Permit •� CITY OF TIGARD - b PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2007 -00242
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 6/13/2007
PARCEL: 1S133DD-08600
SITE ADDRESS: 11692 SW 128TH AVE ZONING: R -4.5
SUBDIVISION: VILLAGE AT SUMMER LAKE PARK 4 LOT: 123 JURISDICTION: TIG
PROJECT: AMMANN
Project Description: Installation of residential backflow preventer for irrigation system.
CLASS OF WORK: OTR 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
Owner: FEES
ANA AMMANN
11692 SW 128TH AVE Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fcc 6/13/2007 $36.25
[TAX] 8% State Surcha 6/13/2007 $2.90
Phone : 503 524 - 1840 Total $39.15
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # :
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 -0100. You may obtain copies of
these rule . - : esti. s t. OUNC by calling 503.246.6699 or 1.800.332.2344.
/// /
Issu - • By: k J �� ' Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Plu j g Permit Application
FOR OFFICE USE ONLY -
City of Tigard Date/By: f Q 7 Permit No.: I C H 749
ligi
V 13125 SW Hall Blvd., Tigard, OR 97223
• • Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Other Permit No.:
Inspection Line: 503.639.4175 Date/By:
T I G A R D and - or. ov Date Ready/By:
d /Meth •:
Internet: www.ti y+ /� S See Page 2 for
www.tigard-or.gov Notified/Method: ' /�V Supplementallnformatioa
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
. JOB SITE INFORMATION 1/ AND LOCATION Site utilities
Job site address: I I to. I Z S V v 1 Z g1 Y yA�✓ � �j Catch basin or area drain 16.60
City /State /ZIP: �1 9 A , op- G� f273 Dry -well, leach line, or trench drain 16.60
: \� Footing drain (no. linear fl.: ) Page 2
Suite/bldg. /apt. no.: I Project name:
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: _) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION OF WORK Backflow Backflow preventer
/ Page 2
S{�)��A 4.1 -' f rUlci +" I(„�% � n I �/` *Y1 {n. kto.7 Backwater valve r 16.60
6....m & li Clothes washer 16.60
Dishwasher 16.60
a PROPERTY OWNER ❑ TENANT Drinking fountain 16.60
/�,�� Ejectors /sump 16.60
Name: A11 r\fh 1 (' Expansion tank 16.60
Address: \ 1L 1 12 2 Av liy , Fixture /sewer cap 16.60
City /State /ZIP: I `/f�!'(iA r )$ " - d D- 5 Floor drain /floor sink/hub 16.60
Phone: (5 6-4- , - I 0 Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
. Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Phone: Sink/basin/lavatory 16.60
( ) Fax: )
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
CONTRACTOR • Water closet 16.60
Business name: Water heater 16.60
Address: / a Other:
1 n I I I✓ Subtotal
City /State /ZIP: /
M inimum permit fee: $72.50 2/ , Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 fi-J(
CCB Lie.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee) pl. 9(
Authorized signature:
TOTAL PERMIT FEE 39 . / S
Print name: Date: This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
1:\ Building \ Permits \PLM- PermitApp.doc 12/27/06 440-4616T( 1 0/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
. Valuation: Permit Fee:
Storm & Rain Drain - Ist 100' 55.00
$1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof. to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work:
Are you capping, adding or replacing fixtures? If "yes", Plan Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased sewer fees * . Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: Replace greater, except systems designed and stamped by licensed
Previous Capped Added Existing engineer.
Baptistry/Font
Bath - Tub /Shower i ❑ New exterior plumbing site utilities for any complex structure
Jacu as defined in OAR918- 780 -0040.
-Jacuzzi/Whirlpool
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive Thru ❑ Any multipurpose fire sprinkler system.
Cuspidor/Watcr Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash Isometric or Riser Diagram
Floor Drain /sink - 2" ❑ Isometric or riser diagram is required for new buildings
that meet the qualifications above.
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink -Bar/Lavatory
- Bradley *Note: If the fixture work under this permit results in an
• - Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i.'\Building\Permits\PLM- PermitApp.doc 12/27/06
CITY OF TIGARD Lj sic, -i
BUILDING DIVISION PERMIT #:
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 1 3)
Inspection Requests (24 Hrs.): (503) 639 -4175 ,�' ` :_
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: 1....4S 1- t Ar-4- QS.s � CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
V./ •WNER 3J 51 - pri _£ 1 W/ 0 l/t"$?, PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: Pour Time:
Coodee# Inspection Description ' Confirm # Contact # Message
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Corrections /Comments /Instructions:
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I I PASS 1 I PARTIAL APPROVAL n CANCEL 1 I NO ACCESS
FAIL I I CALL FOR INSPECTION n ADDITIONAL FEES ASSESSED
Inspector: V iA ( A 1 -/ Date: Phone #: (503) 718-