Permit CITY TIGARD PLUMBING PERMIT
a r^ DEVELOPMENT SERVICES PERMIT #: P 03/13/2000
-00079
'" '� �� DATE ISSUED: 03
13125 SW H all Blvd., Tigard, OR 97223 (503) 639 -4171 /13/20
SITE ADDRESS: 09120 SW LOCUST ST PARCEL: 1S135AB- 00203
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SUBDIVISION: TOWN OF METZGER ZONING: R -4.5
BLOCK: LOT: 005 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 a residential backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
DAVID ADDERLY,SHARON PRMT GEO 03/13/200C $25.00 0000610
9120 SW LOCUST 5PCT GEO 03/13/200C $2.00 0000610
TIGARD, OR 97223
Total $27.00
Phone 1: 503 - 452 -3987
Contractor: •
ACTION PLUMBING & HEATING
19587 SW RED OAK LN
ALOHA, OR 97007 REQUIRED INSPECTIONS
Phone 1: 503 - 356 -9630 RP /Backflow Preventer
Reg #: LIC 138159 Final Inspection
PLM 34 -369PB
ORIGINAL
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.
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Issued By: 4 Permittee Signature
Call (503) 63T-4175 by 7:00 P.M. for an inspection needed the next business day
CITY OF TIGARD Plumbing Permit Application Plan Check#
13125 SW HALL BLVD. Commercial and Residential Rec'd By
TIGARD, OR 97223 Date Rec'd
(503) 6394171 Date to P.E.
Print or Type Date to DST
Red
Incomplete or illegible applications will not be accepted Permit #OG,l -7q
Related SWR #
Called
Name of Development/Project FIXTURES (individual) QTY PRICE AMT
Job Sink 11.50
Address Stre ;Address 11 i Suite Lavatory 11.50
\ �v `^' eN.X 1 Tub or Tub /Shower Comb. 11.50
Bldg # r 4 Ity /State Zip Shower Only 11.50
�g,l. \G p � e �122� Water Closet 11.50
Nam V``3 (� ` -Cf
P\ \ I Urinal 11.50
Owner 1a\ng Adddregs 0 Suite Dishwasher 11.50
R. ` , DC`t`S- Garbage Disposal 11.50
a
-City/State Zip Phone
N\,, v c � ` Q t - - s S ` J " Z Laundry Tray 11.50
Name YC ` u '- Washing Machine 11.50
J G v .,, Floor Drain/Floor Sink 2" 11.50
Occupant Mailing Address Suite 3" 11.50
4" 11.50
City /State Zip Phone
Water Heater 0 conversion 0 like kind 11.50
Name Gas piping requires a separate mechanical permit.
\ _ MEG Home New Water Service 32.00
Contractor i lina A dyes Q � ( � Gi ` \ te MFG Home New San/Storm Sewer 32.00
`� SW hexJltt � N. Hose Bibs 11.50
Prior to permit ity /State Phone Roof Drains 11.50
issuance, a copy \ p�c OO� Drinking Fountain 11.50
of all licenses are Oregon Const. Cont. Board Lic.# Exp. ate
'--
required if l ` q\ t O Z \ JD ` Other Fixtures (Specify) 15.00
expired in COT -"K. Plumbing \ #Q ` p / /
database O \
� C
Name •
Architect Sewer - 1st 100' 38.00
Or Mailing Address Suite Sewer - each additional 100' 32.00
Water Service - 1st 100' 38.00_
Engineer City /State " Zip Phone
Water Service - each additional 200' 32.00
Describe work to be done: Storm & Raln Drain - 1st 100' 38.00
New 0 Repair 0 Replace with like kind: Yes 0 No 0 Storm & Rain Drain - each additional 100' 32.00
Residential 0 Commercial 0
Additional description of work: Commercial Back Flow Prevention Device 32.00
Residential Backflow Prevention Device' J 19.00 i (�
Catch Basin 11.50
Are you capping, moving or replacing any fixtures? Insp. of Existing Plumbing or Specially Requested 50.00
Yes 0 No 0 Inspections per/hr
If yes, see back of form to indicate work performed by Rain Drain, single family dwelling 45.00
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Grease Traps 11.50
WORK COULD RESULT IN INCREASED SEWER FEES. QUANTITY TOTAL
I hereby acknowledge that I have read this application, that the information ----- given is correct, that I am the owner or authorized agent of the owner, and Isometric or riser diagram is required if Quantity Total is > 9 ��
that plans submitted are in compliance with Oregon State Laws. 'SUBTOTAL •
Signet I ant Date
g p-Th 8% SURCHARGE
ontac Pe e p Phone
..-- vs.% sr4� 3 S 1 c � 0 '*PLAN REVIEW 25% OF SUBTOTAL
1. BATH HOUSE $178.00 Required only if fixture qty. total is > 9
2 BATH HOUSE $250.00 �7 TOTAL a
3 BATH HOUSE $285.00
(This fee includes all plumbing flktures In the dwelling and the first 'Minimum permit fee is $50 + 8% surcharge, except Residential Backflow Prevention
100 feet of sanitary sewer storm sewer and water service) Device, which Is $25 + 8% surcharge
"All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
I:tdstsVormstplumapp.doc 12/17/99
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PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved I Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
I:ldslsVormslplumapp.doc 12/17/99