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11980 SW CARMEN STREET
\ CITY OF TIGARD __ PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2004-00030
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 1/21/04
SITE ADDRESS: 11980 SW CARMEN ST PARCEL: 2S103BD-02800
SUBDIVISION: CARMEN PARK ZONING: R-4.5
BLOCK: LOT: 003 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERF: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: 100' sewer line wort; to connect existing house to lateral. Reimbursement Dist. #25 paid. Septic tank to be
pumped and filled or removed.
Owner: FEES v
Description Date Amount
REEVES, MICHAEL D AND NADINE K — ---
1 1980 SW CARMEN ST !I'I.U�1131 I' rmit FCC 1/21/C4 $72.50
TIGARD, OR 97223 I TAX]8%0 Stat:Surchar; 1/21/04 $5.80
Total $78.30
Phone
Contractor:
OWNFP
REQUIRED INSPECTIONS
Phone : Final Inspection ---�--_----____---__-`-�v�---__—�
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
Issuer) By: .?��_l��.���1� Permittee Signature_-4:' I L /
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the n6t business Jay"
CITYOF TIGARD SEWER;;ONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT#: SWR2004-00021
13125 SW Hall Blvd.; Tigard. OR 97223 (503) 639-4171 DATE iSSUED: 1!21,04
SITE ADDRESS; 11980 SW CARMEN ST PARCEL: 2S103BD-02800
SUBDIVISION: CARMEN PARK ZONING: R-4.5
_e BLOCK: LOT: JURISDICTION: 'r1G
TENANT NAME:
USA NO: FIXTI IRE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL. TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection.
Owner: ------ _�_
—
REEVES, MICHAEL D AND NADINE K --- — -------FEES -
11980 SW CARMEN ST Description Date Amount
TIGARD, OR 97223 [SWUSA]Swr Connect 1/21/04 $2,40000
[SWUSA]Swr Connect 1/21/04 $0.00
Phone: [SWINSP]Swr Inspect 1/21/04 $35.00
Contractor:
f S WINSP]Swr Inspect 1/21/04 $0.00
Total $2,435.00
Phone:
Reg #:
Required Inspections
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The tots; amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located,the installer shall purchase a"Tap and Side Sewer' Perm
Issued by: LL//–Ile
Permittee Signature:
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next" usiness day
Building Fixtures
i"Itimbin Permit Application e e e
City of Tigard �airi»ea /-o21-r?,/ Permit No.�h/hv�0�1-�C�3y
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Reiiew
Phone: 503.639.4171 Fax: 503.598.1960 Dau/By: Owet Pernw Na
24-Hour Inspection Line: 503.639.4175 Dau Ready/By )u'1` 0 see Page 2 far
Internet: www.ci.tigard.or.us Notifted/Mclhod: (' Suppiementallnformatlun
TYPE OF WORK FEE" SCHEDULE
❑New construction ❑Demolition - For special information use rbecklisr.
_- Description t Ea. Total
[ Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 It for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 249.20
❑ 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 350.00
❑Accessory building ❑Multi-family SFR(3)bath 399.00
- - Each additional bath/kitchen 45.00
E]Mester builder E3 Other:
-�-_ Fire sprinkler(_sq.ft) Page 2
JOB SITE INFORMATION AND LOCATION _ Site utilities
Job site address: ) ' G v��J Catch basin ar are;drain _ 16.60 -
City/State/ZIP: ' / '2jj 3 Drywell,let ch line,or trench drain 16.60
Suite/bldg./apt.no.: Project name: Footing drain(no.linear ft.: I Page 2 -
Manufactured home utilities 110.00
Cross street/directions to job site: - - -
Manholes 16.60
_ Rain drain connector 16.60
Sanitary sewer(no.linear ft.: Pan 2 c�C�
Storm sewer(no.linear ft.:_) Page 2
Subdivision: _--_ Lot n Water service(no,linear ft.: ) Page 2 W
Fixture or Item
Tax map/parcel no.: --
-._.. Absorptior valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.61
Dishwasher 16.60
Drinking fountain 16.60
❑ PROPERTY OWNEREl_ TENANT
Ejectors/sump 16,60
Name: C, -T' - Expansion tank 16.60
Address: C44- 11 Fixture/sewer cep 16.60
City/State/ZIP: - 0 /7-',��' Floor drain/floor sink/hub 1 16.60
- � Garbage disposal 16.60
Phone:(. )3) jar S Fax:( ) Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON
---- Ice maker 16.60
Business name:
Interceptor/grease trap 16.60
Contact name: Medical gas(value:S ) 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 Urinat 16.60
CONTRAC".OR - 'Nater closet 16.60
Business name: �� � Ir, y Water heater 16.60
Address: -,_ Other: I
- Subtotal
City/State/ZIP: _ _ -
____ Minimum permit fee: $72 SU �-,� S C
Phone:( ) Fax:( ) J Residential backflow minimum permit fee: $36.25
CCB Lic.: PI11n#pg Lic.no.: Plan review (25%of permit fee) -
State surcharge(11%of permit fee)
authorized signature: TO'rAL PERMIT FEE
Print name: la 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,;rrvice Board.
iXButlding\PermiU\PI-MF-PermitAppdoc 12103 410./61MIOWCOM•'WEB)
I'lumbini: Permit Application - City of Tigard
Page - Supplemental Information
Fee Schedule: _ Residential Firs Suppression Systems:
Site Utilities Qty' Fee(ea) Total Square Foota e: Permit Fee:
Footing drain-I" 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 30 7,201 and greater $309.00 -
Sewer-each additional 100' 46.40
Water Service-Ist 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$5,0UJ.00 Minimum fee$72.50
Stomi&Rain Drain-each additional 100' 46.40 $5,001 AO to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for each
Qty. Fee(ea) Total additional$100.00 or(taction thereof,to and
Fixture or Item _ including$10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to;525,000.00 $148.50 for the first$10,000.00 and$1.54 for
Residential Backflow Prevention Device each additional S 100.00 or fraction thereof,to
(minimum permit fee 536.25) 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 S1.45 for
each additional S 100.00 or fraction thereof,to
Inspection of existing plumbing or and including$50,000.00.
specially requested inspections-per hour 72.50 $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
Subtotal: each additional$100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
please indicate work performed by fixture. Failure to
accuratel•, report fixtures could result in increased sewer fees*.
Quandt b (Fist re)Work t'erformed
FIiture'rype: Replace
New Moved Existing Capped t omments regarding fixture v�ork:
Ifa tistr /Pont
Ilath -11 -- --^-
-Jacuzzi/Whirl ool _ ---_-_-- ---__--_---._ -_ _
Car Wash -Each Stall
-Drive Thru
Cu dor/Water Aspirator ----- - -- --
Dishwasher -Commercial
I -Domestic
Drinking Fountain
Eye Wash -- - - - --
Floor Drain/sink 2"
4„ ---
Car Wash Drain _
Garbage -Domestic -
Disposal -Commercial *Note: If the fixture work under this permit results in an
-Industrial increase of sewer EDUs,a sewer permit will be issued and
Ice MachJRefri .Drains --- fees assessed for the sewer increase must he paid before the
Oil Separator Gas Station
Rec.vehicle Dump Station plumbing permit can be issued.
Shower -Gang
-Stall
Sink -Bar/lavatory _ _-_ Quantity Total
-Bradley _ - Isometric or riser diagram is required if fixture quantity
-Commercial _ total is>9.
-Service -
Swinuning Pool Filter
Washer-Clothes
Water Extractor1_ Ian Review
WaterCloset-Toilet -_ Plan review is required if fixtur-r quantity total is '0'
Urinal
Other Fixtures:
,\auiidinp,Perm n%P1.M PermrtApp doe !/Ol
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503) 639-4175
MST
INSPECTION DIVISION Business Line: (503) 639-4171
BUP
Received Date Requested u' v `�` AM PM r _ BUP -
Location Suite —_ MEC
Contact Person — L Ph
Contractor Ph( —) SWR
BUILDING TenanttCl*n 721 ' ,��'L� _ _ ELC
Footing ELC
Foundation Access:
Ftg Drain ELR _- -_-__- --
Crawl Drain
Slab Inspection Notes: SIT
Post& Beam
Shear Anchors --- -
Ext Sheath/Shear
Int Sheath/Shear
Framing - - - -_
Insulation
Drywall Nailing - - _ -— --- -— -
Firewall
Fire Sprinkler --- - ------- -- -
Fire Alarm
Susp'd Ceiling - -- W—_— -
Roof
Other. -
Final �-
PASS PART FAIL �—
PLUMBING — —
Post&Beam
Under Slab — --
Rough-In
Water Service — - _ -- -
ft"a-ry Sewer` L
Catch Basin/Manhole
Storm Drain --�_---
Shower Pan
A PART FAIL4kyi -- ---- ------- - --
_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 [j Please call for reinspection RE: _— Unable to inspect--no access
Fire Supply Line
ADA /01Ins /
Approach/Sidewalk Dots �, InspectorExt
____1
Other
Final DO NOT REMOVE thHs Inspection record from the job %Ite.
PASS PART FAIL
02/11/2004 16:11 A13-848-6832 HOL.LENBACH & HURIi F'AliL H�
Hoffienbach- & Hurd.Tnc.
3430-A S.W. 209th Ave.. EXCAVATIMGAND (MLYMS Office (503) 591-5987
Aloha , OR. 97007-1073 mn..i 0121901 Fax(503) 94"32
Email: hanWO@Jtmo.com
RESIDENTIAL SANITARY SEWER
AS-1BUI ,T
Dole: It _ - atuilding P«ma a PL-h7
Building ContTBotor: OWri/A, RC46-uf-S
Subdivision: _- -- __- Address: ---
Depth of Correction to City Stuhout: Dta4nae off curb tc Cii�► Stubout: _— --
Type of?*: � Sire of tide: �____--
Type of Cormmbon: . !6UAFP, Inspection Date:
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— — 02/11/2004 15:19 503-848-6832 HOLLENBACH & HURD PAGE
ALOHA SANITARY SERVICE iNvoi,E NO
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 82FJ 1
503-644-2"797 503-648-6254 503-639-5188
NAMr
� AUDFESB,
STATE: G_J�Y- ZIP;
WORK' CEI I-:
P.O*
Jae $ITE,
PAID By _ CHAdCiE r> CHECK 1-1
CASH L3 CREDIT CARP LI —
DRIVFR j1/�// _ ^lu, a,/ AMOUNT
DATE
PUMP SEPTIC TANK
❑ LINE OPENING �.---
❑ INSPECTION FEE
- U SERVICE CALL —
❑ LABOR, LOCATING, DoGINu,BACKFILL _ _,-
_ L1 -MATERIAL
l
TOTAL
THIS IS Noi A SEP?7C SYSTF---M IN.SPF-CnON REPORT - -- - REMARKS - -
I
I TvPE or TANK. STELL .J CONCRETE ❑ PLASTIC L1 HOMEMADE ❑
HOHILONIIAI LJ VERTICAL ❑ RECTANGLE LJ ❑ OTHER—_---- _ -._---
SIZE OF TANK: 350 Ll 500 a 750 ❑ 1000 C] 12a6 t3 1500 C] 2000 U 3000 D
LID LOCATION: INLET L3OUTLET ❑�.•-- 1�IDDLE U ENTIRE TOP J
YANK CONDITION: GOOD U I Fmw1:1 POOR U
FI1lINGS: BAFF� CONCRETE U CAST IRON J PLASTIC LJ
NEIns NEw LID?;Its ❑ SIZE
GROUND COVER OVER TANK -
COMMENTS ON CONDITION OF DRAINFIFLD ETC..
r
DATE
SIGNED Q• _ --