Permit CITY OF TIGARD
�,.d, DEVELOPMENT SERVICES PLUMBING • PERMIT
r. �. vv.? f''� PERM I T # • PLM97 -0263
,_,,;L .II 13125SW Hall Blvd.,Tigard, OR97223 (503)6394171 DATE ISSUED: 07/08/97
PARCEL: 1S136CC -00100
SITE ADDRESS...: 11765 SW PACIFIC HWY
SUBDIVISION • ZONING: C —P
BLOCK • LOT • JURISDICTION: TIG
CLASS OF WORK.. :ALT GARBAGE DISPOSALS.: 0 MOBILE HOME SPACES.: 0
TYPE OF USE •COM WASHING MACH • 0 BACKFLOW PREVNTRS..: 1
OCCUPANCY GRP..:B FLOOR DRAINS • 0 TRAPS : 0
STORIES • 0 WATER HEATERS • 0 CATCH BASINS • 0
FIXTURES LAUNDRY TRAYS • 0 SF RAIN DRAINS : 0
SINKS 0 URINALS • 0 GREASE TRAPS : 0
LAVATORIES • 0 OTHER FIXTURES • 0
TUB /SHOWERS...: 0 SEWER LINE (ft) ...: 0
WATER CLOSETS.: 0 WATER LINE (ft)...: 300
DISHWASHERS • 0 RAIN DRAIN (ft)...: 0
Remarks: Installing water line and backflow preventer
Owner: FEES
GENERAL MOTORS INC. type amount by date recpt
11765 SW PACIFIC HWY PRMT $ 80.00 B 07/08/97 97- 296890
TIGARD OR 97223 5PCT $ 4.00 B 07/08/97 97- 296890
Phone #:
Contractor
DETEMPLE CO INC
1951 NW OVERTON ST
PORTLAND OR 97209
Phone #: 227 -2641 $ 84. TOTAL
Reg #..: 000025
REQUIRED INSPECTIONS
This permit is issued subject to the regulations contained in the Water Line Insp
Tigard Municipal Code, State of Ore. Specialty Codes and all other RP /Backflow Prey
applicable laws. All work will be done in accordance with Final Inspection
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 952-1 -0080. You may
obtain copies of these rules or direct questions to OUNC by calling
(503)246 -1987.
Issue P ermi ttee Signature:, ea t d B y • ILA,-
g
++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++ + + + + + + + + + + + + ++
Call 639 -4175 by 6:00 p.m. for an inspection needed the next business day
+++++++++++++++++++++++++++++++++++++++++++++++ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++
ITY OF TIGARD Plumbing Application Reed By itt■.\
3125 SW HALL BLVD. Commercial and Residential oats Reed 4 4 7 -s-11
. 1GARI, OR 97223 bats to P.E.
Oats to OST
.03) 639 -4171 Permit l ti h7-r3
Print or Type Related SWR s
Incomplete or illegible applications will not be accepted Called
NUM of Development/Project . F J § !divi.chsal) MillaLCIAlagti
Sink
Job (@rItZAL. lo;oe 'Ifr fNIW 6 v(t 9.00
Address Street dress 0 - Suite Lavatory 9.00
Ad
117G:05 5 . W. rAL I FIG f j LQ ij , Tub or Tub/Shower Comb. 9.00
Bldg s I G�r /State Zip Shower Only 9.00
I I Coton oft. 1 7123 water closet 9.00
Name
• $ AMA washer 9.00
Owner mom Address - Suite Gasbags DIsposal 9.00
Washing Machine 9.00
City/State Zip Phone Floor Drain r 9.00
3 ' 9.00
Name 5AME. 4' 9.00
Occupant ng Address Suite
Marli Water Heater 9.00
Laundry Room Tray - 9.00
City/State Zip Phone Urinal - 9.00
Ptg Other Fbdures (Specify) 9.00
T 1M PLE La, 9.00 '
Contractor keeling Addrsas Suits
-
. . - 9.00 - - -
•
_ Ki 51 Aiu outtfoN
_ 9.00 . to Issuance (Prior
applicant m ' r�'(( -ABU Op- q71 Phone 2 44 1 9.00
provide an Oregon Const. Cont. Board Lice Exp. Date - 9.00
contractors 00001510 b - 2- It 9.00 _
Informatition Plumbing 2.4 e-1.5 5 Ez' 3 0- 1.7 sewer - 1st 130' 30.00
Sewer - each additional 100' 25.00
for COT COT Business Tax or Metro $ Exp. Date t
Service Water Sece -at 107
database). a 0 Oa i9 6C0 12- I q 1 •1 30.00 3 0
Name water Service - each additional 200' / 25.00 -7,x7 Architect NA b fAC h (.t T1 , N 6 , C(� . r1' 1 Stonm a Rain Drain -1st 100' • 30.00
or Wang Address Suite Storm & Rain Orin - each additional 100 25.00
3 0 5 0 1 VA 1 ' K Mobds Home Space 25.00
Engineer wA RAJ 4 a 4$090 90Z-9 Phone Commercial Back Flow Prevention Device or Ardi- , 25.00 25
Describe wart New 0 Addition 0 Alteration y/ Repair 0 Residential Beddow Prevention Device' 15.00
n be done: Residential 0 Non - residential 0 My Trap or Waste Not Connected to a Fixture 9.00
- +cditional description of work Catch Basin
9.00
Insp. of Existing Plumbing 40.00
fiA VS" 4 IN-MI t`i Far' VA t)L - per/hr
tasting use of Specially Requested Inspections so.00
.aiding or property 6 -r4E V H t -rt4/+ ' I iA11 N(o C.1 Rain Drain. single family hg 3000
mposed use of Grease Traps 9.00
adding or property A Nl E
QUANTITY TOTAL - ,) x• - s
.,re you capping , moving or replacing any fbdures? Yes Q No Qf Isometric or riser diagram is rooting it Ouandy Toot is > 9 ?`.t .,+% . .
;Ryes see back of form) SUBTOTAL .r'`..o R
' hereby acknowledge that I have read this application. that the information "o
.ven is correct. that I am the owner or authorized agent of the owner. and 5% SURCHARGE _ _ ':.::.--",:.:=';' �1
'tat clans submitted are in `1
camp6ance with Oregon State Laws. .. ..
- gnaturs of ! Agent Date P LAN REVIEW 25% OF SUBTOTAL .. _ , , /
7 _ 8 1 7 Required «w d &rare qty. twat is 3. 9 "' " /� \
E
/ V!/ TOTAL - ; I o `I .
Person Name Phone
'Minimum
S A M I- 211 -26 41 Prevention h permit . which s i 15 + surcharge except Residential Beddow
1: \plmapp.doc 12/96 (dst)
'LEAS_E_COMPLETE AS APPROPRIATE TO PROJECT:
t.
1 Fixtures to be capped, moved or replaced Qty
Sink
Lavatory
Tub or Tub/Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain —
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify) - -
. .
•
• _
,OMMENTS REGARDING ABOVE:
V V
•
I:\plmapp.doc 12/96 (dst)
7/26/99 Activities for Case #: PLM97 -00263
1:52:34 PM
Assigned Hold Updated •
Activity Description Date 1 Date 2 Date 3 To Done By Disp. Level By Updated Notes
PLMC003 Application received 7/8/97 B PASS BON 7/8/97
PLMC005 Permit Created 7/8/97 B PASS BON 7/8/97
PLMC799 Final Inspection 9/22/97 MS PASS J'H 9/26/97
PLMC710 Water Line Insp 7/8/97 7/25/97 MS PASS J'li 7/31/97
PLMC750 RP /Backflow Preventer 7/8/97 7/25/97 MS FAIL J'Ii 7/31/97 call back for reinspection on
backflow device
PLMCO50 (F) Issue permit 7/8/97 B PASS BON 7/8/97
PLMC711 Water Service Insp 7/25/97 MS PASS J'H 7/31/97
PLMC750 RP /Backflow Preventer 8/5/97 MS PASS • MRS 8/5/97 device was tested ok
. PLMC800 Case Finaled 9/26/97 MS PASS J'H 9/26/97
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