Permit A • CITY OF TIGARD PLUMBING PERMIT
�;� DEVELOPMENT SERVICES PERMIT #: PLM2004 -00158
' .� I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/13/04
SITE ADDRESS: 10865 SW PARK ST PARCEL: 2S103DA -03700
SUBDIVISION: ZONING: R -3.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Irrigation backflow device.
FEES
Owner:
Description Date Amount
DICKINSON, WAYNE A + TRACY M
10865 SW PARK ST [PLUMB] Permit Fee 4/13/04 $36.25
TIGARD, OR 97223 [TAX] 8% State Surcharl 4/13/04 $2.90
Total $39.15
Phone :
Contractor:
JOHN SLAUGHTER LANDSCAPING
15055 SW 100TH AVE
TIGARD, OR 97224 REQUIRED INSPECTIONS
Phone : 503 - 639 - 1336 RP /Backflow Preventer
Final Inspection
Reg #: PLM 12288
LIC BACKFLOW & AL)
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 : • ' v • is suspended
for more than 180 days. ATTENTION: Oregon law requires you to folio ■ uI- 1 ed b he Oregon
&Ilike Aft
Issued B P ermittee Signat - , ��7A
Call (503) 639 -4175 by 7:00 P.M. for an inspection neede tOr T day
Building Fixtures
R
Plumbing Permit Application FOR OFFICE USE ONLY
City of Tigard Daeny . 7/ /3 /D / 4'/ Permit No.P,(,/) ,.(J6 1
13125 SW Hall Blvd., Tigard, OR 97223 /iy Plan Revie Phone: 503.639.4171 Fax: 503.598.1960 '�III DateBy: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 ay 31
c` Date Ready /By: 1 ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: /( )G Supplemental Information
TYPE OF WORK FEE* SCHEDULE
El w construction ❑ Demolition For special in ormation use checklist.
Description Qty. Ea. Total
Addition/alteration/replacement
0 Other: New 1 - 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
EKand 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: (obi, j S» P4-p- IL S S' Catch basin or area drain 16.60
City/State/ZIP: ei, g a.. -1 c A 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
e „4( 4- t 1 i4 (-3 p 4 4 fob- S T Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) 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 I6.60
DESCRIPTION OF WORK Backflow preventer / Page 2
/3‘,1,1e-F1 o m / fir- I t' , Y‘-/-"""-' Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Er PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: wily 02_, 17i e j ez , y 0 Expansion tank 16.60
Address: to 06S s v ()g-v Fixture/sewer cap 16.60
City/ State/ZIP: 1 t , 04, Floor drain /floor sink/hub 16.60
Phone: ( ) Fax: (_, �) Garbage disposal 16.60
❑ APPLICANT El CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:...30140 S�14,4- L. LAS. SGt, V 't✓� -S Interceptor /grease trap 16.60
Contact name: ,� k SI L�� Medical gas (value: $ ) Page 2
Address: I �' ( 00- 4>� Primer 16.60
City/ State/ZIP: '' q.1-O 6 II Roof drain (commercial) 16.60
►�
Phone: ,03) g 3 q - / 3 3 b ( I Fax:: 410) 63 2 Z"7 9 ^ � Sink/basin / lavatory 16.60
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
. CONTRACTOR . . Water closet 16.60
Business name: J h n Sly L(-, C se , n t , Water heater 16.60
Y Other:
Address: ISM S s- 5L) Icy +/L Subtotal
City/ State/ZIP. D OP- en 2_7.-H -
Minimum permit fee: $72.50 �
Phone: 61) ) 61 et . 1 3 3 b Fax: (51i3 ) 6? /
4 1 - 21 2 7 Residential backflow minimum permit fee: $36.25 , a %
% =� ng Lic. no.: Plan review (25% of permit fee)
CCB Lic.:
ZZg , � /Hi State s u rcharge (8% of permit fee)
�� , ��, 30 Ago _
Authorized signature: :_ �. . / CO' ~� TOTAL PERMIT FEE . 3g, /5
Print name:1)bt� b S • �. . Date: pr4 /10 0,94 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 \Permits\PLMF- PernhtApp.doc 12/03 440- 46I6T(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:. -
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
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
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or
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
• Ar 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
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 Isometric or riser diagram is required if fixture quantity
- Commercial
- 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 \Permits \PlM- PennitApp.doc 3/03
CITY OF TIGARD 24 -Hou
BUILDING r Inspection Lir :'1503) 639 -4175 MST
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received 3 1 Date Requested, 1- 4 V AM PM BUP
Location /n e? 6 5 fra / Suite MEC _
Contact Person Ph ( ) (C 3 /3 3 ,t1 �l S •
Contractor Ph ( ) 61 6 2.Z. I SWR
BUILDING Tenant/Owner ELC
Footing .. ELC
Foundation Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
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
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan •
Ot r: �
I
A PART FAIL
CHANICAL
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 ❑ Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line
ADA
Date
Approach/Sidewalk Ins P
ector
Other:
Final DO NOT REMOVE this inspectio Ext
record from the job site.
PASS PART FAIL