Permit C ITY OF TIGARD PLUMBING PERMIT
i � DEVELOPMENT SERVICES PERMIT #: PLM2003 -00170
,.� II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/1/03
SITE ADDRESS: 12242 SW TIPPITT PL PARCEL: 2S1036C -08100
SUBDIVISION: MLP1999 -00005 MOSES PP2000 -077 ZONING: R -4.5
BLOCK: LOT: 001 JURISDICTION: TIG
CLASS OF WORK: ALT 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: ft
WATER CLOSETS: WATER LINE: 32 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Install approx. 30' of water line.
FEES
Owner:
Description Date Amount
MOSES, JAY H + MARY JO
19061 SW INDIAN SPRINGS RD [PLUMB] Permit Fee 5/1/03 $72.50
LAKE OSWEGO, OR 97035 [TAX] 8% State Tax 5/1/03 $5.80
Total $78.30
Phone :
Contractor:
KENNEDY PLUMBING
13985 SW FARMINGTON RD
BEAVERTON, OR 97005 REQUIRED INSPECTIONS
Phone : 643 Water Line Insp
Final Inspection
Reg #: LIC 10967
MET 00003528
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
Issued By: 4/ , i J % Permittee Signature: -- 1 •
Call (503) 639 -4175 by 7:00 P.M. for an inspection neede th - next b siness day
r -- sge
Plumbing Permit Application 1
Date received/. 66 Permit noTL 1 X)3 -Co/ 2
AT', " Ci of Tigard
1 � 1 Sewer permit no.: Building permit no.:
.411., . - 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: I Receipt no.:
Land use approval: Case file no.: T-7( Payment type:
TYPE OF PERi11T
121 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family O Tenant improvement
0 New construction ❑ Addition/alteration/replacement U Food service ❑ Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: I a ol`! 2- 51.3 p,,-; if .l Q CZ, Description Qty. Fee (ea.) Total
Bldg. no.: 1 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: IBlock: I Subdivision: SFR (2) bath
Project name: 0,!-1 rn OS BPS SFR (3) bath
City /county: "Ti and 1,04 I ZIP: C 1 A Each additional bath/kitchen
Description and �ocation o work on premises: 3C Site utilities:
/fit - /i0 4 /®i 4.., s0 j Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: - n , r l u ;r1 Manholes
Address: 139 8 5 S u) a rn■ }t. n J Rain drain connector
City: 6fii, I State: 0( I ZIP: Q 1005 Sanitary sewer (no. lin. ft.)
Phone: , 6`-3 . 55 3 5 I Fax: I E -mail: Storm sewer (no. lin. ft.)
Plumb. bus. reg. no:
CCB no.: Co (Oct 61 I g• 34 - H 2. Water service (no. lin. ft.) . . . , 9 - - .
City /metro lic. no.: 1313 Fixture or item:
Absorption valve
Contractor's representative signature: ( I ) 4t
Back flow preventer
Print name: c5he (I (-l'Q SS Date: 44 . Z 8.03 Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: SQlan Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print): I Il " O cue S Floor
Garbage disosal sposal sinks/hub
J 0.
Mailing address: '/ l 0b I IY\ - on Se ' n 4 D Hose bibb i
City: t oict 0 S &.e 0 I State: 01 1 ZIP: 9 D 5 Ice maker
Phone: GS 9 et 5 9 f 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: ,;:) `/4 / 62f; pe 1)r
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $ 2
O Visa Cl MasterCard expires if a permit is not obtained Plan review (at _ %) $
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $ 5- q' /4
Expires TOTAL $ 7, . 3 0
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440-4616 (6/00/COM)
PLUMBING PERMIT FEES:
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
16.60 for each utility connection)
Lavatory 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/Storm 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
Other Fixtures (Specify) 16.60 Urinal
( ��) 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.
"All New Commercial Buildings require plans with Isometric or riser diagram and
plan review.
i:\dsts \forms\plm- fees.doc 10/10/00
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639
INSPECTION DIVISION Business Line: (503) 639 -417 5
- -.r MST
' BUP
Received Date Requested 6 AM i — PM BUP
Location / a a / 1 - Pt— Suite MEC
Contact Person .P Ph ( ) PLM 3 - 0 0 1 - 1 0
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 / j 1 1 � = l �� -
Fire Alarm /
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
dfV�ter Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
/ Oti - ••
PART FAIL
E ANICAL
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: LI Unable to inspect - no access
Fire Supply Line
ADA '
Approach/Sidewalk Date Inspector 0. 77Z Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL