Permit C ITY OF TIGARD PLUMBING PERMIT
� DEVELOPMENT SERVICES PERMIT #: PLM2002 -00348
-- I 1312 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 9/4/02
SITE ADDRESS: 09685 SW SERENA WAY PARCEL: 2S114BA -03500
SUBDIVISION: PICKS LANDING NO.2 ZONING: R -4.5
. BLOCK: LOT: 105 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 commercial backflow preventer. .
FEES
Owner:
Type By Date Amount Receipt
JERRY GRACE PRIM CTR 9/4/02 - $36.25 27200200000
9685 SW SERENA WAY 5PCT CTR 9/4/02 . $2.90 27200200000
TIGARD, OR 97224
Total $39.15
Phone 1: 503 - 684 -8102
Contractor:
KENNEDY PLUMBING
13985 SW FARMINGTON RD
BEAVERTON, OR 97005 REQUIRED INSPECTIONS
Phone 1: 643 -5535 RP /Backflow Preventer
Reg #: LIC 10967 Final Inspection
PLM 34 -42PB
•
•
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 -00.10 through OAR 952 - 0001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
/
Issued By: 411 / / A. if Permittee Signature: /
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
j
Plumbing Permit Application
Date received: 4 0 Permit no,+�/}) a -6i9 3V b
�.=f,�.�y,' , City of Tigard
Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: Expire date:
Fax: (503) 598 - 1960 Date issued: By:TR I Receipt no.:
Land use approval: Case file no.: Payment type:
7'YPE OF PEIU%IIT
le & 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 inforn ation use checklist)
Job address: G ( (o $ 5 50 Se 6e to ltd Description � . 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: 'Block: I Subdivision: SFR (2) bath
Project name: ,3-€11 G- (0.A...(2, SFR (3) bath
City /county: (i G6W ytDbv I ZIP: et 1 A ai Each additional bath/kitchen
Description and location of work on premises: Site utilities:
t� �Gt
ht(,A o i J t Cq, Catch basin/area drain
Est. date of completion/inspection: r, • 36 .02- Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
• Manufactured home utilities
Business name:. Ke ny-ye & t �,t vis-to i 1 Manholes
Address: 139 g 5 Svc v �G v mi err- fo n Rain drain connector
City: g,/.{-r\ I State: 6 ✓ I ZIP: 9 /DO 5 Sanitary sewer (no. lin. ft.)
Phone: 6'i3.5 5 3,5 I Fax: I E -mail: Storm sewer (no. lin. ft.)
Plumb. bus. reg. no: 1 ^�t2t°d Water service (no. lin. ft.)
CCB no.: t O g b 1 I g' `
3
City/metro lic. no.: t 373 Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer 1 3i,
Print name: we (T . t. Date: 3 O' 0 2 - Backwater valve •
CONTACT PERSON Basins/lavatory
Name: ' Ot, r, ,p �(�. Clothes washe
Dishwasher •
Address:
Drinking fountain(s)
City: CJt� I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print): ).t? (( (C.,-4_.§..- Floor drains/floor sinks/hub
Mailing address:9 68 Si 5vo � C•40. not �C, A, Garbage disposal
Hose bibb
City: ^ c c fck I State: Or I ZIP j 1a Ice maker
Phone: 6S . S 102 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
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ CJ •a 5
Notice: This permit application
0 Visa 0 MasterCard expires if a permit is not obtained Plan review (at _ %) $
Credit card number: / / w State surcharge (8 %) .... $ a . / 0
Expires / within 180 days after it has been TOTAL $ 39.15
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (600/COM)
PLUMBING PERMIT FEES: .6 , 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/Stonn 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 $36.25 + 8% state surcharge.
** Ali New Commercial Buildings require plans with isometric or riser diagram and
plan review.
is \dsts \forms\plm- fees.doc 10/10/00