Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES DATE ISSUED: PLM20 1 -00516
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 06993 SW LOCUST ST PARCEL: 1S136AA -09100
SUBDIVISION: VENTURA ESTATES ZONING: R -4.5
BLOCK: LOT: 013 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: Irrigation backflow prevention device.
FEES- • -
Owner: V
Type By Date Amount Receipt
WINGATE CORP PRMT CTR 10/11/01 $36.25 27200100000
15840 S POPE LANE •
SPOT CTR 10/11/01 $2.90 27200100000
OREGON CITY, OR 97045.
-" Total $39.15
Phone 1: 503 - 793 =8895 .
Contractor: -
I M PLUMBING
411 HARNEY WAY
VANCOUVER, WA 98661 REQUIRED INSPECTIONS
Phone 1: 310 -2083 RP /Backflow Preventer
Reg #: LIC 115262 Final Inspection
PLM 37 -357pb •
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 � .,�� Permittee Signature 4
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed' the ne • u • ess day
•
f ' "
Plumbing Permit Application
Date received: /V/(./ p 7 Permit no.:/iai /-i Q,S / d
.., City of Tigard
i b Sewer permit no.: Building permit no.:
.A4-'../ - 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: By� GtJ I Receipt no.:
r/S/ ��d / 4rJ n r90
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCIIEI)ULE (for special information use checklist)
Job address: 6 9'9,3 s uJ 'p P as T Description Qty. Fee (ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax map /tax lot/account no.: (includes 100 ft. for each utility connection)
SFR (1) bath
Lot: AS 'Block: I Subdivision: V /1,4— & S SFR (2) bath .
Project name: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: //ti / / Manholes
Address: y// / 6 /1.-1 cy dt//i- Rain drain connector
City: VA/ enu //g,__ I State: k/4ZIP: 94760 6/ Sanitary sewer (no. lin. ft.)
Phone: 11S-44311- I Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: 115 7).7.... I Plumb. bus. reg. no: Water service (no. lib. ft.)
City/metro lic. no.: Fixture or item:
Contractor's representative signature: ,,,,t,/l Absorption valve
Back flow preventer
Print name: 61, • t a / Date: to it o Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
• City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Floor drains/floor sinks/hub
Name (print): Garbage disposal
Mailing address: Hose bibb
City: I State: I ZIP: Ice maker
Phone: I Fax: I 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 per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
L Tubs/shower /shower pan
Urinal '
Name: 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 $ �� .
Notice: This permit application Plan review (at _ %) $
❑ Visa ❑ MasterCard expires if a permit is not obtained
Credit card number: / / within 180 days State surcharge (8 %) .... $ 2 . 9 a Expires ays after it has been TOTAL $ 39 • /5
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 5 440-4616 (6i00/COM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16 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 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
Urinal
Other Fixtures (Specify) 16.60 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 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25 •
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
**PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device; which is $38.25 + 8% state surcharge.
** All New Commercial Buildings require 2 sets of plans with isometric or riser
diagram for plan review.
i:\dsts \forms\plm- fees.doc 08/29/01
CITY OF TIGARD BUILDING INSPECTION DIVISION
MST 2O f OG I R 0
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171 MST
Date Requested lb / Z AM PM BLD
2 Location I q 3 Si- Suite MEC
Contact Person Ph 7 3 fib' L� DD (— oos7(o
Contractor Ph SWR
BUILDING Tenant/Owner ELC
aining Wall ELR
Footin Access: 13 6
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes: - i
Slab SIT
Post & Beam
Ext Sheath /Shear rb�/
Int Sheath /Shear
Framing
Insulation
Drywall Nailing �j y
Fire wall . p e - r L$ C 2 r <-
Fire Sprinkler
Fire Alarm r
Susp'd Ceiling
Roof
Misc:
•
• FAIL
-ING
Under Slab r0 t M
Top Out
Water Service
Sanitary Sewer
Ra'' 'rains
PART FAIL
' ANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm .
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA
Approach /Sidewalk Date "b / Z - / d Inspector Ext
Other
Final
PASS PART FAIL . DO NOT REMOVE this inspection record from the job site.