Report Jul. 1. 2013 5:42PM No. 4128 P. 1
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AMP 16
UNDER -
GROUND �
'EIS
JUL 1 2013
CITY OF TIGARD
BUILDING DIVISION
FAX TRANSMITTAL SHEET
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P .O. Box 777, Clackamas, OR 97015
Phone; (503) 657.6123 FAX: (503) 656-206]
cCBtt 116182
2O13 5 :_ 42 PM5035981960 CITY OF TIGARD N0, 4128 P. 2 _
I H�IL 0102
CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
• COMMUNITY DEVELOPMENT Permit #: 1 P52013 00084
T r o A itt.) 13125 SW Hall Blvd., Tigard OR 97223 503,718.2439 Date Issued: 07/01/2013
Parcel: 1S135BB00800
Juri'adloton: Tigard
Site address: 10655 SW GREENBURG RD
Project Ewing Irrigation Subdivision: HILLSBORO Lot: PTS 1-2
Project Description: Installation of double check valve for fire supply line,
Contractor. OREGON UNDERGROUND INC owner EW(NG IRRIGATION PRODUCTS INC
PO BOX 777 3441 E HARBOUR DR
CLACKAMAS. OR 97015 PHEONIX, AZ 85034
•
PHONE; 503 - 657 -6723 PHONE;
FAX: 503 -658 -2061
s --
0escriptl _ Date Amount
Specifics;: Permit Fee • COM 07/01/201
8177,52
12% Slate Surcharge • Building 07/01/2013 521.30
Type of Use: COM Plan Review • Fire Life Safety - COM D7/D1 /2013
Class of Work: ALT Type of Const: 571.01
Occupancy Grp: Height et
Stories:
Commer 9 orinkLar System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard:
Density. 0 Design Area: 0
K Factor. 0
Commercial Fire Alarm System:
Firs Alarm Required: Alarm Type:
Pull Station Required: Smoke Detectors Req:
Battery Cots Provided: Out Shoots Required:
. _ Total 5289.83
Valuetli
Sprinkler valuation; Required Items and Reports (Conditions)
$9.500,00
Residential Square Footage: 0
Fire Alarm verluatlon: 50,00
This permit is issued subject to the regulatlons contained in the Tigard Municipal Code. Slate of OR. Specialty Codes and all other
applicable law. All work wit be done In accordance with approved pions, This permit will expire it work Is not started within • 1B0 days of
Issuance. or .. In is suspense's for more the 180 days. ATTENTION: Oregon law requires you to follow the rules Adopted by the Oregon
Utility • 'cation Can • Those rules are set forth in OAR 952.001 -0010 through 0 • - •
or dl ct questions to OUNC • . , g You may obtain a Copy of the rules
8 2.1987 or 1.800.3322344.
la Lied ay:
, ) / • PermiK nature:
Can 503.639.4176 by 7!0D a.m. for the next avalla • pection date.
Thle permit card shalt be kept In a conspicuous place on the jeb elte until completion of the project
Approves plane are required on the job she at the time of each Inspection.
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PNWS•AW WA " •
BACKFLOWAS'EMBLY TEST REP r n iiiisb d i PNWS -AWWA BACKFLOWASSEMBLYTESTREP REI130VED
`"PROPERTY _ I ' I� P A�EMENT I PROPERTY 11 �lp REPtACEMENT
- OWN �. j., : .. PH 6 1 OWNER: f ° 1 --' , / 1 /.•,: .• s PHONE:/ I} 11
MAILING JUL _ MAILING ti ~
ADDRESS: 1 , ` ` , . , n . ,.. . ! ADDRESS: 07_, r . I i ► F (' C c ti V G6 : lli
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CITY ! STATE_'' - \ � I P c .l t I CI TY / ZIP '
o ASSEMBLY I •�.
,71:1 ASSEMBLY
ADDRESS: ADDRESS:
STREET I STREET
❑R.P.B.A. ❑ D.C.V.A. 0 R.P.D.A. ❑DC.D.A. ❑P.V.B.A. ❑S,V.B.A 0A.V,B_ ❑AIR GAP II ❑R.P.B.A_ ❑ D.C.V.A_ 0 R.P.D.A. ❑D.C.D.A. ❑P.V.B.A. QS- V.B.A. ❑A. V.B. ❑AIR GAP
SIZE: L1J.LJJ MAKE: .-- • .. . MODEL: -1• ., f l', SIZE: L I,' •I - 1- I MAKE: ,- f - MODEL: r" . - j :: i
WATER SERIAL I WATER SERIAL
PURVEYOR: .. { NUMBER: ;f; " >< i !' PURVEYOR: 1 - NUMBER:
ASSEMBLY - ■ i! ASSEMBLY S
LOCATION: I . - .. r 4 , I +_„ , ; (.;✓:.. ' I LOCATION: ; %.`.:. i i I - ..- -, f /,/ :2
I •
• '•
I
REDUCED PRESSURE ASSE BLY P.V.B.A / S.V.B.A INITIAL TEST REDUCED PRESSURE ASSEMBLY P.V.B.A / S.V.B.A INITIAL TEST +
m1 CHECK a i.'a =' E:: AIR CHECK PASSED Q . . II CHECK 'ai°,1;. ,: ' AIR CHECK PASSED I]
PRESS DROP (AEI CH CK 7 INLET FAILED ❑ PRESS DROP (4R) CHECK 171 INLET FAILED ❑
INITIAL RELIEF VALVE I N I TIAL AJdL1 v
- 1 -ES•I• OPENED AT (B }�TIGII ❑ / "/ OPENED AT. PRESS MOP T OPENED AT (B)1 ❑ •;� orexeo AT: PRESS DROP DATE:
DATE:
611N Z PSID PSID P MIN PEED LEAKED "--1 PS1P5113
RESULTS (LEAK : D ❑
BUFFER c / . ' j: S RESULTS BUFFER 1 - / WD PSID PSID MID A - B = 1 CH CK i72 I A A. B = I CHECK #2
MEN 3 PSI I MIN 3 PSI
RELIEF VALVE IT1GH ❑ 7 { DID NOT FAILED SYSTEM , RELIEF VALVE (TIGHT 0Jj__ DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ !LEAK: D �D OPEN ❑ ❑ PSI PASS ❑ FAIL ❑ 'LEAKED L] PSID OPEN 13 PSI
COMMENTS COMMENTS
REPAIRS REPAIRS
AND /OR 1 AND /OR
PARTS I ` PARTS
REDUCED PRESSURE MBLY P.V.B. A. /S -V.B.A AFTER REPAIRS '-•--- •
REDUCED PRESSURE ASSEMBLY - P.V.B.A./S.V.B.A. AFTER REPAIRS
,11 CHECK CHECK
(Al
TEST PRESS DROP CHECK (A) I DATE MI CH CHEC PRESS DROP ��'���`� ''�� DATE: #1 TEST -RELIEF I OPENED AT PRESS DROP RELIEF CHECK WI OPENED AT PRESS DROP
AFTER OPENED (B) TIG ❑ ps(D / / AFTER OPENED (at) TIGHT ❑ nip / /
'm � '
REPAIRS "'m I I REPAIRS '=)
BUFFER CHEC' 112 BUFFER ' CHECK N2
A B
PASSED ❑ t A -.
.....a ITIGH CI P SI D PSID PSID ball I T1GIiT ❑ PSID PSID PSID PASSED 0
m EN COMPLETING AND SUBMITTING ' IS TEST REPORT, THE TESTER CERTIFIES THAT THE IN COMPLETING. AND SUBMITTING THIS TEST REPORT. THE TESTER CERTIFIES THAT THE
- - ASSEMBLY HAS BEEN TESTED AND . AMNED IN ACCORDANCE WITH ALE. APPLICABLE ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
Lrl RULES AND REGULATIONS OF E WATER SYSTEM, AND STATE REGULATIONS - RULES AND REGULATIONS OF THE WATER - SYSTEM, AND STATE REGULATIONS. •
•
, r3AUGE CALIBRATION PATE ' tJ( 1 / • DETECTOR METER READING - - " - "+ GAUGE CALIBRATION DATE ; I ?• I r DETECTOR METER READING
ESTER SIGNATURE _ ; / • CER TK � TESTER SIGNATURE/' CERT
! . °.= l I 7.`. : , ��. , _
E IN
:ESTERS NAME PRINTED, GAUGE B 1 TESTERS NAME PRIRED
.. • i.1 ': ( 1 . 1. , r -, . _ , I ` -r - ( "") GAUGE N
- :ESIERSADDRESS k TESTERS ADDRESS
1. 1 PHONEY
_ PHONE w
-, :OMPANY NAME . • .. ; 1 COMPANY NAME '
. ❑ SERVICE RESTORED € C] SERVICE RESTORED
REPORT RECEIVED BY (REPRESENTATIVE Of OWNER) - i f REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER)
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