Permit C ITY OF TIGARD PLUMBING PERMIT -
- A DEVELOPMENT SERVICES PERMIT #: PLM2004 -00432
-hi DATE ISSUED: 9/17/2004
13125 SW Hal B lvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 10630 SW PARK ST PARCEL: 2S103DA -04400
SUBDIVISION: FANTASY HILL ZONING: R -3.5
BLOCK: LOT: 003 JURISDICTION: TIG
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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Sewer connection.100 ft. & (1) hr. inspection.
FEES
Owner:
Description Date Amount
NOLES, DAVID RAND
MARGARET L [PLUMB] Permit Fee 9/17/2004 $55.00
10630 SW PARK ST [HRPLM] Hourly Plumb. 9/17/2004 $62.50
TIGARD, OR 97223 [TAX] 8% State Surcharl 9/17/2004 $9.40
Phone : Total $126.90
Contractor:
REQUIRED INSPECTIONS
Phone : Sewer Inspection
Final Inspection
Reg #:
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. ts
Issued By: , , Permittee Signature: 19�%/ZIK
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures RECEIVED. .
Plumbing Permit Application FOR OFFICE USE ONLY
City of Ti and SEP 1 Al g Received Permit No � 4 (1 -� (gel
13125 SW Hall Blvd., Tigard, OR 97223 , Date/By:
r
Phone: 503.639.4171 Fax: 503.598.1960 CITY OF /,N ? :, Plan Review
Other Permit No.:
24- Hour Inspection Line: 503.639.4175 BUILD %N 44 c•11' I*� ®See Page 2 for
www.ci.tigard.or.us Internet: www.ci.ti Note Ready/By: B
g Notified/Method: n rf Supplemental Information
• TYPE OF WORK . - ' - : _ .FEE* SCHEDULE: '' -'' '
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
plAddition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
' , CATEGORY OF CONSTRUCTION * ' i= , • . -- - -'. SFR (1) bath 249.20
Till- 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: ( 20 5 (N PAt (C 5 r Catch basin or area drain 16.60
City/ State/ZIP: y 6-44 Oizt- 6e. N 6/7113-3P/5 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
p kC(F(C j+(I4J Y Rain drain connector 16.60
Sanitary sewer (no. linear ft.: /i 0 ) Page 2 •007
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
S k) e L 70 iJ I4-t6 U N b Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
' VI PROPERTY OWNER ••I ❑ TENANT . Drinking fountain 16.60
Ejectors /sump 16.60
Name: QJ I h k N 0 L.$ Expansion tank 16.60
Address: J 0 63 0 5 oj P g - e lc ST Fixture/sewer cap 16.60
City/ State/ZIP:' (1 C O op En ) 4'122_3- 3845- Floor drain/floor sink/hub 16.60
Phone: 3 ) ice° 7s5-3 Fax: ( ) Garbage disposal 16.60
• ❑ APPLICANT 0 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: ( ) Fax: : ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
-CONTRACTOR
. Water closet 16.60
Business name: Water he • ter 16.60
Address: Other , r ���'[. � ,,, • -
City/ State/ZIP: v► I t
Subtotal
Minl turn permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 , f ?.
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
v- State surcharge (8% of permit fee) ',go
Authorized signature:
TOTAL PERMIT FEE �.4 O
AV Print name: AV it p 0 Le$ Date: glf 6[ 0q. 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.
i:\ Building \Pemtits\PLMF- PermitApp.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:: '`: Permit:Fee; :,,r,, - - . .
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
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00
'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
Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit Fee:. -
$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
•
Fixture Type: 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"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial *Note: If the fixture work under this permit results in an
- Industrial
Ice Mach./Refrig. Drains increase of sewer EDUs, a sewer permit will be issued and
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
- Bradley Quantity Total
Comme iat 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:\ BuildingTermits \PLM- PertmtApp.doc 3/03
ALOHA SANITARY SERVICE
INVOICE NO. a
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 9370
503 - 644 -2797 • 503 - 648 -6254 * 503 - 639 -5188
NAME: - �-4^-d / /
I
ADDRESS: i • 3..4) . , .. . / •
CITY: A/i/ , STATE: U `--' ZIP:
HOME: 42,(1 - 7c57.3 WORK: CELL:
JOB SITE �/l40 ?) P.0.#:
PAID BY CHARGE ❑ CHECK ❑ CASH ❑ CREDIT CAIta)
DATE ? -15 -6-5 DRIVER b51k) 'Ilsuar!¢ Ztou! AMOUNT
CO PUMP SEPTIC TANK Zref) co
❑ LINE OPENING
❑ INSPECTION FEE
❑ SERVICE CALL
❑ LABOR, LOCATING, DIGGING, BACKFILL
O MATERIAL
- - THIS IS NOT A SE IC SYSTEM INSPECTION REPORT - - TOTAL $ ...Z5 ap
A/ , - - REMARKS'- -
TYPE OF TANK: STEEL ❑ ONCRETE 0 P LA IC 0 HOMEMADE ❑
HORIZONTAL ❑ VE ICAL ❑ R CTANGLE ❑ ❑ OTHER
SIZE OF TANK: 350 ❑ 500 0 7 1 0 11 0 0 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑
LID LOCATION: INLET ❑ OUTLET • MIDDLE 0 ENTIRE TOP ❑
TANK CONDITION: GOOD ❑ FAIR ❑ POOR ❑
FITTINGS: BAFFLES ❑ CONCRET 6 CAST IRON ❑ PLASTIC ❑
NEEDS NEW LID? YES ❑ SIZE
GROUND COVER OVER TANK
COMMENTS ON CONDITION OF DRAINFIE • ETC.
-
SIGNED BY DATE 7 .15 -eS
CITY OF TIGARD
4 • •
BUILDING DIVISION PERMIT #: PLM2004 -00432
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 9/17/2004
Phone: (503) 639 - 4171 U�,d'41eIljt
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 6/24/2005 TIME: 7:09AM PAGE: 16
SITE ADDRESS: 10630 SW PARK ST CLASS OF WORK:
SUBDIVISION: FANTASY HILL LOT #: 003 TYPE OF USE:
PROJECT NAME: NOLES
DESCRIPTION: Sewer connection.100 ft. & (1) hr. inspection.
OWNER: NOLES, DAVID R AND, PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: 6/24/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
350 Septic tank 010117 -01 503 - 620.7553 Y
Corrections /Comments /Instructions:
, /,
4-
-4A.A
1 /4Fr /, 1, ,<Z
, - 7,,■— - Jr— r -
d ja ix 1 - / 7 I . - - 1
t9t PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
/19/2./o Inspector: D ate: 3 1 Phone #: (503) 718-