Permit CI OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2007 - 00212
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 5/21/2007
PARCEL: 2S103DA - 03201
SITE ADDRESS: 10625 SW PARK ST ZONING: R - 3.5
SUBDIVISION: DERRY DELL PLAT 2 LOT: 034 JURISDICTION: TIG
PROJECT: WINTERS
Project Description: Replace 70ft of sanitary sewer and decommission septic tank.
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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: 70 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
WINTERS, GERRY L
10625 SW PARK ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 5/21/2007 $72.50
[TAX] 8% State Surcha 5/21/2007 $5.80
Phone : Total $78.30
Contractor:
WOLCOTT PLUMBING CONTRACTORS
PO BOX 20698
PORTLAND, OR 97294 REQUIRED ITEMS AND REPORTS
•
Contact # : PM 503- 235 -8784
FAX 503- 491 -2932
Reg #: LIC 23847
PLM 26 -208PB
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 or 1.800.332.2344.
Issued By: / Permittee Signature: 3„et_. 4/i(401101
41111111P— -
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
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Plin Prmjt A rca o nl FOR OFFICE USE ONLY
City of Tigard e ►�y 2007 Received 1 permit No ► �,
q 13125 SW Hall Blvd., Tigard. OR t9 natc/BDate/By: __6, _ t
7
Plan Review
Phone; 503.639.4171 F �+ �y0i 59g 1.96 rlcig ; other Permit N I 2 I)4 .k _paw
T 1 G A RD Inspection line: 503.639,41115! ! 2. .lIkJ Dale Ready /By: 1 .: :# _ 13 See Page 2 fns
Internet: www.tigard- or,�- gcyI T• ..r , T „T(, • Notified/Method: Supplemental Iatormalien
TY)Pte. WORK FEE* SCHEDULE
El Ncw construction El Demolition For spedrt/[njornrarinn use checklist
. _ Description I Qty. I Ea. I Total
N.Addition/altcration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 R. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
—
fig 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
—
❑ Accessory building El Multi-family SFR (3) bath 399.00
— Each additional bath/kitchcn _ 45.00
[] Master builder 0 Other: Fire sprinkler ( se. IL) Page 2 •
JOB SITE INFORMATION 'AND' LOCATION L „ Site utilities
Job site address: lows p s / Catch basin or arca drain 16.60
City / State/ZIP; ` I q'/ Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: l Project name: ju r Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site; Manholes 16.60
1I JA Itf / � IP J Rain drain connector 16.60
' I / (� ►' t( Sanitary sewer (no, linear ft, '1.11r=1-- Page 2 i
Storm sewer (no. linear ft.: Page 2
Subdivision: f Lot no.: Water service (no. linear ft.: _-_•, Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16,60
• • • • • • ..DII S CRiWTION. OF' ::VYORI( ' _ • :' Page 2
Backflow prcvcntcr
P
i 1 f� L a 91 &,(• 01 Backwater valve 16.60
I P P1 44_4 _ • . i L f' Clothes washer 16.60
Dishwasher T 16.60
..:.., Drinking fountain 16,60
..:: .. PikOPERTY O : • ;. ( ] • TENA�IVT:; : • F , rs/ 16.60
J o , sump
Name: /C l Expansion tank 16,60
Address; / (9f2 5 Fixture /sewer cap 16.60
City / State/ZIP: Floor drain /floor sink/hub 16,60
Phone: (2t--- D,?,0'4i. : ( ) • Garbage disposal 16.60
- •• se •
1AP PI-t6r4T 0: EO NTAgr .. VER90N.
Flo bib 6
: . , ... Ice maker 16.60
Business name: WOLCOTT dba JACK HOWk: _ _ Intarcxptor /grease trap 16.60 —
Contact name: \ McNeal gas (value; $ ) Page 2
Address: P.O. BOX 20698 Primer 16.60
City/ State/ZIP: PORTLAND OREGON 97294 Roof drain (commercial) 16.60
Phone: (503) 235 -8784 1 Fax: : (5113) 491.2932 Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E-mail: Urinal 16.60
CONTRACTOR ; . • .• • • . Water closet 16.60
Business name: WOLCOTT clba JACK HOWK l . ' Water heater _ 16.60
Address: P.O. BOX 20698 Omer: gA ` ic
City /State/ZIP: PORTLAND, OREGON 97294 — Subtotal 5d2 /
Minimum permit fee: $72.50
Phone: (503) 235 -8784 Fax: (503) 235 -8784 Residential backflow minimum permit fee: $36.25
CCB Lic.: 23847 Plumbing Lie. no.: 26 -208PB Plan review (25% of permit fee)
Authorized signature: ,/ State surcharge (8% ofpclmitfee) .. j rt
/ 1 ° TOTAL PE V
!sf ' / D ate. ��
/• o This permit application expires if a permit is RMIT not obFE n�rfh
�rint name:
180 days after it has been accepted as eompl
FAX BACK TO JACK IIO ( *Fee methodology set by Id-county Building Industry Service Board,
?%Buitdi VVK n . (5031 491 -2432
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CITY OF TIGARD •
13125 SW Hall Blvd.
Tigard, OR 97223
INDIVIDUAL •
File No. Reimbursement District # 29
City of Tigard
Sewer Reimbursement District
Deferral Agreement
City of Tigard Resolution No. 03 -55 provide that payment of certain portions of reimbursement fees
imposed on lot owners who have connected to sewers construction through City Reimbursement Districts
(Tigard Municipal Code Chapter 13.09) may be deferred until the lot is developed.
The undersigned owner(s) of the real property described below do hereby acknowledge deferral in the
amount of $15,019 and record their agreement to pay this amount to the City of Tigard upon partitioning or
otherwise developing the property in accordance with Resolution No. 03 -55. The obligation to pay this
deferred amount transfers to purchasers upon sale of the real property.
The real property that is the subject of this agreement is Lot 34 Derry Dell Plat 2, recorded as Book 16
Page 31, Washington County (Tax Lot 2S103DA lot 032010, addressed as 10625 SW Park St).
7
IN WITNESS WHEREOF, I hereunto set my hand on this. / day of HAY , 200/
Ti L; •
• Print Name3UNNA. J Print Name
Signature Signature
''t) o :its
Address Address
4 : \`S \No G x"11`1. Tigard, OR 97224
STATE OF OREGON )
) ss. •
County of Washington ) n
This instrument was acknowledged before me on /6 (date) by: � t- 2 P 7 "" / J - rEk
(name of person(s)).
de]-77 OFFICIAL SEAL 9
ct+•: • DEBBIE R RORIBRIQ
s Signature • iLY11191E.
NOTARY PUBLIC • OREGON •
f ` COMMISSIONNO. 403350 My Commission Expires: 3/9 4?
MY COMMISSION EXPIRES MARCH 2I 2010
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Accepted on behalf of the City of Tigard this 2-I day of M '- , 2007
Q•
Engineer
NO CHANGE IN TAX STATEMENT
I:lengt2008 -2007 ry dpIreimbursemerd districts combined cost 8letdeferral agreement - winters 10825 sw park st.doc
CITY OF TIGARD
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BUILDING DIVISION PERMIT #: PLM2007 -00212
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 5/21/2007
Phone: (503) 639 -4171 ;"� �*
Inspection Requests (24 Hrs.): (503) 639 -4175 ��'!�ijl��
INSPECTION WORKSHEET FOR DATE: 6/6/2007 TIME: 7:01AM PAGE: 63
SITE ADDRESS: 10625 SW PARK ST CLASS OF WORK:
SUBDIVISION: DERRY DELL PLAT 2 LOT #: 034 TYPE OF USE:
PROJECT NAME: WINTERS
DESCRIPTION: Replace 70ft of sanitary Mier and decommission septic tank.
OWNER: PHONE #:
CONTRACTOR: WOLCOTT PLUMBING CONTRACTORS PHONE #: 503 - 23548784
Inspection Request Scheduled For: Date: 6/6/2007 Pour Time. e ,�/�
Code #' Inspection Description Confirm # Contact # M - - s. V 1 ' L
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399 Plumbing final 04964601 503.660 -0225 Y
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Inspector: e 0 Date: (-9 4 1 Phone #: (503) 718- 2- 1 L1/41
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Dalko Carp,
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13023 NE Hwy. 99#7
Vancauver, WA 98686
(360) 887-2969 Port, (503) 285-5838 ..
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I JACK HONK PLUMBING COMPANY
Mfr Redi- Rooter Drain Service
" ••, -R0 0 .�' 1075 W Historic Columbia River Hwy • Troutdale, OR 97060
Fax " " " " " "' Phone: (503) 235 -8784 • Fax: (503) 491-2932
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Phone: Date:
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CITY OF TIGARD •
BUILDING DIVISION PERMIT #: PLM2007 -00212
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 5/21/2007
Phone: (503) 639 -4171
Inspection Requests (24 Hrs.): (503) 639 -4175 . IL
INSPECTION WORKSHEET FOR DATE: 5/24/2007 TIME: 7:00AM PAGE: 33
SITE ADDRESS: 10625 SW PARK ST CLASS OF WORK:
SUBDIVISION: DERRY DELL PLAT 2 LOT #: 034 TYPE OF USE:
PROJECT NAME: WINTERS
DESCRIPTION: Replace 7011 of sanitary sewer and decommission septic tank.
OWNER: PHONE #:
CONTRACTOR: WOLCOTT PLUMBING CONTRACTORS PHONE #: 503.235 -8784
Inspection Request Scheduled For: Date: 5/24 /2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
395 Misc. inspection 048993 -01 503- 235 -8784 Y
Corrections /Comments /Instructions:
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AlIV 4;
' ASS PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector; M Date: /
L G��� Phone #: (503) 718 - � �
CITY OF TIGARD
BUILDING DIVISION �, PERMIT #: PLM2007 -00212
13125 SW Hall Blvd., Tigard, OR 97223 - , DATE ISSUED: 5/21/2007 ' . A, Phone: (503) 639 -4171
Inspection Requests (24 Hrs.): (503) 639 -4175 I I�
INSPECTION WORKSHEET FOR DATE: 5/25/2007 TIME: 117A
M PAGE: 42
SITE ADDRESS: 10625 SW PARK ST CLASS OF WORK:
SUBDIVISION: DERRY DELL PLAT 2 LOT #: 034 TYPE OF USE:
PROJECT NAME: WINTERS
DESCRIPTION: Replace 70ft of sanitary sewer and decommission septic tank.
OWNER: PHONE #:
CONTRACTOR: WOLCOTT PLUMBING CONTRACTORS PHONE #: 503-235 -8784
Inspection Request Scheduled For: Date: 5/25/2007 Pour : -- -.
Code # Inspection Description Confirm # Contact # essage e
399 Plumbing final 049085.01 503- 235 -8784 Y
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Corrections/Comments/Instructions:
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❑ PASS Vi PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: li Date: / " ' Phone #: (503) 718-
CITY OF TIGARD
BUILDING DIVISION PERMIT #: PLM2007 -00212
13125 SW Hall Blvd., Tigard, OR 97223 - DATE ISSUED: 5/21/2007
Phone: (503) 639 -4171 A l
Inspection Requests (24 Hrs.): (503) 639 -4175 III..
INSPECTION WORKSHEET FOR DATE: 5/29/2007 TIME: 7:02AM PAGE: 46
SITE ADDRESS: 10625 SW PARK ST CLASS OF WORK:
SUBDIVISION: DERRY DELL PLAT 2 LOT #: 034 TYPE OF USE:
PROJECT NAME: WINTERS
DESCRIPTION: Replace 70ft of sanitary sewer and decommission septic tank.
OWNER: PHONE #:
CONTRACTOR: WOLCOTT PLUMBING CONTRACTORS PHONE #: 503-235.8764
Inspection Request Scheduled For: Date: 5/29/2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
315 Post/beam plumbing 049154 -01 503-235 -8764 N
Corrections /Comments /Instructions:
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❑ PASS 0 PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
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Inspector: Date Phone #: (503) 718
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CITY OF TIGARD _
BUILDING DIVISION PERMIT #: PLM2007.00212
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 5/21 /2007
Phone: (503) 639 -4171 i
Inspection Requests (24 Hrs.): (503) 639 -4175 , -' I I..
INSPECTION WORKSHEET FOR DATE: 6/1 /2007 TIME: 7:02AM PAGE: 52
SITE ADDRESS: 10625 SW PARK ST CLASS OF WORK:
SUBDIVISION: DERRY DELL PLAT 2 LOT #: 034 TYPE OF USE:
PROJECT NAME: WINTERS
DESCRIPTION: Replace 70ft of sanitary sewer and decommission septic tank.
OWNER: PHONE #:
CONTRACTOR: WOLCOTT PLUMBING CONTRACTORS PHONE #: 503-235 -8784
Inspection Request Scheduled For: Date: 6/1 /2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
320 Plumbing rough -in 049381 -01 503- 235 -8784 N
Corrections /Comments /Instructions:
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❑ PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION V ADDITIONAL FEES ASSESSED
Inspector: I” I D ate: v Phone #: (503) 718 -2J