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Permit CITY TIGARD PLUMBING PERMIT l DEVELOPMENT SERVICES PERMIT #: 8/7/03 3 -00409 E�II� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/7/03 SITE ADDRESS: 08627 SW LODI LN PARCEL: 2S111DA-01200 SUBDIVISION: APPLEWOOD PARK NO. 1 ZONING: R -7 BLOCK: LOT: 008 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 for irrigation system. FEES Owner: Description Date Amount CHA, ERIC I + STEPHANIE W 8627 SW LODI LN [PLUMB] Permit Fee 8/7/03 $36.25 TIGARD, OR 97224 [TAX] 8% State Tax 8/7/03 $2.90 Total $39.15 Phone : Contractor: AMERICAN GREEN LLC 10389 NW HELVETIA RD HILLSBORO, OR 97124 REQUIRED INSPECTIONS RP /Backflow Preventer Phone : 647 - 9027 Final Inspection Reg #: LIC 6283 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 Iss ed By: k _ i ; #.4.61/ Permittee Signature: % «i „Ai ___ Call (503 -4175 by 7:00 P.M. for an inspection needed the next business day Building Fixtures P1tiinbin Permit Application FOR OFFICE USE ONLY Received cy 7 Plumbing / Date/By: l e '5 Permit No.: 6.// -a 6, Planning Appr.val Sewer City of Tigard Date/By: Permit No.: 13125 SW Hall Blvd. Plan Review Other Tigard, Oregon 97223 Date/By: Permit No.: Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use //yeniv�dl � � Date /By: Case No.: Internet: www.ci.tigard.or.us �. �, ,. � Contact Juris.: Z See Page 2 for _ 24 -hour Inspection Request: 503- 639 -4175 " Name/Method: Supplemental Information. MI , „ r d TitI QF W...ORK m ,,; , .:.:. ._ #FEE* ;$101 ) .E.ti for special, 4 ation use clheckliagit ❑ New construction III Demolition Description I Qty. I Fee(ea) j Total ❑ Addition/alteration/replacement El Other: ' New 1 rkitaullly dwelh OWM 4 i di ntraludesro100 Jt ,for each'�utility I.VME.. ;, .,: ,, , ; ,,CATEGORYOF. .:CONSTRUCTION;= ;,_ r:= SFR (l) bath 249.20 ❑ 1 & 2- Family dwelling ❑ Commercial /Industrial SFR (2) bath 350.00 ['Accessory Building ❑ Multi- Family SFR (3) bath 399.00 ❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00 . l„ „JOB SITE INFORMATION „and,LOCATI'®N „ �. A Fire sprinkler sq ft Page Job site address: 8 > 27 6-cd.' t,i ,:a , :5 .,. z _ s i - t tilitiea,V, : i <. m , t::� 1 Suite #: Bldg. /Apt. #: Catch basin /area drain 16.60 Project Name: Drywell/leach line /trench drain . 16.60 J Footing drain (no. linear ft.) Page 2 Cross street/Directions to job site: Manufactured home utilities 110.00 A/ (f f ' 5-cu-ed te:" Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.) Page 2 Subdivision: Lot #: Storm sewer (no. linear ft.) Page 2 Water service (no linear ft) Page 2 Tax map/parcel #: ., # fi n , _ nt _�'„ VR:if WORKS , . n . z :i x.. bso , ,,,, F. s . _ %....., m ,,, �,- �, �� -�� �� "� � mixture or�Item� � � � � . � � � . �� °������ �' � Absorption valve 16.60 _ Backflow preventer Page 2 3 (G • a s _ Backwater valve 16.60 Clothes washer 16.60 Dishwasher 16.60 Drinking fountain 16.60 PROPERTYrOWNER,., t. ..' : 14 1.00VAMAI.ilioanQ Ejectors /sump 16.60 Name: 6174j Expansion tank 16.60 Address: f 6 Z7 4_Ddi' 44 Fixture /sewer cap - 16.60 City /State /Zip: /4 ,4/ ©/ Q7Z�f Floor drain floor sink/hub 16.60 / 9 / Garbage disposal 16.60 Phone: Fax: Hose bib 16.60 APPETCANT : :C6 .:.: ka 0 CCONT0..160MSO :: Ice maker 16.60 Name: „4 , ). �ylP,., Z L( Interceptor /grease trap 16.60 Address: / 'Y(9 ,U :(). ,C rj, -, 44 ' /ee/ Medical gas - value: $ Page 2 Primer 16.60 City /State /Zip: ,c/(fb & 97 /Z <P Roof drain (commercial) . 16.60 Phone:5703 b4/7 9 z7 Fax:s23 ‘ Sink/basin/lavatory 16.60 E -mail: Tub /shower /shower pan 16.60 M 4 ~ .i. R h Urinal • 16.60 Business Name: ``,�� Water closet 16.60 J�rfJF /ir/i.:� ���:Z LL Water heater 16.60 Addre :e/Zip: Other 5-A--.44 � Other / �� ' r t 4 = iPlumbing P.ermit(F,ees* ` �" olitROikt Ph one: Fax �;�. ,s.Ht ,,,�__ _ ._ , _� Plumb. Lic. #: Subtotal $ CCB Lic. #: v 6L �.3 Minimum P.etttTitJFei��3R5k $ �j / 2 Authorized Residential Backflow Minin ee $36.25 d (O Signature: t , ,� -- •fir Date: V7/05 Plan Review (25 %ofPe lt - '$ ,e4M/ /` /4h L-OKif State Surcharge (8% of Permit Fee) $ c9 9D (Please print name) TOTAL PERMIT FEE - $ ,,q 9, /5-- Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans with isometric or 180 days after it has been accepted as complete. riser diagram for plan review. *Fee methodology set by Tri -County Building Industry Service Board. i:\Dsts\Permit Forms \PlmPermitApp.doc 01/03 Plumbing Permit Application - City of Tigard - Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: ' � `Site Util►tiesi y Qty g Fee (ea) Total ''= so4rerFoota e, PermitFee : . 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 Valuation: 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 additional $100.00 or fraction thereof, to and �k °` ° °: �Fixtureor Item „,. Qty . Fee-(ea) "kTbtal "' "i,i�.� � ate. � n =�� 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 *. Zyp Comments regarding fixture work: Q u antity by (Fixture) Work Per -forn ed g g Ixt e a Q P ,�, a. *, .v $eplace��. a, i o- 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 *Note: If the fixture work under this permit results in an Garbage - Domestic Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and - Industrial fees assessed for the sewer increase must be paid before the Ice Mach. /Refrig. Drains plumbing permit can be issued. Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar /Lavatory - Bradley - Commercial - Service Swimming Pool Filter Washer - Clothes Water- Extractor Water Closet - Toilet Urinal Other Fixtures: i:\Dsts\Permit Forms\PlmPermitAppPg2.doc 01/03 • _ _.___ ____ . _ _ . r _____ .. i . . • ,,,,,A _ ....: ❑ \DM >NE W P W S -AW W A ❑ EXISTING BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED PROPERTY ❑ REPLACEMENT OWNER: PHONE: MAILING . ADDRESS: f�( Z —7 5 c, Z O) / ' CITY .(/.6/i,.- STATE C ZIP 9�z ASSEMBLY f ADDRESS: ' " STREET ; ' ❑R.P.B.A. © D.C.V.A:-❑ R.P.D. A. ❑�D.C.D.A. ❑P. V.B. A. ❑S.V.B.A. ❑A..V.B. ❑AIR GAP 1 SIZE: I l� I01 MAKE: F / .1 MODEL: 1 �/ WATER _ _ �` /� r PURVEYOR: f�" --,? .., _.�' - NUMBER: 6 J C�� . ASSEMBLY &" LOCATION: / /ka <X:-- / REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST #1 CHECK I :b:OUBLE CHECK: AIR CHECK PASSED - G' - ^ PRESS DROP (A)1 CHECK #1 INLET FAILED ❑ INITIAL RELIEF VALVE OPENED AT (B) TIGHT -�9-- OPENED AT: PRESS DROP TEST DATE: MIN 2 PSID RESULTS 'LEAKED ❑ PSID BUFFER EJ f--.. - A - B = I CHECK #2 PSID PSID MIN 3 PSI RELIEF VALVE ITIGHT -- Z -DID NOT FAILED SYSTEM PASS ❑ FAIL ❑ I LEAKED ,—,M OPEN ❑ ❑ PSI. COMMENTS REPAIRS AND /OR - PARTS REDUCED PRESSURE ASSEMBLY P. V.B.A. /S.V.B.A. AFTER REPAIRS NI CHECK . PRESS DROP - ( L._. _. . � D.0 V A " "" • •''" , DATE: TEST RELIEF CHECK #1 OPENED AT PRESS DROP AFTER OPENED (B) I TIGHT P SID / / REPAIRS MIN 2MD BUFFER CHECK #2 A - B _ • ee I TIGHT ❑ PSID PSID PSID PASSED ❑ b IN COMPLETING AND SUBMITTING- THIS TEST REPORT, THE TESTER CERTIFIES THAT THE • ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS. GAUGE CALIBRATION DATE - I /// G DETECTOR METER READING TESTER SIGNATURE v J � /'�� /� h , - C � < TESTERS NAME PRINTED ( C.` i' �/ (,� GAUGE # TESTERS ADDRESS ° / ' +'HONE I OCJ /%�.!a i A4c A f,r( -- 'COMPANY NAME ❑ SERVICE RESTORED = . REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) -- _— WHITE - Water System Copy — PINK - Customer Copy ` YELLOW - Tester Copy CITY OF TIGARD 24 -Hour BUILDII • Inspection Line: (503) 639 -4175 INSPECTIO DIVISION Bus'nes Line: (503) 639 -4171 MST - g12 65 . BUP Received `� Date Requested a 05 AM PM BUP Location gl.0 ? az.c) i& / Suite MEC Contact Person Dt Ph ( ) ' o��s PLM AO g - -GoVQ Contractor Ph ( ) SWR BUILDING Tenant/Owner ELC Footing ELC Foundation Access: Ftg Drain � yp ELR Crawl Drain C/ Slab Inspe on es: SIT Post & Beam Shear Anchors Ext Sheath /Shear Int Sheath/Shear Framing Insulation Drywall Nailing Firewall Fire Sprinkler Fire Alarm Susp'd Ceiling r 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 Pa Oth- • 4 e. PART FAIL HANICAL 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 F / Inspector Ext Other: Final DO NOT REMOVE this inspectiocord from the job site. PASS PART FAIL