Permit .•. �� CITY OF TIGARD PLUMBING PERMIT
MI6 DEVELOPMENT SERVICES PERMIT #: PLM2002 -00064
c� 'l l 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/26/02
SITE ADDRESS: 11705 SW PACIFIC HWY M PARCEL: 1S136CD
SUBDIVISION: ZONING: C -
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: A2 FLOOR DRAINS: 2 TRAPS:
STORIES: WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: 1 SF RAIN DRAINS:
SINKS: 2 URINALS: GREASE TRAPS:
LAVATORIES: 5 OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 2 WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: 2 sinks, 5 lays. (2 cap), 2 water closets (cap 1), 1 mop sink, 2- 2" floor sinks, 1 water heater, 1 backflow
preventer.
FEES
Owner:
Type By Date Amount Receipt
PACIFIC CROSSROADS PROPERTIES, PRMT CTR 2/25/02 $262.20 27200200000
BY WYSE INVESTMENT SERVICES CO 5PCT CTR 2/25/02 $20.98 27200200000
200 SW MARKET ST STE 345
PORTLAND, OR 97201 Total $283.18
Phone 1:
Contractor:
BRUCE STEELE PLUMBING
11735 SW FOOTHILL DR
PORTLAND, OR 97225 REQUIRED INSPECTIONS
Phone 1: 643-9916 Rough -in Insp
Reg #: PLM 34 -401 PB Final Inspection
LIC 86514
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 sus.;-nded for more
than 180 days. ATTENTION: Oregon law requires you to follow rules adopted • . he O zgon Utility
Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 throug OA' 9524101-0080.
You may obtain copies of these rules or direct questions to OUNC by calling, slit 6- 1'%:7_—
411
'
Issued By: i __ __ / .A j i P th Permittee Signaturej m —
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
acJi2_, 0 3- - 0®110
= -,, - -.. PlumbingPermit Application
{ L2 Date received :9 - Jo, L Permit no.:1Ly9j,./ 2 GOD6
>� City of Tigard 7 �J I \
City J' g Sewer permit no.: Building permit no.:
\
Address: 13125 SW Hall Blvd, Tigard, OR 97223 l )
City of Tigard Phone: (503) 639 -4171 �)'� Project/appl. no.: Expire date: Q
Fax: (503) 598 -1960 c507-7 e Date issued: By•M Receipt no.:
Land use appIOVal: 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 SCHEDULE (for special information use checklist)
Job address: `/ j 3 (j) PA G/ Description Qty. Fee (ea.) Total >
Bldg. no Suite no New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection) T "
Tax map /tax lot/account no.: SFR (1) bath
Lot: Block: Subdivision: SFR (2) bath _
P
R_„,
roject name: A U 1 ZNO' SFR (3) bath _
City /county: 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 al= —
PLUMBING CONTRACTOR Footing drain (no. lin. ft.) __
Manufactured home utilities
Business name: 5 tux • nesommomm Manholes _
Address: AL 0 L _ t v - 1. Rain drain connector _
EMIR 10 c1 State: co IP: 9 7 2. ' Sanitary sewer (no. lin. ft.) _
ILA Phone: G, 0 ,2 " 4 Fax: � E -mail: , Storm sewer (no. lin. ft.) —
/ CCB no.: ar;.+�•i. ' ' ' I'f Plumb. bus. reg. no: • Cf i-rrel Water service (no. lin. ft.)
Fixture or item: ■--
�V� City /metro lic. no.: 1 l 3 -�'•r • p .—
i -y C re resentative si nature: fl if f�/� l� I � d !i l Absorption valve
p p g Back flow preventer NM
Print name: r. • Date 2 S" Z Backwater valve •
.: CONTACT PERSON Basins/lavatory =
Name: Clothes washer
Address: Dishwasher _
^ . Drinking fountain(s) _
City: State: ZIP: Ejectors/sump —
Phone: Fax: E -mail: Expansion tank _
�' ";`' OWNER . Fixture /sewer cap =
Name (print): Floor drains/floor sinks/hub
Garbage disposal
Mailing address: —
Hose bibb _
City: State: ZIP: Ice maker
Phone: Fax: 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 =
ENGINEER . Tubs/shower/shower pan =�
. _ Urinal
Name: Water closet _
Address: Water heater. _
City: State: ZIP: Other: I
Phone: Fax: E -mail: Total =
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ �D
Notice: This permit application Plan review (at _ %) $
❑ Visa CI MasterCard expires if permit is not obtained
Credit card number: / / State surcharge (8 %) .... $ a-O
Expires within 180 days after it has been TOTAL $ L' 3 . / R I
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6100 /COM)
t '
PLUMBING PERMIT FEES: � -
^,sad ,, c z,,-- - �, r. , 0 ': ,'g`�1 .r, j : , ,tti .`1' ,- f , '
.3�� �,:� �.o- ���� � '� �., <.� � ° . TO TAL�-�' Neiti`1 and 2 =famil �iiviiellings�'orily:�,, � . ,, ��''' ,� (�
�::, . �:-� � ;;s. •.� i t : � ; , •% ��.� � > .�., 'M �� � �PRICE� .� a �,, °,�,.... �_ �1,. + ,. • � ° „,� T �
4FIXTU ;�'(indl _," �,. ,E <QTY;, .` „` `AMOUNT° 3(i ingfixtures9in :1-,,4A PRICE �xTO AL
Sink '' -N 7 - 16.60 3 3. w ?the dwell g_ the f rst 100 f t . ,, i QTY (ea) 6 AMOUNT -
Lavatory 16:60 for,,ea c hutlht c onn ` ectfon_
3, (1J One (1) bath $249,20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet "'di' 16.60 SUBTOTAL ` °_ . ,.. `,' y
Urinal .. 16.60 8% STATE SURCHARGE w°: :s
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL ' '- -
Garbage Disposal 16.60 TOTAL
Laundry Tray ) 16.60 /t _ a
Washing Machine 16.60
Floor Drain /Floor Sink 2" 9._ 16.60 3.. )
3" 16.60 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 - . ' f ' ' ' '' , Qiiantity.b' Work; Performed " •
Gas piping requires a separate mechanical FixtureType:',, '•, ' Newt._ ,;'Moved °'° . Replaced ,, ; / -
permit. /�a . . ,. . , -_ , s = .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 M
Floor Dra /Sink: 2" 4 '
Sewer - 1st 100' 55.00 3 •
Sewer - each additional 100' - 46.40 4"
Water Service - 1st 100' 55.00 Water Heater Jr
Water Service - each additional 200' 46.40 Other Fixtures
4 66 ecify) Storm &Rain Drain - 1st 100' 55.00 e S j', 1,4c _ -
Storm & Rain Drain - each additional 100' 46.40 .
Commercial Back Flow Prevention Device i ! 46.40
. � �fG,y�
Residential Backflow Prevention Device` 2f.bb '
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL 1 :`, . -,,,. -y -,
Isometric or riser diagram is required if `, ., i °.'
Quantity Total is > 9 .{ 4 ` "y ;
*SUBTOTAL I . Ia 4
ii,'. .
8% STATE SURCHARGE ' a _ ''' ':.,-%l
**PLAN REVIEW 25% OF SUBTOTAL ; T�;` j '' ° °,'w`t°'r. ;;
z § `_`< - > i s .; � ra`x`�2
Required only if fixture qty. total is > 9 0,4.:',,; i - �
TOTAL ,,,:, ; . F,E., $ 3 (
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25•+ 8% state surcharge. .
* * All New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
1 IX . .
i:\dsts \forms\plm- fees.doc 12/26/01 '
•r
493614
® [j Kw -
PN WS -AW WA B CKFLOW ASSEMBLY TEST REPORT 0 REMOV D
PROPERTY ❑ REPLACEMENT
9WNER: / i 4 i e�i7- PHONE:
AiAILING ' 442a6c1
ADDRESS: I 7i0s - CITY b 7\ STATE_, ZIP
ASSEMBLY A
ADDRESS: , f l y
STREET
❑R.P.B.A. C.C.V.A. ❑ R.P.D.A ❑DAC J P.V.B.A. ❑S.V.B.A. ❑ A.V.B. ❑AIR GAP
LQ L
SIZE: I I I. MAKE: A. 4(, vs MODEL: 007 c(
WATER SERIAL
PURVEYOR: nn� ,� �� `'C.f ' , a �O� ^^ �— NUMBER: �®
LOCATION: l.Law l �'(�b - i AO
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST �+
#1 CHECK I: DOUBLE CHECK : AIR CHECK PASSED
PRESS DROP (A) CHECK #1 INLET FAILED ❑
INITIAL RELIEF VALVE B TIGHT �� OPENED AT PRESS DROP
TEST OPENED AT ) I DATE:
MIN 2 PSID LEAKED ❑ PSIS ��jj��
RESULTS BUFFER I PSID PSID `C'�
A - B = I CHECK #2
MIN 3 PSI 2 • �
RELIEF VALVE (TIGHT DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ !LEAKED,❑ PSID OPEN -G ❑ PSI
•
COMMENTS
REPAIRS •
AND /OR
PARTS ,
REDUCED PRESSURE ASSEMBLY P.V.B.A./S.V.B.A. AFTER REPAIRS
#1 CHECK DCV:Pi . : >:'
TEST PRESS DROP (A) CHECK #1 DATE:
RELIEF I OPENED AT PRESS DROP / /
AFTER OPENED (B) TIGHT PS ID
REPAIRS MEN 2eaD
BUFFER CHECK #2
_
A - B nm+rea I 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 OF IBA WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRATION / /DETECTOR METER READING 3
TESTER SIGNATURE C. *P. - ( /.,r�� /�� SLift �
3
TESTERS b I �7 9 G � 1.7�( . , l 7
TESTERS ADDRESS /1 _ _ �, _ _„(� PHONE #
COMPANY NAME
REPORT RECEIVE �� (R ❑ SERVICE RESTORED
(REPRESENTATIVE OF OWNER)
WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester Copy
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested / /�z-- AM PM BUP
Location //CGS Suite MEC
Contact Person � - / Ph ( ) L G<:oz — D Do
Contractor ' Ph ( ) SWR
BUILDING Tenant/Owner c ELC
Footing
ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Ina Sheath/Shear I /
Framing e z * J I n s u l a t i o n
'Drywall Nailing '°' ''' C--"Z
, Fire Sprinkler
aZgig
Roof
O - r:
' PASS PART FAIL
PLUMBING
Post & Beam
Under Slab .�/a _Si -A S -.../-5-
Rough-In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan 2 `%►
Other:
-S 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 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 Inspector ` Ext
Other:
Final DO NOT REMOVE this in ecti record from the job site.
PASS PART FAIL •
C6T TIGARD 24 -Hour
I nspection Line: (503) 639 - 4175 `
`' BUILDING MST
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Requested 3 -g AM PM BUP
Location / 1 - 7 D ,C Suite MEC
Contact Person I Ph ( ) . o/ 4/0s PLM c qn Coo caV
Contractor Ph ( ) SWR
-
BUILDING Tenant/Owner 61- 6 Qe_44 ELC
Footing
ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain
Slab spection Fotes: SIT
Post & Beam I OL , 0
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
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan ,
Other: , wit)
Fin
�P� PART FAIL c
MECHANICAL /1/0/-eC P J c; Alt $; Orc
Rough-In Beam
l kt f U--ye, /O O G , U ✓,`
Gas Line /j
Smoke Dampers ✓,p r 76 <Or .
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 ! i Inspector�r 1 2 r • Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL
C1( OF TIGARD 24 -Hour
• BUILDING Inspection Line: (503) 639 -4175 -�
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received Date Requested IT A /1 'M BUP
Location ( 7 U l - _ , MEC
Contact Person ���vy� / Ph ( ) 't RI 4 4 0 3 7 PLM •0 (2 4606
' '
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: 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 & B- .1
,410. lab 'isS S
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Fin -
FAIL
MECH AL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Anal /
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 2t Oc Inspector ' /1% &4 7 e o Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL