Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PL 11/200 -00205
V I I I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/11/2004
SITE ADDRESS: 09580 SW LAKE SIDE DR PARCEL: 2S111CA -04800
SUBDIVISION: SUMMERFIELD NO.12 ZONING: R -7
BLOCK: LOT: 668 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: 1 SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of (1) shower and (1) water heater.
FEES
Owner:
Description Date Amount
ARDITI, RALPH V + NANCY KAY
9580 SW LAKESIDE DR [PLUMB] Permit Fee 5/11/2004 $72.50
TIGARD, OR 97224 [TAX] 8% State Surcharl 5/11/2004 $5.80
Total $78.30
Phone : 503 - 518 - 1905
Contractor:
NELSON PLUMBING SERVICES LLC
20565 SW 104TH
TUALATIN, OR 97062 REQUIRED INSPECTIONS
Phone : 503 Rough -in Insp
Final Inspection
Reg #: LIC 157769
PLM 34 -431 PB
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 -66 .
Issue B y: / _ �, Permittee Signatur _ ,, _��,� d
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
May 10 04 09:34a Bryan Nelson 5036910723 p.1
A .
Plumbing Permit Appli% CE,OV 1 olt Ofl 1c'1': t is ONLY
Cl of Tigard Received . Permit No.:
131 SW
13125 Blvd., Tigard, OR 97223 0 1 ° 2►• Plan Review ��� , /'" Da •
Phone: 503.639.4171 Fax: 503.598.1960 I/ st't "4,l4l" i : Date/By: Other Permit No.:
24- Hour inspection Line: 503.639.4175 CVTY OF i � " '' . i Date Ready/By: 0 See Page 2 for
Internet: wWW.Ci.tlgald Or.US I � Notified/Method: / Supplemental Information
TYPE OF fit., FEE* SC •' DUCE 1
❑ New construction ❑ Demolition For sped iaformation use checklist
Desert lion 04 . Ea Total
. ddition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
/ - and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building El Multi SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler (_- sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: • ik • e t \ ! I) C. Catch basin or area drain 16.60
City/State/ZIP: / ' P � . Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt no.: \� 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: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
/� n 'rn Ejectors/sump 16.60
Name: YJ . �, f �� A Co t Expansion tank 16.60
Address: 1 � - '� ""~ ^ ( Fixture/sewer cap 16.60
City/ State/ZIP: Floor drain/floor sink/hub 16.60
( W7) S / Q -• I C O Garbage. disposal 16.60
Phone: O "/ Fax:( )
❑ APPLICANT y CONTACT PERSON
Ice I bib 16.60
ce maker 16.60
Business name:
by-14 Interceptor /grease trap 16.60
Contact name: WA. -e , L V1 Medical gas (value: $ ) Page 2 .
Address: Primer 16.60
City /State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax: : ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan ` 16.60 1 ( P ,gyp
E - mail: Urinal 16.60
CONTRACTOR r v Water closet 16.60
Business name: Nl p it -N (.� Y �-y n ' xl S Water heater 11111 16.60 Lt, . (.00 Address: -7 JC.)," I 0-1-41-1,A. Other:
City/ State/ZIP: �(i t I 4 t. 4 ( t l - cr-51 Q Subtotal
M inimum permit fee: ` : $72.50 ✓1 ,
Phone: (e2 2 ( Q _S S Fax: ( CD" 1 k - (5-7 23 Residential backflow minimum permit fee: $36.25 1 li • jl,
CCB Lie.: t ---f ( 0`7 Plumbing Lic. no.: J 1 7 (i) Plan review (25% of permit fee) !
State surcharge (8% of permit fee).
Authorized signature: I� ` TOTAL PERIvi1TFEE.
Print name: c1�)�r1 � 1(
U � ( l c 7 V D ate: 5 i b / V ( This permit application expires s if a permit is not obtain •w itJj q
(/ ' (J 1 V 180 days after it has been accepted as complete. Ou
*Fee methodoloev set by Tri- County Buildine Industry Service Board.
•
CITY OF TIGARD 24 -Hour
BUILDING,. Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received G� Date Requested 3- ( AM PM BUP
Location / 5 K O 9 e.LQ-Q ; n/ Suite MEC
Contact Person f — / Ph ( )6 — (*=, 5 PLM
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 j
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
er ervice
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
•th
S PART FAIL
ECHANICAL
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 Line
ADA
A
/
pproach/Sidewalk Dat v I nspector Ext
PP
Other:
Final D • NOT REMOVE this inspection record from the job site.
PASS PART FAIL