Permit CITY TIGARD PLUMBING PERMIT
I DEVELOPMENT SERVICES PERMIT #: PLM2003 -00226
R�� II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/29/03
SITE ADDRESS: 11765 SW WALNUT ST PARCEL: 2S103BA -00600
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT 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.
FEES
Owner:
Description Date Amount
GEORGE DRAKE
11765 SW WALNUT ST [PLUMB] Permit Fee 5/29/03 $36.25
TIGARD, OR 97223 [TAX] 8% State Tax 5/29/03 $2.90
Total $39.15
Phone : 503 - 515 - 2191
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone : RP /Backflow Preventer
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
Issued By � - Permittee Signature: A.—
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
1
. Plumbing Permit Application OFFICE USE ONLY
Date received: .572.q 03 Permit no.eLM61ao3�0
A, i City of Tigard 9 Sewer ermit no.: Buildin g Permit no.:
Address: 13125 SW Hall B 97 D permit
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 MAY 2 9 2003 Date Issued: BReceipt no.:
Land use approval: CITY OF TIGAR 776 Case file no.: Payment type:
a i. • •∎
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: /17 6p 5 S W W u <ybt tt 43 t- 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: (Block: 'Subdivision: SFR (2) bath
Project name: SFR (3) bath
City/county: I ZIP: 972 Z.3 Each additional bath /kitchen
D�e w cri tion and location of work on emises: Site utilities:
fray i- ia/` cut t a *2 , -e," Catch basin /area drain
Est. date of c mpletion /inspection: Drywells /leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: (2 Wn/ER__ Manholes
Address: Rain drain connector
City: 'State: I ZIP: Sanitary sewer (no. lin. ft.)
Phone: I Fax: 1E-mail: Storm sewer (no. lin. ft.)
CCB no.: 'Plumb. bus. reg. no: Water service (no. lin. fl.)
City/metro lic. 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
Address: Dishwasher
Drinking fountain(s)
City: I State: I ZIP: Ejectors /sump
Phone: Fax: E -mail: Expansion tank
OWNER' Fixture /sewer cap
Name (print): C .e ,, . ) • . Floor drains /floor sinks /hub
Garbage disposal
Mailing address: //-7 c s- Sc.43 W al 0. tt,4 Hose bibb
City: 'T al d State: pie ZIP:
7 Z Z 3 Ice maker
/
Phone:S %; j/S 2 / 9/I Fax: E-mail: I 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 ORS C apter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: S 2 Sump
Tubs /shower /shower pan
Name: Urinal
Address: Water closet
Water heater
City: I State: ZIP: Other:
Phone: I Fax: E -mail: Total
Not all junsdicnons accept credo cards, please call Junsdicnon for more information Minimum fee $
Notice: This permit application i
Plan review (at
❑ Visa ❑ MasterCard ( %) $
expires if a permit is not obtained o
Credit card number / / within 180 days after It has been State surcharge (8%) .... $ .2, 0
Expires TOTAL $ 39 • IS
Name of cardholder as shown on credit card accepted as complete.
S
Cardholder signature Amount 440 -4616 (6 /00 /COM)
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION 'DIVISION Business Line: (503) 639 -4171 MST
BUP
•
Received Date Requested ( l0 AM PM BUP
Location / 7 3 t),' .� Suite c� MEC
Contact Person -e-0 C/ .e Ph ( ) ‘57A ( d / PLM 3 - )c) 2
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 .,1v1 t- C /r YII C�I...e l AA e r
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
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan o
Other:
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 4 _� D Inspector i Ext
Other: -
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL