9885 SW PEMBROOK STREET i
9885 SW "--brook Street
CITYOF I G A R D — PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2001-00278
13125 SN Hall B!vd.,Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 6/29/01
PARCEL: 2S111 BD-00307
SITE ADDRESS: 09885 SVJ PEMBROOK ST
SUBDIVISION. PEMBROOK HF!GHTS ZONING: R-3.5
BLOCK: LOT: 007 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH. BACKFLOW PP,EVNTRS:
OCCUPANCY GRP: FLOOR DRAINS: TRAPS:
STORIES: WATER HEATEPS: 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: 60 ft
Remarks: Connect rear rain drains to existing front drains. Install yard drain.
FEES
Owner:
Type By Date Amount Receipt
POND, DL: .NlE P M + PRMT CTR 6/29/01 $72.50 27200100000
POND, SUSAN L VIROSTEK 5PCT CTR 6/29/01 $5.80 27200100000
9885 SW PEMBROOK ST
TIGARD, OR 97224 Total $78.30
Phone 1:
Contractor.
OWNER
REQUIRED INSPECTIONS
Phone 1: Rain Drain Insp
Final Inspection
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 sat ,forth in OAR 952-0001-0010 through OAR 952-0001-0080.
You may obtain copies of these ruleF or direct questions to OUNC by calling (503) 246-198
Issued By: L1-1;�_;-) Permittee Signature'~_ f /
Cell( 3)839-4179 by 7:00 P.M. for an inspection needed the next business day
Plumbing Permit Application
Date received: ,2 p-0 Permit no.: 00 ,0
City of Tigard Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd,Tigard,OR 97223
Ciq'gfl'if;ard Phone: (503) 639-4171 Project/appl.no.: Expiredate:
Fax: (503) 598-1960 Date issued: By: I Receipt no.:
Land use approval: _ Case file no.: Paytnent type:
U I &2 family dwelling or accessory U Commercial/industrial U Multi-family U Tenant improvement
U New construction U Addition/alter ition/replacenlent U Food swl vicc U f hher: _
JOB SITE e 1
Job address: Y y 1lescri►tion Qht - tee(ca.) Il olal
New 1-and 2-family dwellings only: �^
Bldg.no.: Suite no.: (includes 10011.for each utilityconnection)
Tax map/tax lot/account no.: SFR(I)bath _ 1
Lot: Block: Subdivision: SFR(2)bath
Project name: SFR(3)bath _
City/county: c f , IP: Each additional bath/kitchen
Description anNo,catioof work (vises: A I SiteuNliHes:
�� Catch basin/area drain
Est.date of completion/inspection: Drywellsfleach line/trench drain
Footing drain(no.lin.ft.)
1 Manufactured home utilities
Business name: Manholes
NI
Address: Rain drain connector
City: State: ZIP: Sanita sewer(no.lin.ft.)
Phone: Fax: E-mail: Storm sewer(no.lin.ft.)
CCB no.: Plumb.bus.reg.no: Water service(no.tin.ft.)
Fixture or Item:
City/metro lic.no.: Absorption valve
Contractor's representative signature: Back flow preventer
Print name: Date: Backwater valve
0111 EKE III Basins/lavatory
Name: C Clothes washer
_ Dishwasher
Address: v► C�4 4 Drinking fountain(s)
City: CState: ZI Ejectors/sum
Phone: '>' ax: E-mail: Expansion lack _
Fixture/sewer cap
Floor drains/floor sinks/hub
Name(print): (lU Garbage disposal — —
Mailing address: Ot -Hose bibb
City: i x ^C State: ZIP: ' - Ice maker
Phone: _ — ax: E-mail: Interceptor/ rease trap
Owner installation/residential maintenance only: The actual installation Primers)
will be made by me or th ntenance an r air I de by my regular Roof drain(commercial) _
employee on the pro I n as per O rapt 447. / Sink(s),hasin(s),lays(s)
Owner's signal ur _ fl Date: Cs Sum
'1'uhs/shower/shower pan
Urinal
Name: _ _ —_ Water closet
Address: _ Water heatet
City: State: ZIP: _ Other:
---—
Phone: Fax: Email: Totts
—. Minimum fee................$
Not all jurisdictions accept credit carets.pleax call jurisdiction for more information. Notice:This permit application Plan review(al 91,) $
Ll Visa U MasterCard expires if a permit is not obtained Credit card number: __ 1—L— within I80 days after it has been State surcharge(896)....$ �a
Expires TOTAL
_ accepted as complete. """""""""""' - J
Name of cardholder W shown on credit card
S
--Cater ai(pnatute Amount 410-4616(WWCOM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2damlly dwellings only: --1—
FIXTURES individuate,___ QTY ea AMOUNT (includes all plumbing fixtures in PRICE TOTAL
--- 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Sink for ear"h utility connection) __ __
Lavatory 16.80 One 1 bath $249.20
Tub or Tub/Shower Comb. 16.60 Two(2)bath $350.00
Shower Only 16.60
-- Three 3 bath 3399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 _ s%STATE SURCHARGE
Dishv.+st er 16.60 _ PLAN REVIEW 25•/.OF SUBTOTAL
TOTAL
Garbage Disposal
Laundry Tray 16.60
Washing Machine 16.60
ts.6o PLEASE COMPLETE:
Floor Drain/Floor Sink 2� T
f4" uantl b WoO Performed
Water Heater o conversion O like kindFixture Type: New Moved Replaced Removed/
Gas piping requires a separate mechanical Ca od
ermil. Sink --
MFG Home New Water Service Lavatory —
MFG Home New San/Storm Sewer 48.40 Tub or Tub/Shower
Hose Bibs 16.s0 Combination -- --—
Roof Drains 16.60 Shower Onl
16.60 Water Closet --
Drinking Fountain Urinal
Other Fixtures(Specify) 16.60 Dishwasher ---—
r3arbage Disposal
Laundry Room Tra
Washin Machine
Ess Floor Drain/Sink: 2"Sewer-1st 100' _ 3"
Sewereach additional 100' 4"
Water HeaterWater Service-1st 100' Other FixturesWater Service-each additional 200' S eclStorm8Rain Orain-1st100'Storm&RainDraineachadditic ial 100'Commercial Back Flow Prevention Device Residential Backflow Prevention Device'Catch Basin Inspectionof Existing Plumbing or Specially Re nested Inspections COMMENTS REGARDING ABOVE:
R5 n Drain,single family dwelling . _
urease Traps 16.80 —
r QUANTITY TOTAL —
Isometric or riser diagram is required If
�q!2 Total Is >9
- — "SUBTOTAL
81,1.STATE SURCHARGE
"PLAN REVIEW 25%OF SUBTOTAL
P.equirN only if fixture total is>9
— TOTAL S
*Minimum permit fee is$72 50•a%state surcharge,except Residential BacAllow
Prevention Device,which Is$38 25•a%slate surharge
"All New Commercial Buildings require dans with isometric or riser diagram and
plan review
i:\dsts\forms\pinl-fees.doc 10110/00
CIT Y OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175
MST
INSPECTION DIVISION Business Line: (503)639-4171
7 BUP
Received Date Re nested -___—'�_. AM—_ PM BUP
--u'YyL�/�)�S-�' Yfi Suite MECJ
Location .- - pp�.�e.--r-- - _
Contact Person _ \� 4'R k PLM
Contractor �_-_ __�___ --__ Ph SWR `_-
BUILDINGTenant/Owner _._..__ .,� -5& ELC
Footing
ELC
FoundationAccess:
Access: , -,
Ftg Drain ELR
Crawl Drain m-i a _ �G e) `�'��,-.'aK
Slab Inspection Notes: SIT
Post& Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Sheath/Shear
Framing - - --_- -- -- - -- -
Insulation % r1`4 un
�-
Drywall Nailing �1/1 -C�e '•'� w
Firewall ,
Fire Sprinkler
Fire Alarm
Susp'd Ceiling -
Roof
Other: _
Final _
PASS PART FAIL
PLUMBING
Post&Beam
Under Slab - -
Rough-In
Water Service --- -
Sani�Sewer
etch Basin/Manhole
Storm Drain ;- -- -
Shower F?pn _
al
PART FAIL
CHANICAL _.-__-- ---_-----_---
Post&Beam
Hough-In --
Gas Line
Smoke Dampers --
Final
PASS PART FAIL
AL
ELECTRIC _- _..
Service - --•---- --------------- ---
Rough-In -- -- -- ----- - -
UG/Slab
Low Voltage - -__.-- ----
Fire Alarm
Final Reinspection fee of$ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART__F_AIL
SITE _ Please call for reinspection RE:.. Unable to inspect-no access
Fire Supply LineADA
-
Approach/Sidewalk Data_ Inspector /� / G � __ Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL