Permit y
^ CITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2002 -00195
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6!3(02
SITE ADDRESS: 06620 SW KINGSVIEW CT PARCEL: 1S125DA 11100
SUBDIVISION: CHARLES ESTATES ZONING: R -4.5
BLOCK: LOT: 006 JURISDICTION: TIG
CLASS OF WORK: ALT 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 backflow preventer device.
FEES
Owner:
Type By Date Amount Receipt
TETSUYA IMAMURA PRMT CTR 6/3/02 $36.25 27200200000
6620 SW KINGSVIEW
5PCT CTR 6/3/02 $2.90 27200200000
TIGARD, OR 97223
Total $39.15
Phone 1: 503 - 293 -3802
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone 1: RP /Backflow Preventer
Final Inspection
Reg #:
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.
Issued By: u � Permittee Signature: /
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next busi ess day
7
•
Plumbing Permit Application
Mi ,s- /U" Date received b - •'3'"e, 2-" Permit no. 71
L» a- • ao 1 Ci 5
City of Tigard /'
Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR-97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By6P) Receipt no.:
Land use approval: Case file no.: Payment type:
a f ', r a t
> e F,., ; , .,;�. ' .TYPE PERMIT � _ •, -}.
❑ 1 & 2 family dwelling or accessory Cl Commercial /industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
a , ' a s w t ` '1. ^ JOB SITE INFORMATION :;w v .: ;;:FEE S special infor ation;use checkl i
Doti address: ' 6620 SR) i �,�sV ► �r N Cfi
Description Qty. Fee(ea.) Total
�
Bldg. no.: quite no.: New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: (Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
ceity/county : '-/ rga rei I ZIP' 9 722 3 Each additional bath/kitchen
c e iption-andzlocatron_of::_work on:premises:› Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells /leach line /trench drain
' ••" a'' „ K. Y" r "''��' PLUMBING'CONTRACTOR - � d- ,� t; Footing drain (no. lin. ft.)
Manufactured home utilities
Business -name? O(,c ` ■ Manholes
Address: . /2o S(A) kj vi (/leW cif- , Rain drain connector
Cityp T ` a rd �J j State:( ZIP:'. Ci /722 3 Sanitary sewer (no. lin. ft.)
itPhorie:=- V3 386+2 Fax: E -mail: Storm sewer (no. lin. ft.)
GCB-71F. I Plumb. bus. reg. no: Water service (no. lin. ft.)
City /metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve SS
Back flow preventer i GIV•q
Print name: Date: Backwater valve
' .., _ ,: `; CONTACT PERSON ' ' Basins /lavatory
Name: Clothes washer
Address: Dishwasher
Drinking fountain(s)
City: I State: I ZIP:
Ejectors/sump
Phone: Fax: E -mail: Expansion tank .
2. -•z •, :; OWNER - ... ; . Fixture /sewer cap
_ (print):, I Vvla vl1 U Vol Floor drains /floor sinks /hub
`` `^ u Garbage disposal
TM iling_addeess :; ( s W ' v►,JSV 1'eW et • - Hose bibb
7Comity7 'Tj arei tI- State? 0 2 I Zkpr:' g t]223 Ice'maker
Phone: 1 . 9)3 YLi3 -3 R02I Fax: E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial) ,,,
employee on the property I own as - r ORS Chapter 447. Sink(s), basin(s), lays(s)
(Ownerls- signature " ✓' r .,— Date: 3 D 2 Sump
ENGINEER Tubs /shower /shower pan
Name: Urinal
ame:
Water closet
Address: Water heater
City: I State: I ZIP: Other: •
Phone: I Fax: I E -mail: Total -
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee) $ r� 6 as
Notice: This permit application
U Visa . ❑ MasterCard n -revie tat _ %) $
• expires-if a permit is not obtained -
Credit card number: / L within 180 days after it has been State surcharge (8 %) .... $ s
Expires TOTAL $ 3 9 • /S
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440-4616 (6/00 /COM)
PLUMBING PERMIT FEES' .
' ' ' :.;,_4;,..::,' 4 , n " °PRICE . :TOTAL ; Newland 2, -fa`m ly; dwellin only:, , r "`_
, FIXTURES (individual)" ' - QTY i(ea) :AAMOUNT;' %,(include all plumbing fixtures ht -. :- e 'PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft QTY ;(ea) AMOUNT `
a tor each�utility'connection) . "n y x,, ., - „ ; - . - , ,.
Lavatory 16.60
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60
SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE '
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL '
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 •
3" 16.60 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 , . ' - , ', - . `Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: " New x Moved Replaced Removed/
permit. . - ,. - . Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory '
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain ' 16.60 Water Closet _
Other Fixtures (Specify) 16.60 Urinal .
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2" `
Sewer - 1st 100' 55.00 3.
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device* 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50 •
Requested Inspections per /hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25 F
Grease Traps 16.60
QUANTITY TOTAL , "
Isometric or riser diagram is required if s' 1 . � ; `,
Quantity Total is > 9 i ��'.'� °�`�t e' c
.. - % =.,,
*SUBTOTAL 4 : ,,:: ;, .. , a e,
8% STATE SURCHARGE Tfg4,174 ' ; "(
**PLAN REVIEW 25% OF SUBTOTAL:`% ° '' j "`
Required only if fixture qty. total is > 9 , - ` tl,41 = 1',,
TOTAL $
'' r , :'
4
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25+ 8% state surcharge.
** All New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
is \dsts \forms\plm - fees.doc 12/26/01
CITY OF TIGARD 24 -Hour
BUILDING - r 1 Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
/ BUP
Received Date Requested &A/ AM PM BUP
Location (c9 9 -) / /4'1 i)- ?.et -!) Suite MEC
Contact Person Ph ( ) 0 ? . 3 FO 2• PLM 2 6 O / f
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing ELC
Foundation Access: ��
Ftg Drain ELR
Crawl Drain
Slab Inspectio o es: 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` /AN „A
Post & Beam AFT-
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other: r
�7
PART FAIL
4111517 ANICAL
- •st -& Beam -
Rough -In
Gas Line _
Smoke Dampers
Final
P ASS PART FAIL
ELECTRICAL ir / Afa r
Service
Rough -In
Low olt
Low Voltage v
Fire Alarm
Final n Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE 0 Please call for reinspection RE: Unable to inspect – no access
Fire Supply Line — _
ADA
Approach/Sidewalk Date / Inspector J Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL