Permit CITY TIGARD PLUMBING PERMIT
�r; DEVELOPMENT SERVICES PERMIT #: PLM2001 -00261
' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/20/01
PARCEL: 2S103BD -00200
SITE ADDRESS: 11710 SW WALNUT ST
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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Connection of existing single family residence to newly installed sewer lateral.
FEES
Owner:
Type By Date Amount Receipt
CAPPOEN, RAYMOND J PRMT CTR 6/20/01 $72.50 27200100000
SUZANNE 5PCT CTR 6/20/01 $5.80 27200100000
11710 S
11710 SW WALNUT ST
TIGARD, OR 97223 Total $78.30
Phone 1:
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone 1: 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 -0080.
You o tarn cosies of thes- rules or direct questions to OUNC by calling (503) 246 -1987.
O
Iss ed By: /7,1�l A /li I � r Permittee Signature:
L
Call (503) 63' • 175 by 7:00 P.M. for an inspection needed the next business day/
tvQ -ce -co i 9 Plumbing Permit Application
Date received: op of e/ Permit no.:PC Pee/ ... Gte)a(C
41• ,,c, City of Tigard
. / 1 / ?'
�, Y 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: Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
■
Job address: , 1 - 2/ / 1 z ,� Description Qty. Fee(ea.) Total
Bldg. no.: 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: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: �i L 1 1tidditt-TIP: c7 7 ,R,,-) ? Each additional bath/kitchen
Description and loc ion of ryhrk on premises: Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells /leach line /trench drain
Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR *
i �� �� Manufactured home utilities
Business name: r. � _ - .�..: - -_ -
- ' -- _ - - &-.-- w u anholes
Address: Rain drain connector
_City: State: I ZIP: Sanitary sewer (no. lin. ft.) . f_jj e'c.
41 -1/ J2 -I_J Fax: E - mail: Storm sewer (no. lin. ft.)
CCB no.: I Plumb. bus. reg. no: Wa er ser service (no. lin. ft.)
City /metro lie. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
(111 \ 1 It Fixture /sewer cap
Name (print): I II d / L r .i /L Floor drains/floor sinks/hub
_ Garbage disposal
Mailing ac(dress: � � � '/ fr -, r/a J N Hose bibb
City: f i p- /(r _ f } , � — St�/ ' I l. Ice maker
Phone :X / h� /L ' � t`ax: 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 regulaf Roof drain (commercial)
employee on the propefty I own as per OR Chapter 447., , C / Sink(s), basin(s), lays(s)
Owner's signature: L L' Y it- - to '`"" Sump
Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: I State: ZIP: Other:
Phone: Fax: E -mail: Total /�
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: fee $ / r S�
Notice: "Ibis permit application
❑ Visa ❑ 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 ' g6
Expires TOTAL $ 7 ? , 30
Name of cardholder as shown on credit card accepted as complete.
Cardholder signature Amount 440-4616 (6M00 /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
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 PLEASE COMPLETE:
3" 16.60
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
Urinal
Other Fixtures (Specify) 16.60 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.
hdstsVonns\plm- fees.doc 10/10/00