Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00086
TI G A 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/18/2012
Parcel: 1 S134CD10600
Jurisdiction: Tigard
Site address: 11725 SW 116TH AVE
Project: Brown Subdivision: BURLWOOD NO.4 Lot: 39
Project Description: Replace 25' of water service & 60' of sanitary sewer service. Install (1) backflow preventer device. Repipe (1) bath
and install (1) water heater.
Contractor: JACK HOWK PLUMBING /RESCUE ROOTER Owner: BROWN, ALAN LEWIS & TERI J
PO BOX 2830 11725 SW 116TH AVE
CLACKAMAS, OR 97015 TIGARD, OR 97223
PHONE: 503 - 235 -8784 PHONE: 971-275-6205
FAX: 503 -491 -2932
FEES
Quantity Description Date Amount
60 If Sewer Service 04/18/2012 $62.54
Specifics: 35 If Water Service 04 /18/2012 $62.54
1 ea Backflow Preventer 04 /18/2012 $31.27
Type of Use: SF 1 ea Water Piping/DWV 04 /18/2012 $56.29
Class of Work: ALT 1 ea Water Heater 04 /18/2012 $37.52
Type of Const: 1 12% State Surcharge - 04/18/2012 $30.02
Occupancy Grp: Plumbing
Stories:
Total $280.18
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 , w rk is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility otification Ce r. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or di ct questions to OU C lin 03.232.1987 or 1.800.332.2344.
Iss d By: f///A4/ � .8 Permittee Sig �, / i e i
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.
APR 16 2012(MON) 09: RRS /JackHouk /RescueRooter (FAX)503 491 2932 P.001 /003
i
Plumbing Permit Application /
Building Fixtures RECEIVED FOR OFFICE USE ONLY
IlL City of Tigard Received " ,� =_� ,
n 13125 SW Hull myth. Tigard, OR 9722 da�
Phone: 5(13,039.4171 Fax: 503.59 849'60 _ 1 7 2012 plan Review
Dat Other Permit No.:
TIGARD Inspection Line: 503.639,41 Date Rea B 1 y
Internet: www,rigard- or.gov _ . y ' 1 see rent z r "'
CITY , • Notified/Method: Supplcwental Llforma
' . 1'x1 ,` 1 d . • , , + „ p11 y1 � .. +1 tl t' `.,. 'rr. {t!�,I I',�tN )Plllldd5 nil P { Qt 4:' It RIP ''. I. ' `C r� i r i Y ^i
y�1. 1. � r Z + }a L I ��a� i 11 1+ b 11 1 i� ' 1 ', t f I ,•' l w r
�, t .; �, : �;� ::R' :d . �i: � :���t;tllni�lf�.l�t�. � . ~MN� C�' r F+.l'.�l,f�'1.;1 a 'Qa�'�t F �
k �: t ''t ' t tel: h:a„ .�:tf�� t`��,,,�ll,. :I.��L�
❑ New construction ❑ Demolition For special information ace checklist
Description 1 Qty. 1 Ea. 1 Total
f rAddi tion/altera(ion/replacement ❑ Other. • New I. 2-family dwellings (includes 100 It for each utility connection)
: � to�' 'Anger f '�+ ' rY�Ui a r f �. py r t .. ry ��,
E� + i!!' ` 1. 1'. +1;<1f F,u 11, n �1 q I f a : ✓ I r uyy)),,�,���� E d) Ii'�j'���1 4,a1 1 kli SFR (I) bath 312.70
i:a48iTit�: � '.:. � f1F . � h1'ml. el�;�,t, +, ��0.'.�tOUfLin�F :� :� �.f{hYlhGul' { t � .. + ".0 �
KI- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi - family SFR (3) h,rh 5011.32
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: •
�} ( @�! { n, r� 111} �� t Fire sprinkler c____ sq. ft) Page 2
' ' i .., ., , . ! ,J +, ,. 1 t � ia 1 ( i 1.1j1 i 1 ^ ,stlA . . t1sl it{ H�l'lil}4{ Site u
Job site address: I '1Ij � �' � Catch basin era ca drain 18.76
City /State/21P: - 11a rA - I 7g Drywell, Inch line, or trench drain 18.76
Footing drain (no, linear It: ) Page 2
Suite/bldg./apt, no.: I Project name ( VVi l d Manufactured home utilities 50.03
Cross sired /directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _J /,./ Fr Page 2 al.
Sturm sewer (no. linear (1: ) Page 2
I Fixture or item water service (no. !incur R: •- ,_J r. 1� r.Zj
Subdivision: J Lot Ile.: :
Tax x map /parcel no.: Backflow pre enter 3117 1' ,i. 4
��1frltt�;��p +s o , tryry F .. IR t rIn ra, m tr1.�".�te r'1"P'jr iPC 1 {r >r ' ,� 1°�; e� li � •! I3 dtwater
t a valve 12.51 r
It
i r .i�r�ui1N t.�t`��Fll �t1 �u 11 4 d N t o el l� + �r �r t� ',�, �1!'�„�
d .. h - • ��J, , a1t �' t�� utohu(Iflt(` yi�i�in�a 111 :i1,�t �1,u1��� t t.1
� ,,, , J _ll ,, a'i„• , a;tl Cloth w
�D`1'1'�t 1 -- n 'S ��Z ZG7 0 -: 1 ...., 7 .- es washer 25,02
1 ��t-�/ /� a51/4/06. � Dishwasher 25.02 -
,_
f / OW / ' � �} / 60 Pr c_. Drinking fountain 25.02
e r 1.04e ' l �j( ' 7Z.. /A)=1.4./ Ejectors/sump 25.02
i! i t i�n����pi��, �p { Jr' li i ^r1Tlt1i'ict i tit tq { �j 61u+f�a,1'17�t :it,.t F.xpansion tank 12.51
t t ,7 {i i�IGi�m 11lFrsnfa�t•l . r Y�ft `r}"E3n -�'�;i {� lt,h�,i. M�:Zi,� �� ��,� t+U ;L'��`��1 !'"j i� uV ll�'i I ii' -
tat. +. n..t a r., t .. .a.,.,....,,1 ' , .0
Name: 49/1 raj Fixture/sewer cap 25.02
Address: ll
j l f-,jh "lib' _Floor drain /floor sialdhub 25.02
-r 6/V I ri
City/State/ZIP: -t'li i a a - : Ho bi b 25.02
disposal 25.02
_ Hose bib
( ) -- 7 - rr, •ta ) Ice maker 12.51
,(fir l T -ry ntlnm fr " "��'4l �l +i� �`n ' 1' r ;r� Isl 1 i rl .'�..
�.SC1i Y�A�.A" l 4 r :ppll t �1t ;G�i :it >ti,' I .t lllt 11„ LI, d ',�, • �i)ii' 1nrCfC� tOf/ Ciro
n ln�u. a S4 rP, •�j)u,t.itl:i I i, {llRl xPs „LCti Atll�r �i' iltil'':it:i r.u�h,.,„,4,4‘ �t j t �p gtrAt5 p 25.02
Business name: ARS dba JACK ITOWK/RESCUE ROOTER Medical gas (value: $ ) Page 2
Contact name: JOYCE DENNIS Primer 12.
Roof drain (commercial) 12.51
Address: P.O. BOX 2830 Sink /bavittllavatory 25.02
City /Stare/ZIP: CLACKAMAS, OR 97015 Solar units (potable water) 62.54
Phone: (503) 850 -3100 L Fax: : (503) 491 -2932 Tub /shower /shower pan 12.51
E -mail: JDENNI,S(�a ARS,COM Urinal 25,02
q
Ott (2 �!11i1 (tiN , d� { "' �q 1 t jg 'f g rfi : Fri' i r�t,r �t F ; um�ynl�",'.�rt 3; r1p11;r,lt Water closet 25.02
A i �.14.,i, L''h,.t.4 :,. ut,.1..!5�: Uwk41TVZI .,of..3 ..r .,h .a!u��;4.a ofn�,htt,a.. dA E3 uail, Water heater v 37.52 tzfo,. if
Business name: ARS dba JACK AOWKI1tE.SCUE ROOTER _ Water piping/I7WY 56.29
Address: P.O. BOX 2830 Other, 25.02 4
City /State/L11 : CLACKAMAS, OR 9701 Subtotal , 0 7
1 $hone: (503)1350 -3100 Fax: (503) 491 -2932 • T Minimum permit fee: $72.50
'/�V�'/ Plan review (25%ofpermit fee) 30 p
CCR Lic.: 127325 Plumbing Lie. no,; 34469n .. V . .-. (12% 1 •71 7 .1r.: 1 ;:- - -- State surcharge (12/0 of permit fee)
Authorized signature:
TOTAL. PERMIT'
Print name: JOYCE DENNIS Date: I , This permit applies empire ira permit is not obtain ^" "/ ""' 77�"
after It has been accepted no complete. d
P 45 E6 4 _ _ /
'Fee mclbptlolo� sea by fri Couuly Building Industry $ery icc ,,;Ir� �'b
1
I:Wuilelu wa pdtblPLMLFraniiU du I 1 44a CGIf,TI ;OM/W1:01
APR= 16- 2012(MON) 09: 25 AR5 /JackHouk /RescueRooter (FAX)503 491 2932 P. 002 /003
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental information
Fee Schedule: Residential Fire Sup' ression, S stems:
r`,te r , sw,^ .pr {✓��{ �F. j ,, - - tlri.:7 7, 11' +:1:'c pp �7P�� 4,' i 511 (r 11 �.i • .i ev��rit.v. .•p�.n� ;��..�(1� j1 r ! f '� y el•r u � .11'gie ��fi4',',y� ['
f ilik „t.8.'t<: ZT,P4,21, . ,.k 1 1 i ( A : • ] � l � L -s I N ZI',y�.i ti"' y i'( . { �: tw ,( r X 71; -71 11 1 1 [
t w. r r,1.U: � a ,t � :...1.. '.+}'� 1�I1.. {_� 4JC. LLi:� L) �•. .,- I.'1 ?. . :T .z.d.1.1... . 744 � � Ali-le, r .14.'
Footing drain - 1' 100' MI 50.03 0 to 2,000 $121.90
S.�,. a�J -�i
Footing drain - each additional 100' 37.52 - 2.001 to 3.600 $169.69
3,601 to 7200 $29330 ..
Sewer - I st 100' r � 62.54 IF 7201 and greater 5327.54
Sewer - each additional 100' UM 37.52 IIII.11 .
Water Service - 1st 100' I‘Ilialltrillinribir Medical Gas Systems:
Water Service - each additional 100' 37.52 q
Y? I b �;• � ,:p., : .. l:.:l : ;r 1' t 1L ` 415 : � o,1: i! i �`; ; `;. :;, ;L .
Slomt & Rain Drain - 1st 100' 62.54 6
$1.00 to $5 000.00 Minimum fee $72.50
Storm St Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $7230 for the first $5,000.00 and $1.52 for
ii;-.,ti «.;*. ∎ :.'�\'h° S :.. 544 rn; l 1 4 , -?.._y .it./ al � i ( 17. f 1.c..:, -Zu2. � ( _2:7,ii,I each additional $100.00 or fraction thereof. to
and includin. $10 000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first SI 0,000, and $134 for
which no fee is specifically indicated 90.00/hr
each additional $100.00 or fraction thereof, to
(minimum char • a -1/2 hour) and includin_ 525 000.00.
Inspections outside of normal business 90.00/hr $25.001.00 to $50,000.00 $379.50 for the first $25.000.00 and $1.45 for
hours minimum char •,c - 2 hours each additional $100.00 or fraction thereof, to
Rcinspection Fecs 90.00/hr and includin: 550 000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum char: e - 1/2 hour each additional $100.00 or fraction thereof.
Subtotal: Ilt�.{�! /.I
Commercial Fixture Work: .
Are you capping, adding or replacing fixtures? If "yes", ! .':.-4...::.1... � - ti h . , i _^ ° � ;ti i 1 d "
. , ,�� 'n' z ' i '
� ��7( a + ! ;'�
please indicate work performed by fixture. Failure to Plan "review is required for any of the following.
accuratel report fixtures could result In increased sewer fees * . Please check all that apply.
G C 1 } a `+ +' ; e".;+, 15 ',' � Li 1�1 ( (�,r f 1 k ,1,. r n L ,
, .,)�w� , s ,, , � ; t� � ,� �'� ,.1 ❑ Any new commercial building with water service 2" and
`f 7 ,, n'�l rv r,:i i ( t ae 1 a `i� 1� T p t e. d f P i�, {' , realer, except systems designed and stamped b licensed
"r:!...ii_ �" tle..:t.i`.S2:0 14 1.1. •,n! = .. .d$ fi3 1,.! = .: i il e ngineer. Y `^' y
13e . tistrv/Font
Bath •Tubl$hower lilli
- ❑ New exterior. plumbing site utilities for any complex structure
- Jacuzzi/Whirl. I as defined in OAR918 -788-0040.
Car Wash -Each Stull MIME ❑ Medical gas and vacuum systems for health cure facilities.
- Drive Thru -� - Q Any multipurpose fin sprinkler r system.
Cus idor /Water A:. irator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dan Fountain - -Commercial
Domestic �=
Submit 2 sets of plans with any of the above.
4 "rn .. y 1 , r � v
c r ,'Z p } r r 4, M
E e Wash -��� ! 30 r y ;, ♦ Lt G? / '..4; l•i t t�?,31.1_�Y. .V +I �: t.:r..
Floor Drain/sink - 2" ���� 0 Isometric or riser diagram is required for new buildings
MIME that meet the • ualifications above.
- 4 " -� -�
Car Wash Drain IIIIIIIIII - ��
Gurbuge - Domestic
Disposal - Commercial
- Industrial • Comments regarding fixture work:
lee Refri: Drains 1111111111
Oil Se . a
tJil Serator Gas Station)
Rec. Vehicle Dam . Station 1•111101
Shower - Clang
-Stall . -��
Sink - Bar/Lavatory .11.111 '
, -Bradley 11111
- Commercial =IN *Note: lithe fixture work under this permit results in an
S`rvicC increase of sewer EDUs; a sewer permit will be issued and
Swimmin Pool Filter
Washer - Clotho fees assessed for the sewer increase must be paid before the
Water Extractor- MEM - =IN : plumbing permit can be issued.
Water Closet • Toilet 111111111111111i 11=1111111 .
Urinal
Other Fixtures: - - -
http : / /www ;herd- or.gov/ city_ hall/ deparonents /cd /docs/PLMF- PermitApp2doc '