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14615 SW KIAI'SAN LN
CITE` OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2004-00210
13125 SW Hail Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 5/12/2004
SITE ADDRESS: 14615 SW KI IPSAN LN PARCEL: 2S105DA-16200
SUBDIVISION: PACIFIC CRFo i ZONING: R-7
^^ BLOCK: LOY: 050 JURISDICTION: TIC
CLASS ( F WORK: Cl R GARBAGE DISPOSE LS: MOBILE HOME SPACES:
TYPE OF USE. SF WASHING MACH: GACKFLOW PREVNTRS: i
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS- SF RAIN DRAINS:
SINKS: URINALF GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: ft
WATER CLOSETS: YVATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of residential backflow prevention device.
Owner: EES
MEHRAN ADYANI
Description Date Amount
- _-
14615 SW KLIPSAN II'LUN1131 11crmit for 5/12/2004 $ 6.2.5
TIGARD, OR 97224 ITA.\I Iurrluu, 5/12/2004 $2.90
Total $39.15
Phone :
Contractor:
MILLER FACTORS
4010 NE BUFFALO
PORTLAND, OR 97'?l 1 REQUIRED INSPECTIONS
Phone : s03-284-0(,Oo RP/Backflow Preventer W
Final Inspection
Reg #: I'Lh1 79N')Q
This permit is issued subject 'to the regulations contained in the Tigard Municipal Code, Sate ,)f OR.
Specialty Codes and al! cher applicable laws. Al; work will be done in accordance with approvr✓d
plans This permit will expire if work is not started within 180 days of issuance, or if work is Suspended
for more than 180 day's. ATTE=NTION. Oregon law requires you to follow rules adopted by the Oi:�gon
Utility Notification Center. Those ru es are set forth in OAR 952-0001-0010 through OAR
952-0001-0100. You may obtain cc pies of these rules or direct questions to OUNC by calling (503)
246-6699.
� � 9
Issued ll�y: _K - l n Permittee Signature:
Call (503) 63d4175 by 7:00 P.M. for an inspection nepd-ad the next business day
Building Fixtures
Plumhinl; Permit Application FOR OFFICE USE (INLY
City of'Tigard ed �j G! Permit No.Li-
Date/By:
13125 SW Mall Blvd.,Tigard,OR 97223 Plan Review __-
Phone: 503,639.4171 Fax: 503.598.1960 Date/By: Other Permit No.:
24-Hour Inspection Line: 503.639.4175 Date Ready/By: ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Supplemental Informmloo
TYPE OP WORK FEE" §CHEDIJLE
❑New construction - ❑Demolition For special information use checklist.
---_ _- Descri tion I Qty, Ea. I Total
❑Addition/alteration/replacement LI Other: Now I-2-famlly dwellings(in-..ides 100 fl,for each utility connection)
CATEGORY OF CONSTRUCTION - SFR(1)bath 249.20
❑ 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 35P.uu
❑Accessory building ❑Multi-family
SFR(3)bath 3'19.00
---------- - Each additional bath" :cher
El Master builder _ Other: Fire sprinkler(_sq.R.) Page 2
JOB SITE INFORMA fION AND LOCATION Site utilities
Job site address: l (� X41�64 N ��, � Catch basin or area drain I6.60
City/state/ZIP: �.{L�� O R 'L j� Drywell,leach line,or trench drain 16.60
o
Suite/bldg./apt.no.: f Project name_ Footing drain linear R.:— ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60 i
Rain drain connector 16.60
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear.t.:_) Page 2
Subdivision: Lot no.: Water service(no.linear R.: ) Page 2
-- - -- Fixture or ittir,
Tax map/parrel no.: _ Absorption valve 1600 �—
DESCRIPTION OF WORK—` — Backflow preventer Page 2
►t- ___ ___—___-.._. _-__ Backwater valve 16.60
Clothes washer 16.60
----� -- -- - -� Dishwasher 16.60 `—
Drinking fountain 16.60
❑ PROPERTY OWNER �-_❑ TENANT Ejectors/sump 16.60
Name: Expansion tank 16.60
Address: I Q (f L( Lf}'NE Fixture/sewer cap 16.60
City/State/ZIP L _ �- Floor drain/floor sink/hub 16.60
Fax:( ) Oarbap: disposal 16.60
Phone:( ) `{asbib 16.60
—_ ❑ "PLICA e VT �❑ CONTACT PERSON ice a bibmake16.60
Business name: - _ � ._ Interceptor/grease trap 16.60
Contact name: Medical gas(value:S�) Page 2
Address: Primer 1660
City/State/Z[P: Roof drain(commercial) 16.60
Phone: Fax:
Sink/basin/lavatory 16.60
( ) --- :( ) ---
Tub/shower/shower pan 16.611
E-mail: _ _ Urinal 16.60
CONTRACTOR �- _ Water closet 16.60
Businris,�eme: i~\t(I Water heater __ 16.60
Address: 0 10 Other:
Subtotal
City/State/ZIP: �0 r 'Z[J - Minimum permit fee: U a
Phone:( 0) LyE-Q(o Q�)- Fax:-( ) Residential backflow minimum permit f 536.2 r
1I CCB Lic.: Plumbing Lic,no.: Plan review (25%of perm) ee)
tState surcharge(9%of permit fee) 0q.Fe
Authorized signature: _ TOTAL PERMIT FEE /
Print name: t..� � M f LL- Data J ) t`� This permit application expires If a permit Is not ohtalned wlthln
f=J- 180 days after it hes been accepted as complete.
"Fee methodology set by Tri-County Building Industry Service Board.
i�nuildinp\Permlu',PLMF-PermitApp doe 12 03 44j-4616T(10/021C0M/Wa8)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total _§quare Foot_a_ge: Pt,rmit Fee:
Footing drain-I'100' 55.00 0 to 2,000 $115,00
Footing drain-each additional 100' 46.40 2,OUI to 3,600 $160.00 -�-- _
3,601 to 7,200 $220.00 _
Sewer-I st 100' 55.00 7,201 and greater $3,'9.00 _
Sewer-each additional 100' 46.40
Water Ser-ice-Ist 100' _ 55.00 Medical Gas_SVstems: _
Water Service-each additional 100' 46.40 `7aluatio:: 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 1 $72.50 for the first$5,000.00 and$1.52 far etch
!— Qty. Fee(ea) Total additional$100.00 or fraction thereof,to and
Fixture or Itenn _ including$10,000.00.
Commercial[tack Flow Prevention Device 46.40 $10,601.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 f'or
Residential Backflow Prevration Device i each additional$100.00 or fraction thereof,to
(minimum permit fee$36.75) 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 51.45 for
each additional$100.00 or fraction thereof,to
Inspection of existing plumbir of _ and including$50,000.00,
specially requested inspectfor, -p:r hw ur _____72.50 $50,001.00 and up $142 00 for the first$50,000.00 and$1.20 for
Subtotal: each additional$100.00 or fraction thereof.
Fixture Work:
Are you capping, illoving or replacing existing Fixtures? if
"yes", please indicate work performed by fixture. Failure to
accurately report fixtures could r esult in increased sewer fees'.
Quantal,,b Fixt it Work 1'crformed
Fixture'Type: Replace
Ne iv Moved Exiting Capped Commcnts regarding fixture %vork:
Ba list /Font __ _�� — -_--------------- _
Bath -Tub/Shower _
-Jacuzzi/Whirlpool _ -.----..__----_.-__— ---_--.—
Car Wash -Each Stall
_ -Drive Thru _
Cuspidor/Water Aspirator -- `�-----�_"--- - �—
Dishwashet -Commercial
-Domestic
Drinking Fountain ----------- -__-._.-.__---»
Eye Wash
Fluor Drain/sink -2" _ _---Y_--------_��-
4' -
Car Wash Dr,iin
Garbage -Domestic
Disposal -Commercial _ *Note: If the fixture«orlc under this permil results in at.
-Industrial increase of sewer EDUs, a sewer permit will be issued ant'
Ice Mach./Refs .Drains
Oil Separator Gas Station') fees assessed for the sewer increase must be paid beton: the
Rec.Vehicle Dump Station _ _ plumbing permit can he issued.
Shower -Gang _
-Stall
Sink -Bar/1_avatory u:tntit `Total
-Bradley -- Isometric or riser diagram Is requirc:l if fixture quantity
-Commercial total is>9.
-Service -
Swimming Pool Filter
Washer-Clothes
Wpter Fxtractor _ Plan Review
waterCloset-Toilet Plan review is regWred if Oxture quantity total is_9,
Urinal
Other Fixtures.
I\nulldlq\Permlu\PLM-PermitApp doc 3/03
CITY OF TIGARD 24-Hour
BUS-DING ;nspection Line: (503)639-4175 MST ----
INSPECTION DIVISION Business Uae: (503) 639-4171 BLIP
Received _. —Date Reque ed- 'a ,)AMPM —_ BUP _---_____�-__
Location —_-_�L s - -,✓�--SuepP___- --____-- MEC �/----._----
Contact Person ---- . . --- Ph l — F ��� — PLM �JC7
Contractor_ -- ----- - -- . Ph (- ---) — -—-- ..--- - SWR —— ------ —.�
BUILDING Tenant/Owner _-- -- --- ___-- ELC _---
Footing _ ELC
Foundation Access:
Fig Drain ELR -----__._-_
Crawl Drain
Slab Inspection Notes: SIT
Post&Beam -- - --- - -- ---- --------
Shear
-.-Shear Anchors
Ext Sheath/Shear �- - - - - --
Int Sheath/Shear
Framing ---- --- .
Insulation
Drywall Nailing - -
Firewall
Fire Sprinkler
Fire Alarm _-
Susp'd Ceiling
Roof - --
Other:
Final
PASS PART FAIL
PLUMBING
Post& Beam—
Under Slab
Rough-In
Water Service
Sanitary Sewer
Rain Drains - -- -- -
Catch Basin/Manhole
Storm Drain - - - - --
Shower P
Other: -in -- -_
ASA, PART FAIL
M CHANICAL - - -
Post& Beam
Rough-in - --- -- - -
Gas Line
Smoke Dampers - -- - - --
Final
PASS PART FAIL --- -----^ -
ELECTRICAL
Service
Rough-In - -_
UG/Slab
Low Voltage --- --
Fire Alarm
Final El Reinspection fee of$ __ -_required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
_PASS PART FAIL
SITE L_I Please call for reinspection Unable to Inspect-no access
Fire Supply Line
ADA Data Inspector l �.+� Ext
Approach/Sidewalk -_----_-_ - --
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL