Permit C ITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2004 -00061
. DATE ISSUED: 2/11/04
` 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 14125 SW FERN ST PARCEL: 2S104BC 06300
SUBDIVISION: HULTQUIST PART /MLP2002 -00009 ZONING: R -7
BLOCK: LOT: 001 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: 50 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of approximately 50' of sewer service to connect existing house to newly installed sewer lateral.
Septic tank is to be pumped, filled & inspected.
FEES
Owner:
Description Date Amount
LARRY HULTQUIST
14125 SW FERN ST [PLUMB] Permit Fee 2/11/04 1 $72.50
TIGARD, OR 97223 [TAX] 8% State Surcharl 2/11/04 $5.80
Total $78.30
Phone : 503 - 521 - 1668
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : Sewer Inspection
lnsp existing /capped fixtures
Reg #: 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
, 411P
lss d By: 0�ts� (50 by �C.1//t/4 Permittee Signature: ���
Call 50 : • -4175 b 7:00 P.M. for an inspection needed the next business ay
Building Fixtures
Plumbini Permit Application - r . I ' FOR z.OFFICE,1SE `COIXu '- / -
City of Tigard Eie Permit No 4 ( 13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.639.4171 Fax. 503.598.1960 /,,,,,, P i Date/By Other Permit No. j..
f 1 - e0063
24 Hour Inspection Line: 503.639.4175 +e`i I Date Ready /By. ., ll See Page 2 for
Internet: www.ci tigard.or us Notified/Method. / 4(3 Supplemental Information
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❑ Demolition For special information use checklist.
❑ New construction Description I Qty I Ea I Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
F F '4 ,'- , , '4 '4 ,, 4. 4 '4 „, „� �- .,r. c,' r4'4�... J.. �„ ,, , R ., 4
.. Ear.:. ;;, ':;',,.;.:` °x`. SFR (1) bath 249 20
atUr Um l ` =° . CATEGORY OF, CONS , = . >F ' 'F : -fog.
"_��='�`,c ` �'" �r�' a. iirai�'=. r: 5�c^' � �, ��u" as�viaxsaF� -.r�*a.tiYz:�,',t��_,actsz,, ,,r,.l:a.�, *,notnF.,- sn;ai,ro i +...we:Asrlat�, �.�si:,a�, § . . . ,. . - .
� 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
SFR (3) bath 399 00
❑ Accessory building ['Multi-family
Each additional bath/kitchen 45 00
❑ Master builder ❑ Other: Fire sprinkler ( sq ft.) Page 2
i� �..a�M�.� �_aY�,.< ae'.ra�r„ ;;�,. .:t k u..�.�2sa k�.• - :i° .G+; T�r , �.. y,� � ��,'„ �t.�:�., �:k�� tt
;,,, '' 1. , '; ; i<i,J,OB- S1Ti . , 4 ,,, FOI 0 4,5 0 ' T I O N' . AND AT i k,, , , , 1 , l ° ,,fir,;' S ut
' Job site addiessJ / L i/ L S S, W, , 1 ° r 7,■... Catch basin or area drain 16.60
City /State/ZIP: # crt o Drywell, leach line, or trench drain 16 60
ek_ R 2 ��3
1 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: Pro name: ar y„ Manufactured home utilities 110.00
Cross street/directions to job site: /� Manholes 16.60
5 � 115 7-b & "- i 1c' Rain drain connector _ _ 16 60
/ / Z` �� 'I-) / 4 - 5 . ,p�� -7� Sanita ry 9
L"' sewer (no. linear ft.• ) / Page 2 56
� L � rz Storm sewer (no linear ft.: ) Page 2 J
Water service (no. linear ft. ) Page 2
Subdivision: Lot no.:
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
°`
ffie; .1 ` =c ' i' °''; .. rq £ D E S C , TiIO - j t OF W O 3 .r ' ' 'n''',,'-'7,1f,, , rt Page 2
``r'��""�� ze,c' '� „�`'; =n �<m* ��. 1 ��. �a.'� <"_,`` =�. - _ .17Z,
-r 1 i ., e. ) 1.-0 - €i (4„ Backwater valve 16.60
f%C. s
F P / r + A 1--L‘ � � Clothes washer 16 60
( Dishwasher 16 60
fZ 'Vy-. 4`- 16 60
1,• •„ , _ r e - .., a �;, a ? +,:., .- k , ' , ,, i , Drinking fountain
i ,,i ,„„,, s R 01 ] ER i > 1„ : ; _( t.e 'TEN ANT" " 1 16.60
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`a�:"�` �., � :,�a_.x;; a .�_ � ,�... <'6 :.�� "_`..: � ,�T�A"A :�� - �6.''�'-. `� E]eCtOTS /6Ump
Name: LO-Q'r' L A. t x 5 Expansion tank 16.60
c Address:. il / - 1 0 S S (�(,
City /State /ZIP: : "l �-. t J P G , i- 7 ! Fixture /sewer cap 16 60
� D Floor drain /floor sink/hub 16.60
t
n 6 „ � ^ 04_ �T. �� Q /� 7,2-ix 3 ( ) Garbage disposal 16.60
( Phone: (;';;9 .7 ) rJ S44 ® 6, Fax:
�', ,' , � � '^ _ ';,.;�;;x� �� =r ��� = sr; Hose bib 16.60
E,. ,.1,' f ; / . w3 r , �w' �9 ` ;, ::'=,,r PERSO ` ;" :.
a.° s' ?_' - ...*.: -- r.,..Wn % ;a ". AIM, :,,., ,� ,. V " aA,r_ iee maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value• $ ) Page 2
Address:
Pnmer 16.60
Roof drain (commercial) 16.60
City/State /ZIP:
Sink /basin /lavatory 16.60
Phone: ( ) I Fax:: ( )
Tub /shower /shower pan 16.60
E -mail: I Urinal 16.60
° -' ;; €6 . 12A a, "' 1, X, :`; g':'- 16 60
w�; ., ;ek,'- -- G* -TOR a : , ;- .- :•: ' Water closet
"" t �rti :?„ "' <•=F: =t m.- .;;�,�, ���'� ; «: -., _ _ . d��ei'.a ,i;`, ` ,,mac : ., It)). . C, Busin name: c 4:' c.,-,....4- Water heater 16.60
e- 5 S r Other.
4 Address: / t��
� ^ � � Subtotal
Ci ty /State /Z1P: r ✓ L Qr-�. , 7,,)___,P-3 Minimum permit fee. $72.50
c i ( ) Fax: ( ) Residential backflow minimum permit fee. $36.25 7 o Z ' S
1ol i
t ` ,�---- --
_: - Plu mbing Lie. n, Plan review (25% of permit fee)
�(iCBJac �� � ((( j
- State surcharge (8% of permit fee) 5 $d
u - uii -- i zed ' � 0
/ TOTAL PERMIT FEE 7T. 3
/ Pnnt =name: / , i Date: .2-7( ! . , q 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
1 \Buiidmg\Perm,ts\PLMF- PermtApp doc 12/03 440- 4616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information r
•
Fee Schedule: Residential Fire Suppression Systems:
Slitatiias1WV,401,1Vtgl PeAr(iii)7
*aak_uvarcs: , j6YA 6ai TYP.1.AW Akitl T0J VSAItateAl.',99jagP..REK414 ,,FM
Footing drain - l 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
aluation trP.rtm4st
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
4g tY F ((iii)g
er A -,,o0,4454.1 additional $10 000 00 or fraction thereof, to and
including $10,0 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
rififliZAV:11,101,-;=1* &rst: ,r,nty:!: IF:=1
*LI FOIVroVeciil
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"
-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 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:
\BuddingTermds \PLM-PermitAPP doc 3/03
ALOHA - SANITARY SERVICE
INVOICE NO.
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 8257
503 -644 -2797 * 503 - 648 -6254 503- 639 -5188
NAME: , --e ' v1 - ■.,,( / A -- 6a.a--
5.
ADDRESS: �. • �, 2 , i1 ,
CITY: STATE: ZIP:
HOME: /- `66 0' WORK: CELL:
JOB SITE: _� (9,/1/l P.O. #:
PAID BY CHARGE ❑ CHECIca CASH ❑ CREDIT CARD ❑
DATE 2 - --/r 'f y DRIVER Dvd 7 / AMOUNT
(1 PUMP SEPTIC TANK
. 3On CO
❑ LINE OPENING /
❑ INSPECTION FEE
❑ SERVICE CALL /
❑ LABOR, LOCATING, DIGGING, BACKFILL /
❑ MATERIAL
- - THIS IS NOT A SEPTI'' SYSTEM INSPECTION REPORT - - TOTAL $ ,? O dO
--
REMA),cg - -
TYPE OF TANK: S ES/0 CONCRETE ❑ P / ASTIC ❑ HOMEMADE ❑
ORIZONTAL B VERTICAL ❑ ECTANGLE ❑ ❑ OTHER
SIZE OF TANK: 350 ❑ 500 \ El 750 ❑ 1,900. ❑ 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑
LID LOCATION: INLET ❑ \ OU ET . • MIDDLE ❑ ENTIRE TOP ❑
\
TANK CONDITION: GOOD ❑ \ F AIR N POOR ❑
FITTINGS: BAFFLES ❑ CONC"E ❑ CAST IRON ❑ PLASTIC ❑
NEEDS NEW LID? YES ❑ SIZ
GROUND COVER OVER TANK
COMMENTS ON CONDITION OF DRAINFIELD ETC. /
I) /
r
SIGNED BY DATE ._ , / it
Clean Water Services
Our commitment is clear.
col
erf
155 N First Avenue, Suite 270 SANITARY w
Hillsboro, Oregon 97124
(503) 846-8621 SURFACE WATER
EROSION CONTROL PERMIT
ISSUE DATE 040802 EXPIRATION DATE 040704 PERMIT 122357
STRUCTURE ADDRESS 14125 PROJECT 9999 LOT 0
STRUCTURE STREET SW FERN ST
TYPE OCCUPANCY- (1) SINGLE FAMILY PARCEL 281 4 BC 700
OVNER LARRY HULTQUIST
ADDRESS 14125 SW FERN ST
TIGARD OR 97223
PHONE 503-521-1668
EROSION CONTROL FEES
IMSPECTION 26.00
PLAN CHECK 16.90
TDTAL 42.90
A?PL NAME LARRY PHONE
•
AFFILLIATION OWNER
IULMARKS GARAGE ADDITION TO SFR
Number to call for INSPECTION-784678444 ******
Ttis is not a SITE GRADING PERMIT-this permit covers EROSION CONTROL ONLY
SIGNATURE / G%4A.x 4i
ISSUED BY GROSSM
•
Permit conditions: The applicant agrees to comply with all the rules and regulatfbns Clean Water Services. When calling for an inspection, please refer
to the Permit Number. The Permit expires one hundred eighty (180) days from the date of issuance. The District does not guarantee the accuracy of the
location of side sewer laterals.
Revised 6/01 White - USA, Blue - Accounting, Green - Inspection, Yellow - Customer