Permit A CITY OF TIGARD'
PLUMBING PERMIT
l DEVELOPMENT SERVICES PERMIT #: PLM2004 -00379
J I
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/23/2004
SITE ADDRESS: 10735 SW PARK ST PARCEL: 2S103DA -03400
SUBDIVISION: DERRY DELL PLAT 2 ZONING: R -3.5
BLOCK: LOT: 037 JURISDICTION: TIG
CLASS OF WORK: NEW 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: 130 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Sewer service connection.
FEES
Owner:
Description Date Amount
MCGRIFF, JAMES E /SHEILAM
10735 SW PARK ST [PLUMB] Permit Fee 8/23/2004 $101.40
TIGARD, OR 97223 [TAX] 8% State Surcharl 8/23/2004 $8.12
Total $109.52
Phone:
Contractor:
THEODORE D. MCBEE
13691 SE WILLINGHAM CT
CLACKAMAS, OR 97015 -7253 REQUIRED INSPECTIONS
Phone : 503 - 239 - 2909 Sewer Inspection
Final Inspection
Reg #: LIC 75513
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.
Issued By: Permittee Signature: le fl e ✓
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Plumbing Permit Application FOR OFFICE USE ONLY
City of Tigard RECEIVE® Received -)7
Date/By: �� � /0 /) Permit No (2 7 /
� ^ „�/��7
13125 SW Hall Blvd., Tigard, O Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 404, .. . , =' 1 & D a Y Other Permit No.:
24- Hour Inspection Line: 503.639.4 r - ( 9 - ■ t I Juris:
Internet: www.ci.tigard.or.us c i V 2 3 2004 ---* Date Ready/By: '/ El See Page 2 for
g Notified/Method: .( U Supplemental Information
11W6R AD EE* A D - r, -. - ; -r; F SCHEDULE
For special information use checklist.
❑ New construction BUILDING D V�I 1
Description I Qty. I Ea. I Total
Addition/alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION _ - ", SFR (1) bath 249.20
G 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
- • JOB SITE INFORMATION AND LOCATION , Site utilities
• Job site address: ( C) • _ Catch basin or area drain 16.60
City/State/ZIP: "Ti 011'd ( 1 _ Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: t I Project \ ect na Footing drain (no. linear ft.: ) Page 2
Cross street/directions to job site: ' o 7 '
Manufactured home utilities 110.00
l etured
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.r3QJ Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK . , Backflow preventer Page 2
•
C- C d I' r 4• Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OWNER " • I TENANT
Ejectors /sump 16.60
Name: <Taa u4. e s MC l l ' Expansion tank 16.60
Address: • Fixture/sewer cap 16.60
City/ State/ZIP: - 7 i1/410. q rel I ) Floor drain/floor sink/hub 16.60
Phone: ( 6, 2n- 725 Fax: ( ) Garbage disposal 16.60
❑ APPLICANT • - `❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/ State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax: : ( ) Sink/basin/lavatory 16.60 .
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR . - = r ., Water closet 16.60 •
Business name: ]\.( E , { _ Water heater 16.60
Address: (314 f 55 • /A)/ r r I 7 f � G 14(► 144 C'l . Other:
Subtotal
C
City/ State/ZIP: C (4 ka tM a S (2R �j70/ 5 � Minimum permit fee: $72.50
Phone: ( 23Q 2 .74,7 Fax: (5 • � j !'!-1070 Residential backflow minimum permit fee: $36.25 / Qi-V
CCB Lic.: (( ! - Plumbing Lic. no.: Plan review (25% of permit fee)
/ , State surcharge (8% of permit fee) ', )2_,
Authorized signature:
i , . . /t ` . TOTAL PERMIT FEE /Q9 }
Print name: D014 717 .4G)Vl . a N Date: '.2. 3 _,DI7( This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
is\ Building \Peimits\PLMF- PennitApp.doc 12/03 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information - •
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea)• Total Square Footage:. Pertrii Fee:: :...:...:. . .
Footing drain - 1" 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
Sewer - 1st 100' 55.00 3,601 to 7,200 $220.00
00
/ 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
Valuation: Permit Fee:.
Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item Qty. Fee (ea) Total . additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes ", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees * .
Quantity by. (Fixture) Work Performed
FixtureType: Replace
New Moved Existing Capped Comments regarding fixture work:
Baptistry/Font
Bath - Tub /Shower
- Jacuzzi/Whirlpool
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator •
Dishwasher - Commercial •
- Domestic
Drinking Fountain
Eye Wash
Floor Drain/sink - 2"
-3"
- 4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial increase of sewer EDUs, a sewer permit will be issued and
Ice Mach./Refrig. Drains p
Oil Separator (Gas Station) fees assessed for the sewer increase must be paid before the
Rec. Vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink - Bar/Lavatory
Quantity Total •
- Bradley
Commercial Isometric or riser diagram is required if fixture quantity
Service total is >9.
Swimming Pool Filter -
Washer - Clothes
Water Extractor Plan Review •
Water Closet - Toilet Plan review is required if fixture quantity total is >9.
Urinal
Other Fixtures:
i:\ Building \Pemtits\PLM- PermitApp.doe 3/03
i
LO 9
�` ! INVOICE
r',.,
6 4769
P.O. Box 2349
Oregon City, OR
97045
� Complete
New Installations Industrial
ww Repair Existing Systems :: :: . �:: . . Waste
Sewer Connections wm w o w m
■ ■ • ■ Removal
Drainfields m o wm w w . m w m rt m m Septic Tank Cleaning
Cesspools GO Sump
Excavating • `� V Line Cleaning
Richmond Constr t � .
(503) 253 87 'L0%"
of OF 001\s
P p N
Customer P.O. # Bv, ��`N Date O ,
i
Billing Name/Y'CB' . &D 4 k,s 7�
Address
Job Site #
City State Zip Code
Ordered, By c K et Phone 4t4d/- S4 , Date o 7, ∎# : .
Job Location /673C SCQ li94 sY
Service Call $
Labor $
/� 00
Pumping St° o7 G . gallons / O $a7 G O` 0- 7 a. r t
Misc $
170. 00
Conditions of tank/Distribution Box W fl Oil -s 4Z 70A
co
7 4J /i !.5 °etio l 1s /4 TOTAL CHARGES . `l 7
Enviroclear is in no way responsible for damage to the septic tank or lids on the system.
0 TERMS: Net 10 days. 1 -1/2% per month will be charged on past due accounts. (18% per annum).
go 117.
Customer's Signature' f i.
Service Driver's Signatures / ime�� or Datek O
TERMS AND CONDITIONS ON REVERSE SIDE REDEEMABLE IN ALL COUNTIES
TERMS AND CONDITIONS
THE CUSTOMER AGREES TO PAY ALL INVOICES ARISING OUT OF PUMP-
ING SERVICES, AND ANY OTHER SPECIAL SERVICES HEREIN WITHIN 10
DAYS FROM THE DATE OF INVOICE.
THE CUSTOMER AGREES TO PAY SUCH EXTRA AND OVERTIME
CHARGES AS MAY BE INVOICED FROM TIME TO TIME FOR SERVICES
RENDERED, OVER AND ABOVE THE NORMAL SERVICING SCHEDULE, ON
BEHALF OF THE CUSTOMER.
THE CUSTOMER AGREES TO ASSUME RESPONSIBILITY FOR ANY DAM-
AGE TO CUSTOMERS OWN REAL OR PERSONAL PROPERTY ARISING
FROM PUMPING SERVICES WHICH TAKE PLACE ON CUSTOMERS PREM-
ISES, WHERE THE DRIVERS AND VEHICLES OF ENVIROCLEAR HAVE
BEEN INSTRUCTED TO ENTER. THIS INCLUDES, BUT IS NOT LIMITED TO
DRIVEWAYS, TREES, POWER LINES OR POLES, AND BUILDING STRUC-
TURES.
IF ENVIROCLEAR FINDS IT NECESSARY TO ADD LIQUID TO THE TANK ON
JOBSITE, CUSTOMER WILL BE CHARGED FOR THE ADDITIONAL GAL-
LONAGE RESULTING FROM THESE CONDITIONS.
CUSTOMER AGREES TO REIMBURSE ENVIROCLEAR SERVICE FOR ALL
REASONABLE ATTORNEY'S FEES, COURT COSTS AND OTHER EXPENSE
INCURRED BY SAID COMPANY TO ENFORCE COLLECTION OR TO SERVE
THEIR RIGHTS UNDER THIS AGREEMENT.
CUSTOMER AGREES TO THE ABOVE CONDITIONS.
REDEEMABLE IN ALL COUNTIES.
•
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) ' • 75 '
INSPECTION DIVISION Business Line: (503 • 1 T
P
Received Date Requested g R■-C AM P = UP
Location / 6 7 3.S"-- / 3 Suite MEC
Contact Person Ph ( ) St, a— 35 AO0 4F-4z 3 77
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 /�„ C % C � 0
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In %
Water Service
7:}
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Othe
Fi
P SS 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 0 Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line
ADA 6
Approach/Sidewalk Date v, Inspector Ext
Other:
Final DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL