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Permit • CITY OF TIGARD • PLUMBING PERMIT COMMUNITY DEVELOPMENT . Permit #: PLM2012 -00062 • TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/16/2012 Parcel: 2S114BAl2800 Jurisdiction: Tigard • Site address: 16435 SW COPPER CREEK DR Project: Darr Subdivision: COPPER CREEK STAGE 3 Lot: 93 Project Description: Install residential irrigation backflow. • • • • • Contractor: ARTISTIC LANDSCAPES Owner: DARR, BYRON 10670 SW BLACK DIAMOND WAY 16435 SW COPPER CREEK DR TIGARD, OR 97223 TIGARD, OR 97223 • • PHONE: 503-892-6315 PHONE: 503 - 598 -8435 FAX: 503 - 620 -6901 • FEES Quantity Description Date Amount 1 ea Backflow Preventer 03/16/2012 $31.27 • Specifics: 1 12% State Surcharge - 03/16/2012 $8.70 Plumbing Type of Use: SF 41 ea Minimum Fee Adjustment - 03/16/2012 $41.23 Plumbing Class of Work: OTR Type of Const: Occupancy Grp: Stories: • 1 )R D IF . 1 IQ6S • Total $81.20 Required Items and Reports (Conditions) • • • • This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: Call 503.639.4175 by 7:00 a.m. for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. U CITY OF TIGARD PLUMBING PERMIT 1111 a . COMMUNITY DEVELOPMENT Permit #: PLM2012 -00062 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/16/2012 Parcel: 2S114BAl2800 Jurisdiction: Tigard Site address: 16435 SW COPPER CREEK DR Project: Darr Subdivision: COPPER CREEK STAGE 3 Lot: 93 Project Description: Install residential irrigation backflow. Contractor: ARTISTIC LANDSCAPES Owner: DARR, BYRON 10670 SW BLACK DIAMOND WAY 16435 SW COPPER CREEK DR TIGARD, OR 97223 TIGARD, OR 97223 PHONE: 503 - 892 -6315 PHONE: 503 - 598 -8435 FAX: 503 - 620 -6901 FEES Quantity Description Date Amount 1 ea Backflow Preventer 03/16/2012 $31.27 Specifics: 1 12% State Surcharge - 03/16/2012 $8.70 Plumbing Type of Use SF 41 ea Minimum Fee Adjustment - 03/16/2012 $41.23 Class of Work: OTR Plumbing Type of Const: • Occupancy Grp: Stories: • • Total $81.20 Required Items and Reports (Conditions) • This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. � Issued By: I ,/ I r, Permittee Signature: L/ eef 4,/ Call 503.639.4175 by 7:00 a.m. for the next available inspection date. This permit card shall be kept in a conspicuous place on the Job site until completion of the project. Approved plans are required on the job site at the time of each inspection. • HEATH BACKFLOW 03061 • ❑ EW EXISTING BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED PROPERTY ❑ REPLACEMENT ' OWNER: 7:7' rf PHONE: MAILING ADDRESS: / I it ..711 C i 1 � CITY / 7 ,,,v .STATE �_.i - -ZIP 7 Z 1 ASSEMBLY ADDRESS: STREET ❑ R.P.B.A$ D.C.V.A. ❑ R.P.D.A. ❑ D.C.V.A. ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. B. WATER SERIAL PURVEYOR: / / ❑ AIR GAP " SIZE: ( 1 /WWI MAKE: J/✓/ l/.4 5 MODEL: 3 .7 V / PURVEYOR: /4 (C' NUMBER: /' R: 19 / b �j 3 r ASSEMBLY LOCATION: ( f 2,6 ��— REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST MI CHECK I DOUBLE CHECK AIR CHECK PASSED PRESS DROP (A) CHECK # D INLET FAILED ❑ INITIAL RELIEF VALVE g TIGHT OPENED AT: PRESS DRO TEST OPENED AT (>� DATE: MIN 2 PSID LEAKS ❑ PSID RESULTS BUFFER PSID PSID • � ,,2 A - B = I CHECK n #2 TIGHT [ MIN 7 PSI d� • 0 DID NOT FAILED SYSTEM RELIEF VALVE ( no OPEN ❑ ❑ PSI PASS ❑ FAIL ❑ [LEAKED ❑ • COMMENTS REPAIRS AND /OR PARTS ' REDUCED PRESSURE ASSEMBLY P.V.B. A. /S.V.B.A. AFTER REPAIRS 01 CHECK D.C.V. A. TEST PRESS DROP (n) CHECK #I DATE: RELIEF I OPENED AT PRESS DROP / / AFTER OPENED (B) TIGHT ❑ PSID REPAIRS BUFFER 'm"' CHECK #2 A -B= �,.a (TIGHT ❑ PSID PSID PSID PASSED ❑ 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 / OFTH WATER SYSTEM. AND STATE REGULATIONS. GAUGE CALIBRATION DATE ." D - TO; TER EADING TESTER SIGNATURE .R /J / ; Y/_ � a . ? 5 TESTERS NAME PRINTED PO Box f 1565 f Sherwood OR 97140 (503) GAUGE 625-8553 !/ TESTERS ADDRESS Heath Backflow Inc. PHONE w COMPANY NAME i n SERVICE RESTORED REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) WHITE • Water System Copy PINK - Customer Copy YELLOW - Tester Copy Mar 1612 08:50a p.2 Plumbing Permit Application Building Fixtures City of Tigard Received Pea, nb.: 1114 t3' g DateBy:3 / ,, � /� - 0006 a 13 1 25 SW Hall Blvd„ Tigard, Plan Review e Phone: 503.718.2439 Fax: 503 r96 1 p 2012 Dine/Ely: Other Permit No.: Inspection Line: 503.639.4175 IC Date Ready,By it el f� gee page 2 for i A K D Internet: www.tigard- or.gov Notified/Method: a Supplemental Iatormation TYPE OFWatii1&JF I l s uA - iD FEE* SCHEDULE ❑ New construction BU lD�ar$dl�$��S14 �n N For spedul information use checklist Description I Qty. I Ea I Total A Addi tion/alteration /rep1sccmcnt ❑ Other. New I- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (I) bath 312.70 L 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 SFR (3) bath 500.32 ❑ Accessory building ❑ Multi- family Each additional balh/Idtchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) . Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: (pl -135 S Vi Co P P lr tZ C e_4....K- Catch basin or area drain 18.76 Drywell, leach lino, or trench drain 18.76 City/State/ZIP: --r- c -.(, OF el 1 Fooring drain (no. linear ft.: _) Page 2 Suite/bldg./apt. no.: , Project name: V k - - Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: __) Page 2 Storm sewer (no. linear ft.: _) Page 2 j Water service (no. linear ft.: _) Page 2 Subdivision: Lot no.: Fixture or item: Tax map/parcel no.: Backllow preventer 1 31.27 SI.. ,7i1 DESCRIPTION OF WORK Backwater valve 12.51 e Clothes washer 25.02 (1.6T *1-1--- OIL -Gir= _ .) P t7E r i . Dishwasher 25.02 t )Cie. Drinking fountain 25.02 . Ejectors /sump 25.02 lg PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 • Name: r2, ye /J if), R-2,Z Fixture /sewer cap 25.02 �( t /3.5 � it) C)PfC2 C -rt lyL Floor ge disposal sink/hub 25.02 Address: Garbage disposal 25.02 City/State/ZIP: 71 q , o /0 4- ' 7 Hose bib 25.02 Phone: (03) 567 g $ 535 Fax: ( ) Ice maker i 12.51 0APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02 - Business name: (i tS Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: .6Fiz yUSC-cf Roof drain (commercial) 12.51 Address: tQ &7.0 - it) 151A-( pl " d% I 1 Sink/basin/lavatory 25.02 City/State /ZIP: 77 Q "VD i 6g.. 570.- Solar units (potable water) 62.54 Phone: 60) t. - 0/ 5 Fax:: (503 6,„0- Tub/shower/shower pan 12.51 E -mail: /NPO i,) /3-a7677G-1.470P.544pecpD,V • ceN9 Urinal I 25.02 Water closet 25.02 CONTRACTOR Water beater 37.52 Business name: AZDSTTe., L,lpp / `! Waterpiping/DWY 56.29 Address: /C& G' ., )51/)--eye pfr ryienn,0 i3O - ty other: ! 25.02 City /State/ZIP: '77 dg--._ -3 Subtotal Minimum permit fee: $72.50 Phone: (t)'3) ,1D-• --6,3 i 5- Fax: ( 535) G 6,16 I Plan review (25% of permit fee) CCH Lic.: ,66 a (, 7 414' Plumbing Lic. no.: State surcharge (12% of permit fee) Authorized signature: TOTAL PERMIT FEE O /r go Print name: I �" ge riI t� 5 Date: 3.- 6-12... This permit application expires if a permit is not obtained within 180 days after it bas been accepted as complete- 'Fee methodology set by Tti Hui; ding Industry Service Board. 1: teuild :ng\PeraitoPLMU•r'ermitApp.dec 10lc1 /09 40- 4516T( 10/UVCOMJWEB) Mar 16 1208:50a p.1 10670 SW Black Diamond Way Tigard, OR 97223 503-892-6316 Artistic Landscapes Fax 503 - 620.6901 www. arhsti cla nd scapespdx. cc m Fax Ta City of Tigard Building Permits From; Sarah IGnsey@ Artistic Landscapes Fax: 503 -598 -1960 Pages: 3 Including Cover Page Phone: 503- 718 -2439 Date: 3 -16-12 Re: Backflow Permit cc: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply 0 Please Recycle • Comments: Hello, Here is our application and credit card authorization for a plumbing permit (backflow) for 16435 SW Copper Creek Dr. Please fax permit and receipt back to: Sarah © Artistic Landscapes Fax: 503- 620 -6901 Thank you so much!