Permit p CITY OF TIGARD PLUMBING PERMIT
111 g , COMMUNITY DEVELOPMENT Permit #: PLM2013 -00093 •
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/20/2013
Parcel: 2S109DA14200
Jurisdiction: Tigard
Site address: 12639 SW MOUNT VISTA CT
Project: Arlington Heights No. 3, Lot 61 Subdivision: ARLINGTON HEIGHTS NO.3 Lot: 61
Project Description: (1) backflow preventer
Contractor: LANDSCAPE OREGON, INC. Owner: STONE BRIDGE HOMES
PO BOX 2386 4230 GALEWOOD ST SUITE 100
TUALATIN, OR 97062 LAKE OSWEGO, OR 97035
P
PHONE: 503 - 387 -7577
HONE: 503 - 692 -5945
FAX: 503 - 692 -0768
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 03/20/2013 $31.27
Specifics: 1 12% State Surcharge - 03/20/2013 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 03/20/2013 $41.23
Type of Use: SF Plumbing
Class of Work: OTR
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or direct questions to OUNCC by 503.232.1987 or 1.800.332.2344. /�
Issued By: /����`ti lip O ( .e CU Permittee Signature: ()Yd A p
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Applicatian V ED
Building Fixtures MAR 2 0 2013 FOR OFFICE 1.1SE ONLY
City of Tigard •
Risen cal � ' DI L '
�
- �/ Of TIGARD 7 Fennit No.: r AO 3 - p 9
lit 13125 SW Hall Blvd., Tigard, OR 972 I 1 Dale/B v J i 3
Phone: 503. Fax: 503.59 7thcr Penn: t Nn.:
T1GAP.D InspecIinn Line: 503.639.4:75 D e �d Saris: &I See on
Internet: www.tigard -or.gcv Notified/Method
,DING DNISIO n Pi to B: 114 Supplemental Information
iii
-:11:-F.:.:: - T7`FE OF WORK _ = Sci.IED[.tT.IE
® New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. ; Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft for each utility connection)
I
r,,,= ::.,..,�,,.,_ , _ ,:, �f!: .... .,. 1 SFR (1 bath 312.70
n.. -, . - . • __ , t CATE.�ORY- :OF 'tb1\`3TRU�'LJO1�T -- - 1
,I'a 690? . .._ _ 5.14 i3.._. n - I - '4
® 1- and 2- family dwelling E] Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi-family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other Foe sprinkler (- sq. ft) Page 2
r= y = " =_ 4.Q E . LYFORM:+41' Tt„�4N11:TZOCATkoN ; a - Site utilities:
Job site address: ,loo �a 3 q j - i.L /'11 t v 1 c- f CL- 1 "- Lcit. ,� Catch basin or area chain ] 8.76
City/State/ZIP: C Drywef, leach line, or trench drain 18.76
! l C {i�tiLL�� n Z . 7 �0 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /aptno.: i.7 I Projectname:Ar/ 1cj T C I Manufactured home utilities I 50.03
Cross street/directions to lob site: 131' e.../- ri.e - 7 Manholes I 18.76
/2 /t4 Ccr -tz ' SQL( /Y1/ ed" iIi ct-v 04 --- Rain drain connector I 38.76
Sanitary sewer (no. linear ft-: ) Page 2
c 1/1--L-Le.... 2u a'Lt ori+z
Storm sewer (no. linear ft: __) Page 2
" L j1'- LI' 1 E.-#- CT ' Water service (no. linear ft: _ ) Page 2
Subdivision: A-r E I Y-11' - 0,-1 a,Gf 1 Lot nc.: (. f [ Fixture or item:
Tax map/parcel no.: 5s ' f/`�,' o er I x 31.27 31.2 7
_ - - Bac1d1 w prevent � 1 �7
``Y ` i'' N!'1. 1':_ = - - ;'11) C ilif „ N i' %' : € _ :3. ;_ - _ _= Backwat valve 12.51
Clothes washer � 25.02
Landscape Irrigation Back Flow Device Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
iI,P.',I _ _ .: : I ,_ - F -- _ Expansion tank 12.51
-, � : :!irrS : - :. : '. .. :�1 : _ - !}I� : ' : _ - - __ - Expa
,
Name: Stone Bridge Homes NW LLC Fixture's t war cap 25.02
Floor crain/floorsinlulhub 25.02
Address: 4230 Galesvood Street Suite 100 -
Garbagc disposal I 25.02
City/State/ZIP: Lake Oswego, OR 97035 ` Hose bib 25,02
Phone: ( ) I Fax: ( ) Ice maker 12.51
'4;14r1 . 'II - `-11[94 %' I 1. ' i _ - �lnterceptor/greasetrap 25.02
•11 .i!91E ur F : Y -_ r _ ,! ; � - coif PEIt
Business name: Landscape Oregon, Inc Medico! has (value: S ) Page 2
Primer ' 12.51
Contact name: Ellen Sparrow
Rnof drain (commercial) 12.51
Address: P.O. Box 2386 . Sink/basin/lavatory 25.02
L City/State/ZIP: Tualatin, OR 97062 ' Solar units (potable water) 62.54
Phone (503) 692 -5945 I Fax: : (503 -) 692 -0768 Tub/showeeshower pan 12.5]
E -mail: e1Ien@landscapeoregon.com • Urinal • 25.02
25.02
., "_-' -i .� - - - .. _, 1,..:;1:: Water heater 37.52
Business name: Landscape Oregon, Inc. Water pipin8, 56.29
Address: P.O. Box 2386 Other: 25.02
City /State /ZIP: Tualatin, OR 97062 Subtotal 31.27
Phone: (503) 692 -5945 I Fax: (503) 692 -0768 Minimum permit fee: $72.50 72.50
Plan review (25% of permit fee)
CCB Lic.: LCB 7804 I Plumbing Lic. no.:
State surcharge (12% of permit fee) 8.70
Authorized signatu 4 , , 7 j "; � / � � o TOTAL PERMIT FEE 81.20
This permit application expires :1i a permit Is not obtained within 180 days
Print name: Ellen Sparrow Date ::)D after It has been accepted as complete.
•Fee methodology set by Tri- County B.117ding Industry Service Board
I :•,Buildre'Pn i tU- PermiiApp.doe Ia'OIR? 440 4616T( IC/C21COMIV.'EB)
L.•d 89LO - £O9 ue113 dLS :ZI Cl. OZ Jej
HEATFI 6 83 �j
• HACKrLo VV1 NEW PLY� �l - coo l
C INC.
NEW
. BACKFLOW ASSEMBLY TEST REPORT 9 REPOACEMENr
Q PROPERTY IZ - 4 - . J , - ; 4 - PHONE:
OWNER: /�`� :
MAILING
ADDRESS: -
ADDRESS: LT c' / /f
CITY e �''� /� -• STATE �
ZIP 7 �
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ASSEMBLY ., .
SSEMBLY .
co ADDRESS: STREET
4 ❑R.P.B.A. U.C.v.A ❑ R: P.D.A: []U.C.D.A - ❑P. V:B.IA ❑S.V.B.A.. ❑AV_B. • ❑AIR GAP
. SIZE: L.0.10 MAKE: /'v'MO 4
co i , DEEL: —a SERIAL WATER .. .. NUMB R... / { l r 10 % .0 Y
IC) PURVEYOR: ASSEMBLY `� I r ,� / �,,
LOCATION: r�
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REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST t
xl CHECK 1
DOUBLE, - CHECK'; AIR CHECK PASSED '~
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PRESS DRUP :.,......t—
A ) I CHECK til INI•F ,FAILED ❑ (•
INITIAL RELIEF vALVe (B)FIGHT `gr�'f OPENED AT. PRESS DROP DATE:
OPENED AT /
TLS ( MIN 2 PSID LEAKED ❑ PAD 4,- 1 y1 J 3
RESULTS BUFFER ( Psln PSID
A - B - I CHECK #2 t s
MIN PSI DID NOT FAILED SYSTEM
RELIEF VALVE ( s I
LE AKED❑ �D OPEN ❑ ❑ PSI i
PASS ❑ FAIL ❑ ti j¢
COMM / OIS /97, i �/ l �`� S/ / l REPAIRS ((1 / 1 /l'i f` 1/ / -
. ATIDfOR .
PARIS ----
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- REDUCED PRESSURE ASSEMBLY P.V.R.A:IS.V.B.A. AFTER REPAIRS ---C)
n CIIECK (A)1 : `'D:C'''f- 'r „ } DATE: C.
PRESS DROP ' I
T FST CHECK. # 1 OPENED AT PRESS DROP ! •
AEL]£F. (BS 'TIGHT ❑ PSID
AFTER OPENED
�'�
CHECK #2
REPAIRS 6t3F�R ' PASSED ❑
A 6 mai I r9 ( ❑ ''_PSID PSID P _
C I N COMPLETING' AND SUBMITTING THIS TEST REPORT; THE TESTER CERTUIES THAT THE
m
_ ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
W • RULES AND REGULATIONS OF P1EE WATER 'SYSTEM, AND STATE REGULATIONS:
GAUGE CALIBRATION DATE I. 1 / / J_DETECTTO.R METER READING •
a . G -__ 1275„__„
CERTx
- TESTE SIGNAT D . Brad Heath 93101059
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TESTERS NAME PRINTED PO Box I565 Sherwood OR 91140 c503i gaii553 • • PHONE Y
TESI£RS ADD0.E55
. Hcadoackf low Inc. p SPRylcE RESTORED_ •
COMPANY •
NAME
OFOUNU OFF / LEFT OFF
(0 REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER)
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