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12520 SW 112"' Avenue
SEWER CONNECTION PERI4�IT
CITY ^C T I G /� R
DEVELOPMENT SERVICES PERMIT#: SWR2002-00320
13125 SW Hall Blvd. Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 12/2/02
PARCEL: 2S103AC-03100
SITE ADDRESS; 12520 SW 112TH AVE
SUBDIVISION: MCMICHAEL HEIGII FS ZONING: 1l45
BLOCK: LOT: 004 _ JURISDICTION: I Ic
TENANT NAME:
USA NO: FIXT t IriC UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILLINGS:
INSTALL TYPE: LTPSVVR IMPERV SURFACE:
Remarks: Sewer connection for existing residence to newly installed lateral. Reimbursement District#21 fee
of$5,020.00 paid on this date.
Owner: _ — _FEES _
ELSNER, IVAN EDITH Description Date �^ Amount
12520 SW 112TH
TIGARD, OR 97223 [SWUSA]Swr Conncct 12/2/02 $2,300.00
[SWUSA]Swr Conncct 12/2/02 $0.00
Phone: [SWINSPI Swr Inspect 12/2/02 $35.00
[SWINSP] Swr Inspect 12/2/02 $0.00
Contractor: Total $2,335.00
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 total 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 b 1 /h %' ]` Permittee Signature:
y.
t
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
CITY OF
'T IGARD _ PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2002-00487
13125 SW Hall Blvd.,Tigard, OR 97223 (50.',1 639-4171 DATE ISSUED: 12/18/02
PARCEL: 2S103AC-03100
SITE ADDRESS: 12520 SW 112TH FIVE
SUBDIVISION: MCMICHAEL HEIGHTS ZONING: R-4.5
BLOCK: LOT: 004 ^_ JURISDICTION_ TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BPCK`r-OW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPG:
STORIES: 'NATER HEATERS: CATCH rsASINS:
FIXTURES _ LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE: TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: 90 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of approximately 90 If of sewer line to connect existing house to new sewer lateral. Septic tank is to
be pumped, filled and inspected. Reimbursement District fee paid. _
FEES �
Owner:
- Description Date Amount
ELSNER, IVAN EDITH iPIA v1131 permit Fr 12;18/02 $72.50
12520 SW 112TH
TIGARD, OR 97223 ['I A i is Starr I a% 12/18/02 $5.80
Total $78.30
Phone
Contractor:
TED MCBEE EXCAVATING INC
11428 NE SCHUYLER
PORTLAND, OR 97220 REQUIRED INSPECTIONS
Phone : 939-524(1Misc.
Inspection
Misc. Inspection
Reg#: LIC 110314 Final Inspection
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 rules or direct questions to OUNC by calling (503) 246-6699.
Issued By: _ _ _ _ _ Permittee Signature: ' _
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Plumbing Peri:ait application '
— Date received:/ %`t r; y Permit no...- t;'
Cit of Tigard City g Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd,Tigard,OR 97223
City of Tigard Phone: (503) 639-4171 ProjecUappl.no.: Espirc date:
Fax: (503) 598-1960 Date issued: _ By:Y R Receipt no
Land use approval: Case file no.: Payment type:
OF PERMIT
&2 family dwelling or accessory ❑Commercial/industrial ❑Multi-family ❑Tenant improvement
New construction ❑Addition/alteration/replacement ❑Food service ❑Other:
Job address: j Description Qty. hee(ea.) Tlotal
Nets I-and 2-family dwellings only:
Bldg. no.: Suite no.:
— (includes 1110 ft.for each utility connection)
Tax map/tax lot/account no.: _ SFR(1)bath
Lot: Block: Subdivision: SFR(2)bath
Project name: SFR(3)bath
City/county: ZIP: it Each additional bath/kitchen
e criptiop,and to ion of on pr ises: I Site utilities:
Catch basin/area drain
Est,daic of completion/i spection: Drywells/leach line/trench drain
Footing drain(no.lin. R.)
Manufactured home utilities
Business name: Manholes
Address: Rain drain connector
City; () I I State: ZIP: Sanitary sewer(no,lin, fl,)
Phone: Fax: - ja E-mail: Storm sewer(no.lin. fl,) _
CCB no.: Plumb bus.reg.ro: Water service(no, in. 1t.
_ fixture or item:
City/metro lie.no.:
Absorption valve
Contractor's representative signature Back flow preventer
Print name: ? Hate: Backwater valve
CONTACTI Basins/lavatory
-- Clothes washer _
Dishwasher
Address: Drinking fountain(s) —
Cit State: ZIP: __ Ejectors/sump_
i
one: - Fax: E-mail: Expansion tank _
Fixture/sewer ca _
Floor drains/floor sinks/hub _
Name print): ^ _ - C3arba a isposa __ _.
Mailing address: Ilose bibb —_
City: __ ZIP: Ice maker
State:
Phone: Fax: E-mail: Interceptor/grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Raofdrain(commercial)
employee on the property I own es per ORS Chapter 447. Sink(s),basin(s),lays(s)
Owner's signature: Date: I Sump
Tubs/shower/shower pan
Urine
Name _ Water closet
Address: Water heater _
City: State: Z.IP: Other:
Phone: Fax: I E-mail: Total
Minimum fee........ ....... S _
Not all jurisdictions accept credit cards,piton call jurisdiction for entire Information Notice: This permit application
O visa O MasterCard expires if a permit is not obtained Plan review(at—u %) S
credit cud number --— --- -- —1 within 180 days after it has been State surcharge(8/o)....
— spares
-77112
—Nartx of cu&ol er as shown noon crtdu card
accepted as complete. TOTAL........................
— ---- S -- Wo./61616r00/COMI
Ca tr n`"1___ Amouni
PLUMBNG PERMIT FEES:
PRICE TOTAL New 1 and 2-family dwellings only:
FIXTURES (Individual) QTY ea AMOUNT (includes al!plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first1)0 ft. QTY (ea) AMOUNT
for each utility connection) _
Lavatory 16.60 One 1 bath _ $249.20 _
Tub or Tub/Shower Comb. 16.60 Two(2)bath $350.00 _
Shower Only 16.60 Three 3 bath _ _ $399.00
Water Closet _ 16.60 SUB TO_TAL _
Urinal 16.60 a%STATE SURCHARGE _
Dishwasher 16.60 PLAN REVIEW 25%OF SUBTOTAL
Garbage Disposal 16.60 TOTAL —
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" 1660
3" 16.60 PLEASE COMPLETE:
4" 16.60 _
Water Heater O conversion O like kind 16.60 Quantity b Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
ermit _ Capped
MFG Home New Water Service 46.40 Sink _
MFG Home New San/Storm Sewer 4640 Lavatory
Tub or Tub/Shower
Hose Bibs 1660 Combination
Roof Drains 1660 Shower Only
Drinking Fountain 16.60 Water Closet
Other Fixtures(Specify) 16.60 Urinal
Dishwasher
Garbage Disposal _
Laundry Room Tray
Washing Machine
Floor Drain/Sink: 2"
Sewer-t st 100' 55.00 3„
Sewer-each additional 100' 4640 4" _
Water Service-1 st 100' 55.00 Water Heater
Water Service-each additional 200' 46.40 Other Fixtures
(Specify)
Storm&Rein Drain-1st 100' 5500
Storm 8 Rain Drain-each additional 100' 46.40 —
Commercial Back Flow Prevention Device 46.40 --
Residential Backflow Prevention Device' 27.55
Catch Basin 1660
Inspection of Existing Plumbing or Specially 6250
Requested Inspections perfhr COMMENTS REGARDING ABOVE:
Rein Drain,single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram in required it
Quentity Total Is >9
*SUBTOTAL
8%
—
8%STATE SURCHARGE
"PLAN REVIEW 25%OF SUBTOTAL
_ Reritmed only it fixture qty total is>9
TOTAL s
Minimum permit fee is$12 50+8%state surcharge,except Residential Backflow
Prevention Device,which Is$36 25 4 8%state surcharge
**All New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
1:\dsts\forms\plm-fees.doc 12/26/01
CITY OF IGARD 24-Hour
BUILT .JG Inspection Line: (503)639-4175
!NST
iNSPECTIOI DIVISION Business Line: (503)639-4171
•T�, BUP
huceived ---- —`—Date Requested AM__010 BUP
Location --
`� '~—Suite _ MEC — ---
--_� -
Contact Person ,,. 0 t ---- Ph PLM}
Contractor _— Ph(—_—_) _— _ _ SWR --
BUILDING _ Tenant/Owner _ _ — ELC
Footing ELC --
Foundation Access:
Ftg Drain ELR —
Crawl Drain
Slab Inspection Notes: SIT _
Post&Beam
Shear Anchors
Ext Sheath/Shear _--
Int Sheath/Shear --
Framing -
Insulation
Drywall Nailing `�� r � -------�- -- --
Firewall (/
Fire Sprinkler - --- - — --
Fire Alarm
Susp'd Ceiling - -- -
Root 1'j
Other:
Final
PASS PART FAIL - --
PLUMBING
Post Beam n
Under
Slab
Rough-In '
Watei Service - ---
i aT ry�S we'i'
Hain Urains ---- -- - —
Catch Basin/Manhole
Stun,.Drain -
Shower Pan
Other:. -- ---
Finel
PASS _PART FAIL
AAl f_CHA MIMI_ ----- -.____..------------
Post& Beam
Rough-In - - - -- - -
Gas Line
Smoke Dampers ----- ------- --_ --- — --
Final
PASS PART FAIL_ - ----------- ---
ELECTRICAL
Service --__ -- --- -----__�-. - - -----------
Rough-In
UG/Slab
Low Voltage --- -- --- -- -- --- --- - - -
Fire Alarm
Final Reinspection fee of$ --- required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
_PASS PART_ _ FAIL_
SITE [� Please call for reinspection RE:_ �- _ ._-_- ___ [� Unable.to Inspect-no access
Fire Supply Line
ADA
Date_J
Approech/Sidewalk D - _ Inspodor_ -Ext
---
Other:
Final DO NOT REMOVE this Inspodion r000rd from the job she.
PASS PART FAIL
From Ste,,•McBee Far: +1(603)W61-3920 To. Rick Bolen Few: +1(603)624-3881 Page 3 of 4 Friday,December 27,2002 11:18 AM
r Ted ����� CCR•110514 24hr (603)261.0606
11428 NE Schuyler St. Mobile (603)91!9.6246
Boring & Excavatingg Inc. Portland,OR 97220 Fax (603)261-6920
C
[December 27, 2002
City of Tigard
Attn, Inspector Rick Bolen
Tigard,OR
ItE9 SEPTIC ABANDONMENT-12620 SW 112'"AVE
To whom it may concern,
This letter is to confirm that the existing septic tank located at the above address has been pumped and
then back filled with W minus granular to compliance with State and City codes for the abandonment of
on site sewage disposal systems
If you have any questions or concerns, contact me direct at (503) 515-4452 or Steve Mr Bee at 1,503)
939-5246.
Sincerely,
Chris Rugloski
Estimates I Scheduling
Ted McBee Boring&Excavating, Inc
CLRlclt
invoice
- (�1111�l�'S ►l:i'�`'Ili Sl:RITIci A
Date
Name -! _-- �-
i
AJdre`j A245- 6--_�:;p '_r _ J� Phone '2 ----
Cit lni On Acct
ial
State Zip Code
Price Amount
NOT RESPONSIBLE FOR DAMAGES PAST CURB LINE OR LANDSCAPING �-
• A service charge of 1.5%will be levied on all past due accounts. Totel: x
• Returned check fee is$20.00.
• In case suit, action or arbitration Is instituted by either pprty for breach or to enforce any
provisions herein, the court shall award reasonable attorhQy's fees and actual costs to the
prevailing party �t trim or arbitration, or upon any gpgeal tak@n therefrom.
Appr /val
Customer Signature
_ PO ROX 1136 Canby, OR 97013 DEO# 37464
l I It I I1 (503) 263-2087 or (503) 632-6138 -- -- _ CGB# 104321)