Permit C ITY OF TIGARD PLUMBING PERMIT
T;,l DEVELOPMENT SERVICES PERMIT #: PLM2004 -00011
"'��1 DATE ISSUED: 1/30/04
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 14125 SW FERN ST PARCEL: 2S104BC -06400
SUBDIVISION: HULTQUIST PART /MLP2002 -00009 ZONING: R -7
BLOCK: LOT: 001 JURISDICTION: TIG
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: 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: 180 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: 190 ft. water line.
FEES
Owner:
Description Date Amount
LARRY HULTQUIST
14125 SW FERN ST [PLUMB] Permit Fee 1/14/04 $101.40
TIGARD, OR 97223 [PLMPLN] Plan Review 1/14/04 $25.75
[TAX] 8% State Surcharl 1/14/04 $8.12
Phone : 503 - 521 - 1668 Total $135.27
Contractor:
TIMBER VALLEY PLUMBING
PO BOX 34
CANBY, OR 97013 REQUIRED INSPECTIONS
Phone : 266 4300 Water Service Insp
Final Inspection
Reg #: MET 00001 185
LIC 42031
PLM 3 -166PB
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
//;
Issued By: /Uu Permittee Signature*
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next busines . day
I ' Site Utilit,Rs
Plumbing Permit Applica i r, Q, nFOR OFFICE USE. ONLY
CEiT
City of Tigard A Received [ R
DateBy 7 —04 tJ Pernut N +: k�1�(;- �G�//
13125 SW Hall Blvd., Tigard, OR 97223 JAN ' I , Plan Review
Phone: 503.639.4171 Fax 503.598 1960 I < <4'�o-�'; ; � I i Date/By Other Permit No.:
24- Hour Inspection Line: 503.639.4175 �7 I ' mr s Sec Page 2 for
CITY 0 '' . . D ate Ready /By:
Internet: www.ci.tigard.or.us " " Notified/Method: Supplemental Information
�!r,- . >.6 >`�.�R�' N;e��;` a., "4 {i ; ' ■ , ��, � ` " '<n I FEE �t�,SCIiEDULE,
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113- a.��,e M .�_ �&u;.dar�,i ,,.a ,rn<l, n'� ter, a;' ,> wl,, ., a ,bt.. �� =rs , � ,,, i .. �' ''` �, w +,;.
❑ New construction ❑ Demolition For special information use checklist.
X Description Qty, Ea. Total
Additton/alteratton/replacement ❑Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
71,' "r " ,' ' ;- -V ,,:v' >, v;: ,''„ '`u-. u :r4";•' 24. '''''', x +g .0 .,j: .0.' Wx d�4)
j k om , i , � ...r3t ° € 4 " : : ' SFR 1 bath 249.20
;, t.., ,„ '' CA TEGOR Y• F
O , 4 CON ; :_ " ( )
'' �' e�� +•;t m.�.` f ur,:. a,. i,. �� dw a :'t:.:ra�N.,w,_�a�a&'.•,n.,�� u�� - a�:J�a� am �a�s(z;9
1- and 2- family dwelling 0 Commercial/industrial SFR (2) bath 350.00
i )g
Accessory building Multi-family SFR (3) bath 399 00
❑Multi -famil
Each additional bath /kitchen 45.00
❑ Master builder ❑ Other:
;: ".t , i . +e A , p ,. _ .. ' .a "tx3w' :.. N Fire sprinkler ( sq. ft.) Page 2
�'•..1{ ,v r 11t`s w4 JOB / SITE =�INFORIs ArION �4 ND ;I OCATION.` :;pig : : :''' , - ' ,, Site utilities
..s:_.'�Kt2,. %ns.n- ,i*Ahh �`.xxF�:�. +u ®i.n'°t'• s'Y p�,'_,<.:,�dh^a's`� ..9k....,ae 2: f`�ippn... axle. ,,.K ,w„R ,i- �'?:2. - ' >
Job site address: / Y/ r a. a � �i, � � 1-1 ‘.. ' E 7 Catch basin or area drain 16.60
City/State /ZIP: 7- -� G- pe`�G CJ f [ 7,Z� 3 Drywell, leach line, or trench drain 16.60
I.,
Suite/bldg. /apt. no.: Project name: . � �J �� 7� 5'�`� Footing drain (no. linear ft • ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
- Manholes 16 60
.� (' ( " Q rt U' 1L PP /-1 _ X_G 7 1-0 1 - ('� Rain drain connector 16.60
1 � s C -e--4" t\-0-7#1/4. 'v &A t A ,,, i.,n. Sanitary sewer (no. linear ft. ) Page 2
Storm sewer (no linear ft. ) Page 2
Subdivision: 8616 L (4) !12/ Lot no.:81- Water service (no. linear ft.: I Page 2 / d f ` O
Fixture or item
Tax map /parcel no.:
ti ;.,, a R cr.. ,--, ,. .,,:': ,;:r ,. # sorption valve 16.60
`
. = Ab
'; - ,e, : .,� , ' = , F- ,.. ;�+ t ,:.t O DESCIP � TION ,, `OF W — ;:, ,,- � /a t E ' , : '..t}'
, -s A 1E
�e•�'w.� >�tnx.: �.,�. ,.., -P�+ ,��,� ,
; ��,.,,,: ti�,.x,.,.,;A�r , ��� �. ,. , . -z,> Backflow preventer Paget
k A. r /s----• t yk„e" 5' Backwater valve 16 60
5 e !t/ l .e_ Le, 3 Y— q Clothes washer 16.60
( Dishwasher 16.60
,�. t e>fi = e;.ii ii i ; i •,mA.i. „ 5" d ;it ,,,', ', ` y .., ,i ;; ;, :' , . Drinking fountain 16 60
,
; .,' `'ROP,ERTY ;>,i ; ;; r.:'' ;' 1 ° i -E'P, , . .' T 1 vtAN T _ S4- =g','41' ", ,.
t;.e ,_. - ��, , �: "F�. __ + ,�� .,;• r_ : _m= :,v_ Ejectors /sump 16.60
Name: J . . . . x i _ (T /4 & , . , f 7 f L1 1 5 Expansion tank 16.60
Address: / ( 0 2 -> 4 t (,(,J L e ( C-17 Fixture /sewer cap 16.60
City/State /ZIP: - OL /'� / 4 7? . j Floor drain /floor sink/hub 16 60
Phone: ( 3 , j f —/ 6 6 6 Fax: ( ) Garbage disposal 16.60
�,�: ,t� �t;n•• �r,. - ��:� +m - *. ,� "-�� ;,.�•.� a i :; ,� „�;;��;' ;��,,; • ra.:: =:, ' : -, Hose bib 16.60
. "1 , ;,° =,-'c3 a ,, 1.t• CONTACT =PERSON'-'
i '+i���,>xA #',;�APPI;IC.ANT ='' : r. _i�7 _ra ;��ir Y y+
s��`�Cr�:�� >,��H '_,- F.?...r- ,a.�- .:,- =�"w.rR.:k� -. �r�r �v�s::. ±j}; t „ate ,�. .. _ ,,�x > °�e -. -1,-,..<,..1-4, Ice maker 16 60
Business name: Interceptor /grease trap ,r, 16.60 <
Contact name: LA rr HG c- / 71--t v r. , , 1 s 5 l' Medical gas (value $ ) � Page 2 7
Address: /L/ /, 5 t t / F -e 1 S'f Primer i' 16.60
Ci /State /ZIP: / Roof drain (commercial) I 16:60: •
r Sink/basin/lavatory 16 60
Phone: ( 7 o3 g f t. 0 R c. ff Fax: : ( )
v Tub /shower /shower pan 16 60
E -mail: Unnal 16.60
g ,m*I. = >+:s:;.,� , >, s. ;s` * '• "� *i-1' '' ''' - �1��; gt3 ,' tl ,r1 :1.`7'1 liti ``° a .4;
� , fa .l, � x: a t-;g` i 1 :d i i ° %. "�,'y,�u: .,�.:,',na;.'.r', „7
` :S;aGs, £' "A t ,rot. 5,' ;r; ,,, 1 :64;. OMM.g9 .1 %0 .i�r l 9�r � ,A i.; ., >; ,• .A r Water closet 16.60
� �; {,, �', � �. `t��' , , . ' • w ; @ (is:,w , ra_ ..��r.� <. ,• .a,>? & �il`s� =ate �. �'..a , , °,_ , , -, �. ,�;,,
Business name: 7 47 r f/6_ j/ I, ? /(44,1,/ j \ y ui Water heater 16 60
Address: f ) 0 3L, _ __J Other. /*/)/ '111P City/State/ZIP: /l y (/� C` / 2( ) / Subtotal n
( /� !'� lam- r ML mum permit fee: $72.50
Phone: (, ) , ,ZLZ - 4.1 c'l 1 I Fax: (7' ' �Z. C - L d e-, :2_, Residential backflow minimum permit fee: $36 r
CCB Lie.: C_ D.0 _0 <j Plumbing Ltc. no.: / 6 (, rg
Plan review (25% of permit fee) 1 2 � ' f i
Authorized signature: /ST--!.e_ /f G
y 30 d � State surcharge (8% of permit fee)
r / TOTAL PERMIT FEE
V
Print name: L le r /' S f< r f e4L D ate: 1 - S -.e= 4 This permit application expires if a permit is not obtained within -IP 180 days after it has been accepted as complete.
*Fee methodology set by Tn -County Building Industry Service Bo rd._
i \Buildmg\Pcmits\PLMU- PermitApp dec 12/03 440- 4616T(10/02 /COM/WEB) p f 36,d
Plumbing Permit Application - City of Tigard ,
Page 2 - Supplemental Information 7:3V1303A
Fee Schedule: Residential Fire Suppression Systems:
Qt) (60:M'grett ,q1LartP4,19„,
Footing drain - l 100' 55.00 09Pr VT1" $115 00
'271'0''
Footing drain - each additional 100' 46.40 ,00 3;600 $160.00 ti9,60111617„2001 ti i $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
r ,
Water Service - 1st 100' /?:ti 55 00 cr. Medical Gas Systems:
Water Service - each additional 100' 46.40 " • "
aIuation
rmit 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
FtlittrardritgaWle TOW 411 freoion additional $100.00 or fraction thereof, to and
1, 6;re'AvA9N.V, 1 L. ALM 411111!eril; 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
/0 / ,ye $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
Fa
fgiTiTifie*ALtk,,WIA tgafiRmi %Nal
eic,-grans
rsamz. Comments regarding fixture work: capp
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"
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 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.
Urinal
Other Fixtures:
\BuddIngWermitsU'LM-PermdApp doc 3/03
CITY OF TIGARD 24 -Hour .
BUILDING Inspection Line: (503) 639 -4175
MST
INSPECTION DIVISION Business Line: (503) 639 -4171
•
BUP
Received ;7/6 r S Z Date Requested c; AM PM BUP
• Location / 2 - AKILLA S ; Suite MEC �}
Contact Person 4A.A :.� . ; ".+' ) �� Z/� P LMD �/��
4 Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
A ccess:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation + /JnK'
Drywall Nailing
Firewall "� 4 # - Fire Sprinkler ,
Fire Alarm
e,
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
( UJMBIN
0 ' .-
Post & Beam
Under Slab
Ro .I- 1
ate Service
Sani ary ewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan h
Other: �. — ice/
Fi ''
4 : - PART 1 .I" CHANICAL IP
-ost & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final ❑ Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE ❑ Please call for re' spection RE: ❑ Unable to inspect - no access
Fire Supply Line '
I, j
ADA D / I Inspector M Ext
Approach /Sidewalk ,
Other:
Final D I NOT REMOVE this inspection record from the Job site.
PASS PART FAIL