Permit CITY TIGARD PLUMBING PERMIT
I DEVELOPMENT SERVICES PERMIT #: PLM2004 -00464
' 13125 S Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/6/2004
SITE ADDRESS: 12140 SW KATH'ERINE ST PARCEL: 2S103BB -10300
SUBDIVISION: YE OLDE WINDMILL ZONING: R -4.5
BLOCK: LOT: 023 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: 1 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: 1 URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: 1 RAIN DRAIN: ft
Remarks: Installation of plumbing fixtures for kitchen remodel.
FEES
Owner:
Description Date Amount
KEITH WOLF
12140 SW KATHERINE ST [PLUMB] Permit Fee 10/6/2004 $72.50
TIGARD, OR 97223 [TAX] 8% State Surcharl 10/6/2004 $5.80
Total $78.30
Phone : 503 - 579 - 1979
Contractor:
R A WARNER PLUMBING
PO BOX 820785
VANCOUVER, WA 98682 REQUIRED INSPECTIONS
Phone : 360 Rough -in Insp
Top -out Insp
Reg #: LIC 151329 Final Inspection
PLM 37 -521PB
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 - 0040'. You may obtain copies of these rules or direct questions to OUNC by calling (503)
L246
Issu A 21/ii „Lie //
Permittee Signature: Z
all (503) 639 4175 by 7:00 P.M. for an inspection needed th - next business day
Building FixtureSR EC E Y E D
a
Plumbing Permit Application FOR OFFICE USE ONLY ' c -
City of Tigard OCT b 1004 Received / y /o
Date/By: 7076;70V _ Permit No :P��no7 y
13125 SW Hall Blvd., Tigard, OR 2.74q, mot/
Plan Review
Phone: 503.639.4171 Fax: 503.5'' 9 OOF TIGA Oyi �uNNl1 Date/By: Other Permit No.:
24- Hour Inspection Line: 503.63 v41I�5(jING DIVISION.., j. Ali - Juris.
www.ci.tigard.or.us Date RelMetho S upplemental Information
See Page 2 for
www.ci.ti
g Notified/Method: �I� Supplemental
:. �" ' R %.. < ,rid. tl Wa . . � x `s E*F"S:CI ° --,: '
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ID New construction E] Demolition For special information use checklist.
Description Qty. Ea. Total
Ad CI Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
_zip ,
,, y;.: .� .; CTEGORO C ON St. C , T ; �.;.r:._, ,.. ,.,,...x,, SFR(1)bath 249.20
tl- and 2- family dwelling ❑ Commerciallindustrial SFR (2) bath 350.00
❑ Accessory building CI Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
z _ ,, a , 4 £_ , , , Fire sprinkler ( sq. ft.) Page 2
" Jdi SITE °, IN OP:IFIATION AND a " i i∎ ` c _ f
",<� ,o, � 9, ,,:.,, ,, t.-„,.> :4 ,a,.e�, s,K , .,. o S ite u til it ies
Job site address: (2f 4) 4 . -) ,� - x A'e S7 Catch basin or area drain 16.60
City/State /ZIP: C-4 O/C--C Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: / I Project name: Footing drain (no. linear ft.: ) Page 2
Z( L Manufactured home utilities 110.00
Cross street/directions to job site: S
Manholes 16.60
Rain drain cdnnector 16.60
Sanitary sewer (no. linear ft.: ) 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.:
..: r _ ,K. ;:-K z;,.:;s,.:. ,- au .,, 'a " ' ,,_, E , Absorption valve 16.60
*.. v ; > , sD SCRIP�TION F W OJ , , n:w n �
� = �. ,. ,n - I ,: �. < ... ,.r� s. : � �, �.�_ . � � : '� �.� " . - , .. Backflow preventer Page 2
PL A.---k (ti /e- / c,,, k Backwater valve 16.60
Clothes washer 16.60
. Dishwasher I. 16.60 /(, , (p Q
� y - ,:5-, , ,. .:. ,, ,_ ,, „ Drinking fountain' 16.60
1' .,� `;ems: =: „ENANT ea
. PR' R„ =m b W " � izt ® .:, .s r .. .. ..six
E jec t ors / sump 16.60
Name: / < & - - / 7 7 , 4 vJot# Expansion tank 16.60
Address: (21({ () S' (44-- is.- .' I-- Fixture /sewer cap 16.60
City /State /ZIP: 1 A_1 G c £ Floor drain/floor sink/hub 16.60
,
( Jr 507 9 /9 7 Garbage disposal ( 16.60 /( (
Phone: SG Fa ( )
�, 'VIM s Hose bib 16.60
t I - ��M MI' it CANT CO1 AC: . ' F. PERSONS
f r" H a �� . A a., . H; tI Ice maker 16.60
Business name: (1... A u o.NRAL, t 1 (R C C 0
Interceptor /grease trap 16.60
Contact name: lIi C (L U jA/2.4 .. 5Y Medical,gas (value: $ ) Page 2
Address: - p() (0._ 82
J 2 0 -26c- Primer 16.60
City/State /ZIP: j ( J (_et,tw - en- c..L}! 9 f [� g Z oo rain (commercial) 16.60
Phone: (364 ) 39 b 63 ? 0 Fax: : ( ) 94..._ -,7-__ Sink/b sin/lavatory 16.60 /G , 4, p
b/s ower /shower pan 16.60
E -mail:
Urinal 16.60
x ,, 3 CONT ,� t . Water c loset
.�.,i .mow ... � ...4 , _.- . 4 ,0� < .,, . _ „ f� .�: � 1a. a a ` 16.60
Business name: 0 4 u usA, I e ...rit_ p (3 & c Water heater 16.60
Address: 7v Lc. 5 20760 Other:
City/State /ZIP: 0j41\,, L t/v� 9 e6 ti e.... Subtotal Ayr, F
permit fee: $72.50 2a co
Phone: ( tmci ) 8 P$ 037 O Fax: ( ) c. ,,,,, _ Residential backflow minimum permit fee: $36.25
CCB Lie.: / �l 3 2 /SY dip Plumbing Lic. no.: '� I �.S ( Al Plan review (25% of permit fee)
S / 3 , / State surcharge (8% of permit fee) ..5 r
Authorized signature: TOTAL PERMIT FEE /,i 30
Print name: f A OtJd-I,�tw -� Date: (C.) - 6 -( 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.
i:\ Building \Permits\PLMF- PermitApp.doc 12/03 440- 4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
„`.'
;, ;; u iaZO. ea otal are xo a e .erir;lt Fee:
�Site,I�E;il�tie's � ,_. �
.�- .,�a ;�' � .��, ? � g C�m,��e,r,
Footing drain - 1 100' 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 alililt1OI1 ,, ,. ,, permit ee
$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 ee(eaj Total additional $100.00 or fraction thereof, to and
5.044 re or Item _ .k ,.,
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 * .
i 1 "z i Quantit b (Fixtu e) Woomii fined
Fix u��YPe h ``tt�� �RePI e
3 avea �xtsno� , c app ea 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"
- 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
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:
is \Building\Permits\PLM- PermitApp doc 3/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection tine: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
( BUP
Received ( a — D to Reque t AM PM BUP
Location (4 O Si Suite 477 ,,1605
Contact Person Ph ( 5 ) &g. 3, 407 — 6 V ' dO 7
Contractor PL1L.-. : • _ (36 ) 77 � - '" ?7 ' SWR
BUILDING Tenant/Owner 5 -(7 (' g 3 c ` 7 Q ELb1 6 /-6 ? ) V G A
Footing
Foundation ELC
Ftg Drain ACC @SS _ - ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing �( � �,)
Firewall �)i 1 ' l�� 1 r° - V • ) S1 -3 ,1N ° & O 5 Pir klt'1
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
C)11
Storm Drain
Shower Pan
Other:
FAIL
CAL ,
- os & Beam
Rough -In
Gas Line
S of a Dampers
ina
1= 1 T/IP PART FAIL
1 1241) AL
e• -
Rough-In
UG /Slab
Low Voltage
*lam
Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
• S _ PART FAIL
SITE - ❑ Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line
ADA
Approach /Sidewalk Inspector /,/ e■ , Ext
Other:
Final DO NOT REMOVE this inspection record from th ob site.
PASS PART FAIL