Permit � CITY OF TIGARD PLUMBING PERMIT
i� DEVELOPMENT SERVICES PERMIT #: PLM2003 -00527
� � 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/1/03
SITE ADDRESS: 16875 SW PACIFIC HY PARCEL: 2S115BD -02600
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SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION: KIN
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: M 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: 750 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Site utility installation of 750' water service.
FEES
Owner:
Description Date Amount
SPACE AGE FUEL INC • PO BOX 607 [PLUMB] Permit Fee 10/1/03 $379.80
GRESHAM, OR 97030 [PLMPLN] Plan Review 10/1/03 $94.95
[TAX] 8% State Tax 10/1/03 $30.39
Phone : 503 665 - 5693 Total $505.14
Contractor:
EAGLE PLUMBING
13801 S FORSYTHE RD
OREGON CITY, OR 97008 REQUIRED INSPECTIONS
Phone : 503 - 650 - 8703 Water Service Insp
Final Inspection
Reg #: LIC 47914
PLM 3 -154PB
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
Issue y: Q � - Permittee Signature: k
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the n xt business day
Plumbing Permit Application
Date received:5. j J .piy Permit no. "' "`3! „Z 7
a, ` City of Tigard AL `J b Sewer permit no.: Building permit no.: •
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date: •
Fax: (503) 598 - 1960 , t, Date issued: Bx,71,71 I Receipt no.:
Land use approval: 10 1 5 20 Case file no.: Payment type: .
0 1 & 2 family dwelling or accessory Clai tistiial -Jr ❑ Multi- family 0 Tenant improvement ,
0 New construction 0 Addition/alteration /replacement 0 Food service 0 Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: J(ff j / �, L414, g gi.,4 Gay Description • Qty. Fee(ea.) Total
Bldg. no.: I Suite no /2.100') : New 1- and 2- family dwellings only:
Tax map/tax lot/account no.: Z s j f r (includes looft.foreachutilityconnection)
SFR (1) bath
Lot: Block: I Subdivision: SFR (2) bath
Project name: 'zie_,E A SFR (3) bath
City/county: ZIP: Gp7z Z4 • Each additional bath/kitchen
Descrintion and locatio of work on premises: _ • � T €„.„ tkri u TV Site utilities: •
(-kp ri-T 0- 12 -- 0 Q-E.- 61.) i y — I Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR Manufactured home utilities
Business name: CAm& ) 1.4t.t441,1/4. • - Manholes
Address: b ,0/ £ OZ-6-y1 A Rain drain connector
City: 0 ' f, ; A) d.pry I State: I ZIP: 9719$ Sanitary sewer (no. lin. ft.)
_Phone: . 'a- 8703 Fax:( -$ E -mail: � Storm sewer (no. lin. ft.)
CCB no.: '/79/ Plumb. bus. reg. no: 3 - /$i/'(g Water service (no. lin. ft.) 75�' 379-.
Fixture or item:
City /metro lie. no.: 1317 Absorption valve
`-f Contractor's representative signature: Back flow preventer
Print name: 'Kt_ , i -• ) Date:'tt) 4 Backwater valve
CONTACT PERSON Basins/lavatory
Clothes washer
Name: �dFdtt' I 1-- i,. Dishwasher
Address: fa & E Cf7 Drinking fountain(s)
City: 6e-c5/1131 I Stater I ZIP: "7030 Ejectors/sump .
Phone: 66,5- t , -. Fax f,,,, -( ,ii. E - mail: Expansion tank
OWNER Fixture/sewer cap •
Name (print): -L lu C Floor drains/floor sinks/hub
�� �!� Garbage disposal
Mailing address: p 86.)e- 6 Hose bibb
City: 6 E mil I State I ZIP: J7o3c) Ice maker
Phone: Ce6 rj- %c)3 I Fax: a, f 4] 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
•
• Water Name: r
��d /��/ � Water closet'
Address: e ( (,f )LT • • R - Water heater
City: 7 , , §. State p ZIP: $ 20I Other:
Phone: .•,'- 478 -413 Fax: 2Cf3 -' 76 - .. . - 1 Total , 8d
Not all jurisdictions accept credit cards, please call jurisdiction for more information Notice: This permit application Minimum fee $
Plan review (at _ %) $ yy• 95
D visa O MasterCard expires if a permit is not obtained
Credit card number: / / State surcharge (8 %) .... $ 3 O' 3 9
Expires within 180 days after it has been TOTAL $ 605. /y
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6I0O /COM)