Permit CITY OF TIGARORj
Gj PLUMBING PERMIT
In DEVELOPMENT SERVICES � 11i� PERMIT #: PLM1999 -00161
• � �l
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/19/99
SITE ADDRESS: 15745 SW SERENA CT PARCEL: 2S111 CD -07500
SUBDIVISION: KERWOOD ESTATES ZONING: R -4.5
BLOCK: LOT: 012 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 residential backflow prevention device for irration system.
FEES
Owner:
Type By Date Amount Receipt
NAVE, PATRICK F + JEANNE L PRMT DRA 5/19/99 $15.00 99- 315523
15745 SW CT MISC DRA 5/19/99 $0.75 99- 315523
TIGARD, OR R 97224 97224
Total $15.75
Phone 1:
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone 1: RP /Backflow Preventer
Reg #: Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans.
This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more
than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility
Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued : y: _ I i• 4 Permittee Signature:
- Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
CITY OF TIGARD Plumbing Permit Application Plan Che
Z 312 HALL BLVD. Commercial and Residential Rec'd B r
TIGARD, OR 97223 Date Rec'd 1'
(503) 639 -4171 Date to P.E.
Print or Type Date to D,$T !�
Incomplete or illegible applications will not be accepted Permit# Lt ��
Related SWR #
Called
Name of Development/Project ` FIXTURES (individual) QTY PRICE AMT
Job p -tkle lam 04 1 X-∎ Sink 9.00
Address Street Address Suite Lavatory 9.00
,- 115�Li c> <13 Sew f 1 A Ci- Tub or Tub /Shower Comb. 9.00
Bldg # City /State Z ip ' r Shower Only 9.00
Name
�> � Water Closet 9.00
y 1Ir E, Dishwasher 9.00
Owner Mailing Address Suite Garbage Disposal 9.00
,' Washing Machine 9.00
City /State Zip Phone Floor Drain/Floor Sink 2" 9.00
Na 3" 9.00
C (...- 4" 9.00
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 9.00
c(- Gas piping requires a separate mechanical permit.
City /State Zip Phone Laundry Room Tray 9.00
Urinal 9.00
N� Other Fixtures (Specify) 9.00
Contractor Mailing Addrest Suite 9.00
9.00
- Prior to permit City /State Zip Phone Sewer - 1st 100' 30.00
issuance, a copy
Sewer - each additional 100' 25.00
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if Water Service - 1st 100' 30.00
expired in COT Plumbing Lic. # Exp. Date Water Service - each additional 200' 25.00
database Storm & Rain Drain - 1st 100' 30.00
Name Storm & Rain Drain - each additional 100' 25.00
Architect Mobile Home Space 25.00
Or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Device
Engineer City /State Zip Phone Residential Backflow Prevention Device" ,r 15.00 .--��
(Irrigation timing devices require a separate /�
Describe work to be done: restricted energy permit.) W
New` Repair 0 Replace with like kind: Yes 0 No 0 Any Trap or Waste Not Connected to a Fixture 9.00
Residential Commercial 0 Catch Basin 9.00
Additional description of work:
' Insp. of Existing Plumbing 40.00
c. Pv-h_k ect, SLS�cm It- s 1�� ' per/hr
Specially Requested Inspections 40.00
per/hr
Are you capping, moving or replacing any fixtures? Rain Drain, single family dwelling 30.00
Yes O No AO Grease Traps 9.00
If yes, see back of form to indicate work performed by QUANTITY TOTAL
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Isometric or riser diagram is required if Quantity Total is > 9
WORK COULD RESULT IN INCREASED SEWER FEES. *SUBTOTAL � - =
I hereby acknowledge that I have read this application, that the information
given is correct, that I am the owner or authorized agent of the owner, and 5% SURCHARGE aX,'
that plans submitted are in compliance with Oregon State Laws.
SI • Owner /Agent Date '"PLAN REVIEW 25% OF SUBTOTAL
1K -196) Required only if fixture qty. total is > 9
TOTAL
Contact Person Name Phone /7 - ,
"Minimum permit fee is $25 + 5% surcharge, except Residential Backflow
Prevention Device, which is $15 + 5% surcharge
""AII New Commercial Buildings require plans with isometric or riser diagram
and plan review
1: ldstslplumapp.doc 7/2/98
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved Replaced Removed/Capped
Sink
Lavatory
Tub or Tub/Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain/Floor Sink 2"
3 „
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
lAdstskplumapp.doc 7/7/98