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Permit CITY TIGARD PLUMBING PERMIT P ERMIT #: PLM2001 -00504 , a il DEVELOPMENT SERVICES DATE ISSUED: 10/8/01 13125 S Hall Blvd., Tigard, OR 97223 (503) 639 -4171 SITE ADDRESS: 12040 SW ROSE VISTA DR PARCEL: 2S103CC -02000 SUBDIVISION: COLONIAL VIEW ZONING: R -4.5 BLOCK: LOT: 015 JURISDICTION: TIG CLASS OF WORK: ALT 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: 80 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS: RAIN DRAIN: ft Remarks: Installation of 80' of sewer line. Existing septic system to be abandoned, or pumped and filled and inspected. FEES Owner: Type By Date Amount Receipt HAZARD, JOHN GERALD + PRMT CTR 10/8/01 $72.50 27200100000 DARLINE GROGAN CO -TRS 5PCT CTR 10/8/01 $5.80 27200100000 12040 SW ROSE VISTA DR TIGARD, OR 97223 Total $78.30 Phone 1: Contractor: TED MCBEE EXCAVATING INC - - - 11428 NE SCHUYLER PORTLAND, OR 97220 REQUIRED INSPECTIONS Phone 1: 939 -5246 Sewer Inspection Reg #: LIC 110314 Final Inspection 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 -0080. You may obtain copies of these rules or direct questions to OUNC by calli. e 503) 246 -1987. Issued By: AO / % ■ __ ___ Permittee Signature. ,r41. Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day - f Plumbing Permit App • - Ti Date received: Qi permit _� '4 , City of igard j JC S ewer permit no.: Building permit no.: Address: 13125 SW Hall Blvd, Tig d, OR 972 City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date: Fax: (503) 598 -1960 Date issued: By:R6 Receipt no.: Land use approval: Case file no.: Payment type: TYPE OF PERMIT r. 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 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: I a 0 Li Q 5 W �� V J \\ Description Qty. Fee(ea.) Total Bldg. no.: I Suite no.: New 1- and 2 -family dwellings only: (includes 100 ft. for each utility connection) Tax map /tax lot/account no.: SFR (1) bath Lot: IBlock: I Subdivision: SFR (2) bath Project name: SFR (3) bath City /county (4p I ZIP: l Each additional bath/kitchen Des ription and location of work o .. mises \ ' • A ► __ , Site utilities: tw .:r. ,air . t� I,_ -,4,, t ii Catch basin/area drain • Est. date of completion/inspecti • : • 1 , k Drvwells/leach line/trench drain PLUMBING CONTRACTOR Footing drain (no. lin. ft.) 411. Manufactured home utilities Business name: W ° !S ©� W( �)^ _ Manholes Address: \I:\ 7, . ` g c . 30 e Rain drain connector City:YO I State: ki ZIP: 91 .), Sanitary sewer (no. lin. ft.) gh Phone: d'1 ft 7 Fax: E -mail: Storm sewer (no. lin. ft.) CCB no.: ,1 )r) 3 k y Plumb. bus. reg. no: Water service (no. lin. ft.) City/metro lic. no.: ( ©OO 6 p Fixture or item: Contractor's re r resentative signature: M% Absorption valve Back flow preventer Print name: 11 1 k ,.. Date: i ie I Backwater valve CONTACT PERSON Basins/lavatory Name: 1 C - '. (- Clothes washer OA Dishwasher Address: Drinking fountain(s) City: I State: I ZIP: Ejectors/sump Phone: Fax: E -mail: Expansion tank Fixture/sewer cap Floor drains/floor sinks/hub Name (print): 0 }�A\N Garbage disposal Mailing address: Hose bibb City: I State: I ZIP: Ice maker Phone: I Fax: I 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 Urinal Name: Water closet Address: Water heater City: I State: I ZIP: Other: Phone: I Fax: I E -mail: Total / tom) Not all jurisdictions accept credit carts, please call jurisdiction for more information. Minimum fee $ ! �- .1[/ Notice: This permit application Plan review (at _ %) $ 0 Visa 0 MasterCard expires if a permit is not obtained Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $ Expires TOTAL $ 7�- Name of cardholder as shown on credit card accepted as complete. $ Cardholder signature Amount 440 - 4616 (6/00/COM) PLUMBING PERMIT FEES: '' i • PRICE TOTAL New 1 and 2- family dwellings only: FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures In PRICE TOTAL Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT Lavatory 16.60 for each utility connection) One (1) bath $249.20 Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00 Shower Only 16.60 Three (3) bath $399.00 Water Closet 16.60 SUBTOTAL Urinal 16.60 8% STATE SURCHARGE Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL Garbage Disposal 16.60 TOTAL Laundry Tray 16.60 Washing Machine 16.60 Floor Drain /Floor Sink 2" 16.60 3" 16.60 PLEASE COMPLETE. . 4" 16.60 Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/ permit. Capped MFG Home New Water Service 46.40 Sink • MFG Home New San/Storm Sewer 46.40 Lavatory Tub or Tub /Shower Hose Bibs 16.60 Combination Roof Drains 16.60 Shower Only Drinking Fountain 16.60 Water Closet 16.60 Urinal Other Fixtures (Specify) Dishwasher Garbage Disposal Laundry Room Tray . Washing Machine Floor Drain /Sink: 2" Sewer - 1st 100' 55.00 3" Sewer - each additional 100' 46.40 4" Water Service - 1st 100' 55.00 Water Heater Water Service - each additional 200' 46.40 Other Fixtures (Specify) Storm & Rain Drain - 1st 100' 55.00 Storm & Rain Drain - each additional 100' 46.40 . Commercial Back Flow Prevention Device 46.40 Residential Backflow Prevention Device' 27.55 Catch Basin 16.60 Inspection of Existing Plumbing or Specially 72.50 Requested Inspections per/hr COMMENTS REGARDING ABOVE: • Rain Drain, single family dwelling 65.25 Grease Traps 16.60 QUANTITY TOTAL Isometric or riser diagram Is required if Quantity Total is > 9 *SUBTOTAL 8% STATE SURCHARGE **PLAN REVIEW 25% OF SUBTOTAL Required only if fixture qty. total is > 9 TOTAL $ * Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow Prevention Device, which is $38.25 + 8% state surcharge. ** All New Commercial Buildings require 2 sets of plans with isometric or riser diagram for plan review. i:\dsts \forms\plm- fees.doc 08/29/01 4' • • '' " -CITY OF TIGARD BUILDING INSPECTION DIVISION 24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171 MST 0 BUP Date Requested / — AM ' J ( PM BLD Location / go A. 1J ,, fr Suite MEC Contact Person Ph 9 3 9 s4(. , 4-4E 00/ Q(> SU Contractor Ph 00) 0(71-'7 r BUILDING Tenant/Owner ELC Retaining Wall ELR Footing Access: Foundation FPS Ftg Drain SGN Crawl Drain Inspection Notes: Slab tzzirr -Q,e> SIT Post & Beam Ext Sheath /Shear Int Sheath /Shear Framing Insulation Drywall Nailing Firewall Fire Sprinkler Fire Alarm Susp'd Ceiling • Roof Misc: Final PASS PART FAIL PLUMBING Post & Beam Under Slab Top Out Water Service Rai Drains 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 PASS PART FAIL SITE Backfill /Grading Sanitary Sewer Storm Drain [ ] Reinspection fee of $ required before next inspection: Pay at City Hall, 13125 SW Hall Blvd Catch Basin Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access ADA / Approach /Sidewalk Date /0 — o � Inspector � � LQ) �.e , E Final PASS PART FAIL DO NOT REMOVE this inspection record from the job site. invoice GIIIFI' S SEPTIC IC SERVICE • Name S 1LU . 4 AW Date o Address I 1) i i) Rost D,SI �/ Phone q ' 5g ab ' Cit y Initial On Acct. State l ) Zip Code q 6 1/)a jrn Price Amount - A a -f /t nd(TftVYU l l F i // • 1 r VY- a 1- • 6 4i?3 .,r NOT RESPONSIBLE FOR DAMAGES PAST CURB LINE OR LANDSCAPING [ _ • A service charge of 1.5% will be levied on all past due accounts. Total: 2 sV • Returned check fee is $20.00. • In case suit, action or arbitration is instituted by either party for breach or to enforce any provisions herein, the court shall award reasonable attorney's fees and actual costs to the prevailing party at trial or arbitration, or upon any appeal taken therefrom. Approval By: Customer Signature Tjhank You P.O. BOX 1136 • Canby, OR 97013 DEQ# 37464 (503) 263 -2087 or (503) 632 -6138 CCB# 104320