Permit ~ ' , CITY OFTIGARD PLUMBING PERMIT
1 DEVELOPMENT SERVICES PERMIT #: PLM2004 -00484
� I DATE ISSUED: 10/25/2004
13125 SW Hall Blvd., Tigard, OR 97223 (50 639 -4171
SITE ADDRESS: 11623 SW PACIFIC HWY PARCEL: 1S136DB-00900
SUBDIVISION: ZONING: R -12
BLOCK: LOT: 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: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: 300 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replacement of domestic residential water service.
FEES
Owner:
Description Date Amount
GENSMAN, MITCHELL EDWARD
18470 PARRETT MTN RD [PLUMB] Permit Fee 10/25/2004 $147.80
SHERWOOD, OR 97140 [TAX] 8% State Surchan 10/25/2004 $11.82
Total $159.62
Phone:
Contractor:
RAYBORN'S PLUMBING INC
PO BOX 69
TUALATIN, OR 97062 REQUIRED INSPECTIONS
Phone : 503 - 692 - 4139 Water Line Insp
Final Inspection
Reg #: LIC 87852
PLM 34 -166PB
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 -6699.
Issued B Y Permittee Signature: r����— - " om/ •�
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
OCT -25 -2004 02:26PM FROM- T -124 P.001/002 F -586
I
Plultih1Sin Perm- V E I/ l i�a O L c c o
r te,, fD,�
City of Tigard 4* f 77y l r Permit Nor? al/ _ , r
13125 SW Hall Blvd., Tigard. OR 97223 PCm Review Odor Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 OCT 1. 25 201 • 4• • . 5 i I wdBy:
24- Flour inspection line: 503.639.4175, l�I, 1, ' • I L fly , w a m Sce Pntj 1 for
w.
Internet: wwei.tigard.or.us O TIGA = 1! lemte l lnfermatio°
T • • •: • .... 4fLJ 1O IVISION - 7 FEE SCh EDULE
For spcdalWarnadon use checklist -
g Ncw construction ❑ Demolition
Dacti timr r Ea. Total
•_4 Addition/afiaation/replacenent ❑ Other. New I -2 -family dwellings (includes 100 R for each utility connection)
.. -. • ..:•_: '... • • • •
CATEGORY OF CONSTRUCTION . . • .. . SFR (1) bath 24920
•
t I- and 2- family dwelling ❑ Commercial mdustrial SFR (2) bath 350.00
SFR (3) bath 399.00
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other. Fare sprinkler sq. ft.) Page 2
"•JOB: SITe • INFORMATION AND LOCATION: Site udtltles
lob site address: 1 1 , o ,r-J Ac.IFic 49.1 Catch basin or area drain 16.60
City/State/ZIP: '- ( 0 Drywall, leach time, or trench drain 16.60
/ Footing drain (no. linear ft.: ,) Page 2
Suite/bldg. /apt.no.: I Project name: ere.
Manufactured home militia 110.00
Cross srrectid rections to job see: Manholes 16,60
Q I;i V Vedfit I .± I */ Tip mil( itA.A9ArTI,Fal Rain drain connector 16.60
PAS -C itiir4. 7 Sanitary sewer (ear. linear ft.: ) Page 2
Storm sewer (no. linear 1: J Page 2
Subdivision:
Lot no.: Water service (no. linear ft.: 300_) Page 2 147 •'
Fixture or item
Tax map/parcel no.: Absorption valve 16.60
. • • • . . • • DESCRIPTION -OF WORK ' • Back low prevrnter Page 2
"RlC•DtJce,F�ler-1 Of 'bM�5'CFC " Re.5 ' O ref./VIAL Backwidervalve 16.60
t ( Clothes washer 16.60
W � ` Dishwasher 16.60
Drinking fountain 16.60 •
.. ` ..PROPERfY OWNUR : . , •• • • 13 'TENANT
Ejectors/sump 16.60
Nome: TY) i'T c / �E1.LlaNfAr1 expulsion tank 16.60
Address: l Sd'7D . ,.11 /
"p MT N- R1a tw
Fixe/sewercap 16.60
Ciry/Statc/Z1P: eV- 911¢0 Floor drain/floor sink/hub 16.60
,1 �
Phone: (E 7a3 1'1 1 Fax: ( ) Garbage disposal II 16.60 Hose bib 16.60
APPLICAN!f ❑ CONTACT PERSON • Ice maker 16.60 •
biterceptoi/grease trap . 16,60
Contact name: Medical gas (value: S _ ) Page 2
Address: Primer 16.60
Roof drain (commercial) 16.60
City/State/ZIP: Sink/basin/lavatory 16.60
Phone ( ) I Fax: ( ) Tub/shower /shower pan 16.60
E-mail: Urinal 16.60
- • • • CO NTRACTOR • • . . Water closet 16.60
Business name: - .1.3 0 .iegygoieWs f,•,/y Water heater 16.60
Address: PO Q O G -. Other:
Subtotal
Clry /Statc/ZIP: 7 -yf n,./ 2 9 7.0 (0 a- Minimum permit fee: 572.50
Phone: (503) 4 9,2 - 4 9 / Fax: ( ) Residential back flow minimum permit fee: 836.25
CCB Lie.: umng e. .: .4 6/o; ^ Plan review (25% of permit fee)
�� ' Plumbing Li no State surcharge (8 %of permit fee) / . •
0
Authorized sipature: TOTAL PERMIT FEE 161 . (�Q/
Print /j _ 1 /iL:, ■, , _ Date: /0 2S O y This permit application expires if a permit is not obtained wtthin
180 days afar it has been 'tempted as complete.
*he methodology an by Tri- County Building IndusW Service Board.
I:WUilainpermiatPLM.PmrtApp doe 1241 440.4616Ttte107ICOMJWEa)
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST
INSPECTION DIVISION Business Line: (503) 639 -4171
/ BUP
l
Received Date Requested -'z 9 AM PM BUP
Location l Suite MEC / p
Contact Person G Ph ( ) "7D 3 - 'W f q PLMa DD `, t" - d O �Q 9
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing ELC
Foundation `Access: / / 11 _
Ftg Crawl Drain
� Vim/ /��� ELR
Crawl Drain
Slab Inspection otes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
dp 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 El Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE 0 Please call for reinspection RE: 0 Unable to inspect — no access
Fire Supply Line
ADA
Date l Inspector
Approach/Sidewalk {- Ext
Other: 111
Final DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL