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Permit CITY TIGARD PLUMBING PERMIT M DEVELOPMENT SERVICES PERMIT #: PLM2004 -00210 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/12/2004 SITE ADDRESS: 14615 SW KLIPSAN LN PARCEL: 2S105DA -16200 SUBDIVISION: PACIFIC CREST ZONING: R -7 BLOCK: LOT: 050 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: Description Date Amount MEHRAN ADYANI 14615 SW KLIPSAN [PLUMB] Permit Fee 5/12/2004 $36.25 TIGARD, OR 97224 [TAX] 8% State Surcharl 5/12/2004 $2.90 Total $39.15 Phone : Contractor: MILLER FACTORS 4010 NE BUFFALO PORTLAND, OR 97211 REQUIRED INSPECTIONS P RP /Backflow Preventer Phone : 503 284 0600 Final Inspection Reg #: PLM 7969 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503) - 246=669°. Issued c : �I #06,0 � /�' Permittee Signature: `/ /A Call (503) 6 • -4175 by 7:00 P.M. for an inspection needed the next business day Building Fixtures Plumbing Permit Application /y FOR OFFICE USE ONLY /j City of Tigard Date/By: l , / Q Permit No.: f t . V � V 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Phone: 503.639.4171 Fax: 503.598.1960 // sidgi... '`P � A. Date/By: Other Permit No.: 24- Hour Inspection Line: 503.639.4175 ■ 1. , �!' I Date Read /B E See Page 2 for P Ready /By: Internet:: www.ci.tigard.or.us Notified/Method: // �TT Supplemental Information ' , l v "�$ ". 2r ;i - 1 ,�Vf I s R'9 /1 Y.�3`t P 1-`. ,i .t '� 4.� i+.i ;J` f ' �'d L "�' - ! E :; 4 F {� . YF e , _ HED V L i. . . ar ,: t i ttit iv 1, < �,. k'4Av' w. 6 ; E . OF WOR, I{ [ 1 Y .. , '' .' , . .� - , - „ ., , �.,,. ' � , j TYxrF.4 "a?k" _..E- .c;inbH " »L t � a4 .... �.�. 4. .. �. 3 . ..Sa¢ .rr7 > ❑ New construction ❑ Demolition For special information use checklist. Description I Qty. I Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) p a of a� e" a as f s ;, i r r '3 t' ' SFR 1 bat 249.20 pia CATE60RY tCOSTUW . at ,, 0 , t ( ) ...�,'t.,.�w ,��<bt ..T ;,��«.. a >. ,, tt�. -,.. �.A, ..: sass '� . ��.m;�_ w- :..�,, ,;.a .aY�_ _c„ J.. , ,-� . ,. .,, . _ . , so .. i,''' ❑ 1 - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 SFR (3) bath 399.00 ❑ Accessory building ❑ Multi- family Each additional bath/kitchen 45.00 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 r 4 � r � 5 t s �, a T "'AND LOCATION; - 1 " 'f r , 1„ n v " , y ,,�, J,OB SITE IP F ' A� _..,, .. , i Site utilities Job site address: 1 i (S cr19 kL-( PSA "-'J ) , Catch basin or area drain 16.60 City/State /ZIP: 176 A.V.) n g_ et 7 -1--z-s Drywell, leach line, or trench drain 16.60 � Footing drain (no. linear ft.: ) Page 2 Suite/bldg. /apt. no.: Project name: get 1/ •t",%. I - 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 Water service (no. linear ft.: ) Page 2 Subdivision: f Lot no.: Fixture or item Tax map /parcel no.: Absorption valve 16.60 ._. . � �7 � �� r� ? �`� ���� ,� DESCRLPTION�.O W F ORK �, f , _ _ ,, �., . 1 Bacleflow preventer Page 2 � i 14....cis -"tl Backwater valve 16.60 T Clothes washer 16.60 Dishwasher 16.60 a e w W c" , „ ;: - Drinking fountain as ��l 1 r.�� � TE ' �� 1 ° , ., +pROPERTS,, OWNER ,, a.,t_1 .,. � - _. . , ,_ N �._2., y.: in.5 Ejectors /sump 16.60 Name:, it/\, Ark om , r Expansion tank 16.60 Address: I (.F6 -11780,.z.4 �/ p , ( c C le L(` Q O r � "' 2.-2A L /II�G Fixture /sewer cap 16.60 City/State/ZIP: t D / t Floor drain /floor sink/hub 16.60 Phone: ( ) Fax ( ) Garbage disposal 16.60 l V_ -_,�, � �� .� � -� �-_ _° „ „�; . � APPLI ANT `A W ®i CONTACT PERSON =z ' Hose bib 16.60 � �a,� t<aO,w�P ;4�:_ *jro e Ice maker 16.60 Business name: Interceptor /grease trap 16.60 Contact name: Medical gas (value: $ ) Page 2 Address: • Primer 16.60 Roof drain (commercial) 16.60 City/State /ZIP: Sinlc/basin / lavatory 16.60 Phone: ( ) Fax:: ( ) Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 ;': - :_.,,,�. ,;. ; =s °r;. e : r'-, :1 a: „ . ,�; ,. .• R . t; ; ,.;. _ _ >;.:°w # §' ' F p.057.0.70:5- t , �� ii, L . r e � i CONIIRAC -, a � , -.th_ 2 _ ` t Water closet 16.60 Business name: 11/\ [(It-4 S Water heater 16.60 %f Other: Address: 4' (� Subtotal City/State /ZIP: e`I I � ©, 1-) 2 Minimum permit fee: 73 0 e ? 5 -- ou' Phone: (0_ ) 2 06, 0 0 Fax: ( ) Residential backtlow minimum permit f e: $3 J pP � ( Plumbin Lit. -no. Plan review (25% of permit t CCB Lie.: - g ee) State surcharge (8% of permit fee) t9 Authorized signature: V TOTAL PERMIT FEE % / Print name: 1.4 (.r (/L. M I e,(.Cir?..._ Date: Sir ` /Dt This permit application expires if a permit is not obtained within 1!1111 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( I 0 /02 /COM /WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Res><dential Fire Suppression Systems: T To tal` S w F , 00ta a. :. E Permit I+'ee �.Ymr.:'..�"� �Qty �,x:aai��i.' -' e� l.< :fie... �'.�,. �[.:w'�?c� � =.�,c3 � � :�.1 , Footing drain - l fit 100' 55.00 0 to 2,000 $115.00 46.40 2,001 to 3,600 $160.00 Footing drain - each additional 100' 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: _ *�:=, w n V : , 4 Water Service - each additional 100' 46.40 = llll`dr1C1Q11:.,..fe ... 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 Teel ea 47.4:46, tal additional $100.00 or fraction thereof, to and FlXtl1r01'rTt�Ill „.' ". ", ' 4` ;1'0 �� °b 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 $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 * . 4€ },' �Quant�tybY (F�xture)RorkPerformed § F t r e i r y e `" � M � a P i a o e � c d regarding Comments re ardin fixture work: _._. - .., N e w rt i1 3u gPP ', 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 fees assessed for the sewer increase must be paid before the Oil Separator (Gas Station) 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 total is >9. - Service 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: i:\ Building \Permits\PLM -PermitAPP.doc 3/03 CITY OF TIGARD 24 -Hour 4SUI4DING Inspection Line: (503) 639 -4175 INSPECTION DIVISION _ Business Line: (503) 639 -4171 MST BUP Received Date Reque ed AM PM BUP Location / ( / v� -4��7 Suite MEC • Contact Person Ai - ate Ph ( �`� �to Od PLM pq bd '4''d do?lb Contractor Ph ( ) SWR BUILDING Tenant/Owner ELC Footing Foundation Access: ELC • 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 Rough -In Water Service Sanitary Sewer Rain Drains Catch Basin / Manhole Storm Drain Shower P� Other: • in PART FAIL MECHANICAL 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: ❑_Unable to inspect — no access Fire Supply Line ADA Approach/Sidewalk Date Sl 2 ' ) 0 L) Inspector (111 I ( Ext. Other: - Final DO NOT REMOVE this inspection record from the Job site. PASS PART FAIL