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Permit CITY TIGARD PLUMBING PERMIT Ai DEVELOPMENT SERVICES PERMIT #: PLM2004 -00533 �� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/23/2004 SITE ADDRESS: 11600 SW TIEDEMAN AVE PARCEL: 1S135CC -00300 SUBDIVISION: ZONING: R -4.5 BLOCK: LOT: JURISDICTION: TIG CLASS OF WORK: OTR 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: 130 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS: RAIN DRAIN: ft Remarks: New sewer connection. FEES Owner: Description Date Amount CHITTENDEN, LLOYD A EVELY 11600 SW TIEDEMAN AVE [PLUMB] Permit Fee 11/23/2004 $101.40 TIGARD, OR 97223 [TAX] 8% State Surcharl 11/23/2004 $8.12 Total $109.52 Phone: Contractor: OWNER REQUIRED INSPECTIONS Phone : Sewer Inspection Final Inspection Reg #: • 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 -0100. You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -6699. Issued By: P ," Permittee Signature: s46,,1 Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day Plumbin Permit A 1'c t' cD FOR OFFICE USE ONLY City of Tigard C Received // 7i IV Plan Review permit N �� y -035:77 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: !/7 Phone: 503.639.4171 Fax: 503.598.19CIQOV 2 �] 20 0 4 / \ va�'�k, , ' � I + Date/By: Other Permit No.: / o 9' _ 24- Hour Inspection Line: 503.639.4175 �q e7 - E Y . Date ReaReady/By: ® for See Page 2 for Internet: www.ci.tigard.or.us CITY OF TIGAR I Notified/Method: - � 1 l(f Supplemental Information . • WHAM 1 ' VISION: • • .. ; : .. ` • FEE* .SCHEDULE ❑ New construction ❑ Demolition For special information use checklist Description I Qty. 1 Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 jg 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi - family SFR (3) bath 399.00 ❑ Master builder Each additional bath/Idtchen 45.00 ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: ! j 6,, 5 7 ',01 �" ,�" _ _ , Catch basin or area drain 16.60 City / State/ZIP: C� ��4 " Oy . 7 a Drywell, leach line, or trench drain 16.60 - Suite/bldg. /apt. no.: Project name: Ojt Footing drain (no. linear ft.: ) Page 2 Manufactured home utilities 110.00 Cross street/directions to job site: Manholes 16.60 rt r -Ltirl - 7 - / Rain drain connector 16.60 Sanitary sewer (no. linear ft.: /7d) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2 Tax map /parcel no.: Fixture or item Absorption valve 16.60 DESCRIPTION OF WORK Backflow preventer Page 2 7 ? 0 4-, e.∎> -.j'.,- \„.).� r C ,� i,. , Backwater valve 16.60 Clothes washer 16.60 Dishwasher 1 6.60 ❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60 Ejectors /sump 16.60 Name: 542.,rn e �� rt e (Z2p Expansion tank 16.60 Address: //607 , bo , 77 „2_0(..a Fixture/sewer cap 16.60 City/State/ZIP: --t- A / c Gl,(._ 9 �� 3 Floor drain/floor sink/hub 16.60 Phone: (613) 6 8 .-- Fax: ( ) Garbage disposal 16.60 • ❑ APPLICANT .. CONTACT PERSON Hose bib 16.60 • Ice maker 16.60 Business name: ,L /.sud -�- zizs„,„_ Interceptor /grease trap 1 6.60 Contact name: Medical gas (value: $ ) Page 2 Address: Primer 16.60 City/ State/ZIP: Roof drain (commercial) 16.60 Phone: ( ) Fax:: ( ) Sink/basin/lavatory 16.60 Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet 16.60 Business name: ,, 93 nw ,,, / Water heater 16.60 Address: Other: City/State/ZIP: Subtotal Minimum permit fee: $72.50 x Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 /Q -9 6 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (8% of permit fee) /s'__, Authorized signature: TOTAL PERMIT FEE io9 -.. Print name: I Date: 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\PLM- PennitApp.doc 12/03 440- 4616T(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) Totat Square Footage:: Per Fee Footing drain - 100' 55.00 0 to 2,000 $115.00 Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00 Sewer - 1st 100' ! 55.00 3,601 to 7,200 $220.00 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 Storm & Rain Drain - 1st 100' 55.00 Valuation: - Permit Fee: - $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 - New 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 Ice MachiRefrig. Drains increase of sewer EDUs, a sewer permit will be issued and 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 Commercial Isometric or riser diagram is required if fixture quantity - 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•PermitApp.doe 3/03 • ALOHA SANITARY SERVICE INVOICE NO. 8600 SW Hillsboro Hwy., Hillsboro, OR 97123 9033 503 - 644 -2797 • 503 - 648 -6254 • 503 - 639 -5188 NAME: 2 Z. z .t EA/ ADDRESS: //4 d0 C4 / if F,»,'4/ R 7J CITY: / /7 STATE: a -1 ZIP: 7.2/-- HOME: ‘1 � P �, WORK: CELL: JOB SITE: f» / / . P.0.#: PAID BY CHARGE ❑ HECK CASH ❑ CREDIT CARD ❑ DATE // - , 19 6 `74 ( DRIVER ,6 it,/,g 7 Zloa! AMOUNT PUMP SEPTIC TANK add ❑ LINE OPENING ❑ INSPECTION FEE ❑ SERVICE CALL ❑ LABOR, LOCATING, DIGGING, BACKFILL ❑ MATERIAL cS e &prf. I TOTAL $gdd - - THIS IS NOT A SEPTIC SYSTEM INSPECTION REPORT - - - - - REMARKS - - TYPE OF TANK: STEEL ❑ CONCRETE Oe. PLASTIC ❑ HOMEMADE HORIZONTAL ❑ VERTICAL ❑ RECUT NGIE OTHE SIZE OF TANK: 350 ❑ 500 ❑ 75 _I - 1000 ❑ 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑ LID LOCATION: INLET ❑ UTLET ❑ MIDDLE ❑ ENTIRE TOP ❑ TANK CONDITION: GO FAIR ❑ POOR ❑ FITTINGS: BAFFLES ❑ CONCRETE ❑ CAST IRON ❑ PLASTIC ❑ NEEDS NEWLID? YES ❑ SIZE GROUND COVER OVER TANK COMMENTS ON CONDITION OF DRAINFIELD ETC. SIGNED BY DATE CITY OF TIGARD 24 -Hour BUILDING Inspection Line: (503) 639 -4175 INSPECTION DIVISION Business Line: (503) 639 -4171 MST BUP Received Date Requested //' 30 AM IPM BUP Location J / 1p n O A-yr Suite MEC Contact Person / Ph ( ) 1 �3� --08 a-- PLMo7O 0 4 / - 06533 Contractor Ph ( ) 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 a n1110 - ain trains Catch Basin / Manhole Storm Drain Shower Pan Other: Fin 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 Approach/Sidewalk Date )/,'57g/Zt Inspector L� Ext Other: Final DO NOT REMOVE this inspection record from the Job site. PASS PART FAIL