Permit CITY TIGARD PLUMBING PERMIT
14e DEVELOPMENT SERVICES PERMIT #: PLM2004 -00497
°�JI� 13125 SW Hall Blv Ti gard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/1/2004
SITE ADDRESS: 11555 SW TIEDEMAN AVE PARCEL: 1S135CB -00500
SUBDIVISION: ZONING: I -P
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: NEW 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: Connect existing house to newling installed sewer lateral. Septic tank is to be pumped, filled and inspected.
FEES
Owner:
Description Date Amount
GABRIEL INVESTMENT LLC [PLUMB] Permit Fee 11/1/2004 $101.40
10250 SW NORTH DAKOTA ST
TIGARD, OR 97223 [TAX] 8% State Surchari 11/112004 $8.12
Total $109.52
Phone :
Contractor:
BERRYHILL BROTHERS EXCAVATION
20897 SW SCHOLLS - SHERWOOD RD
SHERWOOD, OR 97140 REQUIRED INSPECTIONS
Sewer Inspection
Phone : 503
Insp existing /capped fixtures
Reg #: LIC 62191 Final Inspection
MET 00003514
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved
plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 -000 -00 I hrough OAR
952-I!: -0 :0. You may obtain copies of these rules or direct q -stions O b by calling (503)
24,:- 6699. \' 41P
I - ued By: , � r 11��� / / 7 Permittee Signature A; /1/
Call (503 : • 9-4175 by 7:00 P.M. for an inspection needed the fin: s : .
Probing Permit Application FOR OFFICE USE ONLY • f!
City of Tigard Received '` /
Date/By: // / D7 Permit No.: I L�i�,,$ .w !97
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review oK+YYY "`WWW
Phone: 503.639.4171 Fax: 503.598.1960 A,�, i i Date/By: Other Permit No.:e� J ? t !�
24- Hour Inspection Line: 503.639.4175 _Al, c i I Date Ready/By: El See Page 2�vfo''r^^''ii ✓
Internet: www.ci.tigard.or.us Notified/Method: / iCO• Supplemental Information
TYPE OF WORK _ ' , ±FEE* .SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I 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
❑ 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/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION - _ Site utilities
Job site address: 1 1555 SW I( P aN S Catch basin or area drain 16.60
City/ State/ZIP: Tl OK,yry q 7 f Zz-3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project n ( u LLC Footing drain (no. linear ft.: ) Page 2
�� •Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: 1 ) Page 2 AO 1 * Yo
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: 6do -i T 1 LC Expansion tank 16.60
Address: 182SZ sa pp---(4, NJ-4,s+, Fixture /sewer cap 16.60
City/State/ZIP: T a lam` 611 q 7 2Z Floor drain/floor sink/hub 16.60
1
Phone: (565) ?„ q 5 75 U Fax: ( ) Garbage disposal 16.60
❑ .APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax:: ( )
Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR Water closet 16.60 •
Business Warn -e 1
Il-4 l Water heater 16.60
Address: Other:
City/ State/ZIP:
Subtotal
Phone: ( ) Fes: Minimum permit .
( ) Residential backflow minimum permit fee: fee: $36 5 l /• . Yb
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee) 8. 1
Authorized signature: 1
/I
ii. TOTAL TOTAL PERMIT FEE /C , 5 9
Print name: �v � , /' . Date:' o)/, ) 20044 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.
is\ 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 System s:
Site Utilities Qty. Fee (ea) Total Square Footage:. Permit. Fee:
Footing drain - 1" 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 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
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 increase of sewer EDUs, a sewer permit will be issued and
Ice Mach./Refrig. Drains
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 Isometric or riser diagram is required if fixture quantity
- Commercial total is >9.
- Service
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:\ BuildingTemits \PLM- PcnnitApp.doc 3/03
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• 11055 S.W. Clay •Sherwood, OR 97140
• Telephone: (503) 682 -0233
Date} / - � - ' C I
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Service for 4,,,f4 , �,,
6 — 5th
Address , ..e. i-/L. •
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City AUL / `dam % Pho
For Cleaning Septic Tank `'"� ,' ,
• For Cleaning Drain Line !j 1
For Cleaning Grease Trap
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For Extra Labor - i
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6 T oml i
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Amount Paid B ue
Due Date tiou, Z 200
28c
Signature
Please make check out to present driver
Three percent per month interest charged on bills if not paid in 30 days.
Not responsible for septic tank, drain field, curbing or driveway damage. - _ i
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
l BUP
Received / / /110 y Date Requested /iiS /o( AM PM `" BUP
Location / / S S" '1" I e 0 m4 A-ve. Suite MEC
Contact Person Ph ( ) PLM , 2 no t4 - oO 4 4 '?
Contractor R/ rr 1-1-; I l f3 v1 ( ) 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
hit Sheath/Shear -1 ; e /�. p � ft S3 6 � / )
Framing v l o ,�, a.�� v.���,� �t 1`Cc.� l cc.,e., , c,
Insulation
Drywall Nailing i '"' �IPc�'�
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
RT FAIL
JPLUMBING
Post & Beam
Under Slab
Rough -In
Service
anita Se
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
�r:
UV PART FAIL
MECHANICAL
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: U Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk Date /) / I
6104 Inspector kA 11 p Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL