Permit d
C ITY OF TIGARD PLUMBING PERMIT
Ak DEVELOPMENT SERVICES PERMIT #: PLM2004 -00399
....0-'All 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 9/1/2004
SITE ADDRESS: 12730 SW GLACIER LILY CIR PARCEL: 1S133DA -05100
SUBDIVISION: AMART SUMMERLAKE ZONING: R -7
BLOCK: LOT: 073 JURISDICTION: TIG
CLASS OF WORK: ALT 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: 5 OTHER FIXTURES:
TUB /SHOWERS: 2 SEWER LINE: ft
WATER CLOSETS: 2 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replacing 5 lays, 1 shower, 1 tub valve and (2) toilets.
FEES
Owner:
Description Date Amount
PULITO, GERALDINE K +
BENNETT, EARL C [PLUMB] Permit Fee 9/1/2004 $149.40
12730 SW GLACIER LILY CR [TAX] 8% State Surchan 9/1/2004 $11.96
TIGARD, OR 97223 Total $161.36
Phone : 503 - 524 - 8037
Contractor:
SEYLE'S PLUMBING
PO BOX 2116
LAKE OSWEGO, OR 97035 REQUIRED INSPECTIONS
Phone : 503 Rough -in Insp
Top -out Insp
Reg #: LIC 121862 Final Inspection
PLM 24 -360PB
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 -6699.
Issued By: // i �_ , L Permittee Signature:( \\AI I t ),t,...L
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building fixtures ECE1 ED
Plumbing Permit Application) 0 2004 ; FOR OFFICE USE ONLY
vdi
City of Tigard DateBy Veit c � Permit No Ain �v � r^ �� (,03 13125 SW Hall Blvd., Tigard, OR 97223 CITY OF TIGAF,O Plan Revi:
Phone 503.639.4171 Fax 503.598 1960 DateBy 6 3au � �� ° `' 1 °1� Other Permit No.
t
24- Hour Inspection Line BUILDING DIV
503 639 4175 4J � E (A Date Ready /By. Juns 0 See Page 2 for
Internet: www.ci.tigard or.us Nonfed/Method. 77 Supplemental Information
• �;,g ; s ; '- _...5*' V .r. ^�.gaw i, , — _ $ Air,,, •� �. � N > .': • " > c" airs '^,?G. �cr.'ncs„ �,
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-7 . 'a' h 'TYP OF.� �, v ° l 1 -i' < . - .: w ,FEE *:^SCHEDULE'"' '
.�� xa.�,� _ . _ - `a�,— ��4^`�� =" _...�.,,..ac,'.t`tu r =� �i�,�:A�_ �u7-.z s 3 n G �. k2r.� ='`` z'�`u'SEYa� ss i r.�_: ":257�'«s"::'` .. ia rs,,, rw: „=aasr. - - .. .
For special information use checklist
❑ New construction ['Demolition
Description l Qty. Ea. Total
g Addition/alteration /replacement ❑ Other. New 1-2-family dwellings (includes 100 ft for each utility connection)
•4 ti ='ti's $ 'a ^Src Se+"i Va. #�.=.t� ^<^°'M3"<25y 7R; . . .. e++ T .^^ct :��f., x,
ii✓ . . i°; = ; CAT EGORY ®E4CONSTRUGPI, '` , 0 , t 5 • is . „ SFR (1) bath 249 20
. s =. ss;l.� .,,c�.•-. arsaanw , �m�:�'.a.�; ,, �:.se�:..r,<. - * �. �a” € -..r.
g 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
1=] Accessory building 1=I Multi-family SFR (3) bath 399 00
Each additional bath/kitchen 45 00
❑ Master builder ❑ Other:
_ Fire sprinkler ( sq. ft.) Page 2
°' y JOl3"STTE a6iiiikTION D LfOCATION . z ' ' _,•
, ` s t..:._ ... . c,.=n cz;:^ .;.. - r_. .- =w4 -s;rf : f ..s a a , S ut
Job site address: I Z 73 O &LAG %FR L-i t- L `( 2 t RC Le Catch basin or area drain 16 60
City/State /ZIP: Drywell, 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:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no linear ft.: ) 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.:
;,..,. : , ., a r s, ,* ,'., �t w, ,, ,, Absorption valve 16 60
= `i ::W,0.,i t) `sV E ;pF - WsQRICe '.4.41::-%.„, '
n t . u ,xar' �z s. =.r.r Y t . l Bacicflow preventer Page 2
?AT t'1 145P L �2) Backwater valve 16 60
Clothes washer 16 60 ,
Dishwasher 16 60
Drinking fountain 16 60
? ,a"' ,m' ;a r - ., i" ° °ac- s iz) „ ;ay.„i„ } w •, • <” k .,:,.w: - ' >.. y ,. u, g
, .a PROEE'RT O,H'NI = ;' .: ,y "4 W ® ?i:TENAN , :� t , *
�..o� a:.4a":.dt;y...^;teC.. ;z^1t ^ =::.r�.- ..rmtt »� ' d.�s • ,�,�°^ ° x ., d �% �• �
lY ^",.e: a- =v�
Ej ectors /sump 16.60
Name: got, Iv Expansion tank 16 60
Address: Fixture /sewer cap 16.60
City/State /ZIP: Floor drain/floor sink/hub 16 60
Phone: (03 ) 51 , -1— $037 Fax: ( ) Garbage disposal 16.60
_.:a
.' , _,:,.,: .,,..x.,w 4 ,, Hose bib
CONTACTPERSON " "'•i
3 s ,dz " ,i544: z��su r._�.� x Ice maker 16.60
6 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/basi avatory 5 .6 16 60
Tub /shower /shower pan 1 16 60
E -mail:
Urinal 16 60
;, - 1" a PR54;7- 4r'.:;'ni ' IEgk 14 ,.i'd... `af-*f ..... u #iii4fi 7i, 1 °,fir: ,y".'4 ,„,f ;ii
;` )
/ lia' 'a` 1,101 ' 1 COPif,t.t OR' vT t � y Water closet 16 60
''�� '� �a � i.� �_r._,�� zip;:,= ��'. k '�. �
Business name: S el Le S t p Lt! ri &1N6 (a , Water heater 16 60
Address: (1, 0 , ,Co.f 1L Other: Subtotal
City/State /ZIP. (Ate OS w et, 0
Minimum permit tee $72 50 4 'l
Phone: ( .5) to ....-1.6 °I q Fax: ( 51 3C y — Zeal., kx' / Residential backflow minimum permit fee $36.25 / 7•'1(1
CCB Lic.: j7 .'b°(, Z 4 , y t,� p ( Plumbing Lic. no.: ZN{ — fo 0 � 5 Plan review (25% of permit fee)
t ^ State surcharge (8% of permit fee) 1/. /&
1
Authorized signature: ,.x.. (
TOTAL PERMIT FEE 1 1 I . (d,
Print name: eff 7e,\.1 Date: / It ( This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tn -County Building Industry Service Board
I \Buiidtng\Pernuts\PLMF- PerrrutApp doc 12/03 440-461 6T( 1 0/02/COM/WEB)
Plumbing Permit Application - City of Tigard �► -
Page 2 - Supplemental Information
Fee Schedule: • Residential Fire Suppression Systems:
i`� ` za y , . _ _• '«,�'" ? �
, ;1., , le ea ;Veal = _`.°, °.
S <e .:` :. , .$ " .:•,$ : „ , ) , . , .. _ :, 3 ,'ermi ET 04, ,.
m .. �� .a,.� .*" , 2 ;� quare�F ootage= � .:.. �. r,,, ,�, __�,_ ���
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 � �"
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 $1 52 for each
''''' =$ i' "'' ` ` iz.Fee'` e a f additional $100 00 or fraction thereof, to and
, Fixture or It e rrir K ,4. °: 4 ;: c2 01 t <= )° ' -0 1'01
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
Subtotal: $50,001 00 and up $742 00 for the first $50,000.00 and $1 20 for
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 * .
;; fi ; - ,`',': "� ..., fib, „Quantity liy•( iaiii' ej Work,P,erfo' "rmeil ;.,.
[ z �.a' id
FsxturE # q e ;" , . ' % :: -0 r,'v „ ' "�, Z�Replace
s' :.. '. Mo`ved � Gxis ..,.ac eii 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"
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
Commercial Isometric or riser diagram is required if fixture quantity
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• •
\Budd,ng\Pemuu\PLM- PemutApp doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested o AM PM BUP
Location l °( - 7 36 - Ct-elp- Suite MEC
Contact Person Ph ( ) d PLM 0,3??
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
,O OUI _fir.
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
t , r 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 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinspection RE: El Unable to inspect — no access
Fire Supply Line 171‘,/,
Approach /Sidewalk Date G L/ I nspector
Approach/Sidewalk Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL
CITY OF TIGARD 24 -Hour
BUILDING i Inspection Line 33) 639 -4175
INSPECTION DIVISION Business Line: (503) 63• 1 (, ST
Received Date Requested / Z AM PM :Up
Location _ _41— / i _ . • _, uite E 'O 06 4
Contact Person �� �r� Ph • ( / ) 4. — 7 7 PLM G�Y - Ud �9
Contractor Ph (_� � ' 3 SWR
BUILDING . Tenant/Owner ELC
Footing
Foundation ELC
Ftg Drain Access: �l
Crawl Drain O
CJ ELR
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Fi rewal I
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PA I FAIL
U MBI
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
ower `a 1
Other:
Fin -
$ FAIL
CHA
Post & Beam
Gas Line nn
Smoke Dampers"
Fin -
• P ART FAIL
CTRICAL.
Service
Rough -In ® g *S\
UG /Slab 6 l
Low Voltage
Fire Alarm
Final 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'
® C /Z7f ° / / �\
Approach/Sidewalk st® Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL