Permit J
a
111 CITY OF TIGARD PLUMBING PERMIT
F I� DEVELOPMENT SERVICES PERMIT #: PLM2004 -00029
,� I-' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/21/04
SITE ADDRESS: 13460 SW SANDRIDGE DR PARCEL: 2S105DD -04000
SUBDIVISION: PACIFIC CREST ZONING: R -7
BLOCK: LOT: 016 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: Installation of residetial backflow prevention device for irrigation.
FEES
Owner:
Description Date Amount
SUKENDER R. PALLA
13460 SW SANDRIDGE DR [TAX] 8% State Surcharl 1/21/04 $2.90
TIGARD, OR 97223 [PLUMB] Permit Fee 1/21/04 $36.25
Total $39.15
Phone :
Contractor:
ESEQUIEL ROBLES LANDSCAPING
7076 RIDGEMONT DR N
KEIZER, OR 97303 REQUIRED INSPECTIONS
P RP /Backflow Preventer
Phone : 5O3 - 390 - 4353
Final Inspection
Reg #: PLM 7784
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
/ / ,
ssued B AMA L � ' - Permittee Signature: � y
Call (503163 -4175 by 7:00 P.M. for an inspection needed the next business day
BtuMing r fixtures
Plunibing Permit Application Received FOR OFFICE USE ONLY
Plumbing 1 ' /
or Date/By: / ol/ D 9 Permit No.: Lf/ep `y `/ /
City Ti and Planning • , .proval Sewer
`, g Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503 - 639 -4171 Fax: 503 - 598 -1960 �� M� t, Post - Review Land Use
_ Date/By: Case No.:
Internet: www.ci.tigard.or.us ■ el I Contact Jtui ® See Page 2 for
-
24 -hour Inspection Request: 503 -639 -4175 ' Name/Method: / �• Supplemental Information.
TYPE OF WORK FEE* SCHEDULE (for special information use checklist)
❑ New construction ❑ Demolition Description • • I Qty. I Fee(ea.) I Total
❑ Addition/alteration/replacement ❑ Other: New 1- & 2- family dwellings
CATEGORY OF CONSTRUCTION (includes 100 ft for each utility connection)
❑ 1 & 2- Family dwelling El Commercial/Industrial SFR ( bath 249.20
SFR (2) bath 350.00
['Accessory Building ❑ Multi- Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Fire sprinkler - sq. ft.: Page 2
Job site address: +.14- b W Qrllj-; d g 4,: v e Site Utilities
Suite #: kjZi(p• I Bldg. /Apt. #: Catch basin/area drain 16.60
Project Name: Drywell/leach line/trench drain 16.60
Footing drain (no. linear ft.) Page 2
Cross street/Directions to job site: Manufactured home utilities 110.00
Manholes 16.60
Rain drain connector _ 16.60
• Sanitary sewer (no. linear ft.) Page 2
Subdivision: I Lot #: Storm sewer (no. linear ft.) Page 2
Tax map /parcel #: Water service (no. linear ft.) Page 2
DESCRIPTION OF WORK Fixture or Item
Absorption valve 16.60
Z Qt 0k C I f r I f)Li 1 1 ev Pti t r CO? e 4 • n Backflow preventer Page 2 N
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OWNER I ❑ TENANT Ejectors/sump 16.60
Name: SU KC 11 ci er R Pq (L a Expansion tank 16.60
Address: ( -- &Q) sa a y, 5 e co : V e Fixture/sewer cap 16.60
City /State /Zip: -r" • c, a > y 0 R a Q "3 Floor drain/floor sink/hub 16.60
1 U 1 Garbage disposal 16.60
Phone: Fax: Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON Ice maker 16.60
Name: Interceptor /grease trap 16.60
Address: Medical gas - value: $ Page 2
City /State /Zip: P 16.60
Roof drain (commercial) 16.60
Phone: Fax: Sink/basin/lavatory 16.60
E-mail: Tub /shower /shower. pan 16.60
CONTRACTOR Urinal 16.60
Business Name: , SEtct v jet R4 1.71 e S Water closet 16.60
Water heater 16.60
Address: 70 4, ;4 a ? is n r OY 4_1 Other:
City /State /Zip: K. e tZ e✓ (1 9 Other:
5d3-�7 _ p ' , Plumbin Permit Fees*
Phone: , I ! �r Fax: Subtotal $
CCB Lic. #: Plumb. Lic. #: - net/ Minimum Permit Fee $72.50 $ Q�� {
Authorized Residential Backflow Minimum Fee $36.25 d{(/'
Signature: Date: F ra I • OY Plan Review (25% of Permit Fee) $
&4 ? 2 State Surcharge (8% of Permit Fee) $ • VC
' /'" Please print name) TOTAL PERMIT FEE _ $ ' � /6--
Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans wi isome nc or
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri -County Building Industry Service Board.
I :\Dsts\Permit Forms\PlmPermitApp.doc 01/03
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 7;000- $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
Sewer 3,601 to 7,200 $220.00
ewer - 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
additional $100.00 or fraction thereof, to and
Fixture or Item Qty. Fee (ea) Total 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
specially requested inspections - per hour 72.50 and including $50,000.00.
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 *.
Quantit by (Fixture) Work Performed Comments regarding fixture work: • . . .
Fixture Type: Replace
New Moved Existing Capped
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 *Note: If the fixture work under this permit results in an
Garbage - Domestic P
Disposal Commercial increase of sewer EDUs, a sewer permit will be issued and
- Industrial fees assessed for the sewer increase must be paid before the
Ice Mach. /Refrig. Drains plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory ••
•
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes •
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\Dsts\Permit Forms\PlmPermitAppPg2.doc 01/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION is Business Line: (503) 639 -4171 MST
BUP
Received Date Re. ested — AM PM BUP
Location 49 0 � f 4L. �.!.' !:!i Suite MEC
Contact Person 4 Ph ( ) PLM y D U
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
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
Other:
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 El 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: 0 Unable to inspect — no access
Fire Supply Line
ADA D y) 1 G joy Ins ector t i 1 I i Ate. Ext
Approach/Sidewalk / Inspector
Other:
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL