Permit CITY TIGARD PLUMBING PERMIT
" DEVELOPMENT SERVICES PERMIT #: PLM1999 -00187
I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/21/99
SITE ADDRESS: : 12955 SW WALNUT ST ORIGINAL PARCEL: : R-4 5
4AD -02900
SUBDIVISION:
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: 112 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of 112 feet of sewer line to hook existing house to sewer. Lateral is located on property, no street
opening permit required.
FEES
Owner:
Type By Date Amount Receipt
HAZEL SELLIKEN PRMT DEB 6/21/99 $50.00 99- 316290
12950 SW WALNUT MISC DEB 6/21/99 $2.50 99- 316290
TIGARD, OR 97223
Total $52.50
Phone 1: 590 -4691
Contractor: •
•
REQUIRED INSPECTIONS
Phone 1: Sewer 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 m. : - . copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Iss. ed By: / _ Permittee Signaturet / i
- Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the nefct business day
CITY OF TIGARD Plumbing Permit Application Plan Check #
13125 SW HALL BLVD. Commercial and Residential Rec'd By
TIGARD, OX 97223 Date Rec'd
(503) 639 -4171 Date to P.E.
Print or Type Date to D T
Incomplete or illegible applications will not be accepted Permit it L►7 f� -- 00/S7
Related SWR tt a ,.ok itn
Called
Name of Development/Project FIXTURES (individual) QTY PRICE AMT
Job Sink 11.50
Address Street Address Suite Lavatory 11.50
19 ( 5La) witt>J U - Tub or Tub /Shower Comb. 11.50
Bldg It Ci l /Stet ..? et k Zip 9 7 Shower Only - 11.50
Water Closet 11.50
14 11 .. /4..L. _ ame
Lc. ikS 0 Dishwasher 11.50
Owner Mailing Address Suite Garbage Disposal 11.50
Washing Machine 11.50
City /State Zip Phone Floor Drain/Floor Sink 2" 11.50
Name 3° 11.50
4° 11.50
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 11.50
Gas piping requires a separate mechanical permit.
City /State Zip Phone Laundry Room Tray 11.50
Urinal 11.50
Name
cr)Lo , ` . Other Fixtures (Specify) 15.00
Contractor Mailing Address Suite
Prior to permit City /State Zip Phone Sewer - 1st 100' / / 38.00 '3g, D D
issuance, a copy
Sewer - each additional 100' / 32.00 9,,,GO
of all licenses are Oregon Const. Cont. Board Licit Exp. Date
required if Water Service - 1st 100' 38.00
expired in COT Plumbing Uc. it Exp. Date Water Service - each additional 200' 32.00
database Storm & Rain Drain - 1st 100' 38.00
Name Storm & Rain Drain - each additional 100' 32.00
Architect Mobile Home Space 32.00
or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- 32.00
Pollution Device
Engineer City /State Zip Phone Residential Backflow Prevention Device' 19.00
(Irrigation timing devices require a separate
Describe work to be done: restricted energy permit.)
New 0 Repair 0 Replace with like kind: Yes 0 No 0 Any Trap or Waste Not Connected to a Fixture 11.50
Residential 0 Commercial 0 Catch Basin 11.50
Additional description of work: Insp. of Existing Plumbing 50.00
per/hr
50.00
Are you capping, moving or replacing any fixtures? Specially Requested Inspections per/hr
Yes 0 No 0
Rain Drain, single family dwelling 45.00
If yes, see back of form to indicate work performed by Grease Traps 11.50
fixture. FAILURE TO ACCURATELY REPORT FIXTURE
WORK COULD RESULT IN INCREASED SEWER FEES. QUANTITY TOTAL 2,r. 7U ,o4
I hereby acknowledge that I have read this application, that the information Isometric or riser diagram is required if Quantity Total is > 9
given is correct, that I am the owner or authorized agent of the owner, and *SUBTOTAL , d •
that plans submitted are in compliance with Oregon State Laws. , t 70
Signatur of Owner Agen Date 5% SURCHARGE . 73 .5
Contact P on ame Phone * *PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
it l " _A. sous -, C :'' I TOTAL ' >' 2. SO
k i✓ ii I. Y�C Os *Minimum permit fee is $50 + 5% surcharge, except Residential Backflow
(fvl it ci des Lip, l t' a ss lbt Prevention Device, which is $25 + 5% surcharge
Ci1IMV(111. ". , ; a.:1',. .. _ ) * *All New Commercial Buildings require plans with isometric or riser diagram
and plan review
1: ldstalforrnslplumapp.doc 6/2/99
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New . Moved Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
I 'dsts formAplumapp doc 6/2/99