Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM1999 -00099
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/12/99
SITE ADDRESS: 09475 SW IVANA CT PARCEL: 1S126DC-LEHO4
SUBDIVISION: LEHMANN SQUARE ZONING: R -12
BLOCK: LOT: 004 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of residential backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
WINDWOOD HOMES APPL DRA 4/12/99 $25.00 99- 314407
12655 SW NORTH DAKOTA MISC DRA 4/12/99 $1.25 99- 314407
TIGARD, OR 97223
Total $26.25
Phone 1:590 -4700
Contractor:
14145 ,w aptc2 -r4
4k-f,.0._wdO 02 9'11440. REQUIRED INSPECTIONS
Phone 1: 035 - 3700 RP /Backflow Preventer
Final Inspection
Reg #: r 4
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 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issue B )1, i, Permittee Si nature: I �1 1 � ,
Y � �._., 1 �.. g , AA>,� t
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next b siness day
CITY ON•TIGARD � � Plumbing Permit Application Plan eck
13125 SW HALL BLVD. Commercial and Residential Rec'e. r
�i L A r /
TIGARD, ORRattRED Date Rec'd 4
(503) 639 -4171 Date to P.E.
APP 0 9 1999 Print or Type Date to DST
Incomplete or illegible applications will not be accepted Permit# PiN /g 99 -00099
COMMUNITY DEVELOPMENT Related swR #
Called
Name of Development/Project - IXTIJRES indiviiliiaij °`' : ;_. ` "'`° AVM RICE O
.,... , �s: >F m`�':%m"��, � %. "' = ,- ... � ;gib -� 's:�:�a�; ., T
Job Le.J,,,'1€2_!,. Sv cca.ri Sink 9.00
Address Street Address 1Vd}►.1t✓� Suite Lavatory 9.00
q 'Z5-sto i Tub or Tub /Shower Comb. 9.00
Bldg # City /State Zip Shower Only 9.00
Name
�"-� Water Closet 9.00
Dishwasher 9.00
Owner Mailing Address Suite Garbage Disposal 9.00
Washing Machine 9.00
City/State Zip Phone Floor Drain/Floor Sink 2" 9.00
Name 3" 9.00
4" 9.00
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 9.00
Gas piping requires a separate mechanical permit.
City/State Zip Phone Laundry Room Tray 9.00
Urinal 9.00
Name
- .� dr
> - "4 ,,, 4 Other Fixtures (Specify) 9.00
Contractor Mailing Address ` Suite 9.00
/5 5& ba /6. -.«; fir. 9.00
Prior to permit Ci /State Zip Phone X .2.7 Sewer - 1st 100' 30.00
issuance, a copy 6j •7 - ", G l eve Q 7/ i 6,,767 Sewer - each additional 100' 25.00
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if .5*--Y/ 6-3c, -99 Water Service - 1st 100' 30.00
expired in COT Plumbing Lic. # Exp. Date Water Service - each additional 200' 25.00
database Storm & Rain Drain - 1st 100' 30.00
Name Storm & Rain Drain - each additional 100' 25.00
Architect Mobile Home Space 25.00
or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- f�' 25.00 „ 2 . 5 ° . c.
Pollution Device /
Engineer City/State Zip Phone Residential Backflow Prevention Device* 15.00
(Irrigation timing devices require a separate
Describe work to be done: • restricted energy permit.)
New 18C Repair 0 Replace with like kind: Yes 0 No O Any Trap or Waste Not Connected to a Fixture 9.00
Residential 0 Commercial Catch Basin 9.00
Additional description of work: Insp. of Existing Plumbing 40.00
/rr J cy7 Se ::$t�Piti,--- per/hr
/ Specially Requested Inspections 40.00
per/hr
Are you capping, moving or replacing any fixtures? Rain Drain, single family dwelling 30.00
Yes 0 No Grease Traps 9.00
If yes, see back of form to indicate work performed by QUANTITY TOTAL
fixture. FAILURE TO ACCURATELY REPORT FIXTURE " _
Isometric or riser diagram is required if Quantity Total is > 9 � ^ „��� `:`��
WORK COULD RESULT IN INCREASED SEWER. FEES. *SUBTOTAL '% . e.
I hereby acknowledge that I have read this application, that the information "' °°`"°' ` ` ` aZ
given is correct, that I am the owner or authorized agent of the owner, and 5% SURCHARGE `k; 'sr= ° ('' ! „2C"- that plans submitted are in compliance with Oregon State Laws. , / ./-
Signature of Owner /Agent Date ** u - �A ;° ;-�r�
_ PLAN REVIEW'25 /a OF SUBTOTAL �ry _
� _ / Required only if fixture qty. total is > 9 `' ; " "t° ;'
/ /!/r • /���LGC- -(=e�c ��/
TOTAL 4!; ° a c9.-C
Contact Person Name Phone >9,27 ; '' ; '
/ 7i/ A. 7 Utz 'Minimum permit fee is $25 + 5% surcharge, except Residential Backflow 1 7 �� l ' l' �( / �l �.i .� ! Prevention Device, which is $15 + 5% surcharge
**All New Commercial Buildings require plans with isometric or riser diagram
4' " and plan review
1:ldstslplumapp.doc 7/2/98 1 -drk (.. �+
PLEASE COMPLETE
''''''''''''''''' A.. ''''''''''''''''''''''''
' .
Sink- - - - - -
Lavatory
Tub or Tub/Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
viVashing tvlachine •
Floor Drain/Floor Sink 2"
3 „
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
Ildstskplumapp.doc 7/7/98