 2
' Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16 60
Ram dram connector 16 60
Sanitary sewer (no. linear ft "L�:) Page 2
Storm sewer (no linear ft • ) Page 2
Subdivision: I Lot no : Water service (no linear ft. ) Page 2
Fixture or item
Tax map /parcel no.:
n , . _. :,> . , ti. x ~, Absorption valve 16.60
- .,> ;fig'' a=.. ..:.: >., .
::x '$ .DES U I ® ;.;., -,- _'= .
�r :�"�` '" P�.f'� .��;:;,..-,•�1nh , � ' Al , "',. °:�:�.;.r�.• .:. �$ ar�i''' B preventer Page 2
S -2 --C...,,_ C6 ,,J .1J 6 v Backwater valve 16 60
Clothes washer 16.60 •
Dishwasher 16 60
. ... ... ,+ .., a.•, " = a..• _ ,.s Dnnkmg fountain 16 60
PI2UPER ER _ %y,, ,. 4 . ' Al
n ,• < . -n . ..,, a ,P,= ` c.a .- 'ki-0:. - ` .., s” Z'Au. :', a ' = `st,„ 16 60
Ejectors /sump
Name: /4 „j etJ - CH-, C-c.. ez Expansion tank 16 60
Address: 17' yl9 () S CAJ cz c_ Fixture /sewer cap 16 60
City/State /ZIP: . 0/ g . L.- Q Z. , Floor drain /floor sink/hub 16 60
Phone: ( ,} O3 6 z L -- 3 3 C G Fax: (,,) 67 Z •— 5 Y3 3 Garbage disposal 16 60
1 ;„ ; .. •TIATF ,., :0, iroi ..; ., = 1.:Q Hose bib 1660
'' a i1/4,--,,,,:,;:at:, APPLI v -;T,.: _ _ �" = G®NTACT 4 1 , ' - ,w ._;
�� _. �,rw= =:�«m1�� �� . 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 drain (commercial) 16 60
Phone: ( ) Fax:: ( )
Sink/basin /lavatory 16 60
Tub /shower /shower pan 16 60
::
E -mail -
k. •,., ,, m Y ; y ,..- z •' Unnal 16 60
;e �: #,_,,: (:` CON,TRACTOIt, , ,' ��_ °' >_ '
'"�u,,:�� s>;<:r #'fi;.;.. '� �, ...:tom ° ` �' "" vY aF.,, , ��., ,- Water closet 16 60
Business name: M - /4 d._ r 64 Water heater 16 60
Address: o 8 L '�C�'p Other
City/State /ZIP: /-• 44.0.x; 6..,z— J x% 3 >---- Subtota
< D - Minimum permit fee $72 50
Phone:
( J ) 3 6 S ` 7th Fax: ( ) Residential backflow minimum permit fee $36 25
CCB Lic.: fy r 57S— Plumbing Lic. no.: Plan review (25% of permit fee)
Authorized signature / / State surcharge (8% of permit fee)
TOTAL PERMIT FEE 7e. 3e)
Pnnt name: � - c ,0 6 ., - Date: This permit application expires if a permit is not obtained within
f 180 days after it has been accepted as complete.
*Fee methodology set by Tn -County Building Industry Service Board
1 \Building\Permits\PLM- PemutApp doc 12/03 440- 4616T(10/02 /COM/WEB)
Plumbing Permit Application - City of Tigard of
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Vitbialf:' . r ;,
S' ii F '-0P .; ;Perm t Fe'e
�S><te['7iIaties �
Footing drain - l 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
x- P Fee :. ... .
Storm & Ram Drain - 1st 100' 55.00
$1 00 to $5,000.00 Minimum fee $72.50
Storm & Ram Dram - 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
;�.:._.�,; ,,i¢.,';��y„ �; °,•s.��";:;_.. QkY = .=� ;Fee�(ea)" - ' : � ; T'otal�"
additional $100 00 or fraction thereof, to and
Fxtureor It "ein 4 , ,; .
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 Dram, 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 $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
'` : : " >' r " =Quantify liy (Fiztu) Wo`r'.ltl' rforme$ ,,
Fix'u 8° .`y '�, ; .,.. ,,.,' ; s : ; , =�a,''T wi12e lace`s `"..':3`,�'� :;..:;
" o ' Comments regarding fixture work:
� 4 � .r ���'i:s��'� t � g;� ,'Moved; �,9Frxishn apped'�
` ����':�c<;; ;', '7;a3�"' 'N� «r r;��1� rv�k�.�,� �' ?t'�r: =3�' =€
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher - Commercial
- Domestic
Dnnking 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
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.
Unnal
Other Fixtures.
\Buildmg'Pemuts\PLM- PerrmtApp doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION t Business Line: (503) 639 -4171 MST
BUP
Received Date Re uested 1/ AM PM BUP
Location // Lt?t Suite MEC
Contact Person Ph ( ) (o S26 L1 PLM o�� 7 ✓ooq99
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
ELC
Foundation
Ftg Drain Access: ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Fi rewall
Fire Sprinkler �� J.- - = ' _ —
Fire Alarm
Susp'd Ceiling
Roof Other:
i�� :� /� r _
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab '
Rough -In `%/' /AV/ sue" rI�
Water _ - ice
Rain ' rains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other: •
Fin -"
a," PART FAIL
CHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL ,
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final fl Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE El Please call for reinspection RE: Unable to inspect - no access
Fire Supply Line
ADA
Date p
/ l ( 3) 0 Inspector Ext
Approach/Sidewalk
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL